PDFWAC 182-501-0180

Health care services provided outside the state of Washington—General provisions.

WAC 182-501-0180 through 182-501-0184 describe the health care services available to a Washington apple health client on a fee-for-service basis or to a client enrolled in a managed care organization (MCO) (defined in WAC 182-538-050).
(1) Subject to the requirements, exceptions, and limitations in this section, WAC 182-501-0182, and 182-501-0184, the medicaid agency covers emergency and nonemergency out-of-state health care services provided to eligible Washington apple health recipients when the services are:
(a) Within the scope of the client's or enrollee's health care program as specified under chapter 182-501 WAC or other program rules;
(b) Allowed to be provided outside the state of Washington by specific program WAC; and
(c) Medically necessary as defined in WAC 182-500-0070.
(2) The agency does not cover services provided outside the state of Washington under the Involuntary Treatment Act (chapter 71.05 RCW), including designated bordering cities.
(3) When the agency pays for covered health care services furnished to an eligible Washington apple health client or enrollee outside the state of Washington, its payment is payment in full according to 42 C.F.R. 447.15. No additional payment may be sought from the client (see WAC 182-502-0160).
(4) The agency determines coverage for transportation services provided out of state, including ambulance services, according to chapter 182-546 WAC.
(5) With the exception of designated bordering cities (see WAC 182-501-0175), if the client or enrollee travels out of state expressly to obtain health care, the service must be prior authorized by the agency. See WAC 182-501-0182 for requirements related to out-of-state nonemergency treatment and WAC 182-501-0165 for the agency's medical necessity determination process.
(6) The agency does not cover health care services provided outside the United States and U.S. territories, except in British Columbia, Canada. See WAC 182-501-0184 for limitations on coverage of, and payment for, health care provided to Washington apple health clients or enrollees in British Columbia, Canada.
(7) See WAC 182-502-0120 for provider requirements for payment of health care provided outside the state of Washington.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-23-064, § 182-501-0180, filed 11/16/20, effective 12/17/20; WSR 15-15-053, § 182-501-0180, filed 7/9/15, effective 8/9/15. WSR 11-14-075, recodified as § 182-501-0180, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.04.057 and 74.09.510. WSR 11-14-054, § 388-501-0180, filed 6/29/11, effective 7/30/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035. WSR 08-08-064, § 388-501-0180, filed 3/31/08, effective 5/1/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-501-0180, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090 and 74.09.035. WSR 01-01-011, § 388-501-0180, filed 12/6/00, effective 1/6/01. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-501-0180, filed 5/3/94, effective 6/3/94. Formerly parts of WAC 388-82-135 and 388-92-015.]