WSR 16-01-178
(Washington Apple Health)
[Filed December 22, 2015, 1:48 p.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 15-09-051.
Title of Rule and Other Identifying Information: WAC 182-500-0070 Medical assistance definitionM.
Hearing Location(s): Health Care Authority (HCA), Cherry Street Plaza Building, Sue Crystal Conference Room 106A, 626 8th Avenue, Olympia, WA 98504 (metered public parking is available street side around building. A map is available at or directions can be obtained by calling (360) 725-1000), on January 26, 2016, at 10:00 a.m.
Date of Intended Adoption: Not sooner than January 27, 2016.
Submit Written Comments to: HCA Rules Coordinator, P.O. Box 45504, Olympia, WA 98504-5504, delivery 626 8th Avenue, Olympia, WA 98504, e-mail, fax (360) 586-9727, by 5:00 p.m. on January 26, 2016.
Assistance for Persons with Disabilities: Contact Amber Lougheed by January 22, 2016, e-mail, (360) 725-1349, or TTY (800) 848-5429 or 711.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The agency is striking the definition for "Medical assistance administration," adding definitions for "Medicaid agency" and medically needy income level, and making other changes to improve clarity.
Reasons Supporting Proposal: To provide readers with current and accurate information.
Statutory Authority for Adoption: RCW 41.05.021, 41.05.160.
Statute Being Implemented: RCW 41.05.021, 41.05.160.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: HCA, governmental.
Name of Agency Personnel Responsible for Drafting: Melinda Froud, P.O. Box 42716, Olympia, WA 98504-2716, (360) 725-1408; Implementation and Enforcement: Ann Myers, P.O. Box 42716, Olympia, WA 98504-2716, (360) 725-1345.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The proposed filing does not create a disproportionate impact on small businesses.
A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to HCA rules unless requested by the joint administrative rules review committee or applied voluntarily.
December 22, 2015
Wendy Barcus
Rules Coordinator
AMENDATORY SECTION (Amending WSR 14-01-021, filed 12/9/13, effective 1/9/14)
WAC 182-500-0070 Medical assistance definitions—M.
"Medicaid" ((is)) means the federal medical aid program under Title XIX of the Social Security Act ((under which)) that provides health care ((is provided)) to eligible persons.
"Medicaid agency" means the state agency that administers the medicaid program. The Washington state health care authority (HCA) is the state's medicaid agency.
"Medical assistance" is the term the agency and its predecessors ((used prior to the implementation of the Affordable Care Act in Washington state)) use to mean all federal ((and/or)) or state-funded health care programs, or both, administered by the agency or its ((designee that are now known)) designees. Medical assistance programs are referred to as Washington apple health (WAH).
(("Medical assistance administration (MAA)" is the former organization within the department of social and health services authorized to administer the federally funded and/or state-funded health care programs that are now administered by the agency, formerly the medicaid purchasing administration (MPA), of the health and recovery services administration (HRSA).))
"Medical care services (MCS)" means the limited scope health care program financed by state funds for clients ((who meet the incapacity criteria defined in chapter 182-508 WAC or)) who are eligible for the ((Alcohol and Drug Addiction Treatment and Support Act (ADATSA) program)) aged, blind, or disabled (ABD) cash assistance or the housing and essential needs (HEN) referral program and not eligible for other WAH programs due to their citizenship or immigration status.
"Medical consultant" means a physician employed by or contracted ((by)) with the agency or the agency's designee.
"Medical facility" means a medical institution or clinic that provides health care services.
"Medical institution" See "institution" in WAC 182-500-0050.
"Medical services card" or "services card" means the card ((issued by)) the agency issues at the initial approval of a person's ((Washington apple health ())WAH(())) benefit. The card identifies the person's name and medical services identification number((,)) but is not proof of WAH eligibility ((for WAH)). The card may be replaced upon request if it is lost or stolen, but is not required to access health care through WAH.
"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 purposes of this section, "course of treatment" may include mere observation or, where appropriate, no medical treatment at all.
"Medically needy (MN)" or "medically needy program (MNP)" ((is)) means the state((-)) and federally funded health care program available to ((specific groups of persons)) people who would be eligible as categorically needy (CN), except their monthly income is above the CN standard. Some long-term care clients with income ((and/or)) or resources above the CN standard may also qualify for MN.
"Medically needy income level (MNIL)" means the standard the agency uses to determine eligibility under the medically needy program. See WAC 182-519-0050.
"Medicare" ((is the federal government health insurance program for certain aged or disabled persons under Titles II and XVIII of the Social Security Act. Medicare has four parts:
(1) "Part A" - Covers medicare inpatient hospital services, post-hospital skilled nursing facility care, home health services, and hospice care.
(2) "Part B" - The supplementary medical insurance benefit (SMIB) that covers medicare doctors' 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.
(3) "Part C" - Covers medicare benefits for clients enrolled in a medicare advantage plan.
(4) "Part D" - The medicare prescription drug insurance benefit.)) means the medical aid program under Titles II and XVIII of the Social Security Act.
"Medicare assignment" means the process by which a provider agrees to provide services to a medicare ((beneficiary)) client and accept medicare's payment for the services.
"Medicare cost-sharing" means out-of-pocket medical expenses related to services provided by medicare. For ((medical assistance)) WAH clients ((who are)) enrolled in medicare, cost-sharing may include Part A and Part B premiums, co-insurance, deductibles, and copayments for medicare services. See chapter 182-517 WAC ((for more information)).
"Minimum essential coverage" means coverage ((defined in Section 5000A(f) of Subtitle D of the Internal Revenue Code of 1986, as added by Section 1401 of the Affordable Care Act)) under 26 U.S.C. Sec. 5000A(f).
"Modified adjusted gross income (MAGI)" means the adjusted gross income ((())as determined by the Internal Revenue Service under the Internal Revenue Code of 1986 (IRC)(())) increased by:
(1) Any amount excluded from gross income under ((Section 911 of the IRC)) 26 U.S.C. Sec. 911;
(2) Any amount of interest received or accrued by the ((taxpayer)) client during the taxable year which is exempt from tax; and
(3) Any amount of Title II Social Security income or Tier 1 railroad retirement ((income which is)) benefits excluded from gross income under ((Section 86 of the IRC. See WAC 182-509-0300 through 182-509-0375 for additional rules regarding MAGI)) 26 U.S.C. Sec. 86. See chapter 182-509 WAC.