PDFWAC 182-550-1900

Transplant coverage.

(1) The medicaid agency pays for medically necessary transplant procedures only for eligible Washington apple health clients. Clients eligible under the alien emergency medical (AEM) program are not eligible for transplant coverage.
(2) The agency covers the following transplant procedures when the transplant procedures are performed in a health care facility, as defined in WAC 247-04-020, that has a transplant certificate of need from the department of health:
(a) Bone marrow;
(b) Cornea;
(c) Skin grafts;
(d) Stem cell, autologous and allogeneic;
(e) Intestine;
(f) Kidney;
(g) Liver or combination liver-kidney;
(h) Heart or combination heart-lung;
(i) Lung, single or bilateral;
(j) Pancreas or combination pancreas-kidney; and
(k) Other transplant services determined to be medically necessary. See WAC 182-501-0165 and 182-500-0070.
(3) The agency pays for procedures covered under subsection (2)(a) through (d) of this section, performed at qualified facilities, subject to the limitations in this chapter.
(4) For procedures covered under subsection (2)(e) through (k) of this section, the agency pays facility charges only to those facilities that meet the standards and conditions:
(a) Established by the agency; and
(b) Specified in WAC 182-550-2100.
(5) The agency considers organ procurement fees as being included in the payment to the transplant facility. The agency may make an exception to this policy and pay these fees separately to a transplant facility when an eligible apple health client is covered by a third-party payer that will pay for the organ transplant procedure itself but not for the organ procurement.
(6) The agency, without requiring prior authorization, pays for up to 15 matched donor searches per client approved for a bone marrow transplant. The agency requires prior authorization for matched donor searches in excess of 15 per bone marrow transplant client.
(7) The agency does not pay for experimental transplant procedures.
(8) The agency pays for identical organ transplant procedures as determined medically necessary (see WAC 182-501-0165).
(9) The agency may conduct a postpayment retrospective utilization review as described in WAC 182-550-1700, and may adjust the payment if the agency determines the criteria in this section are not met.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-01-096, s 182-550-1900, filed 12/13/24, effective 1/13/25; WSR 15-18-065, § 182-550-1900, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-1900, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-018, § 388-550-1900, filed 6/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-1900, filed 12/18/97, effective 1/18/98.]