(1) The agency pays:
(a) For dates of admission before August 1, 2007, for only emergency care for an eligible medicaid and CHIP client who goes to another state, except specified border cities, specifically for the purpose of obtaining medical care that is available in the state of Washington. See WAC 182-501-0175
for a list of border cities.
(b) For dates of admission on and after August 1, 2007, for both emergency and nonemergency out-of-state hospital services, including those provided in bordering city hospitals and critical border hospitals, for eligible medicaid and CHIP clients based on the medical necessity and utilization review standards and limits established by the agency.
(i) Prior authorization by the agency is required for the nonemergency out-of-state hospital medical care provided to medicaid and CHIP clients.
(ii) Bordering city hospitals are considered the same:
(A) As instate hospitals for coverage of hospital services; and
(B) As out-of-state hospitals for payment methodology. Agency designated critical border hospitals are paid as instate hospitals. See WAC 182-550-3900
(c) For out-of-state voluntary psychiatric inpatient hospital services for eligible medicaid and CHIP clients based on authorization by a division of behavioral health designee.
(d) Based on the agency's limitations on hospital coverage under WAC 182-550-1100
and other applicable rules.
(2) The agency authorizes and pays for comparable hospital services for a medicaid and CHIP client who is temporarily outside the state to the same extent that such services are furnished to an eligible medicaid client in the state, subject to the exceptions and limitations in this section. See WAC 182-550-3900
(3) The agency limits out-of-state hospital coverage for persons eligible under state-administered programs as follows:
(a) For a person who receives services under the Involuntary Treatment Act (ITA), the agency does not pay for hospital services provided in any hospital outside the state of Washington (including bordering city and critical border hospitals).
(b) For a person eligible under an agency's general assistance program, the agency pays only for hospital services covered under the person's medical care services' program scope of care that are provided in a bordering city hospital or a critical border hospital. The agency does not pay for hospital services provided to persons eligible under a general assistance program in other hospitals located outside the state of Washington. The agency or its designee may require prior authorization for hospital services provided in a bordering city hospital or a critical border hospital. See WAC 182-550-1200
(4) The agency covers hospital care provided to medicaid or CHIP clients in areas of Canada as described in WAC 182-501-0180
, and based on the limitations described in the state plan.
(5) The agency may review all cases involving out-of-state hospital services, including those provided in bordering city hospitals and critical border hospitals, to determine whether the services are within the scope of the person's WAH program.
(6) If the person can claim deductible or coinsurance portions of medicare, the provider must submit the claim to the intermediary or carrier in the provider's own state on the appropriate medicare billing form. If the state of Washington is checked on the form as the party responsible for medical bills, the intermediary or carrier may bill on behalf of the provider or may return the claim to the provider for submission to the state of Washington.
(8) Out-of-state providers, including bordering city hospitals and critical border hospitals, must present final charges to the agency within three hundred sixty-five days of the "statement covers period from date" shown on the claim. The state of Washington is not liable for payment of charges received beyond three hundred sixty-five days from the "statement covers period from date" shown on the claim.
[Statutory Authority: RCW 41.05.021
, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-019, § 182-550-6700, filed 7/24/14, effective 8/24/14. WSR 11-14-075, recodified as § 182-550-6700, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090
and 2005 c 518. WSR 07-14-051, § 388-550-6700, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.08.090
. WSR 01-02-075, § 388-550-6700, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.08.090
, [74.09.]500, [74.09.]530 and 43.20B.020
. WSR 98-01-124, § 388-550-6700, filed 12/18/97, effective 1/18/98.]