Original Notice.
Preproposal statement of inquiry was filed as WSR 19-02-021.
Title of Rule and Other Identifying Information: WAC 182-501-0060 Health care coverage—Program benefit packages—Scope of service categories and 182-501-0065 Health care coverage—Description of service categories.
Hearing Location(s): On June 4, 2019, at 10:00 a.m., at the Health Care Authority (HCA), Cherry Street Plaza, Pear Conference Room 107, 626 8th Avenue, Olympia, WA 98504. Metered public parking is available street side around building. A map is available at https://www.hca.wa.gov/assets/program/Driving-parking-checkin-instructions.pdf or directions can be obtained by calling 360-725-1000.
Date of Intended Adoption: Not sooner than June 5, 2019.
Submit Written Comments to: HCA Rules Coordinator, P.O. Box 42716, Olympia, WA 98504-2716, email arc@hca.wa.gov, fax 360-586-9727, by June 4, 2019.
Assistance for Persons with Disabilities: Contact Amber Lougheed, phone 360-725-1349, fax 360-586-9727, telecommunication relay services 711, email amber.lougheed@hca.wa.gov, by May 31, 2019.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The agency is revising WAC 182-501-0060 and 182-501-0065 to reflect new coverage for hearing hardware for clients age twenty-one and older effective January 1, 2019. The agency is also updating the table in WAC 182-501-0060 and the description of service categories in WAC 182-501-0065 to reflect current agency policy.
Reasons Supporting Proposal: See purpose.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: HCA, governmental.
Name of Agency Personnel Responsible for Drafting: Jason Crabbe, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-9563; Implementation and Enforcement: Trudi Glant, P.O. Box 45506 [45504], Olympia, WA 98504-5504, 360-725-1795.
This rule proposal, or portions of the proposal, is exempt from requirements of the Regulatory Fairness Act because the proposal:
(1) This rule provides a table that lists:
(a) The following Washington apple health (((WAH))) programs:
(i) The alternative benefits plan (ABP) medicaid;
(ii) Categorically needy (CN) medicaid;
(iii) Medically needy (MN) medicaid; and
(iv) Medical care services (MCS) programs (includes incapacity-based and aged, blind, and disabled medical care services), as described in WAC 182-508-0005; and
(b) The benefit packages showing what service categories are included for each program.
(2) Within a service category included in a benefit package, some services may be covered and others noncovered.
(3) Services covered within each service category included in a benefit 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 prior authorization when allowed by the agency.
(d) Are paid for by the agency or ((its))the agency's 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))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 as required under chapter 182-502 WAC;
(c) Are included in an agency or ((its))the agency's 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) Programs not addressed in the table:
(a) Alien emergency medical (AEM) services (see chapter 182-507 WAC); and
(b) TAKE CHARGE program (see WAC 182-532-700 through 182-532-790);
(c) Postpartum and family planning extension (see WAC 182-523-0130(4) and 182-505-0115(5));
(d) Eligibility for pregnant minors (see WAC 182-505-0117); and
(e) Kidney disease program (see chapter 182-540 WAC).
(6) Scope of service categories. The following table lists the agency's categories of health care services.
(a) Under the ABP, 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 | ABP 20- | ABP 21+ | CN1 20- | CN 21+ | MN 20- | MN 21+ | MCS |
Ambulance (ground and air) | Y | | Y | Y | Y | Y | Y |
Applied behavior analysis (ABA) | Y | N | Y | N | Y | N | N |
Behavioral health services | Y | Y | Y | Y | Y | Y | Y |
((• | Mental health (MH) inpatient care | Y | Y | Y | Y | Y | Y | Y |
• | MH outpatient community care | Y | Y | Y | Y | Y | Y | Y2 |
• | MH psychiatric visits | Y | Y | Y | Y | Y | Y | Y3 |
• | MH medication management | Y | Y | Y | Y | Y | Y | Y |
• | Substance use disorder (SUD) detoxification | Y | Y | Y | Y | Y | Y | Y |
• | SUD diagnostic assessment | Y | Y | Y | Y | Y | Y | Y |
• | SUD residential treatment | Y | Y | Y | Y | Y | Y | Y |
• | SUD outpatient treatment | Y | Y | Y | Y | Y | Y | Y)) |
Blood/blood products/related services | Y | Y | Y | Y | Y | Y | Y |
Dental services | Y | Y | Y | Y | Y | Y | Y |
Diagnostic services (lab and X-ray) | Y | Y | Y | Y | Y | Y | Y |
Early and periodic screening, diagnosis, and treatment (EPSDT) services | Y | N | Y | N | Y | N | N |
Enteral nutrition program | Y | Y | Y | Y | Y | Y | Y |
Habilitative services | Y | Y | N | N | N | N | N |
Health care professional services | Y | Y | Y | Y | Y | Y | Y |
Health homes | Y | Y | Y | Y | N | N | N |
Hearing evaluations | Y | Y | Y | Y | Y | Y | Y |
Hearing aids | Y | ((N)) Y | Y | ((N)) Y | Y | ((N)) Y | ((N)) Y |
Home health services | Y | Y | Y | Y | Y | Y | Y |
Home infusion therapy/parenteral nutrition program | Y | Y | Y | Y | Y | Y | Y |
Hospice services | Y | Y | Y | Y | Y | Y | N |
Hospital services Inpatient/outpatient | Y | Y | Y | Y | Y | Y | Y |
Intermediate care facility/services for persons with intellectual disabilities | Y | Y | Y | Y | Y | Y | Y |
Maternity care and delivery services | Y | Y | Y | Y | Y | Y | Y |
Medical equipment, ((durable (DME)))supplies, and appliances | Y | Y | Y | Y | Y | Y | Y |
((Medical equipment, nondurable (MSE) | Y | Y | Y | Y | Y | Y | Y)) |
Medical nutrition ((services))therapy | Y | ((Y)) N | Y | ((Y)) N | Y | ((Y)) N | Y |
Nursing facility services | Y | Y | Y | Y | Y | Y | Y |
Organ transplants | Y | Y | Y | Y | Y | Y | Y |
Orthodontic services | Y | N | Y | N | Y | N | N |
Out-of-state services | Y | Y | Y | Y | Y | Y | N |
Outpatient rehabilitation services (OT, PT, ST) | Y | Y | Y | Y | Y | N | Y |
Personal care services | Y | Y | Y | Y | N | N | N |
Prescription drugs | Y | Y | Y | Y | Y | Y | Y |
Private duty nursing | Y | Y | Y | Y | Y | Y | N |
Prosthetic/orthotic devices | Y | Y | Y | Y | Y | Y | Y |
Reproductive health services | Y | Y | Y | Y | Y | Y | Y |
Respiratory care (oxygen) | Y | Y | Y | Y | Y | Y | Y |
School-based medical services | Y | N | Y | N | Y | N | N |
Vision care Exams, refractions, and fittings | Y | Y | Y | Y | Y | Y | Y |
Vision hardware Frames and lenses | Y | N | Y | N | Y | N | N |
1 | Clients enrolled in the Washington apple health for kids and Washington apple health for kids with premium programs, which includes the children's health insurance program (CHIP), receive CN-scope of health care services. |
((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.)) |
This rule provides a brief description of the medical, dental, mental health, and substance use disorder (SUD) service categories listed in the table in WAC 182-501-0060. The description of services under each category is not intended to be all inclusive.
(1) For alternative benefits plan (ABP), 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.
(2) The following service categories are subject to the exclusions, limitations, restrictions, and eligibility requirements contained in agency rules:
(a) Ambulance - Emergency medical transportation and ambulance transportation for nonemergency medical needs. (WAC 182-546-0001 through 182-546-4000.)
(b) Applied behavior analysis (ABA) - (((WAC 182-531-1410 through 182-531-1434)))(Chapter 182-531A WAC).
(c) 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, psychological evaluation, nonurgent counseling. (WAC 182-531-1400, 388-865-0215, 388-865-0230, and 388-865-0610 (1)(d)(i).)
(iii) Psychiatric visits. (WAC 182-531-1400 and 388-865-0230.)
(iv) Mental health medication management. (WAC 182-531-1400.)
(v) Substance use disorder (SUD) detoxification. (WAC 388-877B-0100 through 388-877B-0130 and 182-550-1100; WAC 182-556-0400(3).)
(vi) SUD diagnostic assessment. (WAC 388-877B-0500 through 388-877B-0550.)
(vii) SUD residential treatment. (WAC 388-877B-0200 through 388-877B-0280.)
(viii) SUD outpatient treatment. (WAC 388-877B-0300 through 388-877B-0370; WAC 182-533-0701 through 182-533-0730.)))(Chapters 182-538D and 246-341 WAC).
(d) Blood, blood products, and related services - Blood and/or blood derivatives, including synthetic factors, plasma expanders, and their administration. (WAC 182-550-1400 and 182-550-1500.)
(e) Dental services - Diagnosis and treatment of dental problems including emergency treatment and preventive care. (Chapters 182-535 and 182-535A WAC.)
(f) Diagnostic services - Clinical testing and imaging services. (WAC 182-531-0100; WAC 182-550-1400 and 182-550-1500.)
(g) Early and periodic screening, diagnosis, and treatment (EPSDT) - (Chapter 182-534 WAC and WAC 182-501-0050(10).)
(h) Enteral nutrition program - Enteral nutrition products, equipment, and related supplies. (Chapter 182-554 WAC.)
(i)Habilitative services - (Chapter 182-545 WAC).
(((i)))(j)Health care professional services - The following services found in chapter 182-531 WAC:
(i) Office visits((,))and vaccinations((,));
(ii) Screening/brief intervention/referral to treatment (SBIRT), emergency room, and nursing facility((,))services;
(iii) Home-based((,)) and hospital-based ((care))services;
(iv) Surgery, anesthesia, pathology, radiology, and laboratory services;
(v) Obstetric services;
(vi) Kidney dialysis and renal disease services; ((osteopathic care, podiatry services))
(vii) Advanced registered nurse practitioner, naturopathy, osteopathy, podiatry, physiatry, and pulmonary/respiratory services; and
(viii) Allergen immunotherapy services. (((Chapter 182-531 WAC.)
(j)))
(k) Health homes - (Chapter 182-557 WAC).
(l)Hearing evaluations - The following services found in WAC 182-531-0375:
(i) Audiology;
(ii) Diagnostic evaluations; and
(iii) Hearing exams and testing. (((WAC 182-531-0100 and 182-531-0375.)
(k)))
(m)Hearing aids - (Chapter 182-547 WAC).
(((l)))(n)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 182-551-2000 through 182-551-2220.)
(((m)))(o) Home infusion therapy/parenteral nutrition program - Supplies and equipment necessary for parenteral infusion of therapeutic agents. (Chapter 182-553 WAC.)
(p)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 182-551-1210 through 182-551-1850.)
(((n)))(q)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 182-550 WAC.)
(((o)))(r)Intermediate care facility/services for persons with intellectual disabilities - Habilitative training, health-related care, supervision, and residential care. (Chapter 388-835 WAC.)
(((p)))(s)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 182-533-0330.)
(((q)))(t)Medical equipment, ((durable (DME)))supplies, and appliances - Medical equipment and appliances, including wheelchairs, hospital beds, respiratory equipment; casts, splints, crutches, trusses, and braces. Medical supplies, including antiseptics, germicides, bandages, dressings, tape, blood monitoring/testing supplies, braces, belts, supporting devices, decubitus care products, ostomy supplies, syringes, needles, and urological supplies. (Chapter 182-543 WAC.)
(((r) 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, and urological supplies. (Chapter 182-543 WAC.)
(s) Medical nutrition services - Enteral and parenteral nutrition, including supplies. (Chapters 182-553 and 182-554 WAC.)
(t)))(u) Medical nutrition therapy – Outpatient medical nutrition therapy and associated follow-ups. (Chapter 182-555 WAC.)
(v)Nursing facility services - Nursing, therapies, dietary, and daily care services delivered in a licensed nursing facility. (Chapter 388-97 WAC.)
(((u) 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 182-550-1900 and 182-556-0400.)
(v)))(w) 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 182-550-1900 and 182-556-0400.)
(x)Orthodontic services - (Chapter 182-535A WAC).
(((w)))(y)Out-of-state services - (WAC 182-502-0120).
(((x)))(z)Outpatient rehabilitation services (OT, PT, ST) - Evaluations, assessments, and treatment. (WAC 182-545-200.)
(((y)))(aa)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, 388-106-0200, 388-106-0300, 388-106-0600, 388-106-0700, 388-106-0745, and 388-106-0900))Chapters 388-106 and 388-845 WAC.)
(((z)))(bb)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 182-530-2000.) Additional coverage for medications and prescriptions is addressed in specific program WAC sections.
(((aa)))(cc)Private duty nursing - Continuous skilled nursing services provided in ((the home))a private residence, including client assessment, administration of treatment, and monitoring of medical equipment and client care. For benefits for clients ((seventeen years of age and under. (WAC 182-551-3000.)))age seventeen and younger, see WAC 182-551-3000 through 182-551-3400. For benefits for clients age eighteen ((years of age)) and older, see WAC 388-106-1000 through 388-106-1055.
(((bb)))(dd)Prosthetic/orthotic devices - Artificial limbs and other external body parts; devices that prevent, support, or correct a physical deformity or malfunction. (WAC 182-543-5000.)
(((cc)))(ee)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.)
(((dd)))(ff)Respiratory care (oxygen) - All services, oxygen, equipment, and supplies related to respiratory care. (Chapter 182-552 WAC.)
(((ee)))(gg)School-based ((medical))health care services - ((Medical))Early intervention services or special education health-related services provided in schools to medicaid-eligible children ((with disabilities under the Individuals with Disabilities Education Act (IDEA)))ages birth through twenty who have an individualized education program (IEP) or individualized family service plan (IFSP). (Chapter 182-537 WAC.)
(((ff)))(hh)Vision care - Eye exams, refractions, fittings, visual field testing, vision therapy, ocular prosthetics, and surgery. (WAC 182-531-1000.)
(((gg)))(ii)Vision hardware - Frames and lenses. (Chapter 182-544 WAC.)