Medical Assistance - Scope of Care
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Medical Assistance - Scope of Care

Revised January 20, 2009


NOTE:

DSHS provides funding for a wide range of medical services.  The level of medical coverage for any given client depends on the medical assistance Benefit Service Package for which the client is eligible.  This table lists services that may be provided under the specific services/programs if the individual meets all the criteria required to receive the service.  Some services may require prior authorization from DSHS or a DSHS-contracted managed care plan.  This table is provided for general information only and does not in any way guarantee that any services will actually be covered.  Benefits, coverage, and interpretation of benefits and coverage may change at any time.  Coverage limitations can be found in federal statutes & regulations, state statutes & regulations, state budget provisions, and DSHS billing instructions and numbered memoranda.  Clients with questions regarding coverage may call the 800 number on the back of their Client Services Card.

Scope of Healthcare Services Table

                                                          /Categorically Needy/Medically Needy/General Assistance/

Service / Program

CN

S-CHIP/CHP

MN

GA

ADATSA

FP/TC

Adult day health

Y

N

N

N

N

N

Ambulance (ground/air)

Y

Y

Y

Y

Y

N

Ambulatory surgery center

Y

Y

Y

R1

R1

N1

Blood/Blood administration

Y

Y

Y

Y

Y

N

Childbirth education

Y

Y

N

N

N

N

Chiropractic services for children

Y

Y

Y

N

N

N

Dental services

Y

Y

Y

R2

R2

N

Crowns/Dentures

Y3

Y3

Y3

N

N

N

Detoxification

Y

Y

Y

R

R

N

Diabetes education

Y

Y

Y

Y

Y

N

Early periodic screening diagnosis & treatment (EPSDT) program

Y

Y

Y

N

N

N

Family planning services

Y

Y

Y

Y

Y

Y

Hearing Aids & services (audiology & exams)

Y

Y

N4

Y

Y

N

HIV/AIDS Case Management

Y

Y

Y

N

N

N

Home health services

Y

Y

Y

Y

Y

N

Home infusion therapy/parenteral nutrition

Y

Y

Y

Y

Y

N

Hospice/Pediatric palliative care services

Y

Y

Y

N

N

N

Hospital services – inpatient/outpatient

Y

Y

Y

Y

Y

N1

Intermediate care facility/services for the mentally retarded (IMR)

Y

Y

Y

Y

Y

N

Kidney center / end-stage renal disease

Y

Y

Y

Y

Y

N

Maternity care & delivery services

Y

Y

Y

N

N

N

Maternity support / infant case management

Y

Y

N

N

N

N

Wheelchairs, durable medical equipment

Y

Y

Y

Y

Y

N

Nondurable medical equipment (MSE)

Y

Y

Y

Y

Y

N

Enteral nutrition services

Y

Y

Y

Y

Y

N

Medical nutrition therapy

Y4

Y4

Y4

R4

R4

N

Mental health services (general)

Y

Y

Y

R5

N

N

Inpatient hospital care

Y

Y

Y

Y

Y

N

Outpatient hospital care

Y

Y

Y

R

R

N

Mental health services - children

Y

Y

Y

N

N

N

Nursing facility services

Y

Y

Y

Y

N

N

Organ transplants

Y

Y

Y

Y

Y

N

Out-of-state services (excludes boarder cities)

Y

Y

Y

N6

N6

N

Oxygen/respiratory services

Y

Y

Y

Y

Y

N

Personal care services

R

R

R

N

N

N

Physician-related services

Y

Y

Y

Y

Y

R

Prenatal Diagnosis Genetic counseling

Y

Y

Y

N

N

N

Prescription drugs*

Y

Y

Y

Y

Y

R

Private duty nursing for children

Y

Y

Y

N

N

N

Prosthetic/Orthotic devices

Y

Y

Y

Y

Y

N

Psychological Evaluations

Y

Y

Y

N7

N7

N

School medical services

Y

N

Y

N

N

N

Smoking cessation

Y

Y

Y

Y

N

N

Substance abuse services (chemical dependency

Y

Y

Y

Y8

Y8

N

Therapy – occupational, physical, speech

Y

Y

N4

Y

Y

N

Vision care services

Y

Y

Y

Y

Y

N

LEGEND:  Y=Yes, service is usually included; N=No, service is usually not included; R=Restricted with coverage limitations

* Medicare recipients receive outpatient prescriptions through their Medicare Part D plan.

1 Services limited by parent program (e.g., Dental Program limitations, Family Planning sterilizations service).

2 Covers only service codes as listed in the Dental Program billing instructions.

3 Coverage requirements are located in the Dental Program billing instructions.

4 Coverage limited to children age 20 years old and under if done through an EPSDT screening referral.

5 Restricted to GA clients enrolled in Managed Care.

6 Border cities are considered “in state” for GA coverage.

7 Services covered by the local community mental health center.

8 Service is covered directly though the Division of Alcohol and Substance Abuse (DASA).

 

Other Services

  • Alien Emergency Medical (AEM) 

      The Health and Recovery Services Administration (HRSA) covers only those services 

      necessary to treat the client’s emergency medical condition.

  • QMB-Medicare Only 

      HRSA covers only the Medicare coinsurance and deductible up to the Medicare or HRSA

      allowed amount, whichever is less.

  • Non Emergency Medical Transportation (Brokered Transport) 

      HRSA covers non-emergency medical transportation for eligible clients to or from covered 

      services through contracted brokers.  The brokers arrange and pay for the trips for qualifying

      DSHS/HRSA clients.  Currently, eligible clients include Medicaid, S-CHIP, CHP, GA,

      ADATSA, and AEM.

  • Interpreter Services -- Spoken Language 

      HRSA covers interpreter service for eligible clients through contracted brokers.  Requests for

      spoken language interpreter services must be requested by Medicaid providers or authorized

      DSHS staff. 

  • Interpreter Services -- Sign Language 

      HRSA covers the cost of sign language services for eligible clients.  Requests for sign

      language interpreter services must be requested by Medicaid providers or authorized DSHS

      staff and provided by DSHS-approved contractors.

  • Psychiatric Indigent Inpatient (PII) Program 

      HRSA covers voluntary psychiatric inpatient care for clients eligible under the PII program.


CUSTOMER SERVICE PHONE NUMBERS

DSHS clients may call 800.562.3022 (option 1) for more information.

    Providers may call 800.562.3022 (option 2) for more information.

    Locate Medical Assistance Billing Instructions at http://maa.dshs.wa.gov/download/bi.html

ACRONYMS

ADATSA = Alcohol and Drug Abuse Treatment and Support Act

CHP = Children’s Health Program

CN = Categorically Needy Program

FP/TC = Family Planning Only/TAKE CHARGE

GA = General Assistance

MN = Medically Needy Program

S-CHIP = State Children’s Health Insurance Program

Locations for Scope of Care WACs

WACs dealing with Scope of Care can be found at:

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Modification Date: January 20, 2009
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