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.