WAC 182-501-0050

Effective July 1, 2011

WAC 182-501-0050 Healthcare general coverage. (Emergency rule effective 8/17/12.)

WAC 182-501-0050 through 182-501-0065 describe the healthcare 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 182-538-050). For the purposes of this section, healthcare services includes treatment, equipment, related supplies, and drugs. WAC 182-501-0070 describes noncovered services.

     (1) Healthcare service categories listed in WAC 182-501-0060 do not represent a contract for healthcare services.

     (2) For the provider to receive payment, the client must be eligible for the covered healthcare service on the date the healthcare service is performed or provided.

     (3) Under the agency's or the agency designee's fee-for-service programs, providers must be enrolled with the agency or the agency's designee and meet the requirements of chapter 182-502 WAC to be paid for furnishing healthcare services to clients.

     (4) The agency or the agency's designee pays only for the healthcare services that are:

     (a) Included in the client's healthcare benefits package as described in WAC 182-501-0060;

     (b) Covered - See subsection (9) of this section;

     (c) Ordered or prescribed by a healthcare provider who meets the requirements of chapter 182-502 WAC;

     (d) Medically necessary as defined in WAC 182-500-0070;

     (e) Submitted for authorization, when required, in accordance with WAC 182-501-0163;

     (f) Approved, when required, in accordance with WAC 182-501-0165;

     (g) Furnished by a provider according to chapter 182-502 WAC; and

     (h) Billed in accordance with agency or agency's designee program rules and the agency's current published billing instructions and numbered memoranda.

     (5) The agency or the agency's designee does not pay for any healthcare service requiring prior authorization from the agency or the agency's designee, if prior authorization was not obtained before the healthcare 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 agency does not reimburse clients for healthcare services purchased out-of-pocket.

     (7) The agency does not pay for the replacement of 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, or misuse unless:

     (a) Extenuating circumstances exist that result in a loss or destruction of agency-purchased 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 specific agency program rules.

     (8) The agency's refusal to pay for replacement of equipment, device, or supplies will not extend beyond the limitations stated in specific agency program rules.

     (9) Covered healthcare services.

     (a) Covered healthcare services are either:

     (i) "Federally mandated" - Means the state of Washington is required by federal regulation (42 CFR 440.210 and 220) to cover the healthcare service for medicaid clients; or

     (ii) "State-option" - means the state of Washington is not federally mandated to cover the healthcare service but has chosen to do so at its own discretion.

     (b) The agency or the agency's designee may limit the scope, amount, duration, and/or frequency of covered healthcare services. Limitation extensions are authorized according to WAC 182-501-0169.

     (10) Noncovered healthcare services.

     (a) The agency or the agency's designee does not pay for any healthcare service listed as noncovered in WAC 182-501-0070 or in any other agency program rule. The agency or the agency's designee evaluates a request for a noncovered healthcare service only if an exception to rule is requested according to the provisions in WAC 182-501-0160.

     (b) When a noncovered healthcare service is recommended during the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) exam and then ordered by a provider, the agency or the agency's designee evaluates the healthcare service according to the process in WAC 182-501-0165 to determine if it is medically necessary, safe, effective, and not experimental (see WAC182-534-0100 for EPSDT rules).

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.