Title of Rule: Amending WAC 388-501-0135 Patient requiring regulation, 388-502-0120 Payment for medical care outside the state of Washington, 388-505-0540 Assignment of rights and cooperation, 388-512-1230 Refusal to accept medical treatment, 388-513-1350 Defining the resource standard and determining available resources for long-term care (LTC) services, 388-513-1365 Evaluating the transfer of an asset made on or after March 1, 1997, for long-term care (LTC) services, 388-527-2750 Waiver of recovery if undue hardship, 388-527-2790 Filing a lien against real property, 388-529-0100 Scope of covered medical services by program, 388-534-0100 Healthy Kids/EPSDT, 388-535-1050 Dental-related definitions, 388-537-0100 School medical services for students in special education programs, and 388-538-095 Scope of care for managed care enrollees.

Purpose: To correct MAA rules that contain cross-references to rules that have been renumbered or repealed and written into new chapters. MAA recently reorganized and rewrote most of its rules so they are located in the same area of Title 388 WAC. In doing so, some cross-references to rules are now incorrect; this proposal updates those cross-references so users may be referred to the correct rule.

Statutory Authority for Adoption: RCW 74.08.090.

Statute Being Implemented: RCW 74.08.090.

Summary: This proposal corrects cross-references to rules that have been renumbered or repealed and written into new chapters, due to the recent reorganization of MAA rules in Title 388 WAC.

Reasons Supporting Proposal: To ensure the cross-references in MAA rules refer users to the correct WAC cite.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Ann Myers/DCS/RIP, P.O. Box 45533, Olympia, WA 98504-5533, (360) 725-1345.

Name of Proponent: Department of Social and Health Services, Medical Assistance Administration, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: Due to MAAs recent reorganization and rewrite of its rules, several cross-references refer to rules that have been renumbered or repealed when the policy was written into new chapters. This proposal corrects those cross-references by replacing the outdated cross-references with correct WAC numbers.

     The purpose and anticipated effect is to refer users to the correct WAC cite.

Proposal Changes the Following Existing Rules: Due to MAAs recent reorganization and rewrite of its rules, several cross-references refer to rules that have been renumbered or repealed when the policy was written into new chapters. This proposal corrects those cross-references by replacing the outdated cross-references with correct WAC numbers.

September 29, 2000

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

(1) Patient requiring regulation (PRR) is a health and safety program for clients needing help in the appropriate use of medical services.      A client in PRR is restricted to one primary care provider (PCP) and one pharmacy.      Enrollment in the PRR program is for twenty-four months.

     (2) Any client of the department's medical programs is reviewed for assignment to PRR if:

     (a) The client has:

     (i) Made repeated and documented efforts to seek medically unnecessary health services; and

     (ii) Been counseled at least once by a health care provider or managed care plan representative about the appropriate use of health care services; or

     (b) Any three of the following conditions have been met or exceeded in a ninety-day period.      The client:

     (((a))) (i) Received services from four different physicians; or

     (((b))) (ii) Had prescriptions filled by four different pharmacies; or

     (((c))) (iii) Received ten prescriptions; or

     (((d))) (iv) Had prescriptions filled by four different prescribers; or

     (((e))) (v) Used two emergency room (ER) visits.

     (3) If subsections (2)(a) or (b) of this section apply, then the client's use of medical services is reviewed by the department.      The review considers the client's diagnoses, history of services provided, or other medical information supplied by the health care provider or managed care plan.      The review is done by a nurse consultant, physician, or other qualified medical staff according to established medical review guidelines.

     (4) If the medical review finds that the client uses inappropriate or medically unnecessary services the client receives written notice which:

     (a) Asks the client to select a primary care provider and one pharmacy; and

     (b) Notifies the client of their right to request a fair hearing within ninety days (see subsection (6) of this section); and

     (c) Requires the client to respond within twenty days by:

     (i) Selecting a primary care provider and pharmacy; or

     (ii) Submitting additional medical information, which justifies the client's use of medical services; or

     (iii) Writing or calling the PRR representative, who is identified in the PRR notice, requesting assistance; or

     (iv) Requesting a fair hearing (see subsection (6) of this section).

     (5) A client who does not respond to the notice within twenty days is assigned to the PRR program.      The department assigns the client to a PCP and pharmacy.      The client may change the assigned PCP and pharmacy once within the initial sixty days.      The assigned providers will be:

     (a) Located in the client's local geographic area; and

     (b) Reasonably accessible to the client.

     (6) A client has ninety days to request a fair hearing.      A client who requests a fair hearing within twenty days from the date they receive notice under subsection (4) of this section will not be assigned to the PRR program until a fair hearing decision is made.      A client who requests a fair hearing after twenty days may have been assigned a PCP and pharmacist.      An assigned client will remain in PRR until a fair hearing decision is made.

     (7) When a PRR client chooses or the department assigns a PCP and pharmacy, the PCP and pharmacy requirements are:

     (a) A PCP supervises and coordinates medical care for the client.      The PCP makes referrals for specialist care and provides continuity of care.      A PCP must be:

     (i) A physician who meets the criteria under WAC ((388-87-007)) 388-502-0020 and 388-502-0030; or

     (ii) An advanced registered nurse practitioner (ARNP) who meets criteria under WAC ((388-87-007)) 388-502-0020 and 388-502-0030; or

     (iii) A licensed physician assistant, practicing with a sponsoring supervising physician.

     (b) A single pharmacy fills all prescriptions for the client.      For fee for service clients the pharmacy must be contracted with MAA.

     (c) For clients enrolled in a managed care plan, the pharmacy and PCP must be contracted with the client's managed care plan.

     (8) The PRR client's medical assistance identification card (MAID) will be marked in the "restricted" column.

     (9) A client in PRR cannot change their PCP or pharmacy for twelve months unless the:

     (a) Client changes to a residence outside the provider's geographic area; or

     (b) PCP or pharmacy moves out of the client's geographical area; or

     (c) PCP or pharmacy refuses to continue as the client's provider; or

     (d) Client was assigned providers.      The client may change the assigned providers once within sixty days of the initial assignment.

     (10) A PRR client enrolled in a managed care plan must select a PCP and pharmacy from those identified as available within their plan.      In addition to the reasons given in subsection (9) of this section, the client may change a provider if the:

     (a) Chosen or assigned PCP or pharmacy no longer participates with their plan.      The client may:

     (i) Select a new PCP from the list of available PCPs provided by the plan; or

     (ii) Transfer enrollment of all family members to the new department-contracted plan which the established PCP has joined.

     (b) Client chooses a new plan during the managed care program's open enrollment period, which occurs during the twenty-four-month PRR enrollment period as defined in subsection (1) of this section.

     (11) After twenty-four months, a PRR client's use of services is reviewed.      A client is removed from PRR if:

     (a) The billing records show the care received was reasonable and appropriate; or

     (b) The PCP reports the services requested and received were reasonable and appropriate.

     (12) If the client is not removed from PRR under subsection (11) of this section, the client continues to be in PRR for an additional twelve months.      After that twelve-period, the client is reviewed again according to subsection (11)(a) and (b) of this section.

     (13) Under the PRR program, MAA or the client's managed care plan will pay for only:

     (a) Those services authorized by the PCP, the PCP-referred specialist, or the pharmacist; or

     (b) Emergencies services; or

     (c) Family planning services; or

     (d) Women's health care services.      A client enrolled with a managed care plan must self-refer to providers within the plan's network.

     The client may be responsible for payment of services not covered by the PRR program.

[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090.      98-16-044, § 388-501-0135, filed 7/31/98, effective 9/1/98.      Statutory Authority: RCW 74.08.090 and 74.09.522.      97-03-038, § 388-501-0135, filed 1/9/97, effective 2/9/97.      Statutory Authority: RCW 74.08.090.      94-10-065 (Order 3732), § 388-501-0135, filed 5/3/94, effective 6/3/94.      Formerly WAC 388-81-100.]

(1) The medical assistance administration (MAA) pays the provider of service in designated bordering cities as if the care were provided within the state of Washington (see WAC 388-501-0175).      MAA requires providers to meet the licensing requirements of the state in which care is rendered.

     (2) MAA does not authorize payment for out-of-state medical care furnished to clients in state-only funded medical programs.

     (3) MAA applies the three-month retroactive coverage as defined under WAC ((388-80-005)) 388-500-0005 to covered medical services that are furnished to eligible clients by out-of-state providers.

     (4) MAA requires out-of-state providers to obtain a valid provider number in order to be reimbursed.

     (a) MAA requires a completed core provider agreement, and furnishes the necessary billing forms, instructions, and a core provider agreement to providers.

     (b) MAA issues a provider number after receiving the signed core provider agreement.

     (c) The billing requirements of WAC ((388-87-010)) 388-502-0100 and ((388-87-015)) 388-502-0150 apply to out-of-state providers.

     (5) For Medicare-eligible clients, providers must submit Medicare claims, on the appropriate Medicare billing form, to the intermediary or carrier in the provider's state.      If the provider checks the Medicare billing form to show the state of Washington as being responsible for medical billing, the intermediary or carrier may either:

     (a) Forward the claim to MAA on behalf of the provider; or

     (b) Return the claim to the provider, who then submits it to MAA.

     (6) For covered services for eligible clients, MAA reimburses approved out-of-state nursing facilities at the lower of:

     (a) The billed amount; or

     (b) The adjusted statewide average reimbursement rate for in-state nursing facility care.

     (7) For covered services for eligible clients, MAA reimburses approved out-of-state hospitals at the lower of:

     (a) The billed amount; or

     (b) The adjusted statewide average reimbursement rate for in-state hospitals.

     (8) For covered services for eligible clients, MAA reimburses other approved out-of-state providers at the lower of:

     (a) The billed amount; or

     (b) The rate paid by the Washington state Title XIX Medicaid program.

[Statutory Authority: RCW 74.04.050 and 74.08.090.      00-01-088, § 388-502-0120, filed 12/14/99, effective 1/14/00.]

(1) When a person becomes eligible for any of the department's medical programs, they make assignment of certain rights to the state of Washington.      This assignment includes all rights to any type of coverage or payment for medical care which results from:

     (a) A court order;

     (b) An administrative agency order; or

     (c) Any third-party benefits or payment obligations for medical care which are the result of subrogation or contract (see WAC ((388-87-020)) 388-501-0100).

     (2) Subrogation is a legal term which describes the method by which the state acquires the rights of a client for whom or to whom the state has paid benefits.      The subrogation rights of the state are limited to the recovery of its own costs.

     (3) The person who signs the application makes the assignment of rights to the state.      Assignment is made on their own behalf and on behalf of any eligible person for whom they can legally make such assignment.

     (4) A person must cooperate with the department in the identification, use or collection of third-party benefits.      Failure to cooperate results in a termination of eligibility for the responsible person.      Other obligations for cooperation are located in chapters ((388-14)) 388-14A and 388-422 WAC.      The following clients are exempt from termination of eligibility for medical coverage as a result of noncooperation:

     (a) A pregnant woman, and

     (b) Minor children, and

     (c) A person who has been determined to have "good cause" for noncooperation (see WAC 388-422-0015).

     (5) A person will not lose eligibility for medical assistance programs due solely to the noncooperation of any third party.

     (6) A person will be responsible for the costs of otherwise covered medical services if:

     (a) The person received and kept the third-party payment for those services; or

     (b) The person refused to provide to the provider of care their legal signature on insurance forms.

[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090.      98-16-044, § 388-505-0540, filed 7/31/98, effective 9/1/98.      Statutory Authority: RCW 74.08.090 and 74.09.522.      97-04-005, § 388-505-0540, filed 1/24/97, effective 2/24/97.      Statutory Authority: RCW 74.08.090.      94-10-065 (Order 3732), § 388-505-0540, filed 5/3/94, effective 6/3/94.      Formerly WAC 388-83-012, 388-501-0170 and 388-505-0560.]

(1) A disabled client who refuses without good cause to accept available medical treatment which can reasonably be expected to render the client able to work or do homemaking shall become ineligible.

     (2) "Available medical treatment" shall mean medical, surgical or psychiatric therapy, or any combination of these treatments.

     (3) "Reasonably be expected to render the client able to work or do homemaking" shall mean that, in the opinion of the state review team, the recommended medical, surgical, or psychiatric therapy is of such a nature and prognosis that, in the specific instance of the person involved, medical experience indicates that the recommended treatment will restore or substantially improve the person's ability to work for pay in a regular and predictable manner or to engage in homemaking.

     (4) A client has good cause to refuse recommended medical treatment when, according to the best objective judgment of the state office review team, such refusal is based upon one or more of the following conditions:

     (a) The person is genuinely fearful of undergoing recommended treatment.      Such fear may appear to be unrealistic, or entirely emotional in origin, or irrational; however, fear exists in such a degree that treatment would be adversely affected and the doctor may therefore be dubious about undertaking to treat the person;

     (b) The person could lose a faculty, or the remaining use of faculty the client now has, and refuses to accept the risk; or

     (c) The person will not accept recommended medical treatment because of definitely stated religious scruples.

     (5) The controlling principle in determining whether refusal was for or without good cause rests with the state office review team which will be guided by whether a reasonable, prudent person under similar circumstances would accept the recommended treatment.      The determination will be made only after considering all social and medical evidence, including that furnished by the person, who will be provided with an opportunity to set forth in writing objective reasons for declining recommended treatment.      A determination that a refusal to accept treatment without good cause is a decision which the client may appeal according to chapter ((388-08)) 388-02 WAC.

[Statutory Authority: RCW 74.08.090.      94-10-065 (Order 3732), § 388-512-1230, filed 5/3/94, effective 6/3/94.      Formerly WAC 388-93-030.]

This section describes how the department defines the resource standard and available resources when determining a client's eligibility for LTC services.      The department uses the term "resource standard" to describe the maximum amount of resources a client can have and be resource eligible for program benefits.

     (1) The resource standard used to determine eligibility for LTC services equals:

     (a) Two thousand dollars for a single client; or

     (b) Three thousand dollars for a legally married couple, unless subsection (2) applies.

     (2) If the department has already established eligibility for one spouse, then it applies the standard described in subsection (1)(a) to each spouse, unless doing so would make one of the spouses ineligible.

     (3) The department must apply the following rules when determining available resources for LTC services:

     (a) WAC 388-470-0005, Resource eligibility and limits;

     (b) WAC 388-470-0010, How to determine who owns a resource;

     (c) WAC 388-470-0015, Availability of resources;

     (d) WAC 388-470-0060(6), Resources of an alien's sponsor; and

     (e) WAC 388-506-0620, SSI-related medical clients.

     (4) The department determines a client's nonexcluded resources used to establish eligibility for LTC services in the following way:

     (a) For an SSI-related client, the department reduces available resources by excluding resources described in WAC 388-513-1360;

     (b) For an SSI-related client who has a community spouse, the department:

     (i) Excludes resources described in WAC 388-513-1360; and

     (ii) Adds together the available resources of both spouses according to subsection (5)(a) or (b) as appropriate;

     (c) For a client not described in subsection (4)(a) or (b), the department applies the resource rules of the program used to relate the client to medical eligibility.

     (5) A change in federal law that took effect on October 1, 1989 affects the way the department determines available resources of a legally married client.      If the client's current period of institutional status began:

     (a) On or after that date, the department adds together the total amount of nonexcluded resources held in the name of:

     (i) Either spouse; or

     (ii) Both spouses.

     (b) Before that date, the department adds together one-half the total amount of nonexcluded resources held in the name of:

     (i) The institutionalized spouse; or

     (ii) Both spouses;

     (6) If subsection (5)(a) applies, the department allocates the maximum amount of resources ordinarily allowed by law to the community spouse before determining nonexcluded resources used to establish eligibility for the institutionalized spouse.      The maximum allocation amount is eighty-four thousand, one hundred and twenty dollars effective January 1, 2000.

     (7) The amount of allocated resources described in subsection (6) can be increased, only if:

     (a) A court transfers additional resources to the community spouse; or

     (b) An administrative law judge establishes in a ((fair)) hearing described in chapter ((388-08)) 388-02 WAC that the amount is inadequate to provide a minimum monthly maintenance needs amount for the community spouse.

     (8) The department considers resources of the community spouse unavailable to the institutionalized spouse the month after eligibility for LTC services is established, unless subsections (9)(a), (b), or (c) apply.

     (9) A redetermination of the couples' resources as described in subsections (4)(b) or (c) is required, if:

     (a) The institutionalized spouse has a break of at least thirty consecutive days in a period of institutional status;

     (b) The institutionalized spouse's nonexcluded resources exceed the standard described in subsection (1)(a), if subsection (5)(a) applies; or

     (c) The institutionalized spouse does not transfer the amount described in subsections (6) or (7) to the community spouse or to another person for the sole benefit of the community spouse as described in WAC 388-513-1365(4) by either:

     (i) The first regularly scheduled eligibility review; or

     (ii) The reasonable amount of additional time necessary to obtain a court order for the support of the community spouse.

[Statutory Authority: RCW 11.92.180, 43.20B.460, 48.85.020, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.[09.]575, 74.09.585; 20 C.F.R. 416.1110-1112, 1123 and 1160; 42 C.F.R. 435.403 (j)(2) and 1005; and Sections 17, 1915(c), and 1924 (42 U.S.C. 1396) of the Social Security Act.      00-01-051, § 388-513-1350, filed 12/8/99, effective 1/8/00.      Statutory Authority: RCW 74.08.090 and 74.09.500.      99-06-045, § 388-513-1350, filed 2/26/99, effective 3/29/99.      Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.09.575 and Section 1924 (42 USC 1396r-5).      98-11-033, § 388-513-1350, filed 5/14/98, effective 6/14/98.      Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090 and 74.09.575.      97-09-112, § 388-513-1350, filed 4/23/97, effective 5/24/97.      Statutory Authority: RCW 74.08.090 and Title XIX State Agency Letter 95-44.      96-09-033 (Order 3963), § 388-513-1350, filed 4/10/96, effective 5/11/96.      Statutory Authority: RCW 74.08.090 and Title XIX State Agency Letter 94-49, notice of increase in SSI level.      95-05-022 (Order 3832), § 388-513-1350, filed 2/8/95, effective 3/11/95.      Statutory Authority: RCW 74.08.090.      94-23-129 (Order 3808), § 388-513-1350, filed 11/23/94, effective 12/24/94; 94-10-065 (Order 3732), § 388-513-1350, filed 5/3/94, effective 6/3/94.      Formerly parts of WAC 388-95-337 and 388-95-340.]

This section describes how the department evaluates the transfer of an asset made on or after March 1, 1997, by a client who is applying or approved for LTC services.      The department must consider whether a transfer made within a specified time before the month of application requires a penalty period in which the client is not eligible for these services.      Refer to WAC 388-513-1366 for rules used to evaluate the transfer of an asset made before March 1, 1997.

     (1) The department disregards the following transfers by the client, if they meet the conditions described:

     (a) Gifts or donations totaling one thousand dollars or less in any month;

     (b) The transfer of an excluded resource described in WAC 388-513-1360 with the exception of the client's home, unless the transfer meets the conditions described in subsection (1)(d);

     (c) The transfer of an asset for less than fair market value (FMV), if the client can provide evidence to the department that satisfies one of the following:

     (i) An intent to transfer the asset at FMV or other adequate compensation;

     (ii) The transfer is not made to qualify for LTC services;

     (iii) The client is given back ownership of the asset;

     (iv) The denial of eligibility would result in an undue hardship.

     (d) The transfer of ownership of the client's home, if it is transferred to the client's:

     (i) Spouse; or

     (ii) Child, who:

     (A) Meets the disability criteria described in WAC 388-511-1105 (1)(b) or (c); or

     (B) Is less than twenty-one years old; or

     (iii) A son or daughter, who:

     (A) Lived in the home for at least two years immediately before the client's current period of institutional status; and

     (B) Provided care that enabled the client to remain in the home; or

     (iv) A brother or sister, who has:

     (A) Equity in the home, and

     (B) Lived in the home for at least one year immediately before the client's current period of institutional status.

     (e) The transfer of an asset other than the home, if the transfer meets the conditions described in subsection (4), and the asset is transferred:

     (i) To the client's spouse or to another person for the sole benefit of the spouse;

     (ii) From the client's spouse to another person for the sole benefit of the spouse;

     (iii) To the client's child who meets the disability criteria described in WAC 388-511-1105 (1)(b) or (c) or to a trust established for the sole benefit of this child; or

     (iv) To a trust established for the sole benefit of a person who is sixty-fours years old or younger and meets the disability criteria described in WAC 388-511-1105 (1)(b) or (c).

     (f) The transfer of an asset to a member of the client's family in exchange for care the family member provided the client before the current period of institutional status, if a written agreement that describes the terms of the exchange:

     (i) Was established at the time the care began;

     (ii) Defines a reasonable FMV for the care provided that reflects a time frame based on the actuarial life expectancy of the client who transfers the asset; and

     (iii) States that the transferred asset is considered payment for the care provided.

     (2) When the fair market value of the care described in subsection (1)(f) is less than the value of the transferred asset, the department considers the difference the transfer of an asset without adequate consideration.

     (3) The department considers the transfer of an asset in exchange for care given by a family member without a written agreement as described under subsection (1)(f) as the transfer of an asset without adequate consideration.

     (4) The transfer of an asset or the establishment of a trust is considered to be for the sole benefit of a person described in subsection (1)(e), if the transfer or trust:

     (a) Is established by a legal document that makes the transfer irrevocable; and

     (b) Provides for spending all funds involved for the benefit of the person for whom the transfer is made within a time frame based on the actuarial life expectancy of that person.

     (5) When evaluating the effect of the transfer of an asset on a client's eligibility for LTC services received on or after October 1, 1993, the department counts the number of months before the month of application to establish what is referred to as the "look-back" period.      The following number of months apply as described:

     (a) Thirty-six months, if all or part of the assets were transferred on or after August 11, 1993; and

     (b) Sixty months, if all or part of the assets were transferred into a trust as described in WAC 388-505-0595.

     (6) If a client or the client's spouse transfers an asset within the look-back period without receiving adequate compensation, the result is a penalty period in which the client is not eligible for LTC services.      If a client or the client's spouse transfers an asset on or after March 1, 1997, the department must establish a penalty period as follows:

     (a) If a single or multiple transfers are made within a single month, then the penalty period:

     (i) Begins on the first day of the month in which the transfer is made; and

     (ii) Ends on the last day of the number of whole months found by dividing the total uncompensated value of the assets by the statewide average monthly private cost for nursing facilities at the time of application.

     (b) If multiple transfers are made during multiple months, then the transfers are treated as separate events and multiple penalty periods are established that:

     (i) Begin on the latter of:

     (A) The first day of the month in which the transfer is made; or

     (B) The first day after any previous penalty period has ended; and

     (ii) End on the last day of the whole number of months as described in subsection (6)(a)(ii).

     (7) If an asset is sold, transferred, or exchanged, the portion of the proceeds:

     (a) That is used within the same month to acquire an excluded resource described in WAC 388-513-1360 does not affect the client's eligibility;

     (b) That remains after an acquisition described in subsection (7)(a) becomes an available resource as of the first day of the following month.

     (8) If the transfer of an asset to the client's spouse includes the right to receive a stream of income not generated by a transferred resource, the department must apply rules described in WAC 388-513-1330 (6) through (8).

     (9) If the transfer of an asset for which adequate compensation is not received is made to a person other than the client's spouse and includes the right to receive a stream not generated by a transferred resource, the length of the penalty period is determined and applied in the following way:

     (a) The total amount of income that reflects a time frame based on the actuarial life expectancy of the client who transfers the income is added together;

     (b) The amount described in (9)(a) is divided by the statewide average monthly private cost for nursing facilities at the time of application; and

     (c) A penalty period equal to the number of whole months found by following subsections (9)(a) and (b) is applied that begins on the latter of:

     (i) The first day of the month in which the client transfers the income; or

     (ii) The first day of the month after any previous penalty period has ended.

     (10) A penalty period for the transfer of an asset that is applied to one spouse is not applied to the other spouse, unless:

     (a) Both spouses are receiving LTC services; and

     (b) A division of the penalty period between the spouses is requested.

     (11) If a client or the client's spouse disagrees with the determination or application of a penalty period, that person may request a ((fair)) hearing as described in chapter ((388-08)) 388-02 WAC.

[Statutory Authority: RCW 11.92.180, 43.20B.460, 48.85.020, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.[09.]575, 74.09.585; 20 C.F.R. 416.1110-1112, 1123 and 1160; 42 C.F.R. 435.403 (j)(2) and 1005; and Sections 17, 1915(c), and 1924 (42 U.S.C. 1396) of the Social Security Act.      00-01-051, § 388-513-1365, filed 12/8/99, effective 1/8/00.      Statutory Authority: RCW 74.08.090 and 74.09.500.      99-06-045, § 388-513-1365, filed 2/26/99, effective 3/29/99.      Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 74.09.585 and § 17 of the Social Security Act.      97-05-040, § 388-513-1365, filed 2/14/97, effective 3/17/97.      Statutory Authority: RCW 74.08.090.      95-02-027 (Order 3818), § 388-513-1365, filed 12/28/94, effective 1/28/95; 94-10-065 (Order 3732), § 388-513-1365, filed 5/3/94, effective 6/3/94.      Formerly WAC 388-95-395.]

Recovery is waived under this section when recovery would cause an undue hardship, except as provided in subsection (3) of this section.      This waiver is limited to the period during which undue hardship exists.

     (1) Undue hardship exists when:

     (a) The estate subject to adjustment or recovery is the sole income-producing asset of one or more of the heirs and income is limited; or

     (b) Recovery would result in the impoverishment of one or more of the heirs; or

     (c) Recovery would deprive an heir of shelter and the heir lacks the financial means to obtain and maintain alternative shelter.

     (2) Undue hardship does not exist when:

     (a) The adjustment or recovery of the client's cost of assistance would merely cause the client's family members inconvenience or restrict the family's lifestyle.

     (b) The heir divests assets to qualify under the undue hardship provision.

     (3) When a deceased client's assets were disregarded in connection with a long-term care insurance policy or contract under chapter 48.85 RCW, recovery is not waived.

     (4) When a waiver is not granted, the department will provide notice to the person who requested the waiver. The denial of a waiver must state:

     (a) The requirements of an application for an adjudicative proceeding to contest the department's decision to deny the waiver; and

     (b) Where assistance may be obtained to make such application.

     (5) A person may contest the department's decision in an adjudicative proceeding when that person requested the department waive recovery, and suffered a loss because that request was not granted.

     (6) An application for an adjudicative proceeding under this section must:

     (a) Be in writing;

     (b) State the basis for contesting the department's denial of the request to waive recovery;

     (c) Include a copy of the department's denial of the request to waive recovery;

     (d) Be signed by the applicant and include the applicant's address and telephone number;

     (e) Be served within twenty-eight days of the date the applicant received the department's decision denying the request for a waiver.      If the applicant shows good cause, the application may be filed up to thirty days late; and

     (f) Be served on the office of financial recovery (OFR) as described in WAC 388-527-2795.

     (7) An adjudicative proceeding held under this section shall be governed by chapters 34.05 RCW and ((388-08)) 388-02 WAC and this section. If a provision in this section conflicts with a provision in chapter ((388-08)) 388-02 WAC, the provision in this section governs.

[Statutory Authority: RCW 43.20B.080, 74.08.090 and 74.34.010.      99-11-076, § 388-527-2750, filed 5/18/99, effective 6/18/99.      Statutory Authority: 1995 1st sp.s. c 18 and RCW 74.08.090.      95-19-001 and 95-24-037 (Orders 3893 and 3893A), § 388-527-2750, filed 9/6/95 and 11/29/95, effective 10/7/95 and 12/30/95.]

(1) Liens are filed, adjustment sought, and other recoveries effected by the department for medical assistance or state-funded long-term care, or both, correctly paid on behalf of a client consistent with 42 U.S.C. 1396p and chapters 43.20B RCW and 388-527 WAC.

     (2) When the department seeks to recover from a client's estate the cost of medical assistance or state-funded long-term care, or both, provided to the client, prior to filing a lien against the deceased client's real property, notice shall be given to:

     (a) The probate estate's personal representative, if any; or

     (b) Any other person known to have title to the affected property.

     (3) Prior to filing a lien against any of the deceased client's real property, a person known to have title to the property shall be notified and have an opportunity for an adjudicative proceeding as follows:

     (a) Any person known to have title to the property shall be served with a notice of intent to file lien, which shall state:

     (i) The deceased client's name, social security number, if known, date of birth, and date of death;

     (ii) The amount of medical assistance, or state-funded long-term care, or both, correctly paid on behalf of the deceased client the department seeks to recover;

     (iii) The department's intent to file a lien against the deceased client's real property to recover the medical assistance or state-funded long-term care, or both, correctly paid on behalf of the deceased client;

     (iv) The county in which the real property is located; and

     (v) The right of the person known to have title to the property to contest the department's decision to file a lien by applying for an adjudicative proceeding with the office of financial recovery (OFR).

     (b) An adjudicative proceeding can determine whether:

     (i) The amount of medical assistance or state-funded long-term care, or both, correctly paid on behalf of the deceased client alleged by the department's notice of intent to file a lien is correct; and

     (ii) The deceased client had legal title to the real property at the time of the client's death.

     (4) An application for an adjudicative proceeding must:

     (a) Be in writing;

     (b) State the basis for contesting the department's notice of intent to file the lien;

     (c) Be signed by the applicant and state the applicant's address and telephone number;

     (d) Be served on (OFR) within twenty-eight days of the date the applicant received the department's notice of intent to file the lien.      An application filed up to thirty days late may be treated as timely filed if the applicant shows good cause for filing late; and

     (e) Be served on OFR as described in WAC 388-527-2795.

     (5) Persons known to have title to the property shall be notified of the time and place of the adjudicative proceeding by the department when it receives an application for the same.

     (6) An adjudicative proceeding under this section shall be governed by chapters 34.05 RCW and ((388-08)) 388-02 WAC and this section.      If a provision in this section conflicts with a provision in chapter ((388-08)) 388-02 WAC, the provision in this section governs.

     (7) If no known title holder requests an adjudicative proceeding, a lien shall be filed by the department twenty-eight days after the date that the notice of intent to file the lien letter was mailed. The lien will be filed against the deceased client's real property in the amount of the correctly paid medical assistance or state-funded long-term care, or both.

     (8) If an adjudicative proceeding is conducted in accordance with this regulation, when the final agency decision is issued, the department will file a lien against the deceased client's real property for the amount of the correctly paid medical assistance or state-funded long-term care, or both, as established by that final agency decision.

[Statutory Authority: RCW 43.20B.080, 74.08.090 and 74.34.010.      99-11-076, § 388-527-2790, filed 5/18/99, effective 6/18/99.      Statutory Authority: 1995 1st sp.s. c 18 and RCW 74.08.090.      95-19-001 and 95-24-037 (Orders 3893 and 3893A), § 388-527-2790, filed 9/6/95 and 11/29/95, effective 10/7/95 and 12/30/95.]

(1) The scope of medical care which clients can receive is based on the medical program for which they are eligible. Clients eligible for the following medical programs have coverage for the medically necessary services indicated in the specific columns in the chart provided in WAC 388-529-0200:

     (a) Categorically needy (CN) medical coverage is provided as described in the "CN" column. Coverage is modified by the provisions in this section and those found in ((chapter 388-86)) other medical-assistance-related WAC;

     (b) Medically needy (MN) medical coverage is provided as described in the "MN" column and as modified in this section and in ((chapter 388-86)) other medical-assistance-related WAC;

     (c) General assistance - unemployable (GAU) or alcohol and drug abuse treatment and support act (ADATSA) medical coverage is provided as described in the "MCS" column. Coverage is modified by the provisions in WAC ((388-86-120)) 388-556-0500;

     (d) The state-funded children's health program has medical coverage as described in the "CN" column and in subsection (1)(a) of this section;

     (e) State-funded medically indigent (MI) program has medical coverage as described in the "MI" column to the extent that services are related to the qualifying emergency condition. Coverage begins after the client has met the annual emergency medical expense requirement (EMER) as described in WAC 388-438-0100.

     (f) Pregnant undocumented aliens have medical coverage as described in the "CN" column and in subsection (1)(a) of this section.

     (2) "Medically necessary" is a standard for coverage of services under the CN and MN programs. The term is defined in WAC 388-500-0005.

     (3) Entries in WAC 388-529-0200 have the following meanings and conditions:

     (a) "Yes":

     (i) The service must be medically necessary as defined by the program; and

     (ii) The service may have conditions placed on coverage in order to ensure that medical necessity exists. Examples are:

     (A) The prior authorization requirement,

     (B) The primary care provider referral requirement,

     (C) The limit on eyeglasses to be covered for adults only once in a twenty-four-month period without documentation of special circumstances, etc.

     (b) "HK" - the services are provided to children under the healthy kids program as described in WAC ((388-86-027)) 388-534-0100. This is consistent with the broader scope of coverage under the healthy kids program.

     (c) "No" - This entry is used to describe coverage limitations of state-funded programs and indicates that the services are not covered. However, medically necessary services may be available under an "exception to rule" as described in chapter 388-440 WAC.

     (d) "L" - the services are provided under limited circumstances described further under WAC 388-529-0200.

     (e) "R" - the services are provided only as they are directly connected to emergency medical conditions. These program restrictions are described in WAC 388-438-0100.

     (4) Coverage described in this chapter may be further limited by the notations defined in WAC 388-529-0200 and ((the provisions in chapters 388-86 and 388-87)) other medical-assistance-related WAC. Services may require prior authorization to ensure that medical necessity exists.

     (5) Medical service categories not listed in WAC 388-529-0200 may not be covered under typical circumstances. Seeking specific coverage decisions in advance of service delivery is advised. Medical service providers may request authorization for any service which they see as medically necessary under WAC 388-501-0165.

[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090.      98-16-044, § 388-529-0100, filed 7/31/98, effective 9/1/98. Formerly WAC 388-503-0350, 388-529-2910, 388-529-2920 and 388-529-2930.]

(1) Persons who are eligible for Medicaid are eligible for healthy kids (HK) coverage up through the day before their twenty-first birthday.      This coverage is called early and periodic screening, diagnosis and treatment (EPSDT) in federal rule.

     (2) Access and services for healthy kids are governed by federal rules at 42 CFR, Part 441, Subpart B which were in effect as of January 1, 1998.

     (a) The standard for coverage for healthy kids is that the services, treatment or other measures are:

     (i) Medically necessary;

     (ii) Safe and effective; and

     (iii) Not experimental.

     (b) Healthy kids services are exempt from specific coverage or service limitations which are imposed on the rest of the CN and MN program.      Examples of service limits which do not apply to the healthy kids program are the specific numerical limits in WAC ((388-86-073(4), 388-86-090(2), 388-86-098(3))) 388-545-300, 388-545-500, and 388-545-700, etc.

     (c) Services not otherwise covered under the Medicaid program are available to children under healthy kids.      The services, treatments and other measures which are available include but are not limited to:

     (i) Nutritional counseling;

     (ii) Chiropractic care;

     (iii) Orthodontics; and

     (iv) Occupational therapy (not otherwise covered under the MN program).

     (d) Prior authorization and referral requirements are imposed on medical service providers under healthy kids.      Such requirements are designed as tools for determining that a service, treatment or other measure meets the standards in subsection (2)(a) of this section.

     (3) Transportation requirements of 42 CFR 441, Subpart B are met through a contract with transportation brokers throughout the state.

[00-11-183, recodified as § 388-534-0100, filed 5/24/00, effective 5/24/00.      Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090.      98-16-044, § 388-86-027, filed 7/31/98, effective 9/1/98.      Statutory Authority: RCW 74.08.090.      90-12-061 (Order 3019), § 388-86-027, filed 5/31/90, effective 7/1/90; 82-01-001 (Order 1725), § 388-86-027, filed 12/3/81; 81-10-015 (Order 1647), § 388-86-027, filed 4/27/81; 80-15-034 (Order 1554), § 388-86-027, filed 10/9/80; 79-12-047 (Order 1457), § 388-86-027, filed 11/26/79; Order 1112, § 388-86-027, filed 4/15/76; Order 738, § 388-86-027, filed 11/22/72.]

Reviser's note: The bracketed material preceding the section above was supplied by the code reviser's office.2846.1
AMENDATORY SECTION(Amending WSR 99-07-023, filed 3/10/99, effective 4/10/99)

WAC 388-535-1050
Dental-related definitions.

This section contains definitions of words and phrases in bold that the department uses in this chapter. See also chapter 388-500 WAC for other definitions and abbreviations. Further dental definitions used by the department may be found in the Current Dental Terminology (CDT-2) and the Current Procedural Terminology (CPT). Where there is any discrepancy between the CDT-2 or CPT and this section, this section prevails.

     "Access to baby and child dentistry (ABCD)" is a demonstration project to increase access to dental services in targeted areas for Medicaid eligible infants, toddlers, and preschoolers up through the age of five. See WAC 388-535-1300 for specific information.

     "Adult" means a client nineteen years of age or older.

     "Anterior" means teeth in the front of the mouth. In relation to crowns, only these permanent teeth are considered anterior for laboratory processed crowns:

     (1) "Lower anterior," teeth twenty-two, twenty-three, twenty-four, twenty-five, twenty-six, and twenty-seven; and

     (2) "Upper anterior," teeth six, seven, eight, nine, ten, and eleven.

     "Arch" means the curving structure formed by the crowns of the teeth in their normal position, or by the residual ridge after loss of the teeth.

     "Asymptomatic" means having no symptoms.

     "Banding" means the application of orthodontic brackets to the teeth for the purpose of correcting dentofacial abnormalities.

     "Base metal" means dental alloy containing little or no precious metals.

     "Behavior management" means managing the behavior of a client during treatment using the assistance of additional professional staff, and professionally accepted restraints or sedative agent, to protect the client from self-injury.

     "Bicuspid" means teeth four, five, twelve, thirteen, twenty, twenty-one, twenty-eight, and twenty-nine.

     "By report" - a method of payment for a covered service, supply, or equipment which:

     (1) Has no maximum allowable established by MAA,

     (2) Is a variation on a standard practice, or

     (3) Is rarely provided.

     "Caries" means tooth decay.

     "Child" means a client eighteen years of age or younger.

     "Cleft" means an opening or fissure involving significant dental processes, especially one occurring in the embryo.      These can be:

     (1) Cleft lip,

     (2) Cleft palate (at the roof of the mouth), or

     (3) Transverse facial cleft (macrostomia).

     "Comprehensive oral evaluation" means a thorough evaluation and recording of the hard and soft tissues in and around the mouth, including the evaluation and recording of the patient's dental and medical history and a general health assessment.

     "Corona" is the portion of a tooth that is covered by enamel, and is separated from the root or roots by a slightly constricted region, known as the cemento-enamel junction.

     "Craniofacial anomalies" means abnormalities of the head and face, either congenital or acquired, involving significant dental processes.

     "Craniofacial team" means a department of health and MAA recognized cleft palate/maxillofacial team which is: Responsible for management (review, evaluation, and approval) of patients with cleft palate craniofacial anomalies to provide integrated case management, promote parent-professional partnership, making appropriate referrals to implement and coordinate treatment plans.

     "Current dental terminology (CDT), second edition (CDT-2)," a systematic listing of descriptive terms and identifying codes for reporting dental services and procedures performed by dental practitioners.      CDT is published by the Council on Dental Benefit Programs of the American Dental Association (ADA).

     "Current procedural terminology (CPT)," means a description of medical procedures and is available from the American Medical Association of Chicago, Illinois.

     "Dental general anesthesia" means the use of agents to induce loss of feeling or sensation, a controlled state of unconsciousness, in order to allow dental services to be rendered to the client.

     "Dentally necessary" means diagnostic, preventive, or corrective services that are accepted dental procedures appropriate for the age and development of the client to prevent the incidence or worsening of conditions that endanger teeth or periodontium (tissues around the teeth) or cause significant malfunction or impede reasonable development or homeostatis (health) in the stomatognathic (mouth and jaw) system:

     (1) Which may include simple observation with no treatment, if appropriate; and

     (2) Includes use of less costly, equally effective services.

     "Dentin" is the mineralized tissue of the teeth, which surrounds the tooth pulp and is covered by enamel on the crown and by cementum on the roots of the teeth.

     "Dentures" are a set of prosthetic artificial teeth. See WAC 388-535-1240 for specific information.

     "Dysplasia" means an abnormality in the development of the teeth.

     "Enamel" is the white, compact, and very hard substance that covers and protects the dentin of the crown of a tooth.

     "Endodontic" means a root canal treatment and related follow-up.

     "EPSDT/healthy kids" means the department's early periodic screening, diagnosis, and treatment program for clients twenty years of age and younger as described in chapter 388-534 WAC ((388-86-027)).

     "Fluoride varnish" means a substance containing dental fluoride, for painting onto teeth. When painted onto teeth, it sticks to tooth surfaces.

     "Gingiva" means the gums.

     "Hemifacial microsomia" means half or part of the face is smaller-sized.

     "High noble metal" means dental alloy containing at least sixty percent pure gold.

     "High risk child" means any child who has been identified through an oral evaluation or assessment as being at a high risk for developing dental disease because of caries in the child's dentin; or a child identified by the department as developmentally disabled.

     "Hypoplasia" means the incomplete or defective development of the enamel of the teeth.

     "Low risk child" means any child who has been identified through an oral evaluation or assessment as being at a low risk for dental disease because of the absence of white spots or caries in the enamel or dentin.      This category includes children with restorations who are otherwise without disease.

     "Major bone grafts" means a transplant of solid bone tissue(s), such as buttons or plugs.

     "Malocclusion" means the contact between the upper and lower teeth that interferes with the highest efficiency during the movements of the jaw that are essential to chewing.      The abnormality is categorized into four classes, graded by Angle's classification. For coverage, see WAC 388-535-1250.

     "Maxillofacial" means relating to the jaws and face.

     "Minor bone grafts" means a transplant of nonsolid bone tissue(s), such as powdered bone.

     "Moderate risk child" means a child who has been identified through an oral evaluation or assessment as being at a moderate risk for dental disease, based on presence of white spots, enamel caries or hypoplasia.

     "Molars" means:

     (1) Permanent teeth one, two, three, fourteen, fifteen, sixteen, seventeen, eighteen, nineteen, thirty, thirty-one, and thirty-two; and

     (2) Primary teeth A, B, I, J, K, L, S and T.

     "Noble metal" means a dental alloy containing at least twenty-five percent but less than sixty percent pure gold.

     "Occlusion" means the relation of the upper and lower teeth when in functional contact during jaw movement.

     "Oral evaluation" is a comprehensive oral health and developmental history; an assessment of physical and oral health development and nutritional status; and health education, including anticipatory guidance.

     "Oral health assessment or screening" means a screening of the hard and soft tissues in the mouth.

     "Oral health status" refers to the client's risk or susceptibility to dental disease at the time an oral evaluation is done by a dental practitioner.      This risk is designated as low, moderate or high based on the presence or absence of certain indicators.

     "Orthodontic" is a treatment involving the use of any appliance, in or out of the mouth, removable or fixed, or any surgical procedure designed to redirect teeth and surrounding tissues.

     "Partials" means a prosthetic appliance replacing one or more missing teeth in one jaw, and receiving its support and retention from both the underlying tissues and some or all of the remaining teeth. See WAC 388-535-1240 for specific information.

     "Posterior" means teeth and tissue towards the back of the mouth. Specifically, only these permanent teeth: One, two, three, four, five, twelve, thirteen, fourteen, fifteen, sixteen, seventeen, eighteen, nineteen, twenty, twenty-one, twenty-eight, twenty-nine, thirty, thirty-one, and thirty-two.

     "Prophylaxis" means intervention which includes the scaling and polishing of teeth to remove coronal plaque, calculus, and stains.

     "Reline" means to resurface the tissue side of a denture with new base material in order to achieve a more accurate fit.

     "Root planing" is a procedure designed to remove microbial flora, bacterial toxins, calculus, and diseased cementum or dentin from the teeth's root surfaces and pockets.

     "Scaling" means the removal of calculous material from the exposed tooth surfaces and that part of the teeth covered by the marginal gingiva.

     "Sealant" is a material applied to teeth to prevent dental caries.

     "Sequestrectomy" means removal of dead or dying bone that has separated from healthy bone.

     "Therapeutic pulpotomy" means the surgical removal of a portion of the pulp (inner soft tissue of a tooth), to retain the healthy remaining pulp.

     "Usual and customary" means the fee that the provider usually charges non-Medicaid customers for the same service or item.      This is the maximum amount that the provider may bill MAA.

     "Wisdom teeth" means teeth one, sixteen, seventeen, and thirty-two.

[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225.      99-07-023, § 388-535-1050, filed 3/10/99, effective 4/10/99.      Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090.      96-01-006 (Order 3931), § 388-535-1050, filed 12/6/95, effective 1/6/96.]

(1) The medical assistance administration (MAA) pays school districts or educational service districts (ESD) for qualifying medical services provided to an eligible student.      To be covered under this section, the student must be eligible for Title XIX (i.e., either the categorically needy or medically needy programs).

     (2) To qualify for payment under this section, the medical services must be provided:

     (a) By the school district or the ESD; and

     (b) To the eligible special education student as part of the student's individualized education program (IEP) or individualized family service plan (IFSP).

     (3) To qualify for payment under this section, the medical services must be provided by one of the following service providers:

     (a) A qualified Medicaid provider as described under WAC ((388-87-005)) 388-502-0010;

     (b) A psychologist, licensed by the state of Washington or granted an educational staff associate (ESA) certificate by the state board of education;

     (c) A school guidance counselor, or a school social worker, who has been granted an ESA certificate by the state board of education; or

     (d) A person trained and supervised by any of the following:

     (i) A licensed registered nurse;

     (ii) A licensed physical therapist or physiatrist;

     (iii) A licensed occupational therapist; or

     (iv) A speech pathologist or audiologist who:

     (A) Has been granted a certificate of clinical competence by the American speech, hearing, and language association;

     (B) Is a person who completed the equivalent educational and work experience necessary for such a certificate; or

     (C) Is a person who has completed the academic program and is acquiring supervised work experience to qualify for the certificate.

     (4) Student service recommendations and referrals must be updated at least annually.

     (5) The student does not need a provider prescription to receive services described under this section.

     (6) MAA pays for school-based medical services according to the department-established rate or the billed amount, whichever is lower.

     (7) MAA does not pay individual school practitioners who provide school-based medical services.

     (8) For medical services billed to Medicaid, school districts or ESD, must pursue third-party resources.

[Statutory Authority: RCW 74.04.050 and 74.08.090.      00-01-088, § 388-537-0100, filed 12/14/99, effective 1/14/00.]

(1) A managed care enrollee is eligible for the categorically needy scope of medical care as described in WAC 388-529-0100.     

     (a) A client is entitled to timely access to medically necessary services as defined in WAC 388-500-0005.

     (b) The plan covers the services included in the HO contract for plan enrollees.      In addition, plans may, at their discretion, cover services not required under the HO contract.

     (c) MAA covers the categorically needy services not included in the HO contract for plan enrollees.

     (d) Plan enrollees may obtain certain services from either a plan provider or from a medical assistance provider with a DSHS core provider agreement without needing to obtain a referral from the PCP or plan.      These services are described in the HO contract, and are communicated to enrollees by MAA and plans as described in (e) of this subsection.

     (e) MAA sends each client written information about covered services when the client is required to enroll in managed care, and any time there is a change in covered services.      This information describes covered services, which services are covered by MAA, and which services are covered by plans.      In addition, MAA requires plans to provide new enrollees with written information about covered services.

     (f) MAA covers services on a fee-for-service basis for clients enrolled with a PCCM provider.      Except for emergencies, a client's PCCM provider must refer the client for most services not provided by the PCCM provider.      The services that require PCCM provider referral are described in the PCCM contract.      MAA requires PCCM providers to inform enrollees about covered services and how to obtain them.

     (2) For services covered by MAA for managed care enrollees:

     (a) MAA covers services rendered by providers with a current DSHS core provider agreement to provide the requested service;

     (b) MAA may require the provider to obtain authorization from MAA for coverage of nonemergency services;

     (c) MAA determines which services are medically necessary; and

     (d) An enrollee may request a fair hearing for review of MAA coverage decisions.

     (3) For services covered by plans:

     (a) MAA requires plans to contract with a sufficient number of providers as determined by MAA, to deliver the scope of services contracted with the plan in a timely fashion, according to the requirements of the HO contract.      Except for emergency services, plans provide covered services to enrollees through their participating providers;

     (b) MAA requires plans to provide new enrollees with written information about how enrollees may obtain covered services;

     (c) For nonemergency services, plans may require the enrollee to obtain a referral from the PCP, or the provider to obtain authorization from the plan, according to the requirements of the HO contract;

     (d) Plans and their providers determine which services are medically necessary given the enrollee's condition, according to the requirements included in the HO contract;

     (e) An enrollee may appeal plan coverage decisions using the plan's appeal process, as described in WAC 388-538-0110.      An enrollee may also request a ((fair)) hearing for review of a plan coverage decision as described in chapter ((388-08)) 388-02 WAC;

     (f) A managed care enrollee does not need a PCP referral to receive women's health care services, as described in RCW 48.42.100 from any women's health care provider participating with the plan.      Any covered services ordered and/or prescribed by the women's health care provider must meet the plan's service authorization requirements for the specific service.

     (4) Unless the plan chooses to cover these services, or an appeal or a fair hearing decision reverses a denial, the following services are not covered:

     (a) For all managed care enrollees:

     (i) Services that are not medically necessary;

     (ii) Services not included in the categorically needy scope of services; and

     (iii) Services, other than a screening exam as described in WAC 388-538-100(3), received in a hospital emergency department for nonemergency medical conditions.

     (b) For plan enrollees:

     (i) Services received from a participating specialist that require prior authorization from the plan, but were not authorized by the plan; and

     (ii) Services received from a nonparticipating provider that require prior authorization from the plan that were not authorized by the plan.      All nonemergency services covered under the HO contract and received from nonparticipating providers require prior authorization from the plan.

     (c) For PCCM enrollees, services that require a referral from the PCCM provider as described in the PCCM contract, but were not referred by the PCCM provider.

     (5) A provider may bill an enrollee for noncovered services as described in subsection (4) of this section, if the enrollee and provider sign an agreement.      The provider must give the original agreement to the enrollee and file a copy in the enrollee's record.

     (a) The agreement must state all of the following:

     (i) The specific service to be provided;

     (ii) That the service is not covered by either MAA or the plan;

     (iii) An explanation of why the service is not covered by the plan or MAA, such as:

     (A) The service is not medically necessary; or

     (B) The service is covered only when provided by a participating provider.

     (iv) The enrollee chooses to receive and pay for the service; and

     (v) Why the enrollee is choosing to pay for the service, such as:

     (A) The enrollee understands that the service is available at no cost from a provider participating with the plan, but the enrollee chooses to pay for the service from a provider not participating with the plan;

     (B) The plan has not authorized emergency department services for nonemergency medical conditions and the enrollee chooses to pay for the emergency department's services rather than wait to receive services at no cost in a participating provider's office; or

     (C) The plan has determined that the service is not medically necessary and the enrollee chooses to pay for the service.

     (b) For limited English proficient enrollees, the agreement must be translated or interpreted into the enrollee's primary language to be valid and enforceable.

     (c) The agreement is void and unenforceable, and the enrollee is under no obligation to pay the provider, if the service is covered by MAA or the plan as described in subsection (1) of this section, even if the provider is not paid for the covered service because the provider did not satisfy the payor's billing requirements.

[Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2.      00-04-080, § 388-538-095, filed 2/1/00, effective 3/3/00.      Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090.      98-16-044, § 388-538-095, filed 7/31/98, effective 9/1/98.      Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18.      95-18-046 (Order 3886), § 388-538-095, filed 8/29/95, effective 9/1/95.      Statutory Authority: RCW 74.08.090.      93-17-039 (Order 3621), § 388-538-095, filed 8/11/93, effective 9/11/93.]

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