Date of Adoption: June 1, 2001.

Purpose: The department recently reorganized its rules, establishing new chapters for several program and services. WAC 388-501-0300(2) lists services, equipment, supplies, and items that are now codified primarily in new chapters 388-543 and 388-531 WAC. In order to avoid unnecessary duplication, the department is amending WAC 388-501-0300 to eliminate the list in (2), clarify the remaining policies, and add cross-references to WAC 388-501-0165.

Citation of Existing Rules Affected by this Order: Amending WAC 388-501-0300.

Statutory Authority for Adoption: RCW 74.08.090.

Adopted under notice filed as WSR 01-09-037 on April 11, 2001.

Changes Other than Editing from Proposed to Adopted Version: (1) The Medical Assistance Administration (MAA) pays only for equipment, supplies, an services that are listed as covered in MAA published issuances, including Washington Administrative Code (WAC)...

(2) Pursuant to WAC 388-501-0165, MAA covers equipment, supplies, or services that are listed as noncovered when the equipment, supplies, or services are medically necessary justified and: (a) Required Requested under the EPSDT/healthy kids program; or (b) included in an MAA waivered program. or (c) Part of one of the medical assistance programs for Qualified Medicare beneficiaries (QMBs).

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 1, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.
Effective Date of Rule: Thirty-one days after filing.

June 1, 2001

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

(a) Within the scope of an eligible client's medical care program;

(b) Medically necessary as defined in WAC 388-500-0005;

(c) Billed according to the requirements in WAC 388-502-0100, 388-502-0110, and 388-502-0150; and

(d) Within accepted medical, dental, or psychiatric practice standards and are:

(i) Consistent with a diagnosis; and

(ii) Reasonable in amount and duration of care, treatment, or service.

(((d) Not listed under subsection (2) of this section; and

(e) Billed according to the conditions of payment under WAC 388-87-010.

(2) Unless required under EPSDT/healthy kids program; included as part of a managed care plan service package; included in a waivered program; or part of one of the Medicare programs for the qualified Medicare beneficiaries, the MAA shall specifically exclude from the scope of covered services:

(a) Nonmedical equipment, supplies, personal or comfort items and/or services, including, but not limited to:

(i) Air conditioners or air cleaner devices, dehumidifiers, other environmental control devices, heating pads;

(ii) Enuresis (bed wetting) training equipment;

(iii) Recliner and/or geri-chairs;

(iv) Exercise equipment;

(v) Whirlpool baths;

(vi) Telephones, radio, television;

(vii) Any services connected to the telephone, television, or radio;

(viii) Homemaker services;

(ix) Utility bills; or

(x) Meals delivered to the home.

(b) Services, procedures, treatment, devices, drugs, or application of associated services which the department or HCFA consider investigative or experimental on the date the services are provided;

(c) Physical examinations or routine checkups;

(d) Cosmetic treatment or surgery, except for medically necessary reconstructive surgery to correct defects attributable to an accident, birth defect, or illness;

(e) Routine foot care that includes, but not limited to:

(i) Medically unnecessary treatment of mycotic disease;

(ii) Removal of warts, corns, or calluses;

(iii) Trimming of nails and other hygiene care; or

(iv) Treatment of asymptomatic flat feet.

(f) More costly services when less costly equally effective services as determined by the department are available;

(g) Procedures, treatment, prosthetics, or supplies related to gender dysphoria surgery except when recommended after a multidisciplinary evaluation including but not limited to urology, endocrinology, and psychiatry;

(h) Care, testing, or treatment of infertility, frigidity, or impotency. This includes procedures for sterilization reversals and donor ovum, sperm, or womb;

(i) Acupuncture, massage, or massage therapy;

(j) Orthoptic eye training therapy;

(k) Weight reduction and control services not provided in conjunction with a MAA medically approved program. This includes food supplements and educational products;

(l) Parts of the body, including organs tissues, bones, and blood;

(m) Blood and eye bank charges;

(n) Domiciliary or custodial care, excluding nursing facility care;

(o) Hair pieces, wigs, or hair transplantation;

(p) Biofeedback or other self-help care;

(q) Marital counseling or sex therapy;

(r) Any service specifically excluded by statute; and

(s) Home births, except when provided as an approved service under MAA's planned home birth pilot project.

(3) Clients shall be responsible for payment as described under WAC 388-87-010 for services not covered under the client's medical care program))

(2) Pursuant to WAC 388-501-0165, MAA covers equipment, supplies, or services that are listed as noncovered when the equipment, supplies, or services are medically necessary and:

(a) Requested under the EPSDT program; or

(b) Included in an MAA waivered program.

(3) When a client or a client's representative requests equipment, supplies, or services that are listed as noncovered, MAA evaluates the request under WAC 388-501-0165.

(4) MAA evaluates requests for covered equipment, supplies, or services that are subject to limitations or other restrictions, and approves such equipment, supplies, or services beyond those limitations or restrictions when medically necessary, under the standards for covered services in WAC 388-501-0165.

(5) MAA evaluates a request for a service that is in a covered category, but is determined to be experimental or investigational under WAC 388-531-0550, under the provisions of WAC 388-501-0165 which relate to medical necessity.

(6) Clients are responsible for payment as described under WAC 388-502-0160, for services that are not covered under the client's medical care program.

[Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.800. 00-23-052, amended and recodified as 388-501-0300, filed 11/13/00, effective 12/14/00. Statutory Authority: RCW 74.08.090. 93-16-037 (Order 3599), 388-86-200, filed 7/28/93, effective 8/28/93; 93-11-086 (Order 3536), 388-86-200, filed 5/19/93, effective 6/19/93.]

Reviser's note: The bracketed material preceding the section above was supplied by the code reviser's office.

Washington State Code Reviser's Office