PDFWAC 182-501-0060

Health 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) Medical assistance programs for noncitizens (see chapter 182-507 WAC); and
(b) 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
Y
Y
Y
Y
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.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-07-132, § 182-501-0060, filed 3/22/23, effective 4/22/23. Statutory Authority: RCW 41.05.021, 41.05.160, and Thurston County Superior Court in J.C. and H.S. v. Washington State Health Care Authority, no. 20-2-01813-34. WSR 22-08-035, § 182-501-0060, filed 3/29/22, effective 4/29/22. Statutory Authority: RCW 41.05.021, 41.05.160, 2018 c 159. WSR 19-14-020, § 182-501-0060, filed 6/24/19, effective 7/25/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-07-083, § 182-501-0060, filed 3/17/15, effective 4/17/15. Statutory Authority: RCW 41.05.021, 2013 2nd sp.s. c 4, and Patient Protection and Affordable Care Act (P.L. 111-148). WSR 14-06-045, § 182-501-0060, filed 2/26/14, effective 3/29/14. Statutory Authority: RCW 41.05.021. WSR 13-15-044, § 182-501-0060, filed 7/11/13, effective 8/11/13. WSR 11-14-075, recodified as § 182-501-0060, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-501-0060, filed 11/30/06, effective 1/1/07.]