PDFWAC 182-531-0100

Scope of coverage for physician-related and health care professional services—General and administrative.

(1) The medicaid agency covers health care services, equipment, and supplies listed in this chapter, according to agency rules and subject to the limitations and requirements in this chapter, when they are:
(a) Within the scope of an eligible client's Washington apple health program. Refer to WAC 182-501-0060 and 182-501-0065; and
(b) Medically necessary as defined in WAC 182-500-0070.
(2) The agency evaluates a request for a service that is in a covered category under the provisions of WAC 182-501-0165.
(3) The agency evaluates requests for covered services that are subject to limitations or other restrictions and approves such services beyond those limitations or restrictions as described in WAC 182-501-0169.
(4) The agency covers the following physician-related services and health care professional services, subject to the conditions in subsections (1), (2), and (3) of this section:
(a) Alcohol and substance misuse counseling (refer to WAC 182-531-1710);
(b) Allergen immunotherapy services;
(c) Anesthesia services;
(d) Dialysis and end stage renal disease services (refer to chapter 182-540 WAC);
(e) Emergency physician services;
(f) ENT (ear, nose, and throat) related services;
(g) Early and periodic screening, diagnosis, and treatment (EPSDT) services (refer to WAC 182-534-0100);
(h) Habilitative services (refer to WAC 182-545-400);
(i) Reproductive health services (refer to chapter 182-532 WAC);
(j) Hospital inpatient services (refer to chapter 182-550 WAC);
(k) Maternity care, delivery, and newborn care services (refer to chapter 182-533 WAC);
(l) Office visits;
(m) Vision-related services (refer to chapter 182-544 WAC for vision hardware for clients 20 years of age and younger);
(n) Osteopathic treatment services;
(o) Pathology and laboratory services;
(p) Physiatry and other rehabilitation services (refer to chapter 182-550 WAC);
(q) Foot care and podiatry services (refer to WAC 182-531-1300);
(r) Primary care services;
(s) Psychiatric services;
(t) Psychotherapy services (refer to WAC 182-531-1400);
(u) Pulmonary and respiratory services;
(v) Radiology services;
(w) Surgical services;
(x) Cosmetic, reconstructive, or plastic surgery, and related services and supplies to correct physiological defects (e.g., congenital or as a result of illness or physical trauma), or for mastectomy reconstruction for post cancer treatment;
(y) Telemedicine (refer to WAC 182-501-0300);
(z) Tobacco/nicotine cessation counseling (refer to WAC 182-531-1720);
(aa) Vaccines for adults, adolescents, and children in the United States administered according to the current advisory committee on immunization practices (ACIP) recommended immunization schedule published by the Centers for Disease Control and Prevention (CDC). Vaccines outside the regular schedule may be covered if determined to be medically necessary;
(bb) Other outpatient physician services.
(5) The agency covers physical examinations for Washington apple health clients only when the physical examination is for one or more of the following:
(a) A screening exam covered by the EPSDT program (see WAC 182-534-0100);
(b) An annual exam for clients of the division of developmental disabilities; or
(c) A screening pap smear, mammogram, or prostate exam.
(6) By providing covered services to a client eligible for Washington apple health, a provider who meets the requirements in WAC 182-502-0005(3) accepts the agency's rules and fees which includes federal and state law and regulations, billing instructions, and provider notices.
[Statutory Authority: RCW 41.05.021, 41.05.160, and 2021 c 157. WSR 23-04-048, § 182-531-0100, filed 1/26/23, effective 2/26/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-22-017, § 182-531-0100, filed 10/25/19, effective 11/25/19; WSR 18-21-058, § 182-531-0100, filed 10/9/18, effective 11/9/18; WSR 15-03-041, § 182-531-0100, filed 1/12/15, effective 2/12/15. Statutory Authority: RCW 41.05.021. WSR 13-18-035, § 182-531-0100, filed 8/28/13, effective 9/28/13. Statutory Authority: RCW 41.05.021 and 42 C.F.R. 455.410. WSR 13-04-095, § 182-531-0100, filed 2/6/13, effective 3/9/13. Statutory Authority: RCW 41.05.021 and section 1927 of the Social Security Act. WSR 12-18-062, § 182-531-0100, filed 8/31/12, effective 10/1/12. WSR 11-14-075, recodified as § 182-531-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-14-055, § 388-531-0100, filed 6/29/11, effective 7/30/11. Statutory Authority: RCW 74.09.521. WSR 08-12-030, § 388-531-0100, filed 5/29/08, effective 7/1/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-531-0100, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0100, filed 12/6/00, effective 1/6/01.]