WSR 13-15-044
PERMANENT RULES
HEALTH CARE AUTHORITY
(Medicaid Program)
[Filed July 11, 2013, 3:13 p.m., effective August 11, 2013]
Effective Date of Rule: Thirty-one days after filing.
Purpose: Upon order of the governor, the health care authority reduced its budget expenditures for fiscal year 2011 and 2012 by reducing or 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 amended to reflect and support these program cuts.
Citation of Existing Rules Affected by this Order: Amending WAC 182-501-0050, 182-501-0060, 182-501-0065, 182-501-0070, and 182-502-0160.
Statutory Authority for Adoption: RCW 41.05.021.
Adopted under notice filed as WSR 13-12-057 on June 3, 2013.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 5, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 5, Repealed 0.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: July 11, 2013.
Kevin M. Sullivan
Rules Coordinator
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-501-0050 Health care general coverage.
WAC ((388-501-0050)) 182-501-0050 through ((388-501-0065)) 182-501-0065 describe the health care 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, health care services includes treatment, equipment, related supplies, and drugs. WAC ((388-501-0070)) 182-501-0070 describes noncovered services.
(1) Health care service categories listed in WAC ((388-501-0060)) 182-501-0060 do not represent a contract for health care services.
(2) For the provider to receive payment, the client must be eligible for the covered health care service on the date the health care service is performed or provided.
(3) Under the ((department's)) agency's fee-for-service programs, providers must be enrolled with the ((department)) agency or its designee and meet the requirements of chapter ((388-502)) 182-502 WAC to be paid for furnishing health care services to clients.
(4) The ((department)) agency or its designee pays only for the health care services that are:
(a) ((Within the scope of)) Included in the client's ((medical program)) health care benefits package as described in WAC 182-501-0060;
(b) Covered - See subsection (9) of this section;
(c) Ordered or prescribed by a health care 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 its designee program rules and the ((department's)) agency's current published billing instructions ((and numbered memoranda)).
(5) The ((department)) agency does not pay for any health care service requiring prior authorization from the ((department)) agency or its designee, if prior authorization was not obtained before the health care 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 health care 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, deliberate intent, 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 health care services.
(a) Covered health care services are either:
(i) "Federally mandated" - Means the state of Washington is required by federal regulation (42 C.F.R. 440.210 and 220) to cover the health care service for medicaid clients; or
(ii) "State-option" - Means the state of Washington is not federally mandated to cover the health care service but has chosen to do so at its own discretion.
(b) The ((department)) agency may limit the scope, amount, duration, and/or frequency of covered health care services. Limitation extensions are authorized according to WAC ((388-501-0169)) 182-501-0169.
(10) Noncovered health care services.
(a) The ((department)) agency does not pay for any health care 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, unless the agency grants a request for an exception to rule allowing payment for the noncovered service. The ((department)) agency evaluates a request for a noncovered health care 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 health care service is recommended during the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) exam and then ordered by a provider, the ((department)) agency evaluates the health care 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).
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-501-0060 Health care coverage—((Scope of covered categories of service)) Program benefits packages—Scope of service categories.
(((1) This rule provides a list (see subsection (5)) of medical, dental, mental health, and substance abuse categories of service covered by the department under categorically needy (CN) medicaid, medically needy (MN) medicaid, Alien Emergency Medical (AEM), and medical care services (MCS) programs. MCS means the limited scope of care financed by state funds and provided to general assistance and Alcohol and Drug Addiction Treatment and Support Act (ADATSA) program clients.
(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 health care 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 only 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.
Service Categories
CN*
MN
MCS
AEM
(a) Adult day health
C
C
N
E
(b) Ambulance (ground and air)
C
C
C
E
(c) Blood processing/administration
C
C
C
E
(d) Dental services
C
C
C
E
(e) Detoxification
C
C
C
E
(f) Diagnostic services (lab & x-ray)
C
C
C
E
(g) Family planning services
C
C
C
E
(h) Health care professional services
C
C
C
E
(i) Hearing care (audiology/hearing exams/aids)
C
C
C
E
(j) Home health services
C
C
C
E
(k) Hospice services
C
C
N
E
(l) Hospital services -inpatient/outpatient
C
C
C
E
(m) Intermediate care facility/services for mentally retarded
C
C
C
E
(n) Maternity care and delivery services
C
C
N
E
(o) Medical equipment, durable (DME)
C
C
C
E
(p) Medical equipment, nondurable (MSE)
C
C
C
E
(q) Medical nutrition services
C
C
C
E
(r) Mental health services
C
C
C
E
(s) Nursing facility services
C
C
C
E
(t) Organ transplants
C
C
C
N
(u) Out-of-state services
C
C
N
E
(v) Oxygen/respiratory services
C
C
C
E
(w) Personal care services
C
C
N
N
(x) Prescription drugs
C
C
C
E
(y) Private duty nursing
C
C
N
E
(z) Prosthetic/orthotic devices
C
C
C
E
(aa) School medical services
C
C
N
N
(bb) Substance abuse services
C
C
C
E
(cc) Therapy -occupational/physical/speech
C
C
C
E
(dd) Vision care (exams/lenses)
C
C
C
E
*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 (includes incapacity-based medical care services and the medical component of the Alcohol and Drug Addiction Treatment and Support Act (ADATSA) program); 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.
(d) Are paid for by the agency or its designee and subject to review both before and after payment is made. The agency 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 does not pay for covered services, equipment, or supplies that:
(a) Require prior authorization from the agency or its designee, if prior authorization was not obtained before the service was provided;
(b) Are provided by providers who are not contracted with the agency as required under chapter 182-502 WAC;
(c) Are included in an agency or its designee waiver program identified in chapter 182-515 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) The following programs are not addressed in the table:
(i) Alien emergency medical (AEM) services (see chapter 182-507 WAC); and
(ii) TAKE CHARGE program (see WAC 182-532-700 through 182-532-790).
(6) Scope of service categories. The following table lists the agency's categories of health care 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) 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 rules and agency issuances.
(c) The letter "N" means a service category is not included for that program.
(d) Refer to WAC 182-501-0065 for a description of each service category and for the specific program rules containing the limitations and restrictions to services.
Service Categories
CN120-
CN 21+
MN 20-
MN 21+
MCS
Ambulance (ground and air)
Y
Y
Y
Y
Y
Behavioral health services
 
 
 
 
 
•
Mental health (MH) inpatient care
Y
Y
Y
Y
Y
•
MH outpatient community care
Y
Y
Y
Y
Y2
•
MH psychiatric visits
Y
Y
Y
Y
Y3
•
MH medication management
Y
Y
Y
Y
Y
•
Substance use disorder (SUD) detoxification
Y
Y
Y
Y
Y
•
SUD diagnostic assessment
Y
Y
Y
Y
Y
•
SUD residential treatment
Y
Y
Y
Y
Y
•
SUD outpatient treatment
Y
Y
Y
Y
Y
Blood/blood products/related services
Y
Y
Y
Y
Y
Dental services
Y
Y4
Y
Y4
Y4
Diagnostic services (lab and X ray)
Y
Y
Y
Y
Y
Health care 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
N
Hospital services − Inpatient/outpatient
Y
Y
Y
Y
Y
Intermediate care facility/services for persons with intellectual disabilities
Y
Y
Y
Y
Y
Maternity care and delivery services
Y
Y
Y
Y
Y
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
Nursing facility services
Y
Y
Y
Y
Y
Organ transplants
Y
Y
Y
Y
Y
Out-of-state services
Y
Y
Y
Y
N
Outpatient rehabilitation services (OT, PT, ST)
Y
Y
Y
N
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
Y
Y
Y
Y
Y
Respiratory care (oxygen)
Y
Y
Y
Y
Y
School-based medical services
Y
N
Y
N
N
Vision care − Exams, refractions, and fittings
Y
Y
Y
Y
Y
Vision hardware − 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 incapacity-based MCS clients enrolled in managed care.
3
Incapacity-based MCS clients can receive one psychiatric diagnostic evaluation per year and eleven monthly visits per year for medication management.
4
Restricted to those clients who meet the categorical requirements described in WAC 182-535-1060.
5
Only two allowed per lifetime.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-501-0065 Health care coverage—Description of ((covered)) categories of service.
This rule provides a brief description of the medical, dental, mental health, and substance ((abuse)) use disorder (SUD) service categories listed in the table in WAC ((388-501-0060)) 182-501-0060. The description of services under each category is not intended to be all inclusive.
(1) For categorically needy (CN), medically needy (MN), and medical care services (MCS), refer to the WAC citations listed in the following descriptions for specific details regarding each service category. ((For Alien Emergency Medical (AEM) services, refer to WAC 388-438-0110.))
(2) The following service categories are subject to the exclusions, limitations, restrictions, and eligibility requirements contained in ((department)) 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]
(b))) Ambulance((—)) - Emergency medical transportation and ambulance transportation for nonemergency medical needs. (([WAC 388-546-0001 through 388-546-4000]
(c))) (WAC 182-546-0001 through 182-546-4000.)
(b) Behavioral health services - 
(i) Mental health inpatient care - Voluntary and involuntary admissions for psychiatric services. (WAC 182-550-2600.)
(ii) Mental health 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) Mental health medication management. (WAC 182-531-1400.)
(v) Substance use disorder detoxification. (WAC 182-508-0305 and 182-550-1100; WAC 182-556-0400(3).)
(vi) Substance use disorder diagnostic assessment. (WAC 182-508-0330.)
(vii) Substance use disorder residential treatment. (WAC 182-508-0310 through 182-508-0375; and WAC 182-556-0100.)
(viii) Substance use disorder outpatient treatment. (WAC 182-508-0310 through 182-508-0375; WAC 182-533-0701 through 182-533-0730; WAC 182-556-0100 and 182-556-0400.)
(c) Blood ((processing/administration—)), blood products, and related services - 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]
(f))) Diagnostic services((—)) - Clinical testing and imaging services. (([WAC 388-531-0100; 388-550-1400 and 388-550-1500]
(g) Family planning services—Gynecological exams; contraceptives, drugs, and supplies, including prescriptions; sterilization; screening and treatment of sexually transmitted diseases; and educational services. [WAC 388-532-530]
((h))) (WAC 182-531-0100; WAC 182-550-1400 and 182-550-1500.)
(f) Health care 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.)
(g) 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]
(j))). (WAC 182-531-0100 and 182-531-0375.)
(h) Hearing aids - (Chapter 182-547 WAC.)
(i) Home health services((—)) - Intermittent, short-term skilled nursing care, occupational therapy, physical therapy, speech therapy, home infusion therapy, and health aide services, provided in the home. (([WAC 388-551-2000 through 388-551-2220]
(k))) (WAC 182-551-2000 through 182-551-2220.)
(j) Hospice services((—)) - Physician services, skilled nursing care, medical social services, counseling services for client and family, drugs, medications (including biologicals), medical equipment and supplies needed for palliative care, home health aide, homemaker, personal care services, medical transportation, respite care, and brief inpatient care. This benefit also includes services rendered in a hospice care center and pediatric palliative care services. (([WAC 388-551-1210 through 388-551-1850]
(l))) (WAC 182-551-1210 through 182-551-1850.)
(k) Hospital services—Inpatient/outpatient((—)) - Emergency room; hospital room and board (includes nursing care); inpatient services, supplies, equipment, and prescription drugs; surgery, anesthesia; diagnostic testing, laboratory work, blood/blood derivatives; radiation and imaging treatment and diagnostic services; and outpatient or day surgery, and obstetrical services. (([Chapter 388-550 WAC]
(m))) (Chapter 182-550 WAC.)
(l) Intermediate care facility/services for ((mentally retarded—)) persons with intellectual disabilities - Habilitative training, health-related care, supervision, and residential care. (([Chapter 388-835 WAC]
(n))) (Chapter 388-835 WAC.)
(m) 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]
(o))) (WAC 182-533-0330.)
(n) Medical equipment, durable (DME)((—)) - Wheelchairs, hospital beds, respiratory equipment; ((prosthetic and orthotic devices;)) casts, splints, crutches, trusses, and braces. (([WAC 388-543-1100]
(p))) (Chapter 182-543 WAC.)
(o) Medical equipment, nondurable (MSE)((—)) - Antiseptics, germicides, bandages, dressings, tape, blood monitoring/testing supplies, braces, belts, supporting devices, decubitus care products, ostomy supplies, pregnancy test kits, syringes, needles, ((transcutaneous electrical nerve stimulators (TENS) supplies,)) and urological supplies. (([WAC 388-543-2800]
(q))) (Chapter 182-543 WAC.)
(p) Medical nutrition services((—)) - Enteral and parenteral nutrition, including supplies. (([Chapters 388-553 and 388-554 WAC]
(r) Mental health services - Inpatient and outpatient psychiatric services and community mental health services. [Chapter 388-865 WAC]
(s))) (chapters 182-553 and 182-554 WAC.)
(q) Nursing facility services((—)) - Nursing, therapies, dietary, and daily care services. (([Chapter 388-97 WAC]
(t))) (Chapter 388-97 WAC.)
(r) Organ transplants((—)) - Solid organs, e.g., heart, kidney, liver, lung, pancreas, and small bowel; bone marrow and peripheral stem cell; skin grafts; and corneal transplants. (([WAC 388-550-1900 and 388-550-2000, and 388-556-0400]
(u))) (WAC 182-550-1900 and 182-556-0400.)
(s) 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]))
(v) Oxygen/respiratory services - Oxygen, oxygen equipment and supplies; oxygen and respiratory therapy, equipment, and supplies. [Chapter 388-552 WAC]
(w))) - See WAC 182-502-0120 for services out-of-state.
(t) Outpatient rehabilitation services (OT, PT, ST) - Evaluations, assessments, and treatment. (WAC 182-545-200.)
(u) 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]
(x))) 388-106-0200, 388-106-0300, 388-106-0600, 388-106-0700, 388-106-0745, and 388-106-0900.)
(v) 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))) (w) 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))) (x) Prosthetic/orthotic devices((—)) - Artificial limbs and other external body parts; devices that prevent, support, or correct a physical deformity or malfunction. (([WAC 388-543-1100]
(aa) School medical services - Medical services provided in schools to children with disabilities under the Individuals with Disabilities Education Act (IDEA). [Chapter 388-537 WAC]
(bb) Substance abuse services - Chemical dependency assessment, case management services, and treatment services. [WAC 388-533-0701 through 388-533-0730; 388-556-0100 and 388-556-0400; and 388-800-0020]
(cc) Therapy - Occupational/physical/speech—Evaluations, assessments, and treatment. [WAC 388-545-300, 388-545-500, and 388-545-700]
(dd))) (WAC 182-543-5000.)
(y) Psychological evaluation - Complete diagnostic history, examination, and assessment, including the testing of cognitive processes, visual motor responses, and abstract abilities. (WAC 388-865-0610.)
(z) Reproductive health services - Gynecological exams; contraceptives, drugs, and supplies, including prescriptions; sterilization; screening and treatment of sexually transmitted diseases; and educational services. (WAC 182-532-001 through 182-532-140.)
(aa) Respiratory care (oxygen) - All services, oxygen, equipment, and supplies related to respiratory care. (Chapter 182-552 WAC.)
(bb) School-based medical services - Medical services provided in schools to children with disabilities under the Individuals with Disabilities Education Act (IDEA). (Chapter 182-537 WAC.)
(cc) 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.)
(dd) Vision hardware - Frames and lenses. (Chapter 182-544 WAC.)
AMENDATORY SECTION (Amending WSR 12-18-062, filed 8/31/12, effective 10/1/12)
WAC 182-501-0070 Health care coverage—Noncovered services.
(1) The medicaid agency or its designee does not pay for any health care service not listed or referred to as a covered health care service under the medical programs described in WAC 182-501-0060, regardless of medical necessity. For the purposes of this section, health care services includes treatment, equipment, related supplies, and drugs. Circumstances in which clients are responsible for payment of health care services are described in WAC 182-502-0160.
(2) This section does not apply to health care services provided as a result of the early and periodic screening, diagnosis, and treatment (EPSDT) program as described in chapter 182-534 WAC.
(3) The ((department)) agency or its designee does not pay for any ancillary health care service(s) provided in association with a noncovered health care service.
(4) The following list of noncovered health care services is not intended to be exhaustive. Noncovered health care services include, but are not limited to:
(a) Any health care 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 health care services, not specifically allowed under WAC 182-531-0100(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 health care 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 health care services in the following service categories, refer to the WAC citation:
(a) Ambulance transportation and nonemergent transportation as described in chapter 182-546 WAC;
(b) Dental services ((for clients twenty years of age and younger)) as described in chapter 182-535 WAC;
(c) Durable medical equipment as described in chapter 182-543 WAC;
(d) Hearing care services as described in chapter 182-547 WAC;
(e) Home health services as described in WAC 182-551-2130;
(f) Hospital services as described in WAC 182-550-1600;
(g) Health care professional services as described in WAC 182-531-0150;
(h) Prescription drugs as described in chapter 182-530 WAC;
(i) Vision care ((services)) hardware for clients twenty years of age and younger as described in chapter 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 agency or its designee denies all or part of a request for a noncovered health care service(s), the agency or its 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 agency or its 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 agency's or its designee's action was taken; and
(ii) Prepare a response to the agency's or its designee's decision to classify the requested health care 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) 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) ((or nonformulary justification (NFJ)));
(v) Information regarding agency-covered health care services, if any, as an alternative to the requested noncovered health care 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 182-501-0160.
AMENDATORY SECTION (Amending WSR 12-18-062, filed 8/31/12, effective 10/1/12)
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 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 medicaid 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 182-501-0050 (4)(a) and 182-501-0065);
(d) Informing the client of those limitations;
(e) Exhausting all applicable medicaid agency or 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 agency or agency-contracted MCO for medical assistance services furnished to clients. See 42 C.F.R. § 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 the agency's rules, the agency's fee-for-service billing instructions, and the requirements for billing the 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 the agency's rules, the agency's fee-for-service billing instructions, and the requirements for billing the agency-contracted MCO in which the client is enrolled.
(b) A covered service even if the provider has not received payment from the agency or the client's MCO.
(c) A covered service when the agency or its designee denies an authorization request for the service because the required information was not received from the provider or the prescriber under WAC 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 182-501-0050(9), or a noncovered service, defined in WAC 182-501-0050(10) and 182-501-0070. The client and provider must sign and date the HCA form 13-879, Agreement to Pay for Healthcare Services, before the service is furnished. Form 13-879, including translated versions, is available to download at 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 agency or 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 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 agency or 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 182-501-0160 when the agency or its designee denies a request for a noncovered service ((other than a nonformulary drug)) and that the client may choose not to do so;
(viii) ((Specify that the client and their prescriber may request a nonformulary justification (NFJ) in accordance with WAC 182-530-2300 for a nonformulary drug and that the client may choose not to do so;
(ix))) Specify that the client may request an administrative hearing in accordance with chapter 182-526 WAC to appeal the agency's or its designee denial of a request for prior authorization of a covered service and that the client may choose not to do so;
(((x))) (ix) Be completed only after the provider and the client have exhausted all applicable agency or 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 agency or agency designee denials of authorization for requested service(s); and
(((xi))) (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 agency or the client's agency-contracted MCO and the ETR process as described in WAC 182-501-0160 ((or the NFJ process as described in WAC 182-530-2300)) has been exhausted and the service(s) is denied;
(ii) Not covered by the agency or the client's agency-contracted MCO and the client has been informed of his or her right to an ETR ((or NFJ)) and has chosen not to pursue an ETR as described in WAC 182-501-0160 ((or the NFJ process as described in WAC 182-530-2300));
(iii) Covered by the agency or the client's agency-contracted MCO, requires authorization, and the provider completes all the necessary requirements; however the agency or its designee denied the service as not medically necessary (this includes services denied as a limitation extension under WAC 182-501-0169); or
(iv) Covered by the agency or the client's 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 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 agency or its 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 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 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 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 agency or its designee). See subsection (7) of this section for billing a medically needy client for spenddown liability;
(d) The client is under the agency's or an agency-contracted MCO's patient review and coordination (PRC) program (WAC 182-501-0135) and receives nonemergency services from providers or health care 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 182-530-7700 (2)(a)(iii) are met;
(f) The service((s provided to a TAKE CHARGE or family planning only client are not within the scope of)) is within a service category excluded from the client's benefits package. See WAC 182-501-0060;
(g) The services were noncovered ambulance services (see WAC 182-546-0250(2));
(h) A fee-for-service client chooses to receive nonemergency services from a provider who is not contracted with the agency or its designee after being informed by the provider that he or she is not contracted with the agency or its designee and that the services offered will not be paid by the client's health care program; and
(i) 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.
(7) Under chapter 182-519 WAC, an individual who has applied for medical assistance is required to spend down excess income on health care expenses to become eligible for coverage under the medically needy program. An individual must incur health care 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 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 agency or its 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 agency or its 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 182-500-0025; or
(c) The client receives a certification for medical assistance for a retroactive period according to 42 C.F.R. § 435.914(a) and defined in WAC 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 agency or its designee for:
(a) Copying, printing, or otherwise transferring health care information, as the term health care information is defined in chapter 70.02 RCW, to another health care 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, 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).