WSR 02-23-082

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed November 19, 2002, 4:35 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 00-22-015.

Title of Rule: WAC 388-500-0005 Medical definitions.

Purpose: General updating of definitions of terms used throughout MAA rules (chapters 388-500 through 388-599 WAC). Some definitions have been changed to make them clearer; some terms defined in other MAA rules have been added here because they are used in more than one WAC chapter; while some definitions are altogether new.

Statutory Authority for Adoption: RCW 74.08.090.

Statute Being Implemented: RCW 74.08.090.

Summary: See Purpose above.

Reasons Supporting Proposal: It will give readers a better understanding of the terminology that is used throughout MAA WAC.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Kevin Sullivan, P.O. Box 45533, Olympia, WA 98504-5533, (360) 725-1344.

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

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

Explanation of Rule, its Purpose, and Anticipated Effects: General updating of definitions of terms used throughout MAA rules (chapters 388-500 through 388-599 WAC). Some definitions have been changed to make them clearer; some terms defined in other MAA rules have been added here because they are used in more than one WAC chapter; while some definitions are altogether new. It will give readers a better understanding of the terminology that is used throughout MAA WAC.

Proposal Changes the Following Existing Rules: It changes the definitions of terms used throughout MAA rules.

No small business economic impact statement has been prepared under chapter 19.85 RCW. This rule amendment does not impose more than minor costs on businesses.

RCW 34.05.328 does not apply to this rule adoption. The department has analyzed the proposed rule and concludes that it does not meet the definition of a "significant legislative rule" per RCW 34.05.328 (5)(c)(iii). The rule does not: (A) Adopt substantive provisions of law pursuant to delegated legislative authority, the violation of which subjects a violator of such rule to a penalty or sanction; (B) establish, alter, or revoke any qualification or standard for the issuance, suspension, or revocation of a license or permit; or (C) adopt a new, or make significant amendments to, a policy or regulatory program.

Hearing Location: Blake Office Park (behind Goodyear Courtesy Tire), 4500 10th Avenue S.E., Rose Room, Lacey, WA 98503, on January 7, 2003, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Andy Fernando, DSHS Rules Coordinator, by January 3, 2003, phone (360) 664-6094, TTY (360) 664-6178, e-mail fernaax@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, e-mail fernaax@dshs.wa.gov, by 5:00 p.m., January 7, 2003.

Date of Intended Adoption: Not sooner than January 8, 2003.

November 15, 2002

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3183.3
AMENDATORY SECTION(Amending Order 3913, #100246 [WSR 98-15-066], filed 7/13/98, effective 7/30/98)

WAC 388-500-0005   Medical definitions.   ((Unless defined in this chapter or in other chapters of the Washington Administrative Code, use definitions found in the Webster's New World Dictionary.)) This section contains definitions of words and phrases the department uses in rules for medical programs. ((Definitions of words used for both medical and financial programs are defined under WAC 388-22-030.)) Unless defined in this section or in another medical assistance rule (chapters 388-500 through 388-599 WAC), the definitions found in the Webster's New World Dictionary apply. If a definition in this section conflicts with a definition in another medical assistance chapter, the definition in the other chapter applies for the chapter in which it appears.

"Accept assignment" means a process in which a provider agrees to accept the Medicare program's payment as payment in full, except for specific deductible and coinsurance amounts required of the patient.

"Acquisition cost" means the cost of an item excluding shipping, handling, and any applicable taxes.

"Acute" means a medical condition of severe intensity with sudden onset and short duration.

"Acute care" means health care delivered to patients who are experiencing acute illness or trauma. Acute care is generally short-term and provided in a hospital or emergency room setting.

"Acute physical medicine and rehabilitation (acute PM&R)" means a comprehensive inpatient rehabilitative program coordinated by an interdisciplinary team at an MAA-approved rehabilitation facility. The program provides twenty-four-hour-a-day specialized nursing services and an intense level of therapy for a diagnostic category for which the client shows significant potential for functional improvement.

"ADATSA" - See definition for "Alcohol and Drug Addiction Treatment and Support Act."

"Adequate consideration" means that the payment (money, goods, and/or services) received in exchange for property approximates the fair market value of the property transferred. See "Value-Fair Market for an SSI-Related Person."

"Advance directive" means a document, recognized under state law, such as a living will, executed by a client, that tells the client's health care providers and others about the client's decisions regarding his or her medical care in the event the client should become incapacitated. (See WAC 388-501-0125.)

"Advanced registered nurse practitioner (ARNP)" means a person licensed under chapter 18.29 RCW as an advanced registered nurse practitioner.

"Aged" means sixty-five years of age and older.

"Alcohol and Drug Addiction Treatment and Support Act (ADATSA)" means the law and the state-funded program it established which provides medical and treatment services for persons who are incapable of gainful employment due to alcoholism or substance addiction.

"Alcoholism and/or alcohol abuse treatment" means medical and rehabilitative social services that are designed to mitigate or reverse the effects of alcoholism or alcohol abuse, and to reduce or eliminate alcoholism or alcohol abuse behaviors and restore normal social, physical, and psychological functioning. Alcoholism or alcohol abuse treatment is characterized by providing a combination of alcohol education sessions, individual therapy, group therapy, and related activities to persons who have undergone alcohol detoxification treatment and to their families.

"Alien" means a person:

(1) Permanently residing under color of law ("PRUCOL") (see WAC 388-424-0005).

(2) Lawfully present and residing in the United States with intent to remain ("Legal immigrant"). A legal immigrant includes, but is not limited to, a person meeting PRUCOL criteria.

(3) Temporarily residing in the United States for a specifically authorized purpose ("Nonimmigrant").

(4) Who meets the criteria in WAC 388-510-1005 ("Qualified alien").

"Allowed charge or allowed amount" means the maximum amount allowed by medical assistance administration (MAA) for any service, equipment or supply.

"Ambulance" means a ground or air vehicle licensed under RCW 18.73.140.

"Ancillary health services" means supplementary health services ordered by the provider to support the core treatment services provided to the patient. These supplementary services include, but are not limited to, laboratory and radiology services.

"Assets" means income, resources, or any real or personal property that a person or the person's spouse owns and could convert to cash to be used for support or maintenance.

"Assignment of rights" means the client gives the state the right to payment and support for medical care from a third party. The assignment of rights is derived from:

(1) A court order;

(2) An administrative order; or

(3) Any third party benefits or payment obligations.

"Audit" means an assessment, evaluation, examination, or investigation of a health care provider's accounts, books and records, including but not limited to:

(1) Medical, financial and billing records pertaining to:

(a) Billed services paid by the department through Medicaid, Medicaid/Medicare crossover or other state programs for the purpose of verifying the service was provided as billed and was allowable under program regulations; and

(b) General ledger and accounts receivable records or portions thereof to verify compliance with Medicaid third-party liability and coordination of benefits program requirements.

(2) Financial, statistical and medical records, including mathematical computations and special studies conducted to support cost reports submitted to the department.

"Audit claims sample" means a subset of the universe of paid claims from which the sample is drawn, whether based upon judgmental factors or random selection. The sample may consist of any number of claims in the population, up to one hundred percent.

"Authorization number" means a number assigned by MAA that identifies a specific request for approval for services or equipment.

"Authorization requirement" means a condition of coverage and reimbursement for specific services or equipment, when required by WAC or billing instructions. See WAC 388-501-0165 for the authorization process.

"Base period" means the time period used in the limited casualty program which corresponds with the months considered for eligibility.

"Basic Health (BH)" means the health care program authorized by chapter 70.47 RCW and administered by the health care authority (HCA).

"Beneficiary" means an eligible person who receives:

((*)) (1) A federal cash Title XVI benefit; and/or

((*)) (2) State supplement under Title XVI; or

((*)) (3) Benefits under Title XVIII of the Social Security Act.

"Benefit period" means the time period used in determining whether Medicare can pay for covered Part A services. A benefit period begins the first day a beneficiary is furnished inpatient hospital or extended care services by a qualified provider. The benefit period ends when the beneficiary has not been an inpatient for sixty consecutive days of a hospital or other facility primarily providing skilled nursing or rehabilitation services ((for sixty consecutive days)). There is no limit to the number of benefit periods a beneficiary may receive. Benefit period also means a "spell of illness" for Medicare payments.

(("Cabulance" means a vehicle for hire designed and used to transport a physically restricted person.))

"Billed charge" means the same as "usual and customary charge."

"Blind" means meeting the Supplemental Security Income (SSI) program criteria for visual acuity.

"Border area" means an area defined by state law as:

(1) Oregon - Astoria, Hermiston, Hood River, Milton-Freewater, Portland, Rainier, or The Dalles; and

(2) Idaho - Coeur d'Alene, Lewiston, Moscow, Priest River or Sandpoint.

"Bundled services" means services that are incidental to a major procedure and are not separately reimbursable.

"Bundled supplies" means supplies which are considered to be included in the practice expense relative value units (RVU) of the medical or surgical service of which they are an integral part, and are not separately reimbursable.

"By Report" means a method of reimbursement for covered items, procedures, and services for which the department has no set maximum allowable fees. MAA may require the provider to submit a written report to determine reimbursement.

"Carrier" means:

((*)) (1) An organization contracting with the federal government to process claims under Part B of Medicare; or

((*)) (2) A health insurance plan/managed care organization contracting with the department.

"Categorical assistance unit (CAU)" means one or more family members whose eligibility for medical care is determined separately or together based on categorical relatedness.

"Categorically needy" means the status of a person who is eligible for medical care under Title XIX of the Social Security Act. ((See WAC 388-503-0310, chapter 388-517 WAC and WAC 388-523-2305.)) For additional information, see WAC 388-503-0510 and chapter 388-517 WAC.

"Categorically needy program (CNP)" means a federally-matched Medicaid program providing maximum benefits to persons who qualify for medical assistance as persons who meet the income, resource, and categorical rules of the categorically needy program.

"Centers for Medicare and Medicaid Services (CMS)" means the agency within the federal Department of Health and Human Services (DHHS) with oversight responsibility for the Medicare and Medicaid programs. Formerly known as Health Care Financing Administration (HCFA).

"Certified registered nurse anesthetist (CRNA)" means an ARNP with formal training in anesthesia who meets all state and national criteria for certification. The American Association of Nurse Anesthetists specifies the National Certification and scope of practice.

"Chemical dependency" means an alcohol or drug addiction; or dependence on alcohol and one or more other psychoactive chemicals.

"Children's health insurance program (CHIP)" means ((a state-funded medical)) the federal Title XXI program ((for)) under which medical care is provided to uninsured children under age ((eighteen)) nineteen:

((*)) (1) Whose family income ((does not exceed one)) is between two hundred percent and two hundred fifty percent of the federal poverty level; and

((*)) (2) Who are not otherwise eligible under Title XIX of the Social Security Act.

(("Coinsurance-Medicare" means the portion of reimbursable hospital and medical expenses, after subtraction of any deductible, which Medicare does not pay. Under Part A, coinsurance is a per day dollar amount. Under Part B, coinsurance is twenty percent of reasonable charges.))

This program is sometimes referred to as the state children's health insurance program (S-CHIP).

"Chronic" means a disease, illness, or medical condition of long, indeterminate duration.

"Client" means an individual who has been determined eligible to receive medical or health care services under any MAA program.

"Client copay" or "copay" means an amount a client pays to health care providers for specific services.

"Clinical Laboratory Improvement Amendment (CLIA)" means regulations from the U.S. Department of Health and Human Services that require all laboratory testing sites to have either a CLIA registration or a CLIA certificate of waiver in order to legally perform testing anywhere in the U.S.

"Code of Federal Regulations (CFR)" means rules adopted by the federal government.

"Community services office (CSO)" means an office of the ((department which)) department's economic services administration that administers social and health services at the community level.

"Complication" means a disease or condition occurring subsequent to, or concurrent with, another condition and aggravating it.

"Conversion factors" means dollar amounts MAA uses to calculate the maximum allowable fee for physician- or hospital-related services.

"Core provider agreement" is the basic contract between MAA and an entity providing services to eligible clients. The core provider agreement outlines and defines terms of participation in medical assistance programs.

"Countable income" means the dollar amount remaining after the department excludes or disregards certain types of income allowed under client eligibility rules for medical assistance.

"Couple" means, for the purposes of an SSI-related client, ((an SSI-related client living with a person of the opposite sex and both presenting)) a man and woman that live together and both present themselves to the community as husband and wife. The department ((shall consider)) considers the income and resources of such a couple as if the couple ((were)) was married except when determining institutional eligibility.

(("Deductible-Medicare" means an initial specified amount that is the responsibility of the client.

*"Part A of Medicare-inpatient hospital deductible" means an initial amount of the medical care cost in each benefit period which Medicare does not pay.

*"Part B of Medicare-physician deductible" means an initial amount of Medicare Part B covered expenses in each calendar year which Medicare does not pay.))

"Delayed certification" means department approval of a person's eligibility for medicaid made after the established application processing time limits.

"Department" means the state department of social and health services (DSHS).

"Detoxification" means treatment provided to persons who are recovering from the effects of acute or chronic intoxication or withdrawal from alcohol or other drugs.

"Diabetes education program" means a comprehensive, multidisciplinary program of instruction on dealing with diabetes offered by a department of health (DOH)-approved facility to diabetic clients and their support people. Instruction includes nutrition, physical activity, medication management, glucose monitoring, and treating/preventing acute and chronic complications.

"Diagnosis code" means a set of alphabetic, numeric, or alpha-numeric characters assigned by the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9), as a shorthand symbol to represent the nature of a disease.

"Disabilities and long term care administration (DLTCA)" (formerly aging and adult services administration) means the administration within DSHS that manages the state's comprehensive long-term care system that provides in-home, residential, and nursing home services to adults with functional disabilities.

"Disabled" means persons meeting the disability criteria of the Supplemental Security Income (SSI) program found in the Social Security Act.

"Disposable supplies" means supplies which may be used once, or more than once, but cannot be used for an extended period of time.

"Dispute resolution conference" means a meeting for the purpose of resolving disagreement(s) between MAA and a contractor or provider. This meeting is not governed by the Administrative Procedure Act, chapter 34.05 RCW.

"Division of developmental disabilities (DDD)" means the organization within DSHS that supports individuals enrolled in DDD per RCW 71A.10.020 (3) and (4), and WAC 388-825-030.

"Drug addiction and/or drug abuse treatment" means medical and rehabilitative social services provided to an eligible client designed to mitigate or reverse the effects of drug addiction or drug abuse, and to reduce or eliminate drug addiction or drug abuse behaviors and restore normal physical and psychological functioning. Drug addiction or drug abuse treatment is characterized by providing a combination of drug and alcohol education sessions, individual therapy, group therapy and related activities to detoxified drug addicts and their families.

"Dual eligible" means a client who is eligible for both Medicare and Medicaid.

"Durable medical equipment (DME)" means equipment that:

(1) Can withstand repeated use;

(2) Is primarily and customarily used to serve a medical purpose;

(3) Generally is not useful to a person in the absence of illness or injury; and

(4) Is appropriate for use in the client's place of residence.

"Early and periodic screening, diagnosis and treatment (EPSDT)" ((also known as the "healthy kids" program,)) means a program providing early and periodic screening, diagnosis and treatment to persons under twenty-one years of age who are eligible for ((Medicaid or the children's health program)) medical assistance.

"Elective procedure or surgery" means a nonemergent procedure or surgery that can be scheduled at the client's and provider's convenience.

"Electronic fund transfers (EFT)" means ((automatic)) automated bank deposits to a client's or provider's account.

"Emergency medical condition" means the sudden onset of a medical condition (including labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

((*)) (1) Placing the patient's health in serious jeopardy;

((*)) (2) Serious impairment to bodily functions; or

((*)) (3) Serious dysfunction of any bodily organ or part.

"Emergency medical expense requirement (EMER)" means a specified amount of expenses for ambulance, emergency room or hospital services, including physician services in a hospital, incurred for an emergency medical condition that a client must incur prior to certification for the medically indigent program.

"Emergency medical services" means medical services required by and provided to a patient experiencing an emergency medical condition.

"Emergency room or emergency facility" means an organized, distinct, hospital-based facility that:

(1) Is available twenty-four hours a day;

(2) Provides unscheduled episodic services to patients who present for immediate medical attention; and

(3) Is capable of providing emergency medical services.

"Employer-sponsored dependent coverage" means creditable health coverage for dependents offered by a family member's employer or union, for which the employer or union may contribute in whole or part towards the premium.

"EPSDT" - See "early and periodic screening, diagnosis, and treatment."

"Essential spouse" see "spouse."

(("Extended care patient" means a recently hospitalized Medicare patient needing relatively short-term skilled nursing and rehabilitative care in a skilled nursing facility.))

"Estimated acquisition cost (EACH)" means MAA's best estimate of the price providers generally and currently pay for drugs and supplies.

"Evaluation and management (E&M) codes" means procedure codes which categorize physician services by type of service, place of service, and patient status.

"Expedited prior authorization (EPA)" means the process of obtaining authorization that must be used for selected services, in which providers use a set of numeric codes to indicate to MAA which acceptable indications, conditions, diagnoses, and/or criteria are applicable to a particular request for services.

"Experimental" means a term to describe a procedure, equipment, device, drug, or course of treatment, which lacks sufficient scientific evidence of safety and effectiveness. A service is not experimental if the service:

(1) Is generally accepted by the medical profession as effective and appropriate; or

(2) Has been approved by the U.S. Food and Drug Administration (FDA) or other requisite government body.

"Experimental drugs" means drugs the FDA has not approved; or approved drugs used for medical indications other than those listed by the FDA.

"Experimental treatment" means a course of treatment or procedure that:

(1) Is not generally accepted by the medical profession as effective and proven;

(2) Is not recognized by professional medical organizations as conforming to accepted medical practice;

(3) Has not been approved by the FDA or other requisite government body;

(4) Is still in clinical trials, or has been judged to need further study;

(5) Is covered by the federal law requiring provider institutional review of patient consent forms, and such review did not occur; or

(6) Is rarely used, novel, or relatively unknown, and lacks authoritative evidence of safety and effectiveness.

"Explanation of benefits (JOB)" means a coded message on the medical assistance remittance and status report that gives detailed information about the claim associated with that report.

"Family planning services" means services, including the use of contraceptive techniques, that a client uses to plan the number and spacing of the client's children.

"Federally qualified health center (FQHC)" means:

(1) A facility that is receiving grants under section 329, 330, or 340 of the Public Health Services Act; or

(2) A facility that is receiving such grants based on the recommendation of the Health Resources and Services Administration within the Public Health Service as determined by the secretary to meet the requirements for receiving such a grant; or

(3) A tribe or tribal organization operating outpatient health programs or facilities under the Indian Self Determination Act (P.L. 93-638).

Only Centers for Medicare and Medicaid Services-designated FQHCs will be allowed to participate in MAA's Medicaid program.

"Fee-for-service (FFS)" means a payment method MAA uses to reimburse providers for covered medical services provided to medical assistance clients, except those services provided under MAA's prepaid managed care programs.

"Fiscal intermediary" means an organization having an agreement with the federal government to process Medicare claims under Part A.

"Garnishment" means withholding an amount from earned or unearned income to satisfy a debt or legal obligation.

"General assistance expedited Medicaid disability (GA-X)" means a categorically needy medical component for GA-U clients whom the department presumes will meet SSI eligibility once SSA completes the SSI eligibility determination.

"General assistance unemployable (GA-U)" means a state-administered program providing cash assistance and medical care services to persons who are unemployable due to incapacity and who are not eligible for or receiving federal aid.

"Geographic practice cost index (GPCI)" as defined by Medicare, means a Medicare adjustment factor that includes local geographic area estimates of how hard the provider has to work (work effort), what the practice expenses are, and what malpractice costs are. The GPCI reflects one-fourth the difference between the area average and the national average.

"Grandfathered client" means:

((*)) (1) A noninstitutionalized person who meets all current requirements for Medicaid eligibility except the criteria for blindness or disability((; and

*)), and:

(a) Was eligible for Medicaid in December 1973 as blind or disabled whether or not the person was receiving cash assistance in December 1973; and

((*)) (b) Continues to meet the criteria for blindness or disability and other conditions of eligibility used under the Medicaid plan in December 1973; ((and

*)) or

(2) An institutionalized person who was eligible for Medicaid in December 1973 or any part of that month, as an inpatient of a medical institution or resident of an intermediate care facility that was participating in the Medicaid program and for each consecutive month after December 1973 who:

((*)) (a) Continues to meet the requirements for Medicaid eligibility that were in effect under the state's plan in December 1973 for institutionalized persons; and

((*)) (b) Remains institutionalized.

"Health Care Financing Administration (HCFA)" see "Centers for Medicare and Medicaid Services (CMS)."

"Health care financing administration common procedure coding system (HCPCS)" means a coding system established by CMS to define services and procedures not included in Current Physicians Terminology (CPT).

"Health care plan" see "Managed care organization."

"Health maintenance organization (HMO)" means an entity licensed by the office of the insurance commissioner to provide comprehensive medical services directly to an eligible enrolled client in exchange for a premium paid by the department on a prepaid capitation risk basis.

(("Healthy kids," see "EPSDT."))

"Home and community services (HCS) Office" means a disabilities and long term care administration office that manages the state's comprehensive long-term care system which provides in-home, residential, and nursing home services to adults with functional disabilities.

"Home health agency" means an agency or organization certified under Medicare to provide comprehensive health care on a part-time or intermittent basis to a patient in the patient's place of residence.

"Hospice" means a medically-directed, interdisciplinary program of palliative services which is provided under arrangement with a Washington state-licensed and Title XVIII-certified Washington state hospice for terminally ill clients and the clients' families. The hospice program allows the terminally ill client to choose physical, pastoral/spiritual, and psychosocial comfort rather than cure.

"Hospital" means an institution licensed as a hospital by the department of health.

"Income for an SSI-related client," means the receipt by an individual of any property or service which the client can apply either directly, by sale, or conversion to meet the client's basic needs for food, clothing, and shelter.

((*)) (1) "Earned income" means gross wages for services rendered and/or net earnings from self-employment.

((*)) (2) "Unearned income" means all other income.

"Informed consent" means that an individual agrees to a procedure after the provider who obtained a properly completed consent form has done all of the following:

(1) Disclosed and discussed the client's diagnosis;

(2) Offered the client an opportunity to ask questions about the procedure and to request information in writing;

(3) Given the client a copy of the consent form;

(4) Communicated effectively using any language interpretation or special communication device necessary per 42 C.F.R. Chapter IV 441.257; and

(5) Verbally informed the client about all of the following:

(a) The client's right to not obtain the procedure, including potential risks, benefits, and the consequences of not obtaining the procedure; and

(b) Alternatives to the procedure including potential risks, benefits, and consequences; and

(c) The procedure itself, including potential risks, benefits, and consequences.

"Inmate of a public institution" means an individual who is confined in a jail, prison, or other public institution (e.g., hospital).

"Institution" means an establishment ((which)) that furnishes food, shelter, ((medically-related services, and medical care)) and some treatment or services to four or more persons unrelated to the proprietor. ((This includes medical facilities, nursing facilities, and institutions for the mentally retarded.

*"Institution-public" means an institution, including a correctional institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control.

*"Institution for mental diseases" means an institution primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases including medical attention, nursing care, and related services.

*"Institution for the mentally retarded or a person with related conditions" means an institution that:

*Is primarily for the diagnosis, treatment or rehabilitation of the mentally retarded or a person with related conditions; and

*Provides, in a protected residential setting, on-going care, twenty-four hour supervision, evaluation, and planning to help each person function at the greatest ability.

*"Institution for tuberculosis" means an institution for the diagnosis, treatment, and care of a person with tuberculosis.

*"Medical institution" means an institution:

*Organized to provide medical care, including nursing and convalescent care;

*With the necessary professional personnel, equipment and facilities to manage the health needs of the patient on a continuing basis in accordance with acceptable standards;

*Authorized under state law to provide medical care; and

*Staffed by professional personnel. Services include adequate physician and nursing care)) This definition does not include community residential facilities such as adult family homes (AFH), adult residential care (ARC), and assisted living (AL), but does include the following:

(1) "Medical institution" means an institution:

(a) Organized to provide medical care, including nursing and convalescent care;

(b) With the necessary professional personnel, equipment and facilities to manage the health needs of the patient on a continuing basis in accordance with acceptable standards;

(c) Authorized under state law to provide medical care; and

(d) Staffed by professional personnel. Services include adequate physician and nursing care.

(2) "Public institution" means an institution, such as a correctional facility, VA hospital, or VA facility, that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control.

(3) "Institution for mental diseases" means an institution primarily engaged in providing diagnosis, treatment, or care, including medical attention, nursing care, and related services, to persons with mental diseases.

(4) "Institution for the mentally retarded" means an institution that:

(a) Is primarily for the diagnosis, treatment or rehabilitation of the mentally retarded or a person with related conditions; and

(b) Provides, in a protected residential setting, on-going care, twenty-four hour supervision, evaluation, and planning to help each person function at the greatest ability.

(5) "Institution for tuberculosis" means an institution for the diagnosis, treatment, and care of a person with tuberculosis.

"Interdisciplinary team (IDT)" means a group of medical professionals and others who are primarily responsible for the provision or supervision of care and services for a Medicaid client.

"Intermediary" ((means an organization having an agreement with the federal government to process Medicare claims under Part A.)) - See "Fiscal intermediary."

"International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) Edition" means the systematic listing that transforms verbal descriptions of diseases, injuries, conditions and procedures into alpha-numerical designations (coding).

"Intervention" means any medical or dental service provided to a client that modifies the medical or dental outcome for that client.

"Invasive procedure" means a medical intervention that intrudes on the client's person or breaks the skin barrier.

"Investigational" means a term to describe a procedure, or course of treatment, which lacks sufficient scientific evidence of benefit for a particular condition. A service is not investigational if the service:

(1) Is generally accepted by the medical profession as effective and appropriate for the condition in question; or

(2) Is supported by a preponderance of objective scientific evidence, in which the risks and benefits are examined, demonstrating the proposed service to be of greater overall benefit to the client in the particular circumstance than another, generally available service.

"Legal dependent" means a person for whom another person is required by law to provide support.

"Life support" means mechanical systems, such as ventilators or heart-lung respirators, which are used to supplement or take the place of the normal autonomic functions of a living person.

"Limitation extension (LE)" means a process for requesting reimbursement for covered services whose proposed quantity, frequency, or intensity exceeds that which MAA routinely reimburses. Limitation extensions require prior authorization.

"Limited casualty program (LCP)" means a medical care program for medically needy, as defined under WAC ((388-503-0320)) 388-505-0110 and 388-505-0210, and for medically indigent, as defined under WAC ((388-503-0370)) 388-438-0100.

"Limited English proficiency (LEP)" means a limited ability or an inability to speak, read, or write English well enough to understand and communicate effectively in English in normal daily activities. The client decides whether he/she is limited in his/her ability to speak, read, or write English.

"Long-term care services" means the DSHS-administered institutional, home and community-based, or hospice services provided for the elderly and disabled.

"Managed care" means a comprehensive system of coordinated medical and health care delivery including preventive, primary, specialty, and ancillary health services. (See WAC 388-538-050.)

"Managed care organization (MCO)" means a health maintenance organization or health care service contractor that contracts with DSHS under a comprehensive risk contract to provide prepaid health care services to eligible clients under MAA's managed care programs.

"Maximum allowable" means the maximum dollar amount MAA will reimburse a provider for a specific service, supply, or piece of equipment.

"Medicaid" means the ((federal aid)) state and federally funded Title XIX program under which medical care is provided to persons eligible for the:

((*)) (1) Categorically needy program ((as defined in WAC 388-503-0310 and 388-511-1105)); or

((*)) (2) Medically needy program ((as defined in WAC 388-503-0320)).

(("Medical assistance." See "Medicaid."))

"Medical assistance administration (MAA)" means the ((unit)) administration within ((the department of social and health services)) DSHS authorized by the secretary to administer the acute care portion of Title XIX Medicaid, Title XXI state-children's health insurance program (S-CHIP), Title XVI, and the state-funded medical care programs, with the exception of certain nonmedical services for persons with chronic disabilities.

"Medical assistance programs" means both Medicaid and medical care services programs.

"Medical assistance unit (MAU)" means one or more family members whose eligibility for medical care is determined separately or together based on financial responsibility.

"Medical care services" means the state-administered limited scope of care ((financed by state funds and)) provided to general assistance-unemployable (GA-U) and ADATSA clients.

"Medical consultant" means a physician, employed by ((the department)) MAA, who provides medical advice and expertise.

"Medical facility" see "Institution-Medical."

"Medical identification card" means the document MAA uses to identify a client's eligibility for a medical program. These cards were formerly known as medical assistance identification (MAID) cards.

"Medical institution" see "Institution - Medical."

"Medically indigent program (MIP)" means a state-funded medical program for a person who has an emergency medical condition requiring hospital-based services.

"Medically necessary" is a term for describing requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the client that endanger life, or cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the client requesting the service. For the purpose of this section, "course of treatment" may include mere observation or, where appropriate, no treatment at all.

"Medically needy (MN)" ((is)) means the status of a person who is eligible for a federally matched medical program under Title XIX of the Social Security Act, who, but for income above the categorically needy level, would be eligible as categorically needy. Effective January 1, 1996, an AFDC-related adult is not eligible for MN.

"Medically needy program or limited casualty program -medically needy (LCP-MNP)" means a federally matched Medicaid program under Title XIX of the Social Security Act for persons whose income exceeds Medicaid's categorically needy program (CNP) eligibility limits.

"Medicare" means the federal government health insurance program for certain aged or disabled clients under Titles II and XVIII of the Social Security Act. Medicare has two parts:

((*)) (1) "Part A" covers the Medicare inpatient hospital, post-hospital skilled nursing facility care, home health services, and hospice care.

((*)) (2) "Part B" is the supplementary medical insurance benefit (SMIB) covering the Medicare doctor's services, outpatient hospital care, outpatient physical therapy and speech pathology services, home health care, and other health services and supplies not covered under Part A of Medicare.

"Medicare assignment" means the method by which the provider receives payment for services under Part B of Medicare.

"Medicare buy-in premium" means a monthly premium the state pays for a client enrolled in part A and/or part B Medicare.

"Medicare Clinical Diagnostic Laboratory Fee Schedule" means the fee schedule used by Medicare to reimburse for clinical diagnostic laboratory procedures in the state of Washington.

"Medicare coinsurance" means the portion of reimbursable hospital and medical expenses, after subtraction of any deductible, which Medicare does not pay. Under Part A, coinsurance is a per day dollar amount. Under Part B, coinsurance is twenty percent of reasonable charges.

"Medicare crossover" means a claim involving a client who is eligible for both Medicare benefits and Medicaid.

"Medicare deductible" means an initial specified amount that is the responsibility of the client to pay.

(1) "Part A of Medicare-inpatient hospital deductible" means an initial amount of the medical care cost in each benefit period which Medicare does not pay.

(2) "Part B of Medicare-physician deductible" means an initial amount of Medicare Part B covered expenses in each calendar year which Medicare does not pay.

"Medicare fee schedule (MFS)" means the official CMS publication of Medicare policies and relative value units for the resource based relative value scale (RBRVS) reimbursement program.

"Mental health division" means the division within the department of social and health services that has lead responsibility for addressing services for persons who are mentally ill.

"Mentally incompetent" means a client who has been declared mentally incompetent by a federal, state, or local court of competent jurisdiction.

"Modifier" means a two-digit alphabetic and/or numeric identifier that is added to a procedure code to indicate the type of service performed. The modifier indicates a performed service or procedure has been altered by some specific circumstance, but not changed in its definition or code. The modifier can affect payment or be used for information only.

"Month of application" means the calendar month in which a person files the application for medical care. When the application is for the medically needy program, at the person's request and if the application is filed in the last ten days of that month, the month of application may be the following month.

"Nonallowed service or charge" means a service or charge that will not be reimbursed by the department.

"Noncovered service" - See WAC 388-501-0050 for the definition.

"Nonreusable supplies" are disposable supplies, which are used once and discarded.

"Nursing facility" means any institution or facility ((the department [of health] licenses as a nursing facility, or a nursing facility unit of a licensed hospital, that the:

*Department certifies; and

*Facility and the department agree the facility may provide skilled nursing facility care)):

(1) Licensed by the department of health (DOH) as a nursing facility, or a nursing facility unit of a licensed hospital; and

(2) Certified by the department of social and health services' aging and adult services administration.

"Orthotic device" means a corrective or supportive device that:

(1) Prevents or corrects physical deformity or malfunction; or

(2) Supports a weak or deformed portion of the body.

"Out-of-state hospital" means any hospital located outside the state of Washington or outside the designated border areas in Oregon and Idaho.

"Outpatient" means a ((nonhospitalized patient receiving care in a hospital outpatient or hospital emergency department, or away from a hospital such as in a physician's office, the patient's own home, or a nursing facility.

"Patient transportation" means client transportation to and from covered medical services under the federal Medicaid and state medical care programs)) client who is receiving medical services in other than an inpatient hospital setting.

"Outpatient care" means medical care provided in a hospital setting, other than inpatient services.

"Outpatient hospital" means a facility authorized by the department of health to provide outpatient services.

"Pain treatment facility" means an MAA-approved inpatient facility for pain management, in which a multidisciplinary approach is used to teach clients various techniques to live with chronic pain.

"Palliative" means medical treatment designed to reduce pain or discomfort, rather than cure.

"Participating provider" means a practitioner or entity who has a written contract with an MCO to provide health care services to managed care enrollees.

"Patient consent" means the informed consent of the client and/or the client's legal guardian as evidenced by the client's or legal guardian's signature on a consent form, for the procedure(s) to be performed upon or for the treatment to be provided to the client.

"Per diem rate" means the daily rate per client that a facility may bill or is allowed to receive as payment for its services.

"Personal or comfort item" means an item or service, which primarily serves the comfort or convenience of the client.

"Pharmacist" means a person licensed in the practice of pharmacy by the state in which the prescription is filled.

"Pharmacy" means every location licensed by the state where the practice of pharmacy is conducted.

"Physician" means a doctor of medicine, osteopathy, or podiatry who is legally authorized to perform the functions of the profession by the state in which the services are performed.

(("Professional activity study (PAS)" means a compilation of inpatient hospital data, conducted by the commission of professional and hospital activities, to determine the average length of hospital stay for patients.))

"Plan of treatment" or "plan of care" means the written plan of care for a patient which includes, but is not limited to, the physician's order for treatment and visits by the disciplines involved, the certification period, medications, and rationale indicating need for services.

"PM&R" see "acute physical medicine and rehabilitation."

"Point-of-sale (POS)" means a pharmacy claims processing system capable of receiving and adjudicating claims on-line.

"Practice of pharmacy" means the practice of and responsibility for:

(1) Accurately interpreting prescription orders;

(2) Compounding drugs;

(3) Dispensing, labeling, administering, and distributing of drugs and devices;

(4) Providing drug information to the client that includes, but is not limited to, the advising of therapeutic values, hazards, and the uses of drugs and devices;

(5) Monitoring of drug therapy and use;

(6) Proper and safe storage of drugs and devices;

(7) Documenting and maintaining records;

(8) Initiating or modifying drug therapy in accordance with written guidelines or protocols previously established and approved for a pharmacist's practice by a practitioner authorized to prescribe drugs; and

(9) Participating in drug utilization reviews and drug product selection.

"Practitioner" means an individual who has met the professional and legal requirements necessary to provide a health care service.

"Pregnant and postpregnancy women" means eligible female clients who are pregnant or have concluded their pregnancy within the last two to three months.

"Prescription" means an order for drugs or devices issued by a practitioner authorized by state law or rule to prescribe drugs or devices in the course of the practitioner's professional practice for a medically necessary purpose.

"Preventive" means medical practices that include counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of appropriate laboratory and diagnostic procedures intended to help a client avoid or reduce the risk or incidence of illness or injury.

"Primary care" means all health care services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, ARNP, or pediatrician.

"Primary care case management (PCCM)" means a system under which a provider contracts with the state to furnish case management services, which include the provision, coordination and monitoring of primary care to Medicaid clients.

"Primary care provider (PCP)" means a person licensed or certified under Title 18 RCW including, but not limited to, a physician or ARNP who supervises, coordinates, and provides health services to a client or an enrollee, initiates referrals for specialists and ancillary care, and maintains the client's or enrollee's continuity of care.

"Primary language" means the language identified by the client as the language in which he/she wishes to communicate. This may also be referred to as the preferred language.

"Prior authorization" means a process by which clients or providers must request and receive MAA approval for certain medical services, equipment, drugs, and supplies, based on medical necessity, before the services are provided to clients, as a precondition for provider reimbursement. Expedited prior authorization and limitation extension are forms of prior authorization. Also see WAC 388-501-0165 for a complete description.

"Professional component" means the part of a procedure or service that relies on the provider's professional skill or training, or the part of that reimbursement that recognizes the provider's cognitive skill.

"Professional review organization ((for Washington)) (PRO((-W)))" means the ((state level)) organization responsible for determining whether health care activities:

((*)) (1) Are medically necessary;

((*)) (2) Meet professionally acceptable standards of health care; and

((*)) (3) Are appropriately provided in an outpatient or institutional setting for beneficiaries of Medicare and clients of Medicaid and maternal and child health.

"Prognosis" means the probable outcome of a client's illness, including the likelihood of improvement, recurrence, or deterioration in the client's medical condition.

"Prosthetic devices" means replacement, corrective, or supportive devices prescribed by a physician or other licensed practitioner ((of the healing arts)) within the scope of his or her practice as defined by state law to:

((*)) (1) Artificially replace a missing portion of the body;

((*)) (2) Prevent or correct physical deformity or malfunction; or

((*)) (3) Support a weak or deformed portion of the body.

(("Provider" or "provider of service" means an institution, agency, or person:

*Who has a signed agreement with the department to furnish medical care, goods, and/or services to clients; and

*Is eligible to receive payment from the department.))

"Provider" means any person or organization that has a signed contract or core provider agreement with DSHS to provide services to eligible clients.

"Provider number" means an identification number issued to providers who have a signed contract(s) with MAA.

"Psychiatric hospitals" means designated psychiatric facilities, state psychiatric hospitals, designated distinct pediatric psychiatric units, and Medicare-certified distinct psychiatric units in acute care hospitals.

"Regional support network (RSN)" means a single or multiple county authority operating as prepaid health plans through which the mental health division contracts community services (outpatient and acute care inpatient) for the public mental health system.

"Reimbursement" means payment to a provider or other MAA-approved entity who bills in accordance with MAA rules.

"Relative value unit (RVU)" means a unit which is based on the resources required to perform an individual service or intervention.

"Remittance and status report (RA)" means a report produced by Medicaid Management Information System (MMIS), MAA's claims processing system, that provides detailed information concerning submitted claims and other financial transactions.

"Residence" means a client's home or place of living not including a hospital, skilled nursing facility, or residential facility with skilled nursing services available.

"Resource based relative value scale (RBRVS)" means a scale that measures the relative value of a medical service or intervention, based on the amount of physician resources involved.

"Resources for an SSI-related client," means cash or other liquid assets or any real or personal property that an individual or spouse, if any, owns and could convert to cash to be used for support or maintenance.

((*)) (1) If an individual can reduce a liquid asset to cash, it is a resource.

((*)) (2) If an individual cannot reduce an asset to cash, it is not considered an available resource.

((*)) (3) Liquid means properties that are in cash or are financial instruments which are convertible to cash such as, but not limited to, cash, savings, checking accounts, stocks, mutual fund shares, mortgage, or a promissory note.

((*)) (4) Nonliquid means ((all other)) property both real and personal evaluated at the price the item can reasonably be expected to sell for on the open market, but can't readily be converted to cash.

"Retroactive period" means the three calendar months before the month of application.

"Reusable supplies" are supplies designed to be used more than once.

"Revenue code" means a nationally used coding system for billing inpatient and outpatient hospital services, home health services, and hospice services.

"Revised Code of Washington (RCW)" means Washington state law.

"Rural health clinic" means a clinic that is located in a rural area designated as a shortage area, and is not a rehabilitation agency or a facility primarily for the care and treatment of mental diseases.

"Rural hospital" means a rural health care facility capable of providing or assuring availability of health services in a rural area.

"Spell of illness" see "benefit period."

"Spenddown" means the process by which a person uses incurred medical expenses to offset income and/or resources to meet the financial standards established by the department.

"Spouse" means:

((*)) (1) "Community spouse" means a legally married person ((living in the community and married to an institutionalized person or to a person receiving services from a home and community-based waivered program as described under chapter 388-515 WAC)) who does not live in an institution as defined in this section and whose spouse has attained institutional status as described in WAC 388-513-1320.

((*)) (2) "Eligible spouse" means an aged, blind or disabled husband or wife of an SSI-eligible person, with whom such a person lives.

((*)) (3) "Essential spouse" means, a husband or wife whose needs were taken into account in determining old age assistance (OAA), aid to the blind (AB), or disability assistance (DA) client for December 1973, who continues to live in the home and to be the spouse of such client.

((*)) (4) "Ineligible spouse" means the husband or wife of an SSI-eligible person, who lives with the SSI-eligible person and who has not applied for or is not eligible to receive SSI.

((*)) (5) "Institutionalized spouse" means a legally married person ((in an institution or receiving services from a home or community-based waivered program)) who has attained institutional status as described in WAC 388-513-1320.

((*)) (6) "Nonapplying spouse" means an SSI-((eligible))related person's husband or wife, who has not applied or is not eligible for assistance.

"SSI-related" means an aged, blind or disabled person not receiving an SSI cash grant.

"State plan" means the plan filed by the department with the Centers for Medicare and Medicaid Services (CMS), Department of Health and Human Services (DHHS), describing how the state will administer the Medicaid program.

"State supplementary payment (SSP)" means the state-money payment to certain persons receiving benefits under Title XVI, or who would, but for the person's income, be eligible for such benefits, as assistance based on need in supplementation of SSI benefits. This payment includes:

(1) "Mandatory state supplement" means the state-money payment to a person who, for December 1973, was a client receiving cash assistance under the department's former programs of old age assistance, aid to the blind and disability assistance; and

(2) "Optional state supplement" means the elective state-money payment to a person eligible for SSI benefits or who, except for the level of the person's income, would be eligible for SSI benefits.

"Supervision" means authoritative procedural guidance given by a qualified person who assumes the responsibility for the accomplishment of a function or activity and who provides initial direction and periodic inspection of the actual act of accomplishing the function or activity.

"Supplemental security income (SSI) program, Title XVI" means the federal grant program ((for aged, blind, and disabled)) established by section 301 of the Social Security amendments of 1972, and subsequent amendments, and administered by the Social Security Administration (SSA) for aged, blind and disabled persons.

(("Supplementary payment (SSP)" means the state money payment to persons receiving benefits under Title XVI, or who would, but for the person's income, be eligible for such benefits, as assistance based on need in supplementation of SSI benefits. This payment includes:

*"Mandatory state supplement" means the state money payment to a person who, for December 1973, was a client receiving cash assistance under the department's former programs of old age assistance, aid to the blind and disability assistance; and

*"Optional state supplement" means the elective state money payment to a person eligible for SSI benefits or who, except for the level of the person's income, would be eligible for SSI benefits.))

"Technical component" means the part of a procedure or service that relates to the equipment set-up and technician's time, or the part of the procedure and service reimbursement that recognizes the equipment cost and technician time.

"Terminally ill" means the client has a life expectancy of six months or less, assuming the client's disease process runs its natural course.

"Third party" means any entity that is or may be liable to pay all or part of the medical cost of care of a medical program client.

"Timely," when referring to the provision of services, means an enrollee receives medically necessary health care without unreasonable delay.

"Title XIX" ((is)) means the portion of the federal Social Security Act that authorizes grants to states for medical assistance programs. Title XIX is also called Medicaid.

"Title XXI" means the portion of the federal Social Security Act that authorizes grants to states for the children's health insurance program (CHIP).

"Transfer" means any act or omission to act when title to or any interest in property is assigned, set over, or otherwise vested or allowed to vest in another person; including delivery of personal property, bills of sale, deeds, mortgages, pledges, or any other instrument conveying or relinquishing an interest in property. Transfer of title to a resource occurs by:

((*)) (1) An intentional act or transfer; or

((*)) (2) Failure to act to preserve title to the resource.

"Transportation broker" means a person or organization contracted by MAA to arrange, coordinate and manage the provision of necessary but nonemergent transportation services for eligible clients to and from covered medical services.

"Transportation - Brokered" means nonemergent transportation arranged by a broker under contract with MAA, to provide transportation for eligible clients to or from covered medical services.

"Trauma care facility" means a facility certified by the department of health as a level I, II, III, IV or V facility.

"Trauma care service" - See department of health's WAC 246-976-935.

"Usual and customary charge" means the fee that the provider typically charges the general public for the product or service.

"Value-fair market for an SSI-related person" means the current value of a resource at the price for which the resource can reasonably be expected to sell on the open market.

"Value of compensation received" means, for SSI-related medical eligibility, the gross amount paid ((or agreed to be paid)) by the purchaser of a resource.

"Value-uncompensated" means, for SSI-related medical eligibility, the fair market value of a resource, minus the amount of compensation received in exchange for the resource.

"Vendor rate increase" means an adjustment determined by the legislature that is used to periodically increase reimbursement to vendors, including health care providers, that provide certain client services at rates established by MAA.

[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.04.005, 74.08.331, 74.08A.010, [74.08A.]100, [74.08A.]210, [74.08A.]230, 74.09.510, 74.12.255, Public Law 104-193 (1997) and the Balanced Budget Act [of] 1997. 98-15-066, 388-500-0005, filed 7/13/98, effective 7/30/98. Statutory Authority: RCW 74.08.090. 95-22-039 (Order 3913, #100246), 388-500-0005, filed 10/25/95, effective 10/28/95; 94-10-065 (Order 3732), 388-500-0005, filed 5/3/94, effective 6/3/94. Formerly parts of WAC 388-80-005, 388-82-006, 388-92-005 and 388-93-005.]

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

Washington State Code Reviser's Office