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


Revised October 30, 2013



WAC 182-501-0060Healthcare coverage--Program benefits packages--Scope of service categories. (Emergency rule effective 8/17/12.)

NOTE:

The Health Care Authority (HCA) 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 HCA or a HCA-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 HCA billing instructions and numbered memoranda.  Clients with questions regarding coverage may call the 800 number on the back of their Client Services Card.


WAC 182-501-0060

WAC 182-501-0060

Effective July 11, 2011

WAC 182-501-0060 Healthcare coverage--Program benefits packages--Scope of service categories. (Emergency rule effective 8/17/12.)

1.  This rule provides a table that lists:

a.  The categorically needy (CN) medicaid, medically needy (MN) and medical care services (MCS) programs; 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 the agency's designee.

d.  Are paid for by the agency or the agency's designee and subject to review both before and after payment is made.  The agency or the agency's 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 the agency's designee does not pay for covered services, equipment, or supplies that:

a.  Require prior authorization from the agency or the agency's 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 the agency's designee as required under chapter 182-502 WAC;

c.  Are included in an agency or an agency's designee waiver program identified in chapter 388-515 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.  Alien emergency medical (AEM) services are not addressed in the table.  For AEM services, see chapter 388-438 WAC.

6.  Scope of service categories.  The following table lists the agency's categories of healthcare 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.  Under the MCS heading, "DL" refers to the disability lifeline medical program.

c.  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.

d.  The letter "N" means a service category is not included for that program.

e.  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/DL

 Adult day health

 Y

 Y2

 Ambulance (ground and air)

 Y

 Y

 Y

 Blood processing/ administration

 Y

 Y

 Y

 Y

 Y

 Dental services

 Y

 N

 Y

 N

 N

 Detoxification

 Y

 Diagnostic services (lab and X ray)

 Y

 Y

 Y

 Y

 Y

Healthcare professional services

 Y

 Y

 Y

 Y

 Y

 Hearing evaluations

 Y

 Y

 Y

 Y

 Y

 Hearing aids

 Y

 N

 Y

 N

 N

 Home health services

 Y

 Y

 Y

 Hospice services

 Y

 Hospital services - Inpatient/ outpatient

 Intermediate care facility/ services for mentally retarded

 Maternity care and delivery services

 Medical equipment, durable (DME)

Y

 Medical equipment, nondurable (MSE)

 Y

 Y

 Y

 Y

 Y

 Medical nutrition services

 Y

 Y

 Y

 Y

 Y

Mental health services:                

         
  •            Inpatient care

 Y

 Y

 Y

 Y

 Y

  •        Outpatient community mental health services

 Y

 Y

 Y

 Y

 Y3

  •            Psychiatrist visits

 Y

 Y4

  •            Medication management

 Y

 Y

 Y

 Y

 Y

 Nursing facility services

 Y

 Y 

 Organ transplants

 Y

 Y

 Y

 Y

Y

 Out-of-state services

 Y

 Oxygen/respiratory services

 Y

 Personal care services

 Y

 Prescription drugs

 Y

 Y

 Y

 Y

 Y

 Private duty nursing

 Y

 Y

 Y

 Y

 N

Prosthetic/orthotic devices

 Y

 Psychological evaluation5

 Y

 Y

 Y

 Y

 N

 Reproductive health services (includes family planning and TAKE CHARGE)

 Y

 Y

 Y

 Y

 Y

Substance abuse services

 Y

 Y

 Y

 Y

 Y

 Therapy- Occupational, physical and speech

 Y

 Y

 Y

 Vision care - Exams, refractions, and fittings

 Y

 Y

 Y

 Y

 Y

 Vision - Frames and lenses

 Y

Clients enrolled in the children's health insurance program and the apple health for kids program receive CN-scope of medical care.

2Restricted to 18-20 year olds.

3Restricted to DL clients enrolled in managed care.

4DL clients can receive one psychiatric diagnostic evaluation per year and eleven monthly visits per year for medication management.

5Only two allowed per lifetime.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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


Other Services

  • Alien Emergency Medical (AEM) 

      The Health Care Authority (HCA) covers only those services necessary to treat the client’s emergency medical condition.

  • QMB-Medicare Only 

      HCA covers only the Medicare coinsurance and deductible up to the Medicare or HCA      allowed amount, whichever is less.

  • Non Emergency Medical Transportation (Brokered Transport) 

      HCA 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/HCA clients.  Currently, eligible clients include Medicaid, S-CHIP, CHP, MCS,

      ADATSA, and AEM.

  • Interpreter Services -- Spoken Language 

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

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

      HCA staff. 

  • Interpreter Services -- Sign Language 

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

      language interpreter services must be requested by Medicaid providers or authorized HCA   staff and provided by HCA-approved contractors.

  • Psychiatric Indigent Inpatient (PII) Program 

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


CUSTOMER SERVICE PHONE NUMBERS



HCA/DSHS clients may call 800.562.3022 (option 1) for more information on their medical.

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

Locate HCA Billing instructions at http://www.hca.wa.gov/medicaid/billing/pages/bi.aspx

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

MCS = Medical Care Services

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:

Modification Date: October 30, 2013