WAC 388-501-0050 Healthcare general coverage (Emergency Rule effective 4/28/2011)

1. WAC 388-501-0050 through 388-501-0065 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 388-538-050).  For the purposes of this section, healthcare services includes treatment, equipment, related supplies, and drugs.  WAC 388-501-0070 describes noncovered services.   The following definitions apply to this chapter:
   1. "Benefits package" means the set of healthcare service categories included in a client's eligibility program.  See the table in WAC 388-501-0060.
   2. "Healthcare service categories" means the groupings of healthcare services listed in the table in WAC 388-501-0060.  Healthcare service categories are included or excluded depending on the client's benefits package.
   3. "Covered service" means a specific healthcare service within a service category that the department will pay for when all healthcare program requirements have been met.
   4. "Noncovered service" means a specific healthcare service within a service category that the department will not pay for.  Noncovered services are identified in WAC 388-501-0070 and in specific health-care program rules.
2. Healthcare service categories listed in WAC 388-501-0060 do not represent a contract for healthcare services.
3. 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.
4. Under the department's fee-for service programs, providers must be enrolled with the department and meet the requirements of Chapter 388-502 WAC to be paid for furnishing healthcare services to clients.
5. The department pays only for the healthcare services that are:
   1. Included in the client's healthcare benefits package as described in WAC 388-501-0060;
   2. Covered - see subsection (10) of this section;
   3. Ordered or prescribed by a healthcare provider who meets the requirements of Chapter 388-502 WAC;
   4. Medically necessary as defined in WAC 388-500-0005;
   5. Submitted for authorization, when required, in accordance with WAC 388-501-0163;
   6. Approved, when required, in accordance with WAC 388-501-0165;
   7. Furnished by a provider according to Chapter 388-502 WAC; and
   8. Billed in accordance with department program rules and the department's current published billing instructions and numbered memoranda.
6. The department does not pay for any healthcare service requiring prior authorization from the department, if prior authorization was not obtained before the healthcare service was provided; unless;
   1. The client is determined to be retroactively eligible for medical assistance; and
   2. The request meets the requirements of subsection (4) of this section.
7. The department does not reimburse clients for healthcare services purchased out-of-pocket.
8. The department does not pay for the replacement of department-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:
   1. Extenuating circumstances exist that result in a loss or destruction of department-purchased equipment, devices, or supplies, through no fault of the client that occurred while the client was exercising reasonable care under the circumstances; or
   2. Otherwise allowed under Chapter 388-500 WAC.
9. The department's refusal to pay for replacement of equipment, device, or supplies will not extend beyond the limitations in specific department program rules.
10. Covered healthcare services
    1. Covered healthcare services are either:
       1. "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
       2. "State-option" - means the state of Washington is not federally mandated to cover the healthcare service but has chosen to so at its own discretion.
    2. The department may limit the scope, amount, duration, and/or frequency of covered healthcare services.  Limitation extensions are authorized according to WAC 388-501-0169. 
11. Noncovered healthcare services
    1. The department does not pay for any healthcare service listed as noncovered in WAC 388-501-0070 or in any other program rule.  The department evaluates a request for a noncovered healthcare service only if an exception to rule is requested according to the provisions in WAC 388-501-0160.
    2. 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 department evaluates the healthcare service according to the process in WAC 388-501-0165 to determine if it is medically necessary, safe, effective, and not experimental (see WAC 388-534-0100 for EPSDT rules).