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) - (Chapter 182-531A WAC(())).)

(c) Behavioral health services - (Chapter 182-538D WAC, Behavioral health services, WAC 182-531-1400 Psychiatric physician-related services and other professional mental health services, and chapter 246-341 WAC, Behavioral health services administrative requirements(())).)

(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) Community behavioral health support services (CBHS) - (Chapter 182-561 WAC.)

(f)Dental services - Diagnosis and treatment of dental problems including emergency treatment and preventive care. (Chapters 182-535 and 182-535A WAC.)

(((f)))(g)Diagnostic services - Clinical testing and imaging services. (WAC 182-531-0100; WAC 182-550-1400 and 182-550-1500.)

(((g)))(h)Early and periodic screening, diagnosis, and treatment (EPSDT) - (Chapter 182-534 WAC and WAC 182-501-0050(10).)

(((h)))(i)Enteral nutrition program - Enteral nutrition products, equipment, and related supplies. (Chapter 182-554 WAC.)

(((i)))(j)Habilitative services - (Chapter 182-545 WAC(())).)

(((j)))(k)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 services;

(iv) Surgery, anesthesia, pathology, radiology, and laboratory services;

(v) Obstetric services;

(vi) Kidney dialysis and renal disease services;

(vii) Advanced registered nurse practitioner, naturopathy, osteopathy, podiatry, physiatry, and pulmonary/respiratory services; and

(viii) Allergen immunotherapy services.

(((k)))(l)Health homes - (Chapter 182-557 WAC(())).)

(((l)))(m)Hearing evaluations - The following services found in WAC 182-531-0375:

(i) Audiology;

(ii) Diagnostic evaluations; and

(iii) Hearing exams and testing.

(((m)))(n)Hearing aids - (Chapter 182-547 WAC(())).)

(((n)))(o)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.)

(((o)))(p)Home infusion therapy/parenteral nutrition program - Supplies and equipment necessary for parenteral infusion of therapeutic agents. (Chapter 182-553 WAC.)

(((p)))(q)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.)

(((q)))(r)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.)

(((r)))(s)Intermediate care facility/services for persons with intellectual disabilities - Habilitative training, health-related care, supervision, and residential care. (Chapter 388-835 WAC.)

(((s)))(t)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.)

(((t)))(u)Medical equipment, 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.)

(((u)))(v)Medical nutrition therapy – Outpatient medical nutrition therapy and associated follow-ups. (Chapter 182-555 WAC.)

(((v)))(w)Nursing facility services - Nursing, therapies, dietary, and daily care services delivered in a licensed nursing facility. (Chapter 388-97 WAC.)

(((w)))(x)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)))(y)Orthodontic services - (Chapter 182-535A WAC(())).)

(((y)))(z)Out-of-state services - (WAC 182-502-0120(())).)

(((z)))(aa)Outpatient rehabilitation services (OT, PT, ST) - Evaluations, assessments, and treatment. (WAC 182-545-200.)

(((aa)))(bb)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). (Chapters 388-106 and 388-845 WAC.)

(((bb)))(cc)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.

(((cc)))(dd)Private duty nursing - Continuous skilled nursing services provided in a private residence, including client assessment, administration of treatment, and monitoring of medical equipment and client care. For benefits for clients age ((seventeen))17 and younger, see WAC 182-551-3000 through 182-551-3400. For benefits for clients age ((eighteen))18 and older, see WAC 388-106-1000 through 388-106-1055.

(((dd)))(ee)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.)

(((ee)))(ff)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.)

(((ff)))(gg)Respiratory care (oxygen) - All services, oxygen, equipment, and supplies related to respiratory care. (Chapter 182-552 WAC.)

(((gg)))(hh)School-based health care services - Early intervention services or special education health-related services provided in schools to medicaid-eligible children ages birth through ((twenty))20 who have an individualized education program (IEP) or individualized family service plan (IFSP). (Chapter 182-537 WAC.)

(((hh)))(ii)Vision care - Eye exams, refractions, fittings, visual field testing, vision therapy, ocular prosthetics, and surgery. (WAC 182-531-1000.)

(((ii)))(jj)Vision hardware - Frames and lenses. (Chapter 182-544 WAC.)

To be eligible for the community behavioral health support services (CBHS) benefit, a person must meet all requirements and criteria in this section.

(1) General requirements. A person must:

(a) Be eligible for apple health under categorically needy or alternate benefit plan scope of care;

(b) Receive at least one of the following home and community services at home or in a community residential setting:

(i) Medicaid personal care (MPC), as described in WAC 388-106-0015(1);

(ii) Community options program entry system (COPES), as described in WAC 388-106-0015(2);

(iii) Community first choice (CFC), as described in WAC 388-106-0015(3);

(iv) New freedom consumer directed services (NFCDS), as described in WAC 388-106-0015(16); or

(v) Residential support, as described in WAC 388-106-0015(17).

(d) Be age 18 or older; and

(e) Have an eligible diagnosis, as identified in WAC 182-561-0700.

(2) Needs-based criteria. A person must be assessed by home and community services (HCS) or an HCS designee and found to have a demonstrated need for:

(a) Assistance with three or more activities of daily living (ADL), or assistance with body care, or both, as defined in WAC 388-106-0010; or

(b) Hands-on assistance with one or more ADLs.

(3) Risk-based criteria. A person must have:

(a) A behavioral or clinical complexity that requires the level of supplementary or specialized services and staffing available only under the CBHS benefit. This determination is based on the person exhibiting one or more of the following behaviors within the last 12 months and can be prevented only with a high level of staffing, or skilled staff intervention, or both:

(i) Multiple assaults related to a behavioral health condition during inpatient or long-term care;

(ii) Self-endangering behaviors related to a behavioral health condition that would result in bodily harm;

(iii) Intrusiveness related to a behavioral health condition (e.g., rummaging, unawareness of personal boundaries) that places the person at risk of assault by others;

(iv) Chronic psychiatric symptoms that cause distress to and escalate the person or other residents to crisis if not monitored or redirected by staff;

(v) Sexual inappropriateness related to a behavioral health condition that may compromise the safety of the person and other vulnerable adults; or

(b) A history of any of the above behaviors, which are currently only prevented by additional skilled staff intervention.

(4) Other criteria. A person must have:

(a) A history of being unsuccessful in community living settings, as evidenced by at least one or more of the following:

(i) A history of multiple failed stays in residential settings within the past two years;

(ii) Be in imminent danger of losing a current community living setting due to behaviors related to a behavioral health condition or conditions;

(iii) Frequent caregiver turnover due to behaviors related to a behavioral health condition or conditions within the past two years; or

(iv) Be at imminent risk of losing a long-term care living setting without currently receiving the CBHS benefit.

(b) A past psychiatric history, where significant functional improvement has not been effectively maintained due to the lack of the CBHS benefit, as evidenced by one or more of the following:

(i) Two or more inpatient psychiatric hospitalizations in the last 12 months;

(ii) An inpatient stay in a community hospital (acute or psychiatric) or a free-standing evaluation and treatment facility for 30 days or more in the last 12 months, with barriers to discharge related to a behavioral health condition or conditions;

(iii) Discharge from a state psychiatric hospital or a long-term 90/180-day inpatient psychiatric setting in the last 12 months; or

(iv) Be at imminent risk of requiring inpatient level of care without currently receiving the CBHS benefit.

(5) Service eligibility. Covered services may begin on the date the client meets all CBHS benefit criteria described in subsections (1) through (4) of this section. The agency approves one year of continuous eligibility for the CBHS benefit, unless the client:

(a) Moves out-of-state;

(b) Is admitted to an institution, as defined in WAC 182-500-0050, and is likely to reside there for 30 days or longer;

(c) No longer receives any of the home and community services as described in WAC 388-106-0015 (1), (2), (3), (16), or (17), at home or in a community residential setting;

(d) Dies;

(e) Has countable income over 150 percent federal poverty level (FPL); or

(f) Otherwise loses eligibility for medicaid.

(6) Service eligibility denial or termination. The agency provides a written explanation for denials as described in chapter 182-518 WAC.

(a) A change that results in termination takes effect the first of the month following the change as described in WAC 182-504-0120.

(b) A change that results in a decreased scope of care takes effect the first of the month following the advance notice period, as described in WAC 182-504-0120.

(c) A person who does not agree with an agency decision regarding CBHS services, including a denial of eligibility, may request an administrative hearing as described in chapter 182-526 WAC.

(7) Redetermination. The agency reviews client eligibility for CBHS services at least once every 12 months.

(1) The agency has established tiers for community behavioral health support services using the needs-based criteria and risk criteria in WAC 182-561-0300.

(2) At a minimum, a person determined eligible for supportive supervision qualifies to receive Tier 1 services for an average of two hours per day.

(3) The agency determines tiers based on medical appropriateness and clinical acuity, using the following tier structure:

Tier Level	Eligibility Criteria	Renewal or Reassessment Criteria
Tier 1 Services	A person is eligible for Tier 1 services if they: • Demonstrate a qualifying behavior that requires daily intermittent monitoring, redirection, and cueing to promote community stability and to ensure the safety of the person and other residents; or • Have a significant history of behaviors that are well-managed in a highly structured setting but are at risk of recurring in a community setting if not met with the appropriate level of supportive supervision.	For renewal or assessment, the person has a history of behaviors meeting the guidelines for Tier 1, which are currently prevented only by additional skilled staff intervention.
Tier 2 Services	A person is eligible for Tier 2 services if they: • Demonstrate current qualifying behaviors at a frequency that requires an average of 2.1 to 6 hours per day of dedicated staff to redirect, deescalate, and cue to promote community stability and to ensure the safety of the person and the other residents; or • Have demonstrated multiple qualifying behaviors requiring an average of 2.1 to 6 hours per day of one-on-one staffing within the past month. Behaviors may be well-managed in a highly structured setting but are at risk of recurring in a community setting if not met with the appropriate level of supportive supervision.	For renewal or reassessment, the person has a history of behavior or behaviors meeting the guidelines for Tier 2, which are currently prevented only by additional skilled staff intervention at this tier level.
Tier 3 Services	A person is eligible for Tier 3 services if they: • Demonstrate multiple qualifying behaviors at a frequency and intensity that requires an average of 6.1 to 10 hours per day of one-on-one staffing to redirect, engage, deescalate, and cue to promote community stability and to ensure the safety of the person and other residents; or • Have demonstrated multiple qualifying behaviors requiring an average of 6.1 to 10 hours per day of one-on-one staffing within the past month. Behaviors may be well-managed in a highly structured setting but are at risk of recurring or increasing in frequency or severity in a community setting if not met with the appropriate level of supportive supervision.	For renewal or reassessment, the person has a history of behaviors meeting the guidelines for Tier 3, which are currently preventable only by additional skilled staff intervention at this tier level.
Tier 4 Services	A person is eligible for Tier 4 services if they: • Demonstrate multiple qualifying behaviors at a frequency and intensity that requires an average of 10.1 to 16 hours per day of one-on-one staffing to redirect, engage, deescalate, and cue to promote community stability and to ensure the safety of the person and other residents; or • Have demonstrated multiple qualifying behaviors requiring an average of 10.1 to 16 hours per day of one-on-one staffing within the past month. Behavior requires at least one-on-one intervention, even in a structured setting, but the behavior may be at risk of increasing in frequency, or severity, or both, in a community setting if not met with the appropriate level of supportive supervision.	For renewal or reassessment, the person has a history of behavior meeting the guidelines for Tier 4, which are currently prevented only by additional skilled staff interventions at this tier level.
Tier 5 Services	A person is eligible for Tier 5 services when: • The person demonstrates multiple behaviors at a frequency and intensity that requires an average of 16.1 to 20 hours per day of one-on-one staffing to redirect, engage, deescalate, and cue to promote community stability and to ensure the safety of the person and other residents; or • The person's behavior requires daily one-on-one intervention even in the context of a structured setting, and there would be an imminent risk of harm if the person does not receive an average of 16.1 to 20 hours per day of at least one-on-one staffing in a community setting.	For renewal or reassessment, the person has a history of behavior meeting the guidelines for Tier 5, which are currently prevented only by additional skilled staff intervention at this tier level.
Tier 6 Services	A person is eligible for Tier 6 services when: • The person demonstrates multiple qualifying behaviors at a frequency and intensity that requires an average of 20.1 to 24 hours per day of one-on-one staffing or has regular episodes that require multiple staff to redirect, engage, deescalate, and cue to promote community stability and to ensure the safety of the person and other residents; or • The person's behavior requires constant one-on-one monitoring and intervention, even in the context of a structured setting, and there would be an imminent risk of harm if the person does not receive an average of 20.1 to 24 hours per day of at least one-on-one staffing in a community setting.	For renewals or reassessment, the person has a history of behavior meeting the guidelines for Tier 6, which are currently prevented only by additional skilled staff intervention at this tier level.

For purposes of this chapter, eligible diagnoses include only the following:

• Psychotic disorder with hallucinations due to known physiological condition

• Psychotic disorder with delusions due to known physiological condition

• Mood disorder due to known physiological condition, unspecified

• Mood disorder due to known physiological condition with depressive features

• Mood disorder due to known physiological condition with major depressive-like episode

• Mood disorder due to known physiological condition with manic features

• Mood disorder due to known physiological condition with mixed features

• Anxiety disorder due to known physiological condition

• Personality change due to known physiological condition

• Diffuse traumatic brain injury with loss of consciousness sequela

• Paranoid schizophrenia

• Disorganized schizophrenia

• Catatonic schizophrenia

• Undifferentiated schizophrenia

• Residual schizophrenia

• Schizophreniform disorder

• Other schizophrenia

• Schizophrenia, unspecified

• Schizotypal disorder

• Delusional disorders

• Brief psychotic disorder

• Shared psychotic disorder

• Schizoaffective disorder, bipolar type

• Schizoaffective disorder, depressive type

• Other schizoaffective disorders

• Schizoaffective disorder, unspecified

• Other psychotic disorder not due to a substance or known physiological condition

• Unspecified psychosis not due to a substance or known physiological condition

• Manic episode without psychotic symptoms, unspecified

• Manic episode without psychotic symptoms, mild

• Manic episode without psychotic symptoms, moderate

• Manic episode, severe, without psychotic symptoms

• Manic episode, severe with psychotic symptoms

• Manic episode in partial remission

• Manic episode in full remission

• Other manic episodes

• Manic episode, unspecified

• Bipolar disorder, current episode hypomanic

• Bipolar disorder, current episode manic without psychotic features, unspecified

• Bipolar disorder, current episode manic without psychotic features, mild

• Bipolar disorder, current episode manic without psychotic features, moderate

• Bipolar disorder, current episode manic without psychotic features, severe

• Bipolar disorder, current episode manic severe with psychotic features

• Bipolar disorder, current episode depressed, mild or moderate severity, unspecified

• Bipolar disorder, current episode depressed, mild

• Bipolar disorder, current episode depressed, moderate

• Bipolar disorder, current episode depressed, severe, without psychotic features

• Bipolar disorder, current episode depressed, severe, with psychotic features

• Bipolar disorder, current episode mixed, unspecified

• Bipolar disorder, current episode mixed, mild

• Bipolar disorder, current episode mixed, moderate

• Bipolar disorder, current episode mixed, severe, without psychotic features

• Bipolar disorder, current episode mixed, severe, with psychotic features

• Bipolar disorder, currently in remission, most recent episode unspecified

• Bipolar disorder, in partial remission, most recent episodic hypomanic

• Bipolar disorder, in full remission, most recent episode hypomanic

• Bipolar disorder, in partial remission, most recent episode manic

• Bipolar disorder, in full remission, most recent episode manic

• Bipolar disorder, in partial remission, most recent episode depressed

• Bipolar disorder, in full remission, most recent episode depressed

• Bipolar disorder, in partial remission, most recent episode mixed

• Bipolar disorder, in full remission, most recent episode mixed

• Bipolar II disorder

• Other bipolar disorder

• Bipolar disorder, unspecified

• Major depressive disorder, single episode, mild

• Major depressive disorder, single episode, moderate

• Major depressive disorder, single episode, severe without psychotic features

• Major depressive disorder, single episode, severe with psychotic features

• Major depressive disorder, single episode, in partial remission

• Major depressive disorder, single episode, in full remission

• Other depressive episodes

• Premenstrual dysphoric disorder

• Other specified depressive episodes

• Major depressive disorder, single episode, unspecified

• Depression, unspecified

• Major depressive disorder, recurrent, mild

• Major depressive disorder, recurrent, moderate

• Major depressive disorder, recurrent severe without psychotic features

• Major depressive disorder, recurrent, severe with psychotic symptoms

• Major depressive disorder, recurrent, in remission, unspecified

• Major depressive disorder, recurrent, in partial remission

• Major depressive disorder, recurrent, in full remission

• Other recurrent depressive disorders

• Major depressive disorder, recurrent, unspecified

• Cyclothymic disorder

• Dysthymic disorder

• Other persistent mood (affective) disorders

• Disruptive mood dysregulation disorder

• Other specified persistent mood disorders

• Persistent mood (affective) disorder, unspecified

• Unspecified mood (affective) disorder

• Agoraphobia, unspecified

• Agoraphobia with panic disorder

• Agoraphobia without panic disorder

• Social phobia, unspecified

• Social phobia, generalized

• Claustrophobia

• Other phobic anxiety disorders

• Panic disorder (episodic paroxysmal anxiety)

• Generalized anxiety disorder

• Obsessive-compulsive disorder

• Mixed obsessional thoughts and acts

• Hoarding disorder

• Excoriation (skin-picking) disorder

• Other obsessive-compulsive disorder

• Obsessive-compulsive disorder, unspecified

• Post-traumatic stress disorder, unspecified

• Post-traumatic stress disorder, acute

• Post-traumatic stress disorder, chronic

• Dissociative amnesia

• Dissociative fugue

• Dissociative stupor

• Conversion disorder with motor symptom or deficit

• Conversion disorder with seizures or convulsions

• Conversion disorder with sensory symptom or deficit

• Conversion disorder with mixed symptom presentation

• Dissociative identity disorder

• Other dissociative and conversion disorders

• Dissociative and conversion disorder, unspecified

• Somatization disorder

• Undifferentiated somatoform disorder

• Hypochondriacal disorder, unspecified

• Hypochondriasis

• Body dysmorphic disorder

• Other hypochondriacal disorders

• Pain disorder exclusively related to psychological factors

• Pain disorder with related psychological factors

• Other somatoform disorders

• Somatoform disorder, unspecified

• Depersonalization-derealization syndrome

• Nonpsychotic mental disorder, unspecified

• Borderline personality disorder

• Trichotillomania

• Intermittent explosive disorder

• Other impulse disorders

• Impulse disorder, unspecified

• Factitious disorder imposed on self, unspecified

• Factitious disorder imposed on self, with predominantly physical signs and symptoms

• Factitious disorder imposed on self, with combined psychological and physical signs and symptoms

• Other specified disorders of adult personality and behavior

• Conduct disorder confined to family context

• Conduct disorder, childhood-onset type

• Conduct disorder, adolescent-onset type

• Other conduct disorders

• Conduct disorder, unspecified

• Separation anxiety disorder of childhood

• Other childhood emotional disorders

• Childhood emotional disorder, unspecified

• Selective mutism

• Reactive attachment disorder of childhood

• Disinhibited attachment disorder of childhood

• Other childhood disorders of social functioning

• Childhood disorder of social functioning, unspecified

• Traumatic brain injury-related diagnoses