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

     Purpose: The health care authority (the agency) is performing the following actions:

     Amendment of these rules is necessary due to changes the agency is making to WAC 182-502-0005.

     The agency is amending WAC 182-502-0005 to implement 42 C.F.R. 455.410 which mandates states to require all ordering, prescribing, or referring providers to be enrolled as participating providers.

     Citation of Existing Rules Affected by this Order: Amending WAC 182-530-1000 Outpatient drug program -- General and 182-531-0100 Scope of coverage for physician-related and health care professional services -- General and administrative.

     Statutory Authority for Adoption: RCW 41.05.021.

     Other Authority: 42 C.F.R. 455.410.

      Adopted under notice filed as WSR 12-21-110 on October 23, 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     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 2, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 2, Repealed 0.

     Date Adopted: February 6, 2013.

Kevin M. Sullivan

Rules Coordinator

OTS-5094.1

AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-530-1000   Outpatient drug program--General.   (1) The purpose of the outpatient drug program is to reimburse providers for outpatient drugs, vitamins, minerals, devices, and drug-related supplies according to ((department)) medicaid agency rules and subject to the limitations and requirements in this chapter.

     (2) The ((department)) agency reimburses for outpatient drugs, vitamins, minerals, devices, and pharmaceutical supplies that are:

     (a) Covered. Refer to WAC ((388-530-2000)) 182-530-2000 for covered drugs, vitamins, minerals, devices, and drug-related supplies and to WAC ((388-530-2100)) 182-530-2100 for noncovered drugs and drug-related supplies;

     (b) Prescribed by a provider with prescriptive authority (see exceptions for family planning and emergency contraception for women eighteen years of age and older in WAC ((388-530-2000)) 182-530-2000 (1)(b), and over-the-counter (OTC) drugs to promote smoking cessation in WAC ((388-530-2000)) 182-530-2000 (1)(g);

     (c) Prescribed by:

     (i) A provider with an approved core provider agreement; or

     (ii) A provider who is enrolled as a performing provider on an approved core provider agreement;

     (d) Within the scope of an eligible client's medical assistance program;

     (((d))) (e) Medically necessary as defined in WAC ((388-500-0005)) 182-500-0070 and determined according to the process found in WAC ((388-501-0165)) 182-501-0165; ((and

     (e))) (f) Authorized, as required within this chapter;

     (((f))) (g) Billed according to WAC ((388-502-0150)) 182-502-0150 and ((388-502-0160)) 182-502-0160; and

     (((g))) (h) Billed according to the requirements of this chapter.

     (3) Coverage determinations for the ((department)) agency are made by the ((department's)) agency's pharmacists or medical consultants in accordance with applicable federal law. The ((department's)) agency's determination may include consultation with the drug use review (DUR) board.

     (((4) The department may not reimburse for prescriptions written by health care practitioners whose application for a core provider agreement (CPA) has been denied, or whose CPA has been terminated.

     (5) The department may not reimburse for prescriptions written by non-CPA health care practitioners who do not have a current core provider agreement with the department when the department determines there is a potential danger to the client's health and/or safety.))

[11-14-075, recodified as § 182-530-1000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 09-05-007, § 388-530-1000, filed 2/5/09, effective 3/8/09. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.700, 2008 c 245. 08-21-107, § 388-530-1000, filed 10/16/08, effective 11/16/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 07-20-049, § 388-530-1000, filed 9/26/07, effective 11/1/07; 06-24-036, § 388-530-1000, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1000, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-028, § 388-530-1000, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1000, filed 10/9/96, effective 11/9/96.]

OTS-5093.1

AMENDATORY SECTION(Amending WSR 12-18-062, filed 8/31/12, effective 10/1/12)

WAC 182-531-0100   Scope of coverage for physician-related and health care professional services -- General and administrative.   (1) The medicaid agency covers health care services, equipment, and supplies listed in this chapter, according to agency rules and subject to the limitations and requirements in this chapter, when they are:

     (a) Within the scope of an eligible client's medical assistance program. Refer to WAC 182-501-0060 and 182-501-0065; and

     (b) Medically necessary as defined in WAC 182-500-0070.

     (2) The agency evaluates a request for a service that is in a covered category under the provisions of WAC 182-501-0065.

     (3) The agency evaluates requests for covered services that are subject to limitations or other restrictions and approves such services beyond those limitations or restrictions as described in WAC 182-501-0169.

     (4) The agency covers the following physician-related services and health care professional services, subject to the conditions in subsections (1), (2), and (3) of this section:

     (a) Allergen immunotherapy services;

     (b) Anesthesia services;

     (c) Dialysis and end stage renal disease services (refer to chapter 182-540 WAC);

     (d) Emergency physician services;

     (e) ENT (ear, nose, and throat) related services;

     (f) Early and periodic screening, diagnosis, and treatment (EPSDT) services (refer to WAC 182-534-0100);

     (g) Reproductive health services (refer to chapter 182-532 WAC);

     (h) Hospital inpatient services (refer to chapter 182-550 WAC);

     (i) Maternity care, delivery, and newborn care services (refer to chapter 182-533 WAC);

     (j) Office visits;

     (k) Vision-related services (refer to chapter 182-544 WAC for vision hardware for clients twenty years of age and younger);

     (l) Osteopathic treatment services;

     (m) Pathology and laboratory services;

     (n) Physiatry and other rehabilitation services (refer to chapter 182-550 WAC);

     (o) Foot care and podiatry services (refer to WAC 182-531-1300);

     (p) Primary care services;

     (q) Psychiatric services, provided by a psychiatrist;

     (r) Psychotherapy services for children as provided in WAC 182-531-1400;

     (s) Pulmonary and respiratory services;

     (t) Radiology services;

     (u) Surgical services;

     (v) Cosmetic, reconstructive, or plastic surgery, and related services and supplies to correct physiological defects from birth, illness, or physical trauma, or for mastectomy reconstruction for post cancer treatment;

     (w) Oral health care services for emergency conditions for clients twenty-one years of age and older, except for clients of the division of developmental disabilities (refer to WAC 182-531-1025); and

     (x) Other outpatient physician services.

     (5) The agency covers physical examinations for medical assistance clients only when the physical examination is one or more of the following:

     (a) A screening exam covered by the EPSDT program (see WAC 182-534-0100);

     (b) An annual exam for clients of the division of developmental disabilities; or

     (c) A screening pap smear, mammogram, or prostate exam.

     (6) By providing covered services to a client eligible for a medical assistance program, a provider who ((has signed an agreement with the agency)) meets the requirements in WAC 182-502-0005(3) accepts the agency's rules and fees ((as outlined in the agreement,)) which includes federal and state law and regulations, billing instructions, and agency issuances.

     (7) Outpatient drugs are not subject to the rules in this chapter. For rules about outpatient drugs see chapter 182-530 WAC.

[Statutory Authority: RCW 41.05.021 and section 1927 of the Social Security Act. 12-18-062, § 182-531-0100, filed 8/31/12, effective 10/1/12. 11-14-075, recodified as § 182-531-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. 11-14-055, § 388-531-0100, filed 6/29/11, effective 7/30/11. Statutory Authority: RCW 74.09.521. 08-12-030, § 388-531-0100, filed 5/29/08, effective 7/1/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-531-0100, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-0100, filed 12/6/00, effective 1/6/01.]