WSR 01-09-037



(Medical Assistance Administration)

[ Filed April 11, 2001, 4:27 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 01-02-046.

Title of Rule: Amending WAC 388-501-0300 Limits on scope of medical program services.

Purpose: The department recently reorganized its rules, establishing new chapters for several programs and services. WAC 388-501-0300(2) lists services, equipment, supplies, and items that are now codified primarily in new chapters 388-531 and 388-543 WAC. In order to avoid unnecessary duplication, the department is amending WAC 388-531-0300 to eliminate the list in subsection (2), clarify the remaining policies, and add cross-references to WAC 388-501-0165.

Statutory Authority for Adoption: RCW 74.08.090.

Statute Being Implemented: RCW 74.08.090.

Summary: The department is proposing to amend WAC 388-501-0300 by eliminating subsection (2) to avoid duplicating policies that are codified in other rules, primarily chapters 388-531 and 388-543 WAC. The department is also proposing to clarify remaining policy by rewriting it, and to add cross-references to WAC 388-501-0165.

Reasons Supporting Proposal: To eliminate duplicative rules, and to clarify department policy to meet the mandates of the Governor's Executive Order 97-02.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Ann Myers, DPS/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: The proposed rule eliminates the list in subsection (2) to avoid duplicating rules that are codified in chapters 388-531 and 388-543 WAC. It also clarifies the remaining policy and adds cross-references to WAC 388-501-0165. The anticipated effect is to avoid confusion and comply with the mandates in the Governor's Executive Order 97-02.

Proposal Changes the Following Existing Rules: The rules proposed eliminate the list in subsection (2), rewrite the remaining sections for clarification, and add cross-references to WAC 388-501-0165.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department analyzed the proposed rules and concludes that they do not change existing policy, and so will not have a more than minor impact on the small businesses affected by them.

RCW 34.05.328 does not apply to this rule adoption. The department analyzed the proposed rule and concludes that since it does not change existing department policy, it does not make "significant amendments to a policy or regulatory program." Therefore the department concludes that the proposed rules do not meet the definition of a "significant legislative rule."

Hearing Location: Blake Office Building East, 4500 10th Avenue S.E., Rose Room, Lacey, WA 98503, on May 22, 2001, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Kelly Cooper, Rules Coordinator, by May 17, 2001, phone (360) 664-6094, TTY (360) 664-6178, e-mail

Submit Written Comments to: Identify WAC Numbers, Kelly Cooper, Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, by May 22, 2001.

Date of Intended Adoption: Not sooner than May 23, 2001.

April 9, 2001

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

AMENDATORY SECTION(Amending Order 3599 [WSR 00-23-052], filed 11/13/00, effective 12/14/00)

WAC 388-501-0300   Limits on scope of medical program services.   (1) The medical assistance administration (MAA) ((shall pay)) pays only for equipment, supplies, and services that are listed as covered in MAA published issuances, including Washington Administrative Code (WAC), ((billing instructions, numbered memoranda, and bulletins, and)) when the items or services are:

(a) Within the scope of an eligible client's medical care program;

(b) Medically necessary as defined in WAC 388-500-0005;

(c) Billed according to the requirements in WAC 388-502-0100, 388-502-0110, and 388-502-0150; and

(d) Within accepted medical, dental, or psychiatric practice standards and are:

(i) Consistent with a diagnosis; and

(ii) Reasonable in amount and duration of care, treatment, or service.

(((d) Not listed under subsection (2) of this section; and

(e) Billed according to the conditions of payment under WAC 388-87-010.

(2) Unless required under EPSDT/healthy kids program; included as part of a managed care plan service package; included in a waivered program; or part of one of the Medicare programs for the qualified Medicare beneficiaries, the MAA shall specifically exclude from the scope of covered services:

(a) Nonmedical equipment, supplies, personal or comfort items and/or services, including, but not limited to:

(i) Air conditioners or air cleaner devices, dehumidifiers, other environmental control devices, heating pads;

(ii) Enuresis (bed wetting) training equipment;

(iii) Recliner and/or geri-chairs;

(iv) Exercise equipment;

(v) Whirlpool baths;

(vi) Telephones, radio, television;

(vii) Any services connected to the telephone, television, or radio;

(viii) Homemaker services;

(ix) Utility bills; or

(x) Meals delivered to the home.

(b) Services, procedures, treatment, devices, drugs, or application of associated services which the department or HCFA consider investigative or experimental on the date the services are provided;

(c) Physical examinations or routine checkups;

(d) Cosmetic treatment or surgery, except for medically necessary reconstructive surgery to correct defects attributable to an accident, birth defect, or illness;

(e) Routine foot care that includes, but not limited to:

(i) Medically unnecessary treatment of mycotic disease;

(ii) Removal of warts, corns, or calluses;

(iii) Trimming of nails and other hygiene care; or

(iv) Treatment of asymptomatic flat feet.

(f) More costly services when less costly equally effective services as determined by the department are available;

(g) Procedures, treatment, prosthetics, or supplies related to gender dysphoria surgery except when recommended after a multidisciplinary evaluation including but not limited to urology, endocrinology, and psychiatry;

(h) Care, testing, or treatment of infertility, frigidity, or impotency. This includes procedures for sterilization reversals and donor ovum, sperm, or womb;

(i) Acupuncture, massage, or massage therapy;

(j) Orthoptic eye training therapy;

(k) Weight reduction and control services not provided in conjunction with a MAA medically approved program. This includes food supplements and educational products;

(l) Parts of the body, including organs tissues, bones, and blood;

(m) Blood and eye bank charges;

(n) Domiciliary or custodial care, excluding nursing facility care;

(o) Hair pieces, wigs, or hair transplantation;

(p) Biofeedback or other self-help care;

(q) Marital counseling or sex therapy;

(r) Any service specifically excluded by statute; and

(s) Home births, except when provided as an approved service under MAA's planned home birth pilot project.

(3) Clients shall be responsible for payment as described under WAC 388-87-010 for services not covered under the client's medical care program))

(2) MAA covers equipment, supplies, or services that are listed as noncovered when the equipment, supplies, or services are medically necessary and:

(a) Required under the EPSDT/healthy kids program;

(b) Included in a waivered program; or

(c) Part of one of the medical assistance programs for qualified Medicare beneficiaries.

(3) When a client or a client's representative requests equipment, supplies, or services that are listed as noncovered, MAA evaluates the request under WAC 388-501-0165.

(4) MAA evaluates requests for covered equipment, supplies, or services that are subject to limitations or other restrictions, and approves such equipment, supplies, or services beyond those limitations or restrictions when medically necessary, under the standards for covered services in WAC 388-501-0165.

(5) MAA evaluates a request for a service that is in a covered category, but is determined to be experimental or investigational under WAC 388-531-0550, under the provisions of WAC 388-501-0165 which relate to medical necessity.

(6) Clients are responsible for payment as described under WAC 388-502-0160, for services that are not covered under the client's medical care program.

[Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.800. 00-23-052, amended and recodified as 388-501-0300, filed 11/13/00, effective 12/14/00. Statutory Authority: RCW 74.08.090. 93-16-037 (Order 3599), 388-86-200, filed 7/28/93, effective 8/28/93; 93-11-086 (Order 3536), 388-86-200, filed 5/19/93, effective 6/19/93.]

Reviser's note: The bracketed material preceding the section above was supplied by the code reviser's office.

Washington State Code Reviser's Office