WSR 23-05-071
PROPOSED RULES
HEALTH CARE AUTHORITY
[Filed February 14, 2023, 8:03 a.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 22-23-122.
Title of Rule and Other Identifying Information: WAC 182-501-0060 Health care coverage—Program benefit packages—Scope of service categories, 182-555-0300 Eligibility, and 182-555-0500 Covered services.
Hearing Location(s): On March 21, 2023, at 10:00 a.m. In response to the coronavirus disease 2019 (COVID-19) public health emergency, the health care authority (HCA) continues to hold public hearings virtually without a physical meeting place. This promotes social distancing and the safety of the residents of Washington state. To attend the virtual public hearing, you must register in advance https://us02web.zoom.us/webinar/register/WN_KIkQfb4ORnK5hyZi2_3Ddw. If the link above opens with an error message, please try using a different browser. After registering, you will receive a confirmation email containing information about joining the public hearing.
Date of Intended Adoption: March 22, 2023.
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 March 21, 2023, by 11:59 p.m.
Assistance for Persons with Disabilities: Contact Johanna Larson, phone 360-725-1349, fax 360-586-9727, telecommunication[s] relay service 711, email Johanna.Larson@hca.wa.gov, by March 10, 2023.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The agency is amending these rules to provide medical nutrition therapy for eligible adult medicaid clients. The agency is also updating the program names for alien emergency medical (AEM) and TAKE CHARGE referenced in WAC 182-501-0060, consistent with the current names for those programs.
Reasons Supporting Proposal: See purpose above.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: HCA, governmental.
Name of Agency Personnel Responsible for Drafting: Melinda Froud, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-1408; Implementation and Enforcement: Korrina Dalke, P.O. Box 45506, Olympia, WA 98504-5506, 360-725-2005.
A school district fiscal impact statement is not required under RCW
28A.305.135.
A cost-benefit analysis is not required under RCW
34.05.328. RCW
34.05.328 does not apply to HCA rules unless requested by the joint administrative rules review committee or applied voluntarily.
Scope of exemption for rule proposal from Regulatory Fairness Act requirements:
Is not exempt.
The proposed rule does not impose more-than-minor costs on businesses. Following is a summary of the agency's analysis showing how costs were calculated. These rules do not impose any costs on businesses.
February 14, 2023
Wendy Barcus
Rules Coordinator
OTS-4321.1
AMENDATORY SECTION(Amending WSR 22-08-035, filed 3/29/22, effective 4/29/22)
WAC 182-501-0060Health care coverage—Program benefit packages—Scope of service categories.
(1) This rule provides a table that lists:
(a) The following Washington apple health 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 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 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 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))Medical assistance programs for noncitizens (see chapter 182-507 WAC); and
(b) ((TAKE CHARGE program (see WAC 182-532-700 through 182-532-790);))Family planning only programs (see WAC 182-532-500 through 182-532-570);
(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 20 years of age and younger, and the other addresses clients 21 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 | Y |
Applied behavior analysis (ABA) | Y | Y | Y | Y | Y | Y | N |
Behavioral health services | 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 | Y | Y | Y | Y | Y | 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, supplies, and appliances | Y | Y | Y | Y | Y | Y | Y |
Medical nutrition therapy | Y | ((N))Y | Y | ((N))Y | Y | ((N))Y | 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. |
OTS-4320.1
AMENDATORY SECTION(Amending WSR 18-22-060, filed 10/31/18, effective 1/1/19)
WAC 182-555-0300Eligibility.
The medicaid agency covers medical nutrition therapy for clients who are((:
(1) Age twenty and younger; and
(2)))referred to a registered dietitian for medical nutrition therapy by a physician, physician assistant (PA), or an advanced registered nurse practitioner (ARNP).
AMENDATORY SECTION(Amending WSR 18-22-060, filed 10/31/18, effective 1/1/19)
WAC 182-555-0500Covered services.
(1) The medicaid agency covers medically necessary medical nutrition therapy when related to a nutrition-related diagnosis for eligible clients, as described under WAC 182-555-0300.
(2) The agency covers medical nutrition therapy, nutrition assessment, and counseling for conditions that are within the scope of practice for a registered dietitian (RD) to evaluate and treat.
(3) Medical nutrition therapy services may require prior authorization or expedited prior authorization, as described in WAC 182-501-0163.