EMERGENCY RULES
(Medicaid Program)
Effective Date of Rule: December 24, 2011.
Purpose: Upon order of the governor, the health care authority (HCA) reduced its budget expenditures for fiscal year 2011 and 2012 by 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 182-501 WAC and WAC 182-502-0160 are being amended to reflect and support these program cuts.
Citation of Existing Rules Affected by this Order: Amending WAC 388-501-0050 [182-501-0050], 388-501-0060 [182-501-0060], 388-501-0065 [182-501-0065], 388-501-0070 [182-501-0070], and 388-502-0160 [182-502-0160].
Statutory Authority for Adoption: RCW 41.05.021.
Other Authority: Chapter 564, Laws of 2011 (2E2SHB 1738).
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 year 2009, 2010, 2011, 2012 or 2013, 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 percent. As a consequence of the executive order, funding for the benefits was eliminated effective January 1, 2011, as part of these regulatory amendments. HCA is proceeding with the permanent rule adoption process initiated by the CR-101 filed under WSR 10-22-12 [10-22-121] and anticipates filing the CR-102 sometime in January 2012.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.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, 2011.
Kevin M. Sullivan
Rules Coordinator
OTS-4234.1
AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11,
effective 7/1/11)
WAC 182-501-0050
Healthcare general coverage.
WAC
((388-501-0050)) 182-501-0050 through ((388-501-0065))
182-501-0065 describe the healthcare services available to a
client on a fee-for-service basis or to a client enrolled in a
managed care organization (MCO) (defined in WAC
((388-538-050)) 182-538-050). For the purposes of this
section, healthcare services includes treatment, equipment,
related supplies, and drugs. WAC ((388-501-0070))
182-501-0070 describes noncovered services.
(1) Healthcare service categories listed in WAC
((388-501-0060)) 182-501-0060 do not represent a contract for
healthcare services.
(2) 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) Under the ((department's)) agency's or the agency
designee's fee-for-service programs, providers must be
enrolled with the ((department)) agency or the agency's
designee and meet the requirements of chapter ((388-502))
182-502 WAC to be paid for furnishing healthcare services to
clients.
(4) The ((department)) agency or the agency's designee
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 182-501-0060;
(b) Covered - See subsection (9) of this section;
(c) Ordered or prescribed by a healthcare provider who
meets the requirements of chapter ((388-502)) 182-502 WAC;
(d) Medically necessary as defined in WAC
((388-500-0005)) 182-500-0070;
(e) Submitted for authorization, when required, in
accordance with WAC ((388-501-0163)) 182-501-0163;
(f) Approved, when required, in accordance with WAC
((388-501-0165)) 182-501-0165;
(g) Furnished by a provider according to chapter
((388-502)) 182-502 WAC; and
(h) Billed in accordance with ((department)) agency or
agency's designee program rules and the ((department's))
agency's current published billing instructions and numbered
memoranda.
(5) The ((department)) agency or the agency's designee
does not pay for any healthcare service requiring prior
authorization from the ((department)) agency or the agency's
designee, 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) The ((department)) agency does not reimburse clients
for healthcare services purchased out-of-pocket.
(7) The ((department)) agency does not pay for the
replacement of ((department-purchased)) agency-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)) agency-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))
specific agency program rules.
(8) The ((department's)) agency's refusal to pay for
replacement of equipment, device, or supplies will not extend
beyond the limitations stated in specific ((department))
agency program rules.
(9) 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)) agency or the agency's designee
may limit the scope, amount, duration, and/or frequency of
covered healthcare services. Limitation extensions are
authorized according to WAC ((388-501-0169)) 182-501-0169.
(10) Noncovered healthcare services.
(a) The ((department)) agency or the agency's designee
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))
182-501-0070 or in any other agency program rule. The
((department)) agency or the agency's designee 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)) 182-501-0160.
(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)) agency or the agency's designee evaluates the
healthcare service according to the process in WAC
((388-501-0165)) 182-501-0165 to determine if it is medically
necessary, safe, effective, and not experimental (see WAC
((388-534-0100)) 182-534-0100 for EPSDT rules).
[11-14-075, recodified as § 182-501-0050, filed 6/30/11, effective 7/1/11. 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.]
(2) Not all categories of service listed in this section are covered under every medical program, nor do they represent a contract for services. Services are subject to the exclusions, limitations, and eligibility requirements contained in department rules.
(3) Services covered under each listed category:
(a) Are determined by the department after considering available evidence relevant to the service or equipment to:
(i) Determine efficacy, effectiveness, and safety;
(ii) Determine impact on health outcomes;
(iii) Identify indications for use;
(iv) Compare alternative technologies; and
(v) Identify sources of credible evidence that use and report evidence-based information.
(b) May require prior authorization (see WAC 388-501-0165), or expedited authorization when allowed by the department.
(c) Are paid for by the department and subject to review both before and after payment is made. The department or the client's managed care organization may deny or recover payment for such services, equipment, and supplies based on these reviews.
(4) The department does not pay for covered services, equipment, or supplies that:
(a) Require prior authorization from the department, if prior authorization was not obtained before the service was provided;
(b) Are provided by providers who are not contracted with the department as required under chapter 388-502 WAC;
(c) Are included in a department waiver program identified in chapter 388-515 WAC; or
(d) Are covered by a third-party payer (see WAC 388-501-0200), including medicare, if the third-party payer has not made a determination on the claim or has not been billed by the provider.
(5) Scope of covered service categories. The following table lists the department's covered categories of healthcare services.
• Under the four program columns (CN, MN, MCS, and AEM), the letter "C" means a service category is covered for that program, subject to any limitations listed in the specific medical assistance program WAC and department issuances.
• The letter "N" means a service category is not covered under that program.
• The letter "E" means the service category is available on ly if it is necessary to treat the client's emergency medical condition and may require prior authorization from the department.
• Refer to WAC 388-501-0065 for a description of each service category and for the specific program WAC containing the limitations and exclusions to services.
| (( |
||||
*Clients enrolled in the State Children's Health Insurance
Program and the Children's Health Program receive CN scope of
medical care.)) (1) 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 182-501-0050 and 182-501-0055 when applicable.
(b) May be subject to limitations, restrictions, and eligibility requirements contained in agency rules.
(c) May require prior authorization (see WAC 182-501-0165), or expedited authorization when allowed by the agency or the agency's designee.
(d) Are paid for by the agency or the agency's designee and subject to review both before and after payment is made. The agency or the agency's designee or the client's managed care organization may deny or recover payment for such services, equipment, and supplies based on these reviews.
(4) The agency or the agency's designee does not pay for covered services, equipment, or supplies that:
(a) Require prior authorization from the agency or the agency's designee, if prior authorization was not obtained before the service was provided;
(b) Are provided by providers who are not contracted with the agency or the agency's designee as required under chapter 182-502 WAC;
(c) Are included in an agency or an agency's designee waiver program identified in chapter 388-515 WAC; or
(d) Are covered by a third-party payor (see WAC 182-501-0200), including medicare, if the third-party payor 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 182-534 WAC and WAC 182-501-0050(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 agency's categories of healthcare services.
(a) Under the CN and MN headings there are two columns. One addresses 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 "Y" 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 agency issuances.
(d) The letter "N" means a service category is not included for that program.
(e) Refer to WAC 182-501-0065 for a description of each service category and for the specific program WAC containing the limitations and restrictions to services.
| Service Categories | CN1 20- | 21+ | MN 20- | 21+ | MCS DL |
|
| Adult day health | Y | Y | Y2 | N | N | |
| Ambulance (ground and air) | Y | Y | Y | Y | Y | |
| Blood processing/administration | Y | Y | Y | Y | Y | |
| Dental services | Y | N | Y | N | N | |
| Detoxification | Y | Y | Y | Y | Y | |
| Diagnostic services (lab and X ray) | Y | Y | Y | Y | Y | |
| Healthcare professional services | Y | Y | Y | Y | Y | |
| Hearing evaluations | Y | Y | Y | Y | Y | |
| Hearing aids | Y | N | Y | N | N | |
| Home health services | Y | Y | Y | Y | Y | |
| Hospice services | Y | Y | Y | Y | Y | |
| Hospital services - Inpatient/outpatient | Y | Y | Y | Y | Y | |
| Intermediate care facility/services for mentally retarded | Y | Y | Y | Y | Y | |
| Maternity care and delivery services | Y | Y | Y | Y | N | |
| Medical equipment, durable (DME) | Y | Y | Y | Y | Y | |
| Medical equipment, nondurable (MSE) | Y | Y | Y | Y | Y | |
| Medical nutrition services | Y | Y | Y | Y | Y | |
| Mental health services: | ||||||
| • Inpatient care | Y | Y | Y | Y | Y | |
| • Outpatient community mental health services | Y | Y | Y | Y | Y3 | |
| • Psychiatrist visits | Y | Y | Y | Y | Y4 | |
| • Medication management | Y | Y | Y | Y | Y | |
| Nursing facility services | Y | Y | Y | Y | Y | |
| Organ transplants | Y | Y | Y | Y | Y | |
| Out-of-state services | Y | Y | Y | Y | N | |
| Oxygen/respiratory services | Y | Y | Y | Y | Y | |
| Personal care services | Y | Y | N | N | N | |
| Prescription drugs | Y | Y | Y | Y | Y | |
| Private duty nursing | Y | Y | Y | Y | N | |
| Prosthetic/orthotic devices | Y | Y | Y | Y | Y | |
| Psychological evaluation5 | Y | Y | Y | Y | N | |
| Reproductive health services (includes family planning and TAKE CHARGE) | Y | Y | Y | Y | Y | |
| Substance abuse services | Y | Y | Y | Y | Y | |
| Therapy - Occupational, physical and speech | Y | Y | Y | Y | Y | |
| Vision care - Exams, refractions, and fittings | Y | Y | Y | Y | Y | |
| Vision - Frames and lenses | Y | N | Y | N | N | |
| 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. |
[11-14-075, recodified as § 182-501-0060, filed 6/30/11, effective 7/1/11. 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.]
(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)) agency 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])) (WAC 182-546-0001
through 182-546-4000)
(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])) (WAC 182-550-1400 and 182-550-1500)
(d) Dental services -- Diagnosis and treatment of dental
problems including emergency treatment and preventive care.
(([Chapters 388-535 and 388-535A WAC])) (Chapters 182-535 and
182-535A 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])) 182-550-1100)
(f) Diagnostic services -- Clinical testing and imaging
services. (([WAC 388-531-0100; 388-550-1400 and
388-550-1500])) (WAC 182-531-0100; 182-550-1400 and
182-550-1500)
(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 oral health, 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))) (Chapter 182-531 WAC)
(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])) (WAC 182-531-0100 and 182-531-0375)
(i) Hearing aids -- (chapter 182-547 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])) (WAC 182-551-2000 through 182-551-2220)
(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])) (WAC 182-551-1210 through
182-551-1850)
(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])) (Chapter 182-550 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])) (WAC 182-533-0300)
(o) Medical equipment, durable (DME) -- Wheelchairs,
hospital beds, respiratory equipment; prosthetic and orthotic
devices; casts, splints, crutches, trusses, and braces. (([WAC 388-543-1100])) (Chapter 182-543 WAC)
(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])) (Chapter 182-543 WAC)
(q) Medical nutrition services -- Enteral and parenteral
nutrition, including supplies. (([Chapters 388-553 and
388-554 WAC])) (Chapters 182-553 and 182-554 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 182-550-2600)
(ii) Outpatient (community mental health) services - Nonemergency, nonurgent counseling. (WAC 182-531-1400, 388-865-0215, and 388-865-0230)
(iii) Psychiatric visits. (WAC 182-531-1400 and 388-865-0230)
(iv) Medication management. (WAC 182-531-1400)
(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])) (WAC 182-550-1900 and 182-556-0400)
(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 182-502-0120 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])) (Chapter 182-552 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]))
388-106-0200, 388-106-0300, 388-106-0400, 388-106-0500,
388-106-0700, 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])) (WAC 182-530-2000.) 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.])) (WAC 182-551-3000.) 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])) (WAC 182-543-1100)
(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 182-532-530)
(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)) (WAC 182-533-0701 through 182-533-0730;
182-556-0100 and 182-556-0400; 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]
(dd))) (Chapter 182-545 WAC)
(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])) (WAC 182-531-1000)
(ff) Vision hardware -- Frames and lenses. (Chapter 182-544 WAC)
[11-14-075, recodified as § 182-501-0065, filed 6/30/11, effective 7/1/11. 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.]
(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)) 182-534 WAC.
(3) The ((department)) agency or the agency's designee
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)) 182-546
WAC;
(b) Dental services for clients twenty years of age and
younger as described in chapter ((388-535)) 182-535 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)) 182-543 WAC;
(((e))) (d) Hearing ((care services)) aids for clients
twenty years of age and younger as described in chapter
((388-547)) 182-547 WAC;
(((f))) (e) Home health services as described in WAC
((388-551-2130)) 182-551-2130;
(((g))) (f) Hospital services as described in WAC
((388-550-1600)) 182-550-1600;
(((h) Physician-related)) (g) Healthcare professional
services as described in WAC ((388-531-0150)) 182-531-0150;
(((i))) (h) Prescription drugs as described in chapter
((388-530)) 182-530 WAC; ((and
(j))) (i) Vision care ((services)) hardware for clients
twenty years of age and younger as described in chapter
((388-544)) 182-544 WAC; and
(j) Vision care exams as described in WAC 182-531-1000.
(6) A client has a right to request an administrative
hearing, if one is available under state and federal law. When the ((department)) agency or the agency's designee denies
all or part of a request for a noncovered healthcare
service(s), the ((department)) agency or the agency's designee
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)) agency
or the agency's designee 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)) agency's or the agency
designee's action was taken; and
(ii) Prepare a response to the ((department's)) agency's
or the agency's designee 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)) Acknowledgment 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))
agency-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)) 182-501-0160.
[11-14-075, recodified as § 182-501-0070, filed 6/30/11, effective 7/1/11. 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.]
OTS-4231.1
AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11,
effective 7/1/11)
WAC 182-502-0160
Billing a client.
(1) The purpose of
this section is to specify the limited circumstances in which:
(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))
182-500-0085) 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)) an agency-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)) 182-501-0050 (4)(a)
and 182-501-0065);
(d) Informing the client of those limitations;
(e) Exhausting all applicable ((department)) agency or
((department-contracted)) agency-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)) agency or ((department-contracted))
agency-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)) the
agency's rules, the ((department's)) agency's fee-for-service
billing instructions, and the requirements for billing the
((department-contracted)) agency-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)) the
agency's rules, the ((department's)) agency's fee-for-service
billing instructions, and the requirements for billing the
((department-contracted)) agency-contracted MCO in which the
client is enrolled.
(b) A covered service even if the provider has not
received payment from the ((department)) agency or the
client's MCO.
(c) A covered service when the ((department)) agency or
the agency's designee 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))
182-501-0165 (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))) 182-501-0050(9), or a noncovered service,
defined in WAC ((388-501-0050(10) and 388-501-0070))
182-501-0050(10) and 182-501-0070. 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))
http://hrsa.dshs.wa.gov/mpforms.shtml. 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)) agency or
((department-contracted)) agency-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))) 182-501-0070(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)) agency or
((department-contracted)) agency-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))
182-501-0160 when the ((department)) agency or the agency's
designee 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 chapter 388-526 WAC
((388-526-2610)) to appeal the ((department's)) agency's or
the agency designee 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)) agency or
((department-contracted)) agency-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)) agency or
agency designee 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)) agency or the
client's ((department-contracted)) agency-contracted MCO and
the ETR process as described in WAC ((388-501-0160))
182-501-0160 has been exhausted and the service(s) is denied;
(ii) Not covered by the ((department)) agency or the
client's ((department-contracted)) agency-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)) 182-501-0160;
(iii) Covered by the ((department)) agency or the
client's ((department-contracted)) agency-contracted MCO,
requires authorization, and the provider completes all the
necessary requirements; however the ((department)) agency or
the agency's designee denied the service as not medically
necessary (this includes services denied as a limitation
extension under WAC ((388-501-0169)) 182-501-0169); or
(iv) Covered by the ((department)) agency or the client's
((department-contracted)) agency-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)) agency 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)) agency or the
agency's designee 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)) 182-501-0200); 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)) agency or the agency's designee 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)) agency or the agency's designee). See
subsection (7) of this section for billing a medically needy
client for spenddown liability;
(d) The client is under the ((department's)) agency's or
((a department-contracted)) an agency-contracted MCO's patient
review and coordination (PRC) program (WAC ((388-501-0135))
182-501-0135) 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))
182-530-7700 (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))) 182-546-0250(2));
(h) A fee-for-service client chooses to receive
nonemergency services from a provider who is not contracted
with the ((department)) agency or the agency's designee after
being informed by the provider that he or she is not
contracted with the ((department)) agency or the agency's
designee and that the services offered will not be paid by the
client's healthcare program; ((and))
(i) ((A department-contracted)) An agency-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 182-501-0060.
(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))
agency 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)) agency or the agency's designee 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)) agency or the
agency's designee 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))
182-500-0025; 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)) 182-500-0095.
(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)) agency or the agency's designee 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)) canceled, 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).
[11-14-075, recodified as § 182-502-0160, filed 6/30/11, effective 7/1/11. 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.]