Effective Date of Rule: Immediately.
Purpose: Upon order of the governor, the health care authority (HCA) reduced its budget expenditures for fiscal year 2011 and 2012 by reducing or eliminating a number of optional medical services from program benefits packages for clients twenty-one years of age and older. These medical services include vision, hearing, and dental care. Sections in chapter 182-501 WAC and WAC 182-502-0160 are being amended to reflect and support these program cuts.
Citation of Existing Rules Affected by this Order: Amending WAC 182-501-0050, 182-501-0060, 182-501-0065, 182-501-0070, and 182-502-0160.
Statutory Authority for Adoption: RCW 41.05.021.
Other Authority: Chapter 564, Laws of 2011 (2ESSHB [2E2SHB] 1738).
Under RCW 34.05.350 the agency for good cause finds that immediate adoption, amendment, or repeal of a rule is necessary for the preservation of the public health, safety, or general welfare, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the public interest; that state or federal law or federal rule or a federal deadline for state receipt of federal funds requires immediate adoption of a rule; and that in order to implement the requirements or reductions in appropriations enacted in any budget for fiscal year 2009, 2010, 2011, 2012 or 2013, which necessitates the need for the immediate adoption, amendment, or repeal of a rule, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the fiscal needs or requirements of the agency.
Reasons for this Finding: Governor Gregoire issued Executive Order 10-04 on September 13, 2010, under the authority of RCW 43.88.110(7). In the executive order, the governor required DSHS and all other state agencies to reduce their expenditures in state fiscal year 2011 by approximately 6.3 percent. As a consequence of the executive order, funding for the benefits was eliminated effective January 1, 2011, as part of these regulatory amendments. HCA is proceeding with the permanent rule adoption process initiated by the CR-101 filed under WSR 10-22-12 [10-22-121]. HCA has completed a stakeholder review and will filing [file] the CR-102 in May 2013.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.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 5, 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 5, Repealed 0.
Date Adopted: April 26, 2013.
Kevin M. Sullivan
AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-501-0050 Health care general coverage. WAC ((
388-501-0050)) 182-501-0050 through (( 388-501-0065))
182-501-0065 describe the health care 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)) 182-538-050). For the purposes of this
section, health care services includes treatment, equipment,
related supplies, and drugs. WAC (( 388-501-0070))
182-501-0070 describes noncovered services.
(1) Health care service categories listed in WAC
388-501-0060)) 182-501-0060 do not represent a contract for
health care services.
(2) For the provider to receive payment, the client must be eligible for the covered health care service on the date the health care service is performed or provided.
(3) Under the ((
department's)) agency's or its designee's
fee-for-service programs, providers must be enrolled with the
(( department)) agency or its designee and meet the
requirements of chapter (( 388-502)) 182-502 WAC to be paid for
furnishing health care services to clients.
(4) The ((
department)) agency or its designee pays only
for the health care services that are:
Within the scope of)) Included in the client's
(( medical program)) health care benefits package as described
in WAC 182-501-0060;
(b) Covered - See subsection (9) of this section;
(c) Ordered or prescribed by a health care provider who
meets the requirements of chapter ((
388-502)) 182-502 WAC;
(d) Medically necessary as defined in WAC
(e) Submitted for authorization, when required, in
accordance with WAC ((
(f) Approved, when required, in accordance with WAC
(g) Furnished by a provider according to chapter
388-502)) 182-502 WAC; and
(h) Billed in accordance with ((
department)) agency or
its designee program rules and the (( department's)) agency's
current published billing instructions and numbered memoranda.
(5) The ((
department)) agency or its designee does not
pay for any health care service requiring prior authorization
from the (( department)) agency or its designee, if prior
authorization was not obtained before the health care 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)) agency does not reimburse clients
for health care services purchased out-of-pocket.
(7) The ((
department)) agency does not pay for the
replacement of (( department-purchased)) agency-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, deliberate intent, or
(a) Extenuating circumstances exist that result in a loss
or destruction of ((
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))
specific agency program rules.
(8) The ((
department's)) agency's refusal to pay for
replacement of equipment, device, or supplies will not extend
beyond the limitations stated in specific (( department))
agency program rules.
(9) Covered health care services.
(a) Covered health care services are either:
(i) "Federally mandated" - Means the state of Washington is required by federal regulation (42 C.F.R. 440.210 and 220) to cover the health care service for medicaid clients; or
(ii) "State-option" - Means the state of Washington is not federally mandated to cover the health care service but has chosen to do so at its own discretion.
(b) The ((
department)) agency or its designee may limit
the scope, amount, duration, and/or frequency of covered
health care services. Limitation extensions are authorized
according to WAC (( 388-501-0169)) 182-501-0169.
(10) Noncovered health care services.
(a) The ((
department)) agency or its designee does not
pay for any health care service(( :
(i) That federal or state laws or regulations prohibit the department from covering; or
(ii))) listed as noncovered in WAC ((
182-501-0070 or in any other agency program rule. The
(( department)) agency or its designee evaluates a request for
a noncovered health care service only if an exception to rule
is requested according to the provisions in WAC
(( 388-501-0160)) 182-501-0160.
(b) When a noncovered health care service is recommended
during the Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) exam and then ordered by a provider, the
department)) agency or its designee evaluates the health
care service according to the process in WAC (( 388-501-0165))
182-501-0165 to determine if it is medically necessary, safe,
effective, and not experimental (see WAC (( 388-534-0100))
182-534-0100 for EPSDT rules).
[11-14-075, recodified as § 182-501-0050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. 10-07-116, § 388-501-0050, filed 3/22/10, effective 4/22/10. 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.]
(2) Not all categories of service listed in this section are covered under every medical program, nor do they represent a contract for services. Services are subject to the exclusions, limitations, and eligibility requirements contained in department rules.
(3) Services covered under each listed category:
(a) Are determined by the department after considering available evidence relevant to the service or equipment to:
(i) Determine efficacy, effectiveness, and safety;
(ii) Determine impact on health outcomes;
(iii) Identify indications for use;
(iv) Compare alternative technologies; and
(v) Identify sources of credible evidence that use and report evidence-based information.
(b) May require prior authorization (see WAC 388-501-0165), or expedited authorization when allowed by the department.
(c) Are paid for by the department and subject to review both before and after payment is made. The department or the client's managed care organization may deny or recover payment for such services, equipment, and supplies based on these reviews.
(4) The department does not pay for covered services, equipment, or supplies that:
(a) Require prior authorization from the department, if prior authorization was not obtained before the service was provided;
(b) Are provided by providers who are not contracted with the department as required under chapter 388-502 WAC;
(c) Are included in a department waiver program identified in chapter 388-515 WAC; or
(d) Are covered by a third-party payer (see WAC 388-501-0200), including medicare, if the third-party payer has not made a determination on the claim or has not been billed by the provider.
(5) Scope of covered service categories. The following table lists the department's covered categories of health care services.
• Under the four program columns (CN, MN, MCS, and AEM), the letter "C" means a service category is covered for that program, subject to any limitations listed in the specific medical assistance program WAC and department issuances.
• The letter "N" means a service category is not covered under that program.
• The letter "E" means the service category is available on ly if it is necessary to treat the client's emergency medical condition and may require prior authorization from the department.
• Refer to WAC 388-501-0065 for a description of each service category and for the specific program WAC containing the limitations and exclusions to services.
|*Clients enrolled in the State Children's Health Insurance
Program and the Children's Health Program receive CN scope of
medical care.)) (1) This rule provides a table that lists:
(a) The categorically needy (CN) medicaid, medically needy (MN) medicaid, and medical care services (MCS) programs (include incapacity-based medical care services and the medical component of the Alcohol and Drug Addiction Treatment and Support Act (ADATSA) program); and
(b) The benefits packages showing what service categories are included for each program.
(2) Within a service category included in a benefits package, some services may be covered and others noncovered.
(3) Services covered within each service category included in a benefits 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 or its designee.
(d) Are paid for by the agency or its designee and subject to review both before and after payment is made. The agency or its designee 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 or its designee 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 or its designee 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:
(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);
(ii) TAKE CHARGE program (see WAC 182-532-700 through 182-532-790); and
(iii) Psychiatric indigent inpatient program (see WAC 182-550-2600).
(6) Scope of service categories. The following table lists the agency's categories of health care services.
(a) Under the 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 WAC 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 WAC containing the limitations and restrictions to services.
|Service Categories||CN1 20-||21+||MN 20-||21+||MCS|
|Ambulance (ground and air)||Y||Y||Y||Y||Y|
|Behavioral health services||Y||Y||Y||Y||Y|
|•||Mental health (MH) inpatient care||Y||Y||Y||Y||Y|
|•||MH outpatient community care||Y||Y||Y||Y||Y2|
|•||MH psychiatric visits||Y||Y||Y||Y||Y3|
|•||MH medication management||Y||Y||Y||Y||Y|
|•||Substance use disorder (SUD) detoxification||Y||Y||Y||Y||Y|
|•||SUD diagnostic assessment||Y||Y||Y||Y||Y|
|•||SUD residential treatment||Y||Y||Y||Y||Y|
|•||SUD outpatient treatment||Y||Y||Y||Y||Y|
|Blood/blood products/related services||Y||Y||Y||Y||Y|
|Diagnostic services (lab and X ray)||Y||Y||Y||Y||Y|
|Health care professional services||Y||Y||Y||Y||Y|
|Home health services||Y||Y||Y||Y||Y|
|Hospital services - Inpatient/outpatient||Y||Y||Y||Y||Y|
|Intermediate care facility/services for persons with intellectual disabilities||Y||Y||Y||Y||Y|
|Maternity care and delivery services||Y||Y||Y||Y||Y|
|Medical equipment, durable (DME)||Y||Y||Y||Y||Y|
|Medical equipment, nondurable (MSE)||Y||Y||Y||Y||Y|
|Medical nutrition services||Y||Y||Y||Y||Y|
|Nursing facility services||Y||Y||Y||Y||Y|
|Outpatient rehabilitation services (OT, PT, ST)||Y||Y||Y||N||Y|
|Personal care services||Y||Y||N||N||N|
|Private duty nursing||Y||Y||Y||Y||N|
|Reproductive health services||Y||Y||Y||Y||Y|
|School-based medical services||Y||N||Y||N||N|
|Vision care - Exams, refractions, and fittings||Y||Y||Y||Y||Y|
|Vision hardware - Frames and lenses||Y||N||Y||N||N|
|1||Clients enrolled in the children's health insurance program and the apple health for kids program receive CN-scope of medical care.|
|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.|
[11-14-075, recodified as § 182-501-0060, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-501-0060, filed 11/30/06, effective 1/1/07.]
(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. ((
For Alien Emergency
Medical (AEM) services, refer to WAC 388-438-0110.))
(2) The following service categories are subject to the
exclusions, limitations, restrictions, and eligibility
requirements contained in ((
department)) agency rules:
Adult day health -- Skilled nursing services,
counseling, therapy (physical, occupational, speech, or
audiology), personal care services, social services, general
therapeutic activities, health education, nutritional meals
and snacks, supervision, and protection. [WAC 388-71-0702
-- )) - Emergency medical transportation
and ambulance transportation for nonemergency medical needs. (( [WAC 388-546-0001 through 388-546-4000]
(c))) (WAC 182-546-0001 through 182-546-4000.)
(b) Behavioral health services - Crisis mental health services are available to state residents through the regional support networks (RSNs).
(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, nonurgent counseling. (WAC 182-531-1400, 388-865-0215, and 388-865-0230.)
(iii) Psychiatric visits. (WAC 182-531-1400 and 388-865-0230.)
(iv) Mental health medication management. (WAC 182-531-1400.)
(v) Substance use disorder detoxification. (WAC 182-508-0305 and 182-550-1100; WAC 182-556-0400(3).)
(vi) Substance use disorder diagnostic assessment. (WAC 182-508-0330.)
(vii) Substance use disorder residential treatment. (WAC 182-508-0310 through 182-508-0375; and WAC 182-556-0100.)
(viii) Substance use disorder outpatient treatment. (WAC 182-508-0310 through 182-508-0375; WAC 182-533-0701 through 182-533-0730; WAC 182-556-0100 and 182-556-0400.)
(c) Blood ((
processing/administration -- )), blood
products, and related services - Blood and/or blood
derivatives, including synthetic factors, plasma expanders,
and their administration. (( [WAC 388-550-1400 and
388-550-1500])) (WAC 182-550-1400 and 182-550-1500.)
(d) Dental services((
-- )) - Diagnosis and treatment of
dental problems including emergency treatment and preventive
care. (( [Chapters 388-535 and 388-535A WAC])) (Chapters
182-535 and 182-535A WAC.)
Detoxification -- Inpatient treatment performed by a
certified detoxification center or in an inpatient hospital
setting. [WAC 388-800-0020 through 388-800-0035; and
(f))) Diagnostic services((
-- )) - Clinical testing and
imaging services. (( [WAC 388-531-0100; 388-550-1400 and
(g) Family planning services -- Gynecological exams; contraceptives, drugs, and supplies, including prescriptions; sterilization; screening and treatment of sexually transmitted diseases; and educational services. [WAC 388-532-530]
(h))) (WAC 182-531-0100; WAC 182-550-1400 and 182-550-1500.)
(f) Health care professional services((
-- )) - Office
visits, emergency oral health, 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 388-531 WAC]
(i))) (Chapter 182-531 WAC.)
(g) Hearing ((
care -- )) evaluations - Audiology;
diagnostic evaluations; hearing exams and testing(( ; and
hearing aids. [WAC 388-544-1200 and 388-544-1300;
388-545-700; and 388-531-0100]
(j))). (WAC 182-531-0100 and 182-531-0375.)
(h) Hearing aids - (Chapter 182-547 WAC.)
(i) 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 388-551-2000 through
(k))) (WAC 182-551-2000 through 182-551-2220.)
(j) 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 388-551-1210 through 388-551-1850]
(l))) (WAC 182-551-1210 through 182-551-1850.)
(k) 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 388-550 WAC]
(m))) (Chapter 182-550 WAC.)
(l) Intermediate care facility/services for ((
retarded -- )) persons with intellectual disabilities - Habilitative training, health-related care, supervision, and
residential care. (( [Chapter 388-835 WAC]
(n))) (Chapter 388-835 WAC.)
(m) 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 388-533-0330]
(o))) (WAC 182-533-0300.)
(n) Medical equipment, durable (DME)((
-- )) - Wheelchairs,
hospital beds, respiratory equipment; (( prosthetic and
orthotic devices;)) casts, splints, crutches, trusses, and
braces. (( [WAC 388-543-1100]
(p))) (Chapter 182-543 WAC.)
(o) 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, (( transcutaneous electrical
nerve stimulators (TENS) supplies,)) and urological supplies. (( [WAC 388-543-2800]
(q))) (Chapter 182-543 WAC.)
(p) Medical nutrition services((
-- )) - Enteral and
parenteral nutrition, including supplies. (( [Chapters 388-553
and 388-554 WAC]
(r) Mental health services -- Inpatient and outpatient psychiatric services and community mental health services. [Chapter 388-865 WAC]
(s))) (Chapters 182-553 and 182-554 WAC.)
(q) Nursing facility services((
-- )) - Nursing, therapies,
dietary, and daily care services. (( [Chapter 388-97 WAC]
(t))) (Chapter 388-97 WAC.)
(r) 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 388-550-1900 and 388-550-2000, and
(u))) (WAC 182-550-1900 and 182-556-0400.)
(s) Out-of-state services((
-- Emergency services; prior
authorized care. Services provided in bordering cities are
treated as if they were provided in state. [WAC 388-501-0175
and 388-501-0180; 388-531-1100; and 388-556-0500]
(v))) - See WAC 182-502-0120 for services out-of-state.
(t) Outpatient rehabilitation services (OT, PT, ST) - Evaluations, assessments, and treatment. (Chapter 182-545 WAC.)
(u) Oxygen/respiratory services((
-- )) - Oxygen, oxygen
equipment and supplies; oxygen and respiratory therapy,
equipment, and supplies. (( [Chapter 388-552 WAC]
(w))) (Chapter 182-552 WAC.)
(v) 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-]0300,
[388-106-]0400, [388-106-]0500, [388-106-]0600,
[388-106-]0700, [388-106-]0720 and [388-106-]0900]
(x))) 388-106-0200, 388-106-0300, 388-106-0600, 388-106-0700, 388-106-0745, and 388-106-0900.)
(w) 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 388-530-1100])) (WAC 182-530-2000.) Additional
coverage for medications and prescriptions is addressed in
specific program WAC sections.
(y))) (x) 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 388-551-3000.])) (WAC 182-551-3000.) For benefits for clients eighteen years of age
and older, see WAC 388-106-1000 through 388-106-1055.
(z))) (y) Prosthetic/orthotic devices(( -- )) - Artificial limbs and other external body parts; devices that
prevent, support, or correct a physical deformity or
malfunction. (( [WAC 388-543-1100]
(aa) School medical services -- Medical services provided in schools to children with disabilities under the Individuals with Disabilities Education Act (IDEA). [Chapter 388-537 WAC]
(bb) Substance abuse services -- Chemical dependency assessment, case management services, and treatment services. [WAC 388-533-0701 through 388-533-0730; 388-556-0100 and 388-556-0400; and 388-800-0020]
(cc) Therapy -- Occupational/physical/speech -- Evaluations, assessments, and treatment. [WAC 388-545-300, 388-545-500, and 388-545-700]
(dd))) (WAC 182-543-1100.)
(z) Psychological evaluation - Complete diagnostic history, examination, and assessment, including the testing of cognitive processes, visual motor responses, and abstract abilities. (WAC 388-865-0610.)
(aa) Reproductive health services - Gynecological exams; contraceptives, drugs, and supplies, including prescriptions; sterilization; screening and treatment of sexually transmitted diseases; and educational services. (WAC 182-532-530.)
(bb) 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) Vision care((
-- )) - Eye exams, refractions,
(( frames, lenses,)) fittings, visual field testing, vision
therapy, ocular prosthetics, and surgery. (( [WAC 388-544-0250
through 388-544-0550])) (WAC 182-531-1000.)
(dd) Vision hardware - Frames and lenses. (Chapter 182-544 WAC.)
[11-14-075, recodified as § 182-501-0065, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-501-0065, filed 11/30/06, effective 1/1/07.]
(2) This section does not apply to health care services provided as a result of the early and periodic screening, diagnosis, and treatment (EPSDT) program as described in chapter 182-534 WAC.
(3) The ((
department)) agency or its designee does not
pay for any ancillary health care service(s) provided in
association with a noncovered health care service.
(4) The following list of noncovered health care services is not intended to be exhaustive. Noncovered health care services include, but are not limited to:
(a) Any health care service specifically excluded by federal or state law;
(b) Acupuncture, Christian Science practice, faith healing, herbal therapy, homeopathy, massage, massage therapy, naturopathy, and sanipractice;
(c) Chiropractic care for adults;
(d) Cosmetic, reconstructive, or plastic surgery, and any
related health care services, not specifically allowed under
(f) Ear or other body piercing;
(g) Face lifts or other facial cosmetic enhancements;
(h) Fertility, infertility or sexual dysfunction testing, and related care, drugs, and/or treatment including but not limited to:
(i) Artificial insemination;
(ii) Donor ovum, sperm, or surrogate womb;
(iii) In vitro fertilization;
(iv) Penile implants;
(v) Reversal of sterilization; and
(vi) Sex therapy.
(i) Gender reassignment surgery and any surgery related to trans-sexualism, gender identity disorders, and body dysmorphism, and related health care services or procedures, including construction of internal or external genitalia, breast augmentation, or mammoplasty;
(j) Hair transplants, epilation (hair removal), and electrolysis;
(k) Marital counseling;
(l) Motion analysis, athletic training evaluation, work hardening condition, high altitude simulation test, and health and behavior assessment;
(m) Nonmedical equipment;
(n) Penile implants;
(o) Prosthetic testicles;
(p) Psychiatric sleep therapy;
(q) Subcutaneous injection filling;
(r) Tattoo removal;
(s) Transport of Involuntary Treatment Act (ITA) clients to or from out-of-state treatment facilities, including those in bordering cities;
(t) Upright magnetic resonance imaging (MRI); and
(u) Vehicle purchase - New or used vehicle.
(5) For a specific list of noncovered health care services in the following service categories, refer to the WAC citation:
(a) Ambulance transportation and nonemergent transportation as described in chapter 182-546 WAC;
(b) Dental services ((
for clients twenty years of age and
younger)) as described in chapter 182-535 WAC;
(c) Durable medical equipment as described in chapter 182-543 WAC;
(d) Hearing care services as described in chapter 182-547 WAC;
(e) Home health services as described in WAC 182-551-2130;
(f) Hospital services as described in WAC 182-550-1600;
(g) Health care professional services as described in WAC 182-531-0150;
(h) Prescription drugs as described in chapter 182-530 WAC;
(i) Vision care ((
services)) hardware for clients twenty
years of age and younger as described in chapter 182-544 WAC;
(j) Vision care exams as described in WAC 182-531-1000.
(6) A client has a right to request an administrative hearing, if one is available under state and federal law. When the agency or its designee denies all or part of a request for a noncovered health care service(s), the agency or its designee sends the client and the provider written notice, within ten business days of the date the decision is made, that includes:
(a) A statement of the action the agency or its designee intends to take;
(b) Reference to the specific WAC provision upon which the denial is based;
(c) Sufficient detail to enable the recipient to:
(i) Learn why the agency's or its designee's action was taken; and
(ii) Prepare a response to the agency's or its designee's decision to classify the requested health care service as noncovered.
(d) The specific factual basis for the intended action; and
(e) The following information:
(i) Administrative hearing rights;
(ii) Instructions on how to request the hearing;
(iii) Acknowledgment that a client may be represented at the hearing by legal counsel or other representative;
(iv) Instructions on how to request an exception to rule (ETR) or nonformulary justification (NFJ);
(v) Information regarding agency-covered health care services, if any, as an alternative to the requested noncovered health care service; and
(vi) Upon the client's request, the name and address of the nearest legal services office.
(7) A client can request an exception to rule (ETR) as described in WAC 182-501-0160.
[Statutory Authority: RCW 41.05.021 and section 1927 of the Social Security Act. 12-18-062, § 182-501-0070, filed 8/31/12, effective 10/1/12. 11-14-075, recodified as § 182-501-0070, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 09-23-112, § 388-501-0070, filed 11/18/09, effective 12/19/09; 07-04-036, § 388-501-0070, filed 1/29/07, effective 3/1/07.]
AMENDATORY SECTION(Amending WSR 12-18-062, filed 8/31/12, effective 10/1/12)
WAC 182-502-0160 Billing a client. (1) The purpose of this section is to specify the limited circumstances in which:
(a) Fee-for-service or managed care clients can choose to self-pay for medical assistance services; and
(b) Providers (as defined in WAC 182-500-0085) have the authority to bill fee-for-service or managed care clients for medical assistance services furnished to those clients.
(2) The provider is responsible for:
(a) Verifying whether the client is eligible to receive medical assistance services on the date the services are provided;
(b) Verifying whether the client is enrolled with a medicaid agency-contracted managed care organization (MCO);
(c) Knowing the limitations of the services within the scope of the eligible client's medical program (see WAC 182-501-0050 (4)(a) and 182-501-0065);
(d) Informing the client of those limitations;
(e) Exhausting all applicable medicaid agency or agency-contracted MCO processes necessary to obtain authorization for requested service(s);
(f) Ensuring that translation or interpretation is provided to clients with limited English proficiency (LEP) who agree to be billed for services in accordance with this section; and
(g) Retaining all documentation which demonstrates compliance with this section.
(3) Unless otherwise specified in this section, providers must accept as payment in full the amount paid by the agency or agency-contracted MCO for medical assistance services furnished to clients. See 42 C.F.R. § 447.15.
(4) A provider must not bill a client, or anyone on the client's behalf, for any services until the provider has completed all requirements of this section, including the conditions of payment described in the agency's rules, the agency's fee-for-service billing instructions, and the requirements for billing the agency-contracted MCO in which the client is enrolled, and until the provider has then fully informed the client of his or her covered options. A provider must not bill a client for:
(a) Any services for which the provider failed to satisfy the conditions of payment described in the agency's rules, the agency's fee-for-service billing instructions, and the requirements for billing the agency-contracted MCO in which the client is enrolled.
(b) A covered service even if the provider has not received payment from the agency or the client's MCO.
(c) A covered service when the agency or its designee denies an authorization request for the service because the required information was not received from the provider or the prescriber under WAC 182-501-0165 (7)(c)(i).
(5) If the requirements of this section are satisfied, then a provider may bill a fee-for-service or a managed care client for a covered service, defined in WAC 182-501-0050(9), or a noncovered service, defined in WAC 182-501-0050(10) and 182-501-0070. The client and provider must sign and date the HCA form 13-879, Agreement to Pay for Healthcare Services, before the service is furnished. Form 13-879, including translated versions, is available to download at http://hrsa.dshs.wa.gov/mpforms.shtml. The requirements for this subsection are as follows:
(a) The agreement must:
(i) Indicate the anticipated date the service will be provided, which must be no later than ninety calendar days from the date of the signed agreement;
(ii) List each of the services that will be furnished;
(iii) List treatment alternatives that may have been covered by the agency or agency-contracted MCO;
(iv) Specify the total amount the client must pay for the service;
(v) Specify what items or services are included in this amount (such as pre-operative care and postoperative care). See WAC 182-501-0070(3) for payment of ancillary services for a noncovered service;
(vi) Indicate that the client has been fully informed of all available medically appropriate treatment, including services that may be paid for by the agency or agency-contracted MCO, and that he or she chooses to get the specified service(s);
(vii) Specify that the client may request an exception to rule (ETR) in accordance with WAC 182-501-0160 when the agency or its designee denies a request for a noncovered service other than a nonformulary drug and that the client may choose not to do so;
(viii) Specify that the client and their prescriber may request a nonformulary justification (NFJ) in accordance with WAC 182-530-2300 for a nonformulary drug and that the client may choose not to do so;
(ix) Specify that the client may request an administrative hearing in accordance with chapter 182-526 WAC to appeal the agency's or its designee denial of a request for prior authorization of a covered service and that the client may choose not to do so;
(x) Be completed only after the provider and the client have exhausted all applicable agency or agency-contracted MCO processes necessary to obtain authorization of the requested service, except that the client may choose not to request an ETR or an administrative hearing regarding agency or agency designee denials of authorization for requested service(s); and
(xi) Specify which reason in subsection (b) below applies.
(b) The provider must select on the agreement form one of the following reasons (as applicable) why the client is agreeing to be billed for the service(s). The service(s) is:
(i) Not covered by the agency or the client's agency-contracted MCO and the ETR process as described in WAC 182-501-0160 or the NFJ process as described in WAC 182-530-2300 has been exhausted and the service(s) is denied;
(ii) Not covered by the agency or the client's agency-contracted MCO and the client has been informed of his or her right to an ETR or NFJ and has chosen not to pursue an ETR as described in WAC 182-501-0160 or the NFJ process as described in WAC 182-530-2300;
(iii) Covered by the agency or the client's agency-contracted MCO, requires authorization, and the provider completes all the necessary requirements; however the agency or its designee denied the service as not medically necessary (this includes services denied as a limitation extension under WAC 182-501-0169); or
(iv) Covered by the agency or the client's agency-contracted MCO and does not require authorization, but the client has requested a specific type of treatment, supply, or equipment based on personal preference which the agency or MCO does not pay for and the specific type is not medically necessary for the client.
(c) For clients with limited English proficiency, the agreement must be the version translated in the client's primary language and interpreted if necessary. If the agreement is translated, the interpreter must also sign it;
(d) The provider must give the client a copy of the agreement and maintain the original and all documentation which supports compliance with this section in the client's file for six years from the date of service. The agreement must be made available to the agency or its designee for review upon request; and
(e) If the service is not provided within ninety calendar days of the signed agreement, a new agreement must be completed by the provider and signed by both the provider and the client.
(6) There are limited circumstances in which a provider may bill a client without executing form 13-879, Agreement to Pay for Healthcare Services, as specified in subsection (5) of this section. The following are those circumstances:
(a) The client, the client's legal guardian, or the client's legal representative:
(i) Was reimbursed for the service directly by a third party (see WAC 182-501-0200); or
(ii) Refused to complete and sign insurance forms, billing documents, or other forms necessary for the provider to bill the third party insurance carrier for the service.
(b) The client represented himself/herself as a private pay client and not receiving medical assistance when the client was already eligible for and receiving benefits under a medical assistance program. In this circumstance, the provider must:
(i) Keep documentation of the client's declaration of medical coverage. The client's declaration must be signed and dated by the client, the client's legal guardian, or the client's legal representative; and
(ii) Give a copy of the document to the client and maintain the original for six years from the date of service, for agency or the agency's designee review upon request.
(c) The bill counts toward the financial obligation of the client or applicant (such as spenddown liability, client participation as described in WAC 388-513-1380, emergency medical expense requirement, deductible, or copayment required by the agency or its designee). See subsection (7) of this section for billing a medically needy client for spenddown liability;
(d) The client is under the agency's or an agency-contracted MCO's patient review and coordination (PRC) program (WAC 182-501-0135) and receives nonemergency services from providers or health care facilities other than those to whom the client is assigned or referred under the PRC program;
(e) The client is a dual-eligible client with medicare Part D coverage or similar creditable prescription drug coverage and the conditions of WAC 182-530-7700 (2)(a)(iii) are met;
(f) The service((
s provided to a TAKE CHARGE or family
planning only client are not within the scope of)) is within a
service category excluded from the client's benefits package.
See WAC 182-501-0060;
(g) The services were noncovered ambulance services (see WAC 182-546-0250(2));
(h) A fee-for-service client chooses to receive nonemergency services from a provider who is not contracted with the agency or its designee after being informed by the provider that he or she is not contracted with the agency or its designee and that the services offered will not be paid by the client's health care program; and
(i) An agency-contracted MCO enrollee chooses to receive nonemergency services from providers outside of the MCO's network without authorization from the MCO, i.e., a nonparticipating provider.
(7) Under chapter 182-519 WAC, an individual who has applied for medical assistance is required to spend down excess income on health care expenses to become eligible for coverage under the medically needy program. An individual must incur health care expenses greater than or equal to the amount that he or she must spend down. The provider is prohibited from billing the individual for any amount in excess of the spenddown liability assigned to the bill.
(8) There are situations in which a provider must refund the full amount of a payment previously received from or on behalf of an individual and then bill the agency for the covered service that had been furnished. In these situations, the individual becomes eligible for a covered service that had already been furnished. Providers must then accept as payment in full the amount paid by the agency or its designee or managed care organization for medical assistance services furnished to clients. These situations are as follows:
(a) The individual was not receiving medical assistance on the day the service was furnished. The individual applies for medical assistance later in the same month in which the service was provided and the agency or its designee makes the individual eligible for medical assistance from the first day of that month;
(b) The client receives a delayed certification for medical assistance as defined in WAC 182-500-0025; or
(c) The client receives a certification for medical assistance for a retroactive period according to 42 C.F.R. § 435.914(a) and defined in WAC 182-500-0095.
(9) Regardless of any written, signed agreement to pay, a provider may not bill, demand, collect, or accept payment or a deposit from a client, anyone on the client's behalf, or the agency or its designee for:
(a) Copying, printing, or otherwise transferring health care information, as the term health care information is defined in chapter 70.02 RCW, to another health care provider. This includes, but is not limited to:
(i) Medical/dental charts;
(ii) Radiological or imaging films; and
(iii) Laboratory or other diagnostic test results.
(b) Missed, canceled, or late appointments;
(c) Shipping and/or postage charges;
(d) "Boutique," "concierge," or enhanced service packages (e.g., newsletters, 24/7 access to provider, health seminars) as a condition for access to care; or
(e) The price differential between an authorized service or item and an "upgraded" service or item (e.g., a wheelchair with more features; brand name versus generic drugs).
[Statutory Authority: RCW 41.05.021 and section 1927 of the Social Security Act. 12-18-062, § 182-502-0160, filed 8/31/12, effective 10/1/12. 11-14-075, recodified as § 182-502-0160, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. 10-19-057, § 388-502-0160, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090 and 42 C.F.R. 447.15. 10-10-022, § 388-502-0160, filed 4/26/10, effective 5/27/10. Statutory Authority: RCW 74.08.090, 74.09.055, 2001 c 7, Part II. 02-12-070, § 388-502-0160, filed 5/31/02, effective 7/1/02. Statutory Authority: RCW 74.08.090. 01-21-023, § 388-502-0160, filed 10/8/01, effective 11/8/01; 01-05-100, § 388-502-0160, filed 2/20/01, effective 3/23/01. Statutory Authority: RCW 74.08.090 and 74.09.520. 00-14-069, § 388-502-0160, filed 7/5/00, effective 8/5/00.]