PERMANENT RULES
SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
Effective Date of Rule: Thirty-one days after filing.
Purpose: The new rules: (1) Support recently filed rules that meet the Governor's Executive Order 10-06 exemption criteria for rule making because they are necessary to manage budget shortfalls, maintain fund solvency, or for revenue generating activities for fiscal year ending June 30, 2011; (2) assure consistency with how terms are defined and used throughout department medical assistance program rules; (3) meet the requirements of 2E2SHB 1738, the legislation that authorizes the medical purchasing administration and the health care authority (HCA) to merge into one agency effective July 1, 2011, by changing any references to "the department" (DSHS) to "the agency or the agency's designee"; and (4) place defined words and phrases into their own alpha sections which allows readers to locate a definition quickly.
Citation of Existing Rules Affected by this Order: Amending WAC 388-500-0005.
Statutory Authority for Adoption: RCW 74.08.090.
Other Authority: 2E2SHB 1738.
Adopted under notice filed as WSR 11-07-077 on March 22, 2011.
Changes Other than Editing from Proposed to Adopted Version: Added the following cross-references (underlined) to definitions in chapter 388-500 WAC:
WAC 388-500-0020 "Couple" See "spouse." in WAC 388-500-0100.
WAC 388-500-0050 "Ineligible spouse" See "spouse." in WAC 388-500-0100.
WAC 388-500-0050 "Institution for mental diseases (IMD)"
See "institution." in this section.
WAC 388-500-0050 "Institutionalized spouse" See "spouse."
in WAC 388-500-0100.
WAC 388-500-0050 "Intermediate care facility for the
mentally retarded (ICF/MR)" See "institution." in this
section.
WAC 388-500-0070 "Medical institution" See "institution."
in WAC 388-500-0050.
WAC 388-500-0075 "Nonapplying spouse" See "spouse." in
WAC 388-500-0100.
WAC 388-500-0075 "Noncovered service" See "covered
service." in WAC 388-500-0020.
WAC 388-500-0075 "Nursing facility" See "institution." in
WAC 388-500-0050.
WAC 388-500-0085 "Public institution" See "Institution."
in WAC 388-500-0050.
Changed "the department" (DSHS) (strikethrough) to "the
agency" (HCA) or "the agency's designee" (underlined):
WAC 388-500-0005 Chapter 388-500 WAC, other department
agency or agency's designee WAC, ... other department agency or
agency's designee WAC, the definition in the specific WAC
prevails.
WAC 388-500-0010 "Authorization" means the department's
agency's or the agency's designee's determinations ... to the
department's agency's or the agency's designee's decision ...
WAC 388-500-0015 "By report (BR)" means ... the department
agency or the agency's designee determines ... in the
department's agency's or the agency's designee(s) published
fee schedules.
WAC 388-500-0025 "Delayed certification" means department
agency or the agency's designee approval ...
WAC 388-500-0025 "Dental consultant" means ... by the
department agency or the agency's designee.
WAC 388-500-0030 "Early and periodic screening, diagnosis
and treatment (EPSDT)" is a ... for any department agency
healthcare program.
WAC 388-500-0030 "Expedited prior authorization (EPA)"
means ... to indicate to the department agency or the agency's
designee which acceptable ... or department agency or agency's
designee-defined criteria ...
WAC 388-500-0035 "Fee-for-service (FSS)" The general
payment method the department agency or agency's designee uses
... under the department's agency's prepaid managed care
programs.
WAC 388-500-0045 "Health maintenance organization (HMO)"
means ... the department agency on a ...
WAC 388-500-0050 "Institution" ... (3) "Medical
institution" (b)(i) "Hospice care center" - an entity ... and
approved by the department agency or the agency's designee to
be ...
WAC 388-500-0050 "Institution" ... (3) "Medical
institution" (b)(v) "Psychiatric residential treatment
facility (PRTF)" -- a nonhospital ... by the department agency or
the agency's designee to provide ...
WAC 388-500-0050 "Institution" ... (3) "Medical
institution" (c) medical institutions do not ... by the
department agency or the agency's designee as adult family
homes ...
WAC 388-500-0070 "Medical assistance" for the purposes of
... by the department agency or the agency's designee that
provide ...
WAC 388-500-0070 "Medical assistance administration
(MAA)" is the former ... now administered by the agency,
formerly the medicaid purchasing administration (MPA), of
formerly the health and recovery services administration
(HRSA).
WAC 388-500-0075 "NCCI edit" is a ... state regulations,
department agency or the agency's designee fee schedules ...
The department agency or the agency's designee has the final
decision ... NCCI standards or department agency or agency's
designee policy.
WAC 388-500-0085 "Prior authorization" is the requirement
... the department's agency's or the agency's designee's
approval to render ... The department's agency's or the agency's
designee's approval ...
WAC 388-500-0085 "Provider" means ... (1) Has signed a...with
the department agency or the agency's designee, and is ... (2)
Has authorization ... with the department agency or the agency's
designee to provide ...
WAC 388-500-0095 "Regional support network (RSN)" means
...which the department agency or the agency's designee
contracts for ...
WAC 388-500-0100 "Spenddown" is a term used ... by the
department agency.
WAC 388-500-0105 "Third party" means and entity other
than the department agency or the agency's designee that is ...
Other changes:
WAC 388-500-0010 "Agency" means the Washington state health care authority, created pursuant to chapter 41.05 RCW.
WAC 388-500-0020 "Covered service" is a healthcare
service contained within a "service category," that is
included in a medical assistance benefits package as described
in WAC 388-501-0060, included in the medical assistance
program's benefit package. For conditions of payment, see WAC 388-501-0050(5). A noncovered service is a specific
healthcare service (for example, cosmetic surgery), contained
within a service category that is included in a medical
assistance benefits package, for which the agency requires an
approved exception to rule (ETR) (see WAC 388-501-0160). A
noncovered service is not an excluded service (see WAC 388-501-0060).
WAC 388-500-0030 "Emergency medical expense requirement (EMER)" See WAC 388-865-0217(3).
WAC 388-500-0030 "Evidenced-based medicine (EBM)" means
the applications of a set of principles ... and beneficial when
making: (1) pPopulation-based healthcare coverage policies
(see WAC 388-501-0055 describes how the department determines
coverage of services for its healthcare programs by using
evidence and criteria based on health technology assessments),
or; and (2) iIndividual medical necessity decisions (see WAC 388-501-0165 describes how the department uses the best
evidence available to determine if a service is medically
necessary as defined in WAC 388-500-0030).
WAC 388-500-0030 "Extended care services" means nursing
and rehabilitative care in a skilled nursing facility provided
to a recently hospitalized medicare patient needing relatively
short-term skilled nursing and rehabilitative care in a
skilled nursing facility.
WAC 388-500-0045 Move definition of "Healthcare Professional" to after the definition of "Health maintenance organization (HMO)".
WAC 388-500-0045 Add: "Healthcare service category" means a grouping of healthcare services listed in the table in WAC 388-501-0060. A healthcare service category is included or excluded depending on the client's medical assistance benefits package.
WAC 388-500-0070 "Medical facility" means a medical
institution or a medical clinic that provides healthcare
services. A medical clinic does not meet the criteria to be
considered a medical institution (see "medical institution").
WAC 388-500-0075 "Noncovered service(s)" means a specific
healthcare service(s) or item(s) the department has determined
it will not cover or pay for any client under any medical
assistance program. Noncovered services are identified in WAC 388-50-0070 and in specific healthcare program rules See
"covered service" in WAC 388-500-0020.
WAC 388-500-0100 "Scope of healthcare service categories"
are the groupings of healthcare services listed in the table
in WAC 388-501-0060 that are available under each medical
assistance program's benefits package.
WAC 388-500-0100 "State supplemental payment (SSP)" is a state funded cash benefit for certain individuals who are either recipients of the Title XVI supplemental security income (SSI) program or who are clients of the division of developmental disabilities. The SSP allotment for Washington state is a fixed amount of $28.9 million and must be shared between all individuals who fall into one of the groups listed below. The amount of the SSP may vary each year depending on the number of individuals who qualify. The following groups are eligible for an SSP:
(1) Mandatory SSP group--SSP made to a mandatory income level client (MIL) who was grandfathered into the SSI program. To be eligible in this group, an individual must have been receiving cash assistance in December 1973 under the department's former old age assistance program or aid to the blind and disability assistance. Individuals in this group receive an SSP to bring their income to the level they received prior to the implementation of the SSI program in 1973.
(2) Optional SSP group--SSP made to any of the following:
(a) An individual who receives SSI and has an ineligible spouse.
(b) An individual who receives SSI based on meeting the age criteria of sixty-five or older.
(c) An individual who receives SSI based on blindness.
(d) An individual who has been determined eligible for SSP by the division of developmental disabilities.
(e) An individual who is eligible for SSI as a foster child as described in WAC 388-474-0012.
WAC 388-500-0100 "Supplementary payment (SSP)" means the
state money payment to a person receiving benefits under Title
XVI, or who would, but for the person's income, be eligible
for such benefits, as assistance based on need in
supplementation of SSI benefits. This payment includes:
"Mandatory state supplement" - the state money payment to a
person who, for December 1973, was a client receiving cash
assistance under the department's former programs of old age
assistance, aid to the blind and disability assistance; and
"Optional state supplement" - the elective state money payment
to a person eligible for SSI benefits or who, except for the
level of the person's income, would be eligible for SSI
benefits.
A final cost-benefit analysis is available by contacting Gail Kreiger, P.O. Box 45500, Olympia, WA 98504-5500, phone (360) 725-1949, fax (360) 725-9152, e-mail gail.kreiger@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 18, Amended 1, 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 18, Amended 1, Repealed 0.
Date Adopted: June 24, 2011.
Katherine I. Vasquez
Rules Coordinator
4249.8"Assignment of rights" means the client gives the state the right to payment and support for medical care from a third party.
"Base period" means the time period used in the limited casualty program which corresponds with the months considered for eligibility.
"Beneficiary" means an eligible person who receives:
*A federal cash Title XVI benefit; and/or
*State supplement under Title XVI; or
*Benefits under Title XVIII of the Social Security Act.
"Benefit period" means the time period used in determining whether medicare can pay for covered Part A services. A benefit period begins the first day a beneficiary is furnished inpatient hospital or extended care services by a qualified provider. The benefit period ends when the beneficiary has not been an inpatient of a hospital or other facility primarily providing skilled nursing or rehabilitation services for sixty consecutive days. There is no limit to the number of benefit periods a beneficiary may receive. Benefit period also means a "spell of illness" for medicare payments.
"Cabulance" means a vehicle for hire designed and used to transport a physically restricted person.
"Carrier" means:
*An organization contracting with the federal government to process claims under Part B of medicare; or
*A health insurance plan contracting with the department.
"Categorical assistance unit (CAU)" means one or more family members whose eligibility for medical care is determined separately or together based on categorical relatedness.
"Categorically needy" means the status of a person who is eligible for medical care under Title XIX of the Social Security Act. See WAC 388-503-0310, chapter 388-517 WAC and WAC 388-523-2305.
"Children's health program" means a state-funded medical program for children under age eighteen:
*Whose family income does not exceed one hundred percent of the federal poverty level; and
*Who are not otherwise eligible under Title XIX of the Social Security Act.
"Coinsurance-medicare" means the portion of reimbursable hospital and medical expenses, after subtraction of any deductible, which medicare does not pay. Under Part A, coinsurance is a per day dollar amount. Under Part B, coinsurance is twenty percent of reasonable charges.
"Community services office (CSO)" means an office of the department which administers social and health services at the community level.
"Couple" means, for the purposes of an SSI-related client, an SSI-related client living with a person of the opposite sex and both presenting themselves to the community as husband and wife. The department shall consider the income and resources of such couple as if the couple were married except when determining institutional eligibility.
"Deductible-medicare" means an initial specified amount that is the responsibility of the client.
*"Part A of medicare-inpatient hospital deductible" means an initial amount of the medical care cost in each benefit period which medicare does not pay.
*"Part B of medicare-physician deductible" means an initial amount of medicare Part B covered expenses in each calendar year which medicare does not pay.
"Delayed certification" means department approval of a person's eligibility for medicaid made after the established application processing time limits.
"Department" means the state department of social and health services.
"Early and periodic screening, diagnosis and treatment (EPSDT)" also known as the "healthy kids" program, means a program providing early and periodic screening, diagnosis and treatment to persons under twenty-one years of age who are eligible for medicaid or the children's health program.
"Electronic fund transfers (EFT)" means automatic bank deposits to a client's or provider's account.
"Emergency medical condition" means the sudden onset of a medical condition (including labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
*Placing the patient's health in serious jeopardy;
*Serious impairment to bodily functions; or
*Serious dysfunction of any bodily organ or part.
"Emergency medical expense requirement" means a specified amount of expenses for ambulance, emergency room or hospital services, including physician services in a hospital, incurred for an emergency medical condition that a client must incur prior to certification for the medically indigent program.
"Essential spouse" see "spouse."
"Extended care patient" means a recently hospitalized medicare patient needing relatively short-term skilled nursing and rehabilitative care in a skilled nursing facility.
"Garnishment" means withholding an amount from earned or unearned income to satisfy a debt or legal obligation.
"Grandfathered client" means:
*A noninstitutionalized person who meets all current requirements for medicaid eligibility except the criteria for blindness or disability; and
*Was eligible for medicaid in December 1973 as blind or disabled whether or not the person was receiving cash assistance in December 1973; and
*Continues to meet the criteria for blindness or disability and other conditions of eligibility used under the medicaid plan in December 1973; and
*An institutionalized person who was eligible for medicaid in December 1973 or any part of that month, as an inpatient of a medical institution or resident of an intermediate care facility that was participating in the medicaid program and for each consecutive month after December 1973 who:
*Continues to meet the requirements for medicaid eligibility that were in effect under the state's plan in December 1973 for institutionalized persons; and
*Remains institutionalized.
"Health maintenance organization (HMO)" means an entity licensed by the office of the insurance commissioner to provide comprehensive medical services directly to an eligible enrolled client in exchange for a premium paid by the department on a prepaid capitation risk basis.
"Healthy kids," see "EPSDT."
"Home health agency" means an agency or organization certified under medicare to provide comprehensive health care on a part-time or intermittent basis to a patient in the patient's place of residence.
"Hospital" means an institution licensed as a hospital by the department of health.
"Income for an SSI-related client," means the receipt by an individual of any property or service which the client can apply either directly, by sale, or conversion to meet the client's basic needs for food, clothing, and shelter.
*"Earned income" means gross wages for services rendered and/or net earnings from self-employment.
*"Unearned income" means all other income.
"Institution" means an establishment which furnishes food, shelter, medically related services, and medical care to four or more persons unrelated to the proprietor. This includes medical facilities, nursing facilities, and institutions for the mentally retarded.
*"Institution-public" means an institution, including a correctional institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control.
*"Institution for mental diseases" means an institution primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases including medical attention, nursing care, and related services.
*"Institution for the mentally retarded or a person with related conditions" means an institution that:
*Is primarily for the diagnosis, treatment or rehabilitation of the mentally retarded or a person with related conditions; and
*Provides, in a protected residential setting, on-going care, twenty-four hour supervision, evaluation, and planning to help each person function at the greatest ability.
*"Institution for tuberculosis" means an institution for the diagnosis, treatment, and care of a person with tuberculosis.
*"Medical institution" means an institution:
*Organized to provide medical care, including nursing and convalescent care;
*With the necessary professional personnel, equipment and facilities to manage the health needs of the patient on a continuing basis in accordance with acceptable standards;
*Authorized under state law to provide medical care; and
*Staffed by professional personnel. Services include adequate physician and nursing care.
"Intermediary" means an organization having an agreement with the federal government to process medicare claims under Part A.
"Legal dependent" means a person for whom another person is required by law to provide support.
"Limited casualty program (LCP)" means a medical care program for medically needy, as defined under WAC 388-503-0320 and for medically indigent, as defined under WAC 388-503-0370.
"Medicaid" means the federal aid Title XIX program under which medical care is provided to persons eligible for:
*Categorically needy program as defined in WAC 388-503-0310; or
*Medically needy program as defined in WAC 388-503-0320.
"Medical assistance." See "medicaid."
"Medical assistance administration (MAA)" means the unit within the department of social and health services authorized to administer the Title XIX medicaid and the state-funded medical care programs.
"Medical assistance unit (MAU)" means one or more family members whose eligibility for medical care is determined separately or together based on financial responsibility.
"Medical care services" means the limited scope of care financed by state funds and provided to general assistance (GAU) and ADATSA clients.
"Medical consultant" means a physician employed by the department.
"Medical facility" see "Institution."
"Medically indigent (MI)" means a state-funded medical program for a person who has an emergency medical condition requiring hospital-based services.
"Medically necessary" is a term for describing requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the client that endanger life, or cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the client requesting the service. For the purpose of this section, "course of treatment" may include mere observation or, where appropriate, no treatment at all.
"Medically needy (MN)" is the status of a person who is eligible for a federally matched medical program under Title XIX of the Social Security Act, who, but for income above the categorically needy level, would be eligible as categorically needy. Effective January 1, 1996, an AFDC-related adult is not eligible for MN.
"Medicare" means the federal government health insurance program for certain aged or disabled clients under Titles II and XVIII of the Social Security Act. Medicare has two parts:
*"Part A" covers the medicare inpatient hospital, post-hospital skilled nursing facility care, home health services, and hospice care.
*"Part B" is the supplementary medical insurance benefit (SMIB) covering the medicare doctor's services, outpatient hospital care, outpatient physical therapy and speech pathology services, home health care, and other health services and supplies not covered under Part A of medicare.
"Medicare assignment" means the method by which the provider receives payment for services under Part B of medicare.
"Month of application" means the calendar month a person files the application for medical care. When the application is for the medically needy program, at the person's request and if the application is filed in the last ten days of that month, the month of application may be the following month.
"Nursing facility" means any institution or facility the department [of health] licenses as a nursing facility, or a nursing facility unit of a licensed hospital, that the:
*Department certifies; and
*Facility and the department agree the facility may provide skilled nursing facility care.
"Outpatient" means a nonhospitalized patient receiving care in a hospital outpatient or hospital emergency department, or away from a hospital such as in a physician's office, the patient's own home, or a nursing facility.
"Patient transportation" means client transportation to and from covered medical services under the federal medicaid and state medical care programs.
"Physician" means a doctor of medicine, osteopathy, or podiatry who is legally authorized to perform the functions of the profession by the state in which the services are performed.
"Professional activity study (PAS)" means a compilation of inpatient hospital data, conducted by the commission of professional and hospital activities, to determine the average length of hospital stay for patients.
"Professional review organization for Washington (PRO-W)" means the state level organization responsible for determining whether health care activities:
*Are medically necessary;
*Meet professionally acceptable standards of health care; and
*Are appropriately provided in an outpatient or institutional setting for beneficiaries of medicare and clients of medicaid and maternal and child health.
"Prosthetic devices" means replacement, corrective, or supportive devices prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice as defined by state law to:
*Artificially replace a missing portion of the body;
*Prevent or correct physical deformity or malfunction; or
*Support a weak or deformed portion of the body.
"Provider" or "provider of service" means an institution, agency, or person:
*Who has a signed agreement with the department to furnish medical care, goods, and/or services to clients; and
*Is eligible to receive payment from the department.
"Resources for an SSI-related client," means cash or other liquid assets or any real or personal property that an individual or spouse, if any, owns and could convert to cash to be used for support or maintenance.
*If an individual can reduce a liquid asset to cash, it is a resource.
*If an individual cannot reduce an asset to cash, it is not considered an available resource.
*Liquid means properties that are in cash or are financial instruments which are convertible to cash such as, but not limited to, cash, savings, checking accounts, stocks, mutual fund shares, mortgage, or a promissory note.
*Nonliquid means all other property both real and personal evaluated at the price the item can reasonably be expected to sell for on the open market.
"Retroactive period" means the three calendar months before the month of application.
"Spell of illness" see "benefit period."
"Spenddown" means the process by which a person uses incurred medical expenses to offset income and/or resources to meet the financial standards established by the department.
"Spouse" means:
*"Community spouse" means a person living in the community and married to an institutionalized person or to a person receiving services from a home and community-based waivered program as described under chapter 388-515 WAC.
*"Eligible spouse" means an aged, blind or disabled husband or wife of an SSI-eligible person, with whom such a person lives.
*"Essential spouse" means, a husband or wife whose needs were taken into account in determining old age assistance (OAA), aid to the blind (AB), or disability assistance (DA) client for December 1973, who continues to live in the home and to be the spouse of such client.
*"Ineligible spouse" means the husband or wife of an SSI-eligible person, who lives with the SSI-eligible person and who has not applied or is not eligible to receive SSI.
*"Institutionalized spouse" means a married person in an institution or receiving services from a home or community-based waivered program.
*"Nonapplying spouse" means an SSI-eligible person's husband or wife, who has not applied for assistance.
"SSI-related" means an aged, blind or disabled person not receiving an SSI cash grant.
"Supplemental security income (SSI) program, Title XVI" means the federal grant program for aged, blind, and disabled established by section 301 of the Social Security amendments of 1972, and subsequent amendments, and administered by the Social Security Administration (SSA).
"Supplementary payment (SSP)" means the state money payment to persons receiving benefits under Title XVI, or who would, but for the person's income, be eligible for such benefits, as assistance based on need in supplementation of SSI benefits. This payment includes:
*"Mandatory state supplement" means the state money payment to a person who, for December 1973, was a client receiving cash assistance under the department's former programs of old age assistance, aid to the blind and disability assistance; and
*"Optional state supplement" means the elective state money payment to a person eligible for SSI benefits or who, except for the level of the person's income, would be eligible for SSI benefits.
"Third party" means any entity that is or may be liable to pay all or part of the medical cost of care of a medical program client.
"Title XIX" is the portion of the federal Social Security Act that authorizes grants to states for medical assistance programs. Title XIX is also called medicaid.
"Transfer" means any act or omission to act when title to or any interest in property is assigned, set over, or otherwise vested or allowed to vest in another person; including delivery of personal property, bills of sale, deeds, mortgages, pledges, or any other instrument conveying or relinquishing an interest in property. Transfer of title to a resource occurs by:
*An intentional act or transfer; or
*Failure to act to preserve title to the resource.
"Value-fair market for an SSI-related person" means the current value of a resource at the price for which the resource can reasonably be expected to sell on the open market.
"Value of compensation received" means, for SSI-related medical eligibility, the gross amount paid or agreed to be paid by the purchaser of a resource.
"Value-uncompensated" means, for SSI-related medical eligibility, the fair market value of a resource, minus the amount of compensation received in exchange for the resource)) Chapter 388-500 WAC contains definitions of words and phrases used in rules for medical assistance programs. When a term is not defined in this chapter, other agency or agency's designee WAC, or state or federal law, the medical definitions found in the Taber's Cyclopedic Medical Dictionary will apply. For general terms not defined in this chapter, other agency or agency's designee WAC, or state or federal law, the definitions in Webster's New World Dictionary apply. If a definition in this chapter conflicts with a definition in another chapter of TITLE 388 WAC, the definition in the specific WAC prevails.
[Statutory Authority: RCW 34.05.353 (2)(d), 74.08.090, and chapters 74.09, 74.04 RCW. 08-11-047, § 388-500-0005, filed 5/15/08, effective 6/15/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.04.005, 74.08.331, 74.08A.010, [74.08A.]100, [74.08A.]210, [74.08A.]230, 74.09.510, 74.12.255, Public Law 104-193 (1997) and the Balanced Budget Act [of] 1997. 98-15-066, § 388-500-0005, filed 7/13/98, effective 7/30/98. Statutory Authority: RCW 74.08.090. 95-22-039 (Order 3913, #100246), § 388-500-0005, filed 10/25/95, effective 10/28/95; 94-10-065 (Order 3732), § 388-500-0005, filed 5/3/94, effective 6/3/94. Formerly parts of WAC 388-80-005, 388-82-006, 388-92-005 and 388-93-005.]
"Allowable costs" are the documented costs as reported after any cost adjustment, cost disallowances, reclassifications, or reclassifications to nonallowable costs which are necessary, ordinary and related to the outpatient care of medical care clients are not expressly declared nonallowable by applicable statutes or regulations. Costs are ordinary if they are of the nature and magnitude which prudent and cost-conscious management would pay.
"Ancillary services" means additional services ordered by the provider to support the core treatment provided to the patient. These services may include, but are not limited to, laboratory services, radiology services, drugs, physical therapy, occupational therapy, and speech therapy.
"Apple health for kids" is the umbrella term for healthcare coverage for certain groups of children that is funded by the state and federal governments under Title XIX medicaid programs or Title XXI Children's Health Insurance Program, or solely through state funds (including the program formerly known as the children's health program). Funding for any given child depends on the program for which the child is determined to be eligible. Children who may be eligible for medical assistance but who are not included under the apple health for kids umbrella are described in WAC 388-505-0210.
"Authorization" means the agency's or the agency's designee's determination that criteria are met, as one of the preconditions to the agency's or the agency's designee's decision to provide payment for a specific service or device. (See also "expedited prior authorization" and "prior authorization.")
[]
"Benefit period" means the time period used in determining whether medicare can pay for covered Part A services. A benefit period begins the first day a beneficiary is furnished inpatient hospital or extended care services by a qualified provider. The benefit period ends when the beneficiary has not been an inpatient of a hospital or other facility primarily providing skilled nursing or rehabilitation services for sixty consecutive days. There is no limit to the number of benefit periods a beneficiary may receive. Benefit period also means a "spell of illness" for medicare payments.
"Blind" is a category of medical program eligibility that requires a central visual acuity of 20/200 or less in the better eye with the use of a correcting lens, or a field of vision limitation so the widest diameter of the visual field subtends an angle no greater than twenty degrees from central.
"By report (BR)" means a method of payment in which the agency or the agency's designee determines the amount it will pay for a service when the rate for that service is not included in the agency's or the agency's designee(s) published fee schedules. The provider must submit a "report" which describes the nature, extent, time, effort and/or equipment necessary to deliver the service.
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"Categorically needy (CN) or categorically needy program (CNP)" is the state and federally-funded healthcare program established under Title XIX of the Social Security Act for persons within medicaid-eligible categories, whose income and/or resources are at or below set standards.
"Categorically needy (CN) scope of care" is the range of healthcare services included within the scope of service categories described in WAC 388-501-0060 available to individuals eligible to receive benefits under a CN program. Some state-funded healthcare programs provide CN scope of care.
"Centers for Medicare and Medicaid Services (CMS)" means the agency within the federal department of health and human services (DHHS) with oversight responsibility for the medicare and medicaid programs.
"Children's health program or children's healthcare programs" See "Apple health for kids."
"Community spouse" See "spouse" in WAC 388-500-0100.
"Couple" See "spouse" in WAC 388-500-0100.
"Covered service" is a healthcare service contained within a "service category" that is included in a medical assistance benefits package described in WAC 388-501-0060. For conditions of payment, see WAC 388-501-0050(5). A noncovered service is a specific healthcare service (for example, cosmetic surgery), contained within a service category that is included in a medical assistance benefits package, for which the agency or the agency's designee requires an approved exception to rule (ETR) (see WAC 388-501-0160). A noncovered service is not an excluded service (see WAC 388-501-0060).
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"Dental consultant" means a dentist employed or contracted by the agency or the agency's designee.
"Department" means the state department of social and health services.
"Disabled" means unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that:
(1) Can be expected to result in death;
(2) Has lasted or can be expected to last for a continuous period of not less than twelve months; or
(3) In the case of a child age seventeen or younger, means any physical or mental impairment of comparable severity.
Decisions on SSI-related disability are subject to the authority of federal statutes and rules codified at 42 USC Sec 1382c and 20 CFR, parts 404 and 416, as amended, and controlling federal court decisions, which define the old-age, survivors, and disability insurance (OASDI) and SSI disability standard and determination process. See WAC 388-500-0015 for definition of "blind."
"Domestic partner" means an adult who meets the requirements for a valid state registered domestic partnership as established by RCW 26.60.030 and who has been issued a certificate of state registered domestic partnership from the Washington Secretary of State.
"Dual eligible client" means a client who has been found eligible as a categorically needy (CN) or medically needy (MN) medicaid client and is also a medicare beneficiary. This does not include a client who is only eligible for a medicare savings program as described in chapter 388-517 WAC.
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"Emergency medical condition" means the sudden onset of a medical condition (including labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
(1) Placing the patient's health in serious jeopardy;
(2) Serious impairment to bodily functions; or
(3) Serious dysfunction of any bodily organ or part.
"Emergency medical expense requirement (EMER)" see WAC 388-865-0217(3).
"Evidence-based medicine (EBM)" means the application of a set of principles and a method for the review of well-designed studies and objective clinical data to determine the level of evidence that proves to the greatest extent possible, that a healthcare service is safe, effective, and beneficial when making:
(1) Population-based healthcare coverage policies (WAC 388-501-0055 describes how the agency or the agency's designee determines coverage of services for its healthcare programs by using evidence and criteria based on health technology assessments); and
(2) Individual medical necessity decisions (WAC 388-501-0165 describes how the agency or the agency's designee uses the best evidence available to determine if a service is medically necessary as defined in WAC 388-500-0030).
"Exception to rule" See WAC 388-501-0160.
"Expedited prior authorization (EPA)" means the process for obtaining authorization for selected healthcare services in which providers use a set of numeric codes to indicate to the agency or the agency's designee which acceptable indications, conditions, or agency or agency's designee-defined criteria are applicable to a particular request for authorization. EPA is a form of "prior authorization."
"Extended care services" means nursing and rehabilitative care in a skilled nursing facility provided to a recently hospitalized medicare patient.
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"Fiscal intermediary" means an organization having an agreement with the federal government to process medicare claims under Part A.
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(1) Was eligible for medicaid in December 1973 as blind or disabled whether or not the person was receiving cash assistance in December 1973;
(2) Continues to meet the criteria for blindness or disability and other conditions of eligibility used under the medicaid plan in December 1973; or
(3) Was an institutionalized person who:
(a) Was eligible for medicaid in December 1973, or any part of that month, as an inpatient of a medical institution or a resident of a facility that is known as an intermediate care facility that was participating in the medicaid program and for each consecutive month after December 1973; and
(b) Continues to meet the requirements for medicaid eligibility that were in effect under the state's plan in December 1973 for institutionalized persons and remains institutionalized.
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"Healthcare professional" means a provider of healthcare services licensed or certified by the state in which they practice.
Healthcare service category" means a grouping of healthcare services listed in the table in WAC 388-501-0060. A healthcare service category is included or excluded depending on the client's medical assistance benefits package.
"Home health agency" means an agency or organization certified under medicare to provide comprehensive health care on a part-time or intermittent basis to a patient in the patient's place of residence.
"Hospital" means an entity that is licensed as an acute care hospital in accordance with applicable state laws and rules, or the applicable state laws and rules of the state in which the entity is located when the entity is out-of-state, and is certified under Title XVIII of the federal Social Security Act. The term "hospital" includes a medicare or state-certified distinct rehabilitation unit or a psychiatric hospital.
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"Institution" means an entity that furnishes (in single or multiple facilities) food, shelter, and some treatment or services to four or more persons unrelated to the proprietor. Eligibility for medical assistance program may vary depending upon the type of institution in which an individual resides. For the purposes of medical assistance programs, "institution" includes all of the following:
(1) "Institution for mental diseases (IMD)" -- a hospital, nursing facility, or other institution of more than sixteen beds that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services. An IMD may include inpatient chemical dependency facilities of more than sixteen beds which provide residential treatment for alcohol and substance abuse.
(2) "Intermediate care facility for the mentally retarded (ICF/MR)" -- an institution or distinct part of an institution that is:
(a) Defined in 42 CFR 440.150;
(b) Certified to provide ICF/MR services under 42 CFR 483, Subpart I; and
(c) Primarily for the diagnosis, treatment, or rehabilitation for persons with mental retardation or a related condition (see WAC 388-823-0700 for information about what qualifies as a "related condition").
(3) "Medical institution" -- an entity that is organized to provide medical care, including nursing and convalescent care. The terms "medical facility" and "medical institution" are sometimes used interchangeably throughout TITLE 388 WAC.
(a) To meet the definition of medical institution, the entity must:
(i) Be licensed as a medical institution under state law;
(ii) Provide medical care, with the necessary professional personnel, equipment, and facilities to manage the health needs of the patient on a continuing basis in accordance with acceptable standards; and
(iii) Include adequate physician and nursing care.
(b) Medical institutions include all of the following:
(i) "Hospice care center" -- an entity licensed by the department of health (DOH) to provide hospice services. Hospice care centers must be medicare-certified, and approved by the agency or the agency's designee to be considered a medical institution.
(ii) "Hospital" -- defined in WAC 388-500-0045.
(iii) "Nursing facility (NF)" -- an entity certified to provide skilled nursing care and long-term care services to medicaid recipients under Section 1919(a) of the Social Security Act. Nursing facilities that may become certified include nursing homes licensed under chapter 18.51 RCW, and nursing facility units within hospitals licensed by the department of health (DOH) under chapter 70.41 RCW. This includes the nursing facility section of a state veteran's facility.
(iv) "Psychiatric hospital" -- an institution, or a psychiatric unit located in a hospital, licensed as a hospital in accordance with applicable Washington state laws and rules, that is primarily engaged to provide psychiatric services for the diagnosis and treatment of mentally ill persons under the supervision of a physician.
(v) "Psychiatric residential treatment facility (PRTF)" -- a nonhospital residential treatment center licensed by department of health, and certified by the agency or the agency's designee to provide psychiatric inpatient services to medicaid-eligible individuals twenty-one years of age and younger. A PRTF must be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or any other accrediting organization with comparable standards recognized by Washington state. A PRTF must meet the requirements in 42 CFR 483, Subpart G, regarding the use of restraint and seclusion.
(vi) "Residential habilitation center (RHC)" -- a residence operated by the state under chapter 71A.20 RCW that serves individuals who have exceptional care and treatment needs due to their developmental disabilities by providing residential care designed to develop individual capacities to their optimum. RHCs provide residential care and may be certified to provide ICF/MR services and/or nursing facility services.
(c) Medical institutions do not include entities licensed by the agency or the agency's designee as adult family homes (AFHs) and boarding homes. AFHs and boarding homes include assisted living facilities, adult residential centers, enhanced adult residential centers, and developmental disability group homes.
(4) "Public institution" means an entity that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control.
(a) Public institutions include all of the following:
(i) Correctional facility -- an entity such as a state penitentiary or county jail, (includes placement in a work release program or outside of the institution, including home detention).
(ii) Eastern and Western State mental hospitals. (Medicaid coverage for these institutions is limited to individuals age twenty-one and younger, and individuals age sixty-five and older.)
(iii) Certain facilities administered by Washington state's department of veteran's affairs (see (b) of this subsection for facilities that are not considered public institutions).
(b) Public institutions do not include intermediate care facilities, entities that meet the definition of medical institution (such as Harborview Medical Center and University of Washington Medical Center), or facilities in Retsil, Orting, and Spokane that are administered by the department of veteran's affairs and licensed as nursing facilities.
"Institution for mental diseases (IMD)" See "institution" in this section.
"Institutionalized spouse" See "spouse" in WAC 388-500-0100.
"Intermediate care facility for the mentally retarded (ICF/MR)" See "institution" in this section.
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"Limited casualty program (LCP)" means the medically needy (MN) program.
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"Medical assistance" for the purposes of chapters 388-500 through 388-561 WAC, means the various healthcare programs administered by the agency or the agency's designee that provide federally funded and/or state-funded healthcare benefits to eligible clients.
"Medical assistance administration (MAA)" is the former organization within the department of social and health services authorized to administer the federally funded and/or state-funded healthcare programs that are now administered by the agency, formerly the medicaid purchasing administration (MPA), of the health and recovery services administration (HRSA).
"Medical care services (MCS)" means the limited scope of care financed by state funds and provided to disability lifeline and alcohol and drug addiction services clients.
"Medical consultant" means a physician employed or contracted by the agency or the agency's designee.
"Medical facility" means a medical institution or clinic that provides healthcare services.
"Medical institution" See "institution" in WAC 388-500-0050.
"Medically necessary" is a term for describing requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the client that endanger life, or cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the client requesting the service. For the purposes of this section, "course of treatment" may include mere observation or, where appropriate, no medical treatment at all.
"Medically needy (MN) or medically needy program (MNP)" is the state- and federally-funded healthcare program available to specific groups of persons who would be eligible as categorically needy (CN), except their monthly income is above the CN standard. Some long-term care clients with income and/or resources above the CN standard may also qualify for MN.
"Medicare" is the federal government health insurance program for certain aged or disabled persons under Titles II and XVIII of the Social Security Act. Medicare has four parts:
(1) "Part A" - covers medicare inpatient hospital services, post-hospital skilled nursing facility care, home health services, and hospice care.
(2) "Part B" - the supplementary medical insurance benefit (SMIB) that covers medicare doctors' services, outpatient hospital care, outpatient physical therapy and speech pathology services, home health care, and other health services and supplies not covered under Part A of medicare.
(3) "Part C" - covers medicare benefits for clients enrolled in a medicare advantage plan.
(4) "Part D" - the medicare prescription drug insurance benefit.
"Medicare assignment" means the process by which a provider agrees to provide services to a medicare beneficiary and accept medicare's payment for the services.
"Medicare cost-sharing" means out-of-pocket medical expenses related to services provided by medicare. For medical assistance clients who are enrolled in medicare, cost-sharing may include Part A and Part B premiums, co-insurance, deductibles, and co-payments for medicare services. See chapter 388-517 WAC for more information.
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"National provider indicator (NPI)" is a federal system for uniquely identifying all providers of healthcare services, supplies, and equipment.
"NCCI edit" is a software step used to determine if a claim is billing for a service that is not in accordance with federal and state statutes, federal and state regulations, agency or the agency's designee's fee schedules, billing instructions, and other publications. The agency or the agency's designee has the final decision whether the NCCI edits allow automated payment for services that were not billed in accordance with governing law, NCCI standards or agency or agency's designee policy.
"Nonapplying spouse" See "spouse" in WAC 388-500-0100.
"Noncovered service" See "covered service" in WAC 388-500-0020.
"Nursing facility" See "institution" in WAC 388-500-0050.
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"Overhead costs" means those costs that have been incurred for common or joint objectives and cannot be readily identified with a particular final cost objective. Overhead costs that are allocated must be clearly distinguished from other functions and identified as a benefit to a direct service.
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"Physician" means a doctor of medicine, osteopathy, or podiatry who is legally authorized to perform the functions of the profession by the state in which the services are performed.
"Prior authorization" is the requirement that a provider must request, on behalf of a client and when required by rule, the agency's or the agency's designee's approval to render a healthcare service or write a prescription in advance of the client receiving the healthcare service or prescribed drug, device, or drug-related supply. The agency's or the agency's designee's approval is based on medical necessity. Receipt of prior authorization does not guarantee payment. Expedited prior authorization and limitation extension are types of prior authorization.
"Prosthetic devices" means replacement, corrective, or supportive devices prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice as defined by state law to:
| • | Artificially replace a missing portion of the body; |
| • | Prevent or correct physical deformity or malfunction; or |
| • | Support a weak or deformed portion of the body. |
(1) Has signed a core provider agreement or signed a contract with the agency or the agency's designee, and is authorized to provide healthcare, goods, and/or services to medical assistance clients; or
(2) Has authorization from a managed care organization (MCO) that contracts with the agency or the agency's designee to provide healthcare, goods, and/or services to eligible medical assistance clients enrolled in the MCO plan.
"Public institution" See "institution" in WAC 388-500-0050.
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"Retroactive period" means approval of medical coverage for any or all of the retroactive period. A client may be eligible only in the retroactive period or may have both current eligibility and a separate retroactive period of eligibility approved.
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"Spouse" means, for the purposes of medicaid, a person who is a husband or wife legally married to a person of the opposite sex. Washington state recognizes other states' determinations of legal and common-law marriages between two persons of the opposite gender.
(1) "Community spouse" means a person who:
(a) Does not reside in a medical institution; and
(b) Is legally married to a client who resides in a medical institution or receives services from a home and community-based waiver program. A person is considered married if not divorced, even when physically or legally separated from his or her spouse.
(2) "Eligible spouse" means an aged, blind or disabled husband or wife of an SSI-eligible person, who lives with the SSI-eligible person, and is also eligible for SSI.
(3) "Essential spouse" means a husband or wife whose needs were taken into account in determining old age assistance (OAA), aid to the blind (AB), or disability assistance (DA) for a client in December 1973, who continues to live in the home and remains married to the client.
(4) "Ineligible spouse" means the husband or wife of an SSI-eligible person, who lives with the SSI-eligible person, and who has not applied or is not eligible to receive SSI.
(5) "Institutionalized spouse" means a legally married person who has attained institutional status as described in chapter 388-513 WAC, and receives services in a medical institution or from a home or community-based waiver program described in chapter 388-515 WAC. A person is considered married if not divorced, even when physically or legally separated from his or her spouse.
(6) "Nonapplying spouse" means an SSI-related person's husband or wife, who has not applied for medical assistance.
"SSI-related" means an aged, blind or disabled person not receiving an SSI cash grant.
"State supplemental payment (SSP)" is a state-funded cash benefit for certain individuals who are either recipients of the Title XVI supplemental security income (SSI) program or who are clients of the division of developmental disabilities. The SSP allotment for Washington state is a fixed amount of twenty-eight million nine hundred thousand dollars and must be shared between all individuals who fall into one of the groups listed below. The amount of the SSP may vary each year depending on the number of individuals who qualify. The following groups are eligible for an SSP:
(1) Mandatory SSP group--SSP made to a mandatory income level client (MIL) who was grandfathered into the SSI program. To be eligible in this group, an individual must have been receiving cash assistance in December 1973 under the department of social and health services former old age assistance program or aid to the blind and disability assistance. Individuals in this group receive an SSP to bring their income to the level they received prior to the implementation of the SSI program in 1973.
(2) Optional SSP group -- SSP made to any of the following:
(a) An individual who receives SSI and has an ineligible spouse.
(b) An individual who receives SSI based on meeting the age criteria of sixty-five or older.
(c) An individual who receives SSI based on blindness.
(d) An individual who has been determined eligible for SSP by the division of developmental disabilities.
(e) An individual who is eligible for SSI as a foster child as described in WAC 388-474-0012.
"Supplemental security income (SSI) program (Title XVI)" is the federal grant program for aged, blind, and disabled persons, established by section 301 of the Social Security amendments of 1972, and subsequent amendments, and administered by the Social Security Administration (SSA).
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"Third party liability (TPL)" means the legal responsibility of an identified third party or parties to pay all or part of the cost of healthcare for a medical assistance client. A medical assistance client's obligation to help establish TPL is described in WAC 388-505-0540.
"Title XIX" is the portion of the federal Social Security Act, 42 USC 1396, that authorizes funding to states for medical assistance programs. Title XIX is also called medicaid.
"Title XXI" is the portion of the federal Social Security Act, 42 USC 1397 et seq, that authorizes funding to states for the children's health insurance program. Title XXI is also called CHIP.
"Transfer of assets" means changing ownership or title of an asset such as income, real property, or personal property by one of the following:
(1) An intentional act that changes ownership or title; or
(2) A failure to act that results in a change of ownership or title.
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"Usual and customary charge" means the amount a provider typically charges to fifty percent or more of patients who are not medical assistance clients.
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