WSR 14-03-103
PROPOSED RULES
HEALTH CARE AUTHORITY
(Washington Apple Health)
[Filed January 17, 2014, 5:47 p.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 13-17-105.
Title of Rule and Other Identifying Information: WAC 182-500-0085 Medical assistance definitions—P, 182-501-0060 Health care coverage—Program benefits packages—Scope of service categories, and 182-501-0065 Health care coverage—Description of categories of service.
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 http://maa.dshs.wa.gov/pdf/CherryStreetDirectionsNMap.pdf or directions can be obtained by calling (360) 725-1000), on February 25, 2014, at 10:00 a.m.
Date of Intended Adoption: Not sooner than February 26, 2014.
Submit Written Comments to: HCA Rules Coordinator, P.O. Box 45504, Olympia, WA 98504-5504, delivery 626 8th Avenue, Olympia, WA 98504, e-mail arc@hca.wa.gov, fax (360) 586-9727, by 5:00 p.m. on February 25, 2014.
Assistance for Persons with Disabilities: Contact Kelly Richters by February 18, 2014, TTY (800) 848-5429 or (360) 725-1307 or e-mail kelly.richters@hca.wa.gov.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: HCA is updating its program benefits packages and scope of health care service categories effective January 1, 2014, to comply with changes required by the federal Affordable Care Act and recently passed state budget. Some of the changes include adding alternative benefit plan (ABP) as a program; adding applied behavior analysis (ABA) and habilitation services as categories of service; adding preventive exams, vaccinations, and screening, brief intervention, referral and treatment (SBIRT) for chemical dependency to health care professional services; defining habilitation services; and adding naturopathy to the definition of "physician."
Statutory Authority for Adoption: RCW 41.05.021.
Statute Being Implemented: 3ESHB 5034 (chapter 4, Laws of 2013); Patient Protection and Affordable Care Act (Public Law 111-148).
Rule is necessary because of federal law, Patient Protection and Affordable Care Act (Public Law 111-148).
Name of Proponent: HCA, governmental.
Name of Agency Personnel Responsible for Drafting: Kevin Sullivan, P.O. Box 42716, Olympia, WA 98504-2716, (360) 725-1344; Implementation and Enforcement: Gail Kreiger, P.O. Box 45506, Olympia, WA 98504-5506, (360) 725-1681.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The joint administrative rules review committee (JARRC) has not requested the filing of a small business economic impact statement, and these rules do not impose a disproportionate cost 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 JARRC or applied voluntarily.
January 17, 2014
Kevin M. Sullivan
Rules Coordinator
AMENDATORY SECTION (Amending WSR 13-19-037, filed 9/11/13, effective 10/12/13)
WAC 182-500-0085 Medical assistance definitions—P.
"Patient transportation" means client transportation to and/or from covered health care services under federal and state health care programs.
"Physician" means a doctor of medicine, osteopathy, naturopathy, or podiatry who is legally authorized to perform the functions of the profession by the state in which the services are performed.
"Prescribing provider" means any physician or other health care professional authorized by law or rule to prescribe drugs for current clients of Washington's health care programs administered by the agency.
"Prior authorization" is the requirement that a provider must request, on behalf of a client and when required by rule, the agency's or the agency's designee's approval to render a health care service or write a prescription in advance of the client receiving the health care service or prescribed drug, device, or drug-related supply. The agency's or the agency's designee's approval is based on medical necessity. Receipt of prior authorization does not guarantee payment. Expedited prior authorization and limitation extension are types of prior authorization.
"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:
•
Artificially replace a missing portion of the body;
•
Prevent or correct physical deformity or malfunction; or
•
Support a weak or deformed portion of the body.
"Provider" means an institution, agency, or person that is licensed, certified, accredited, or registered according to Washington state laws and rules, and:
(1) Has signed a core provider agreement or signed a contract with the agency or the agency's designee, and is authorized to provide health care, goods, and/or services to medical assistance clients; or
(2) Has authorization from a managed care organization (MCO) that contracts with the agency or the agency's designee to provide health care, goods, and/or services to eligible medical assistance clients enrolled in the MCO plan.
"Public institution" see "institution" in WAC 182-500-0050.
AMENDATORY SECTION (Amending WSR 13-15-044, filed 7/11/13, effective 8/11/13)
WAC 182-501-0060 Health care coverage—Program benefit((s)) packages—Scope of service categories.
(1) This rule provides a table that ((lists)):
(a) Lists the following Washington apple health (WAH) programs:
(i) The alternative benefits plan (ABP) medicaid;
(ii) Categorically needy (((CM))) (CN) medicaid((,));
(iii) Medically needy (MN) medicaid((,)); and
(iv) Medical care services (MCS) programs (includes incapacity-based and aged, blind, and disabled medical care services ((and the medical component of the Alcohol and Drug Addiction Treatment and Support Act (ADATSA) program))), as described in WAC 182-508-0005; and
(b) The benefit((s)) packages showing what service categories are included for each program.
(2) Within a service category included in a benefit((s)) package, some services may be covered and others noncovered.
(3) Services covered within each service category included in a benefit((s)) package:
(a) Are determined((,)) in accordance with WAC 182-501-0050 and 182-501-0055 when applicable.
(b) May be subject to limitations, restrictions, and eligibility requirements contained in agency rules.
(c) May require prior authorization (see WAC 182-501-0165), or expedited authorization when allowed by the agency.
(d) Are paid for by the agency or its designee and subject to review both before and after payment is made. The agency or the client's managed care organization may deny or recover payment for such services, equipment, and supplies based on these reviews.
(4) The agency does not pay for covered services, equipment, or supplies that:
(a) Require prior authorization from the agency or its designee, if prior authorization was not obtained before the service was provided;
(b) Are provided by providers who are not contracted with the agency as required under chapter 182-502 WAC;
(c) Are included in an agency or its designee waiver program identified in chapter 182-515 WAC; or
(d) Are covered by a third-party payor (see WAC 182-501-0200), including medicare, if the third-party payor has not made a determination on the claim or has not been billed by the provider.
(5) ((Other)) Programs not addressed in the table:
(a) ((Early and periodic screening, diagnosis, and treatment (EPSDT) services are not addressed in the table. For EPSDT services, see chapter 182-534 WAC and WAC 182-501-0050(10).
(b) The following programs are not addressed in the table:
(i))) Alien emergency medical (AEM) services (see chapter 182-507 WAC); and
(((ii))) (b) TAKE CHARGE program (see WAC 182-532-700 through 182-532-790);
(c) Postpartum and family planning extension (see WAC 182-523-0130(4) and 182-505-0115(5));
(d) Eligibility for pregnant minors (see WAC 182-505-0117); and
(e) Kidney disease program (see chapter 182-540 WAC).
(6) Scope of service categories. The following table lists the agency's categories of health care services.
(a) Under the ABP, CN, and MN headings there are two columns. One addresses clients twenty years of age and younger and the other addresses clients twenty-one years of age and older.
(b) The letter "Y" means a service category is included for that program. Services within each service category are subject to limitations and restrictions listed in the specific medical assistance program rules and agency issuances.
(c) The letter "N" means a service category is not included for that program.
(d) Refer to WAC 182-501-0065 for a description of each service category and for the specific program rules containing the limitations and restrictions to services.
Service Categories
ABP 20-
ABP 21+
CN1 20-
CN 21+
MN 20-
MN 21+
MCS
Ambulance (ground and air)
Y
 
Y
Y
Y
Y
Y
Applied behavior analysis (ABA)
Y
N
Y
N
Y
N
N
Behavioral health services
 
 
 
 
 
 
 
•
Mental health (MH) inpatient care
Y
Y
Y
Y
Y
Y
Y
•
MH outpatient community care
Y
Y
Y
Y
Y
Y
Y2
•
MH psychiatric visits
Y
Y
Y
Y
Y
Y
Y3
•
MH medication management
Y
Y
Y
Y
Y
Y
Y
•
Substance use disorder (SUD) detoxification
Y
Y
Y
Y
Y
Y
Y
•
SUD diagnostic assessment
Y
Y
Y
Y
Y
Y
Y
•
SUD residential treatment
Y
Y
Y
Y
Y
Y
Y
•
SUD outpatient treatment
Y
Y
Y
Y
Y
Y
Y
Blood/blood products/related services
Y
Y
Y
Y
Y
Y
Y
Dental services
Y
Y
Y
Y4
Y
Y4
Y4
Diagnostic services (lab and X ray)
Y
Y
Y
Y
Y
Y
Y
Early and periodic screening, diagnosis, and treatment (EPSDT) services
Y
N
Y
N
Y
N
N
Habilitative services
Y
Y
N
N
N
N
N
Health care professional services
Y
Y
Y
Y
Y
Y
Y
Hearing evaluations
Y
Y
Y
Y
Y
Y
Y
Hearing aids
Y
N
Y
N
Y
N
N
Home health services
Y
Y
Y
Y
Y
Y
Y
Hospice services
Y
Y
Y
Y
Y
Y
N
Hospital services Inpatient/outpatient
Y
Y
Y
Y
Y
Y
Y
Intermediate care facility/services for persons with intellectual disabilities
Y
Y
Y
Y
Y
Y
Y
Maternity care and delivery services
Y
Y
Y
Y
Y
Y
Y
Medical equipment, durable (DME)
Y
Y
Y
Y
Y
Y
Y
Medical equipment, nondurable (MSE)
Y
Y
Y
Y
Y
Y
Y
Medical nutrition services
Y
Y
Y
Y
Y
Y
Y
Nursing facility services
Y
Y
Y
Y
Y
Y
Y
Organ transplants
Y
Y
Y
Y
Y
Y
Y
Orthodontic services
Y
N
Y
N
Y
N
N
Out-of-state services
Y
Y
Y
Y
Y
Y
N
Outpatient rehabilitation services (OT, PT, ST)
Y
Y
Y
Y
Y
N
Y
Personal care services
Y
Y
Y
Y
N
N
N
Prescription drugs
Y
Y
Y
Y
Y
Y
Y
Private duty nursing
Y
Y
Y
Y
Y
Y
N
Prosthetic/orthotic devices
Y
Y
Y
Y
Y
Y
Y
((Psychological evaluation5
 
 
Y
Y
Y
Y
N))
Reproductive health services
Y
Y
Y
Y
Y
Y
Y
Respiratory care (oxygen)
Y
Y
Y
Y
Y
Y
Y
School-based medical services
Y
N
Y
N
Y
N
N
Vision care Exams, refractions, and fittings
Y
Y
Y
Y
Y
Y
Y
Vision hardware Frames and lenses
Y
N
Y
N
Y
N
N
1
Clients enrolled in the ((children's health insurance program and the)) Washington apple health for kids and Washington apple health for kids with premium programs, which includes the children's health insurance program (CHIP), receive CN-scope of ((medical)) health care services.
2
Restricted to incapacity-based MCS clients enrolled in managed care.
3
Incapacity-based MCS clients can receive one psychiatric diagnostic evaluation per year and eleven monthly visits per year for medication management.
((4
Restricted to those clients who meet the categorical requirements described in WAC 182-535-1060.
5
Only two allowed per lifetime.))
AMENDATORY SECTION (Amending WSR 13-15-044, filed 7/11/13, effective 8/11/13)
WAC 182-501-0065 Health care coverage—Description of service categories ((of service)).
This rule provides a brief description of the medical, dental, mental health, and substance use disorder (SUD) service categories listed in the table in WAC 182-501-0060. The description of services under each category is not intended to be all inclusive.
(1) For categorically needy (CN), medically needy (MN), and medical care services (MCS), refer to the WAC citations listed in the following descriptions for specific details regarding each service category.
(2) The following service categories are subject to the exclusions, limitations, restrictions, and eligibility requirements contained in agency rules:
(a) Ambulance - Emergency medical transportation and ambulance transportation for nonemergency medical needs. (WAC 182-546-0001 through 182-546-4000.)
(b) Applied behavior analysis (ABA) – (WAC 182-531-1410 through 182-531-1434).
(c) Behavioral health services - 
(i) Mental health inpatient care - Voluntary and involuntary admissions for psychiatric services. (WAC 182-550-2600.)
(ii) Mental health outpatient (community mental health) services - Nonemergency, psychological evaluation, nonurgent counseling. (WAC 182-531-1400, 388-865-0215, ((and)) 388-865-0230, and 388-865-0610 (1)(d)(i).)
(iii) Psychiatric visits. (WAC 182-531-1400 and 388-865-0230.)
(iv) Mental health medication management. (WAC 182-531-1400.)
(v) Substance use disorder (SUD) detoxification. (WAC ((182-508-0305)) 388-877B-0100 through 388-877B-0130 and 182-550-1100; WAC 182-556-0400(3).)
(vi) ((Substance use disorder)) SUD diagnostic assessment. (WAC ((182-508-0330)) 388-877B-0500 through 388-877B-0550.)
(vii) ((Substance use disorder)) SUD residential treatment. (WAC ((182-508-0310 through 182-508-0375; and WAC 182-556-0100)) 388-877B-0200 through 388-877B-0280.)
(viii) ((Substance use disorder)) SUD outpatient treatment. (WAC ((182-508-0310 through 182-508-0375)) 388-877B-0300 through 388-877B-0370; WAC 182-533-0701 through 182-533-0730((; WAC 182-556-0100 and 182-556-0400)).)
(((c))) (d) Blood, blood products, and related services - Blood and/or blood derivatives, including synthetic factors, plasma expanders, and their administration. (WAC 182-550-1400 and 182-550-1500.)
(((d))) (e) Dental services - Diagnosis and treatment of dental problems including emergency treatment and preventive care. (Chapters 182-535 and 182-535A WAC.)
(((e))) (f) Diagnostic services - Clinical testing and imaging services. (WAC 182-531-0100; WAC 182-550-1400 and 182-550-1500.)
(((f))) (g) Early and periodic screening, diagnosis, and treatment (EPSDT) – (Chapter 182-534 WAC and WAC 182-501-0050(10).)
(h) Habilitative services – (Chapter 182-545 WAC).
(i) Health care professional services - Office visits, ((emergency oral health,)) vaccinations, screening/brief intervention/referral to treatment (SBIRT), emergency room, nursing facility, home-based, and hospital-based care; surgery, anesthesia, pathology, radiology, and laboratory services; obstetric services; kidney dialysis and renal disease services; osteopathic care, podiatry services, physiatry, and pulmonary/respiratory services; and allergen immunotherapy. (Chapter 182-531 WAC.)
(((g))) (j) Hearing evaluations - Audiology; diagnostic evaluations; hearing exams and testing. (WAC 182-531-0100 and 182-531-0375.)
(((h))) (k) Hearing aids - (Chapter 182-547 WAC.)
(((i))) (l) Home health services - Intermittent, short-term skilled nursing care, occupational therapy, physical therapy, speech therapy, home infusion therapy, and health aide services, provided in the home. (WAC 182-551-2000 through 182-551-2220.)
(((j))) (m) Hospice services - Physician services, skilled nursing care, medical social services, counseling services for client and family, drugs, medications (including biologicals), medical equipment and supplies needed for palliative care, home health aide, homemaker, personal care services, medical transportation, respite care, and brief inpatient care. This benefit also includes services rendered in a hospice care center and pediatric palliative care services. (WAC 182-551-1210 through 182-551-1850.)
(((k))) (n) Hospital services—Inpatient/outpatient - Emergency room; hospital room and board (includes nursing care); inpatient services, supplies, equipment, and prescription drugs; surgery, anesthesia; diagnostic testing, laboratory work, blood/blood derivatives; radiation and imaging treatment and diagnostic services; and outpatient or day surgery, and obstetrical services. (Chapter 182-550 WAC.)
(((l))) (o) Intermediate care facility/services for persons with intellectual disabilities - Habilitative training, health-related care, supervision, and residential care. (Chapter 388-835 WAC.)
(((m))) (p) Maternity care and delivery services - Community health nurse visits, nutrition visits, behavioral health visits, midwife services, maternity and infant case management services, family planning services and community health worker visits. (WAC 182-533-0330.)
(((n))) (q) Medical equipment, durable (DME) - Wheelchairs, hospital beds, respiratory equipment; casts, splints, crutches, trusses, and braces. (Chapter 182-543 WAC.)
(((o))) (r) Medical equipment, nondurable (MSE) - Antiseptics, germicides, bandages, dressings, tape, blood monitoring/testing supplies, braces, belts, supporting devices, decubitus care products, ostomy supplies, pregnancy test kits, syringes, needles, and urological supplies. (Chapter 182-543 WAC.)
(((p))) (s) Medical nutrition services - Enteral and parenteral nutrition, including supplies. (Chapters 182-553 and 182-554 WAC.)
(((q))) (t) Nursing facility services - Nursing, therapies, dietary, and daily care services. (Chapter 388-97 WAC.)
(((r))) (u) Organ transplants - Solid organs, e.g., heart, kidney, liver, lung, pancreas, and small bowel; bone marrow and peripheral stem cell; skin grafts; and corneal transplants. (WAC 182-550-1900 and 182-556-0400.)
(((s))) (v) Orthodontic services – (Chapter 182-535A WAC).
(w) Out-of-state services - ((See)) (WAC 182-502-0120 ((for services out-of-state))).
(((t))) (x) Outpatient rehabilitation services (OT, PT, ST) - Evaluations, assessments, and treatment. (WAC 182-545-200.)
(((u))) (y) Personal care services - Assistance with activities of daily living (e.g., bathing, dressing, eating, managing medications) and routine household chores (e.g., meal preparation, housework, essential shopping, transportation to medical services). (WAC 388-106-0010, 388-106-0200, 388-106-0300, 388-106-0600, 388-106-0700, 388-106-0745, and 388-106-0900.)
(((v))) (z) Prescription drugs - Outpatient drugs (including in nursing facilities), both generic and brand name; drug devices and supplies; some over-the-counter drugs; oral, topical, injectable drugs; vaccines, immunizations, and biologicals; and family planning drugs, devices, and supplies. (WAC 182-530-2000.) Additional coverage for medications and prescriptions is addressed in specific program WAC sections.
(((w))) (aa) Private duty nursing - Continuous skilled nursing services provided in the home, including client assessment, administration of treatment, and monitoring of medical equipment and client care for clients seventeen years of age and under. (WAC 182-551-3000.) For benefits for clients eighteen years of age and older, see WAC 388-106-1000 through 388-106-1055.
(((x))) (bb) Prosthetic/orthotic devices - Artificial limbs and other external body parts; devices that prevent, support, or correct a physical deformity or malfunction. (WAC 182-543-5000.)
(((y) Psychological evaluation - Complete diagnostic history, examination, and assessment, including the testing of cognitive processes, visual motor responses, and abstract abilities. (WAC 388-865-0610.)
(z))) (cc) Reproductive health services - Gynecological exams; contraceptives, drugs, and supplies, including prescriptions; sterilization; screening and treatment of sexually transmitted diseases; and educational services. (WAC 182-532-001 through 182-532-140.)
(((aa))) (dd) Respiratory care (oxygen) - All services, oxygen, equipment, and supplies related to respiratory care. (Chapter 182-552 WAC.)
(((bb))) (ee) School-based medical services - Medical services provided in schools to children with disabilities under the Individuals with Disabilities Education Act (IDEA). (Chapter 182-537 WAC.)
(((cc))) (ff) Vision care - Eye exams, refractions, fittings, visual field testing, vision therapy, ocular prosthetics, and surgery. (WAC 182-531-1000.)
(((dd))) (gg) Vision hardware - Frames and lenses. (Chapter 182-544 WAC.)