HEALTH CARE AUTHORITY
[Filed November 16, 2020, 10:38 a.m., effective December 17, 2020]
Effective Date of Rule: Thirty-one days after filing.
Purpose: The health care authority is amending WAC 182-501-0180 so it applies to both fee-for-service clients and clients enrolled in a managed care organization.
Citation of Rules Affected by this Order: Amending WAC 182-501-0180.
Adopted under notice filed as WSR 20-20-066 on October 1, 2020.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at the Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.
Number of Sections Adopted using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.
Date Adopted: November 16, 2020.
AMENDATORY SECTION(Amending WSR 15-15-053, filed 7/9/15, effective 8/9/15)
WAC 182-501-0180Health care services provided outside the state of Washington—General provisions.
WAC 182-501-0180 through 182-501-0184 ((apply only to))describe the health care services ((payable))available to a Washington apple health client on a fee-for-service basis ((for Washington apple health (WAH) clients))or to a client enrolled in a managed care organization (MCO) (defined in WAC 182-538-050).
(1) Subject to the requirements, exceptions, and limitations in this section, WAC 182-501-0182, and 182-501-0184, the medicaid agency covers emergency and nonemergency out-of-state health care services provided to eligible ((WAH))Washington apple health recipients when the services are:
(a) Within the scope of the client's or enrollee's health care program as specified under chapter 182-501 WAC or other program rules;
(b) Allowed to be provided outside the state of Washington by specific program WAC; and
(c) Medically necessary as defined in WAC 182-500-0070.
(2) The agency does not cover services provided outside the state of Washington under the Involuntary Treatment Act (chapter 71.05
RCW ((and chapter 388-865 WAC
))), including designated bordering cities.
(3) When the agency pays for covered health care services furnished to an eligible ((WAH))Washington apple health client or enrollee outside the state of Washington, its payment is payment in full according to 42 C.F.R. 447.15. No additional payment may be sought from the client (see WAC 182-502-0160).
(4) The agency determines coverage for transportation services provided out of state, including ambulance services, according to chapter 182-546 WAC.
(5) With the exception of designated bordering cities (see WAC 182-501-0175), if the client or enrollee travels out of state expressly to obtain health care, the service must be prior authorized by the agency. See WAC 182-501-0182 for requirements related to out-of-state nonemergency treatment and WAC 182-501-0165 for the agency's medical necessity determination process.
(6) The agency does not cover health care services provided outside the United States and U.S. territories, except in British Columbia, Canada. See WAC 182-501-0184 for limitations on coverage of, and payment for, health care provided to ((WAH))Washington apple health clients or enrollees in British Columbia, Canada.
(7) See WAC 182-502-0120 for provider requirements for payment of health care provided outside the state of Washington.