WSR 10-07-116

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed March 22, 2010, 11:58 a.m. , effective April 22, 2010 ]


     Effective Date of Rule: Thirty-one days after filing.

     Purpose: Correcting errant WAC cross references.

     Citation of Existing Rules Affected by this Order: Amending WAC 388-501-0050 and 388-501-0055.

     Statutory Authority for Adoption: RCW 74.08.090.

      Adopted under notice filed as WSR 10-04-117 on February 3, 2010.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 2, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 2, Repealed 0.

     Date Adopted: March 16, 2010.

Katherine I. Vasquez

Rules Coordinator

4171.1
AMENDATORY SECTION(Amending WSR 09-23-112, filed 11/18/09, effective 12/19/09)

WAC 388-501-0050   Healthcare general coverage.   WAC 388-501-0050 through 388-501-0065 describe the healthcare services available to a client on a fee-for-service basis or to a client enrolled in a managed care organization (MCO) (defined in WAC 388-538-050). For the purposes of this section, healthcare services includes treatment, equipment, related supplies, and drugs. WAC 388-501-0070 describes noncovered services.

     (1) Healthcare service categories listed in WAC 388-501-0060 do not represent a contract for healthcare services.

     (2) For the provider to receive payment, the client must be eligible for the covered healthcare service on the date the healthcare service is performed or provided.

     (3) Under the department's fee-for-service programs, providers must be enrolled with the department and meet the requirements of chapter 388-502 WAC to be paid for furnishing healthcare services to clients.

     (4) The department pays only for the healthcare services that are:

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

     (b) Covered - see subsection (((8))) (9) of this section;

     (c) Ordered or prescribed by a healthcare provider who meets the requirements of chapter 388-502 WAC;

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

     (e) Submitted for authorization, when required, in accordance with WAC 388-501-0163;

     (f) Approved, when required, in accordance with WAC 388-501-0165;

     (g) Furnished by a provider according to chapter 388-502 WAC; and

     (h) Billed in accordance with department program rules and the department's current published billing instructions and numbered memoranda.

     (5) The department does not pay for any healthcare service requiring prior authorization from the department, if prior authorization was not obtained before the healthcare service was provided; unless:

     (a) The client is determined to be retroactively eligible for medical assistance; and

     (b) The request meets the requirements of subsection (4) of this section.

     (6) The department does not reimburse clients for healthcare services purchased out-of-pocket.

     (7) The department does not pay for the replacement of department-purchased equipment, devices, or supplies which have been sold, gifted, lost, broken, destroyed, or stolen as a result of the client's carelessness, negligence, recklessness, or misuse unless:

     (a) Extenuating circumstances exist that result in a loss or destruction of department-purchased equipment, devices, or supplies, through no fault of the client that occurred while the client was exercising reasonable care under the circumstances; or

     (b) Otherwise allowed under chapter 388-500 WAC.

     (8) The department's refusal to pay for replacement of equipment, device, or supplies will not extend beyond the limitations stated in specific department program rules.

     (9) Covered healthcare services

     (a) Covered healthcare services are either:

     (i) "Federally mandated" - means the state of Washington is required by federal regulation (42 CFR 440.210 and 220) to cover the healthcare service for medicaid clients; or

     (ii) "State-option" - means the state of Washington is not federally mandated to cover the healthcare service but has chosen to do so at its own discretion.

     (b) The department may limit the scope, amount, duration, and/or frequency of covered healthcare services. Limitation extensions are authorized according to WAC 388-501-0169.

     (10) Noncovered healthcare services

     (a) The department does not pay for any healthcare service:

     (i) That federal or state laws or regulations prohibit the department from covering; or

     (ii) Listed as noncovered in WAC 388-501-0070 or in any other program rule. The department evaluates a request for a noncovered healthcare service only if an exception to rule is requested according to the provisions in WAC 388-501-0160.

     (b) When a noncovered healthcare ((services)) service is recommended during the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) exam and then ordered by a provider, the department evaluates the healthcare service according to the process in WAC 388-501-0165 to determine if it is medically necessary, safe, effective, and not experimental (see WAC 388-534-0100 for EPSDT rules).

[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 09-23-112, § 388-501-0050, filed 11/18/09, effective 12/19/09; 06-24-036, § 388-501-0050, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090. 01-12-070, § 388-501-0050, filed 6/4/01, effective 7/5/01. Statutory Authority: RCW 74.04.050 and 74.08.090. 00-01-088, § 388-501-0050, filed 12/14/99, effective 1/14/00.]


AMENDATORY SECTION(Amending WSR 09-17-004, filed 8/6/09, effective 9/6/09)

WAC 388-501-0055   Healthcare coverage--How the department determines coverage of services for its healthcare programs using health technology assessments.   (1) The department uses health technology assessments in determining whether a new technology, new indication, or existing technology approved by the Food and Drug Administration (FDA) is a covered service under department healthcare programs. The department only uses health technology assessments when coverage is not mandated by federal or state law. A health technology assessment may be conducted by or on behalf of:

     (a) The department; or

     (b) The health technology assessment clinical committee (HTACC) according to RCW 70.14.080 through 70.14.140.

     (2) The department reviews available evidence relevant to a medical or dental service or healthcare-related equipment and uses a technology evaluation matrix, in order to:

     (a) Determine its efficacy, effectiveness, and safety;

     (b) Determine its impact on health outcomes;

     (c) Identify indications for use;

     (d) Identify potential for misuse or abuse; and

     (e) Compare to alternative technologies to assess benefit vs. harm and cost effectiveness.

     (3) The department may determine the technology, device, or technology-related supply is:

     (a) Covered (See WAC 388-501-0060 for the scope of coverage for department medical assistance programs.);

     (b) Covered with authorization (See WAC 388-501-0165 for the process on how authorization is determined.);

     (c) Covered with limitations (See WAC 388-501-0169 for how limitations can be extended.); or

     (d) Noncovered (See WAC 388-501-0070 for the services determined to be noncovered.).

     (4) The department may periodically review existing technologies, devices, or technology-related supplies and reassign authorization requirements as necessary according to the same provisions as outlined above for new technologies, devices, or technology-related supplies.

     (5) The department evaluates the evidence and criteria presented by HTACC to determine whether a service is covered in accordance with WAC 388-501-0050 (((6))) (9) and (((7))) (10) and this section.

[Statutory Authority: RCW 74.08.090 and 70.14.090. 09-17-004, § 388-501-0055, filed 8/6/09, effective 9/6/09.]

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