PERMANENT RULES
SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
(Medical Assistance)
Effective Date of Rule: January 1, 2007.
Purpose: Adoption of these rules will:
| • | Improve the quality of care received by DSHS clients by using a consistent, evidence-based approach to making benefit coverage decisions. |
| • | Make health and recovery services administration (HRSA) benefit coverage rules clearer, more transparent, and consistent. |
| • | Establish a clear, transparent process by which HRSA determines what services are included under its benefit coverage. |
| • | Maximize program resources through prudent use of cost-effective practices. |
Citation of Existing Rules Affected by this Order: Amending WAC 388-501-0050 Healthcare -- General coverage, 388-501-0160 Exception to rule -- Request for a noncovered healthcare service, 388-531-0100 Scope of coverage for physician-related services -- General and administrative, 388-416-0015 Certification periods for CN and SCHIP medical programs, 388-475-1000 Healthcare for workers with disabilities (HWD) -- Program description, 388-501-0180 Out-of-state medical care, 388-519-0100 Spenddown of excess income for the medically needy program, 388-530-1000 Drug program, 388-530-1150 Noncovered drugs and pharmaceutical supplies and reimbursement limitations, 388-531-1600 Bariatric surgery, 388-533-0340 Maternity support services -- Noncovered services, 388-533-0385 Infant case management -- Noncovered services, 388-535-1265 Dental-related services not covered -- Adults, 388-535A-0040 Covered and noncovered orthodontic services and limitations to coverage, 388-538-063 Mandatory enrollment in managed care for GAU clients, 388-538-095 Scope of care for managed care enrollees, 388-540-130 Covered services, 388-540-140 Noncovered services, 388-540-150 Reimbursement -- General, 388-543-1100 Scope of coverage and limitations for DME, 388-543-1150 Limits and limitation extensions, 388-544-0010 Vision care -- General, 388-544-0450 Vision care -- Prior authorization, 388-544-1100 Hearing aid services -- General, 388-544-1400 Hearing aid services -- Noncovered services, 388-545-900 Neurodevelopmental centers, 388-546-0200 Scope of coverage for ambulance transportation, 388-546-0250 Ambulance services the department does not cover, 388-550-2596 Services and equipment covered by the department but not included in LTAC fixed per diem rate, 388-551-2130 Noncovered home health services, 388-551-3000 Private duty nursing services for client seventeen and younger, 388-553-500 Home infusion therapy/parenteral nutrition program -- Coverage, 388-554-500 Orally administered enteral nutrition products -- Coverage, 388-554-600 Tube-delivered enteral nutrition products and related equipment and supplies -- Coverage, 388-556-0500 Medical care services under state-administered cash programs and 388-800-0045 What services are offered by ADATSA?; new WAC 388-501-0060 Healthcare coverage -- Scope of covered categories of service, 388-501-0065 Healthcare coverage -- Description of covered categories of service and 388-501-0169 Healthcare coverage -- Limitation extension; and repealing WAC 388-501-0300 Limits on scope of medical program services, 388-529-0100 Scope of covered medical services by program and 388-529-0200 Medical services available to eligible clients.
Statutory Authority for Adoption: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700.
Adopted under notice filed as WSR 06-19-098, 06-19-099, and 06-19-100 on September 19, 2006.
Changes Other than Editing from Proposed to Adopted Version: (New wording from what was originally proposed is underlined, deleted wording is lined through): WAC 388-501-0050 subsections (4) through new (7):
(4) The department's fee-for-service program pays only for services furnished by enrolled providers who meet the requirements of chapter 388-502 WAC.
(5) The department does not pay for any service, treatment, equipment, drug, or supply requiring prior authorization from the department, if prior authorization was not obtained before the service was provided.
(6) Covered services
(a) Covered 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 service for Medicaid clients; or
(ii) "State-option" - means the State of Washington is not federally-mandated to cover the service but has chose to do so at its own discretion.
(b) The department may limit the scope, amount, duration, and/or frequency of covered services. Limitation extensions are authorized according to WAC 388-501-0169.
(6) (7) Noncovered services
WAC 388-501-0060, in the table following subsection (5):
| Service Categories | CN* | MN | MCS | AEM |
| (m) Intermediate care facility/services for mentally retarded | C | C | C | |
| (n) Maternity care and delivery services | C | C | N | E |
| (o) Medical equipment, durable (DME) | C | C | C | E |
| (p) Medical equipment, nondurable (MSE) | C | C | C | E |
| (q) Medical nutrition services | C | C | C | E |
| (r) Mental health services | C | C | C | E |
| (s) Nursing facility services | C | C | C | E |
| (t) Organ transplants | C | C | C | N |
| (u) Out-of-state services | C | C | N | E |
| (v) Oxygen/respiratory services | C | C | C | E |
| (w) Personal care services | C | C | N | N |
| (x) Prescription drugs | C | C | C | E |
| (y) Private duty nursing | C | C | N | E |
| (z) Prosthetic/orthotic devices | C | C | C | E |
| (aa) School medical services | C | C | N | N |
| (bb) Substance abuse services | C | C | C | |
| (cc) Therapy - occupational/physical/speech | C | C | C | E |
| (dd) Vision care (exams/lenses) | C | C | C | E |
WAC 388-501-0065, subsections of subsection (2)
(d) Dental Services-Diagnosis and treatment of dental of dental problems including emergency treatment; and preventive care. [Chapter 388-535 WAC and Chapter 388-535A WAC]
(j) Home health services-Intermittent, short-term skilled
nursing care, physical therapy, speech therapy, home infusion
therapy, and health aide services, provided in the home. [WAC 388-551-2000 through WAC 388-551-3000 388-551-2220]
(k) Hospice services-Physician services, skilled nursing care, medical social services, counseling services for client and family, drugs, medications (including biologicals), medical equipment and supplies needed for palliative care, home health aide, homemaker, personal care services, medical transportation, respite care, and brief inpatient care. This benefit also includes services rendered in a hospice care center and pediatric palliative care services. [WAC 388-551-1210 through WAC 338-551-1850]
(x) Prescription drugs-Outpatient drugs (including in nursing facilities), both generic and brand name; drug devices and supplies; some over-the-counter drugs; oral, topical, injectable drugs; vaccines, immunizations, and biologicals; and family planning drugs, devices, and supplies. [WAC 388-530-1100] Additional coverage for medications and prescriptions is addressed in specific program WAC sections.
(y) Private duty nursing-Continues skilled nursing services provided in the home, including client assessment, administration of treatment, and monitoring of medical equipment and client care for clients seventeen years of age and under. [WAC 388-551-3000] For benefits for clients eighteen years of age and older, see WAC 388-106-1000 through WAC 388-106-1055.
dd) Vision care - Eye exams, refractions, frames, lenses,
ocular prosthetics, and nonelective surgery. [WAC 388-544-0250 through WAC 388-544-0550]
WAC 388-501-0169, subsection (4):
(4) In addition to subsection (3), both the department and MCO consider the following in evaluating a request for a limitation extension:
(a) The level of improvement the client has shown to date related to the requested service and the reasonably calculated probability of continued improvement if the requested service is extended; and
(b) The reasonably calculated probability the client's condition will worsen if the requested service is not extended.
A final cost-benefit analysis is available by contacting Kevin Sullivan, P.O. Box 45504, Olympia, WA 98504-5504, phone (360) 725-1344, fax (360) 586-9727, e-mail sullikm@dshs.wa.gov.
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 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 3, Amended 36, Repealed 3.
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 0, Repealed 0.
Date Adopted: November 30, 2006.
Robin Arnold-Williams
Secretary
3789.7(1) Covered services
(a) Covered services are:
(i) Medical and dental services, equipment, and supplies that are within the scope of the eligible client's medical assistance program (see chapter 388-529 WAC) and listed as covered in MAA rules; and
(ii) Determined to be medically necessary as defined in WAC 388-500-0005 or dentally necessary as defined in WAC 388-535-0150.
(b) Providers must obtain prior authorization (PA) or expedited prior authorization (EPA) when required by MAA.
(i) See WAC 388-501-0165 for the PA process.
(ii) The EPA process is designed to eliminate the need for written and telephonic requests for prior authorization for selected services and procedure codes. MAA requires a provider to create an authorization number for EPA for selected procedure codes, using the process explained in the billing instructions for the specific service or program.
(iii) See chapter 388-538 WAC for managed care requirements.
(c) Covered services are subject to the limitations specified by MAA. Providers must obtain PA or EPA before providing services that exceed the specified limit (quantity, frequency or duration). This is known as a limitation extension.
(i) See WAC 388-501-0165 for the PA process.
(ii) The EPA process is designed to eliminate the need for written and telephonic requests for prior authorization for selected services and procedure codes. MAA requires a provider to create an authorization number for EPA for selected procedure codes, using the process explained in the billing instructions for the specific service or program.
(iii) See chapter 388-538 WAC for managed care requirements.
(d) MAA does not reimburse for covered services, equipment or supplies:
(i) That are included in a DSHS waivered program; or
(ii) For a MAA client who is Medicare-eligible if:
(A) The services, equipment or supplies are covered under Medicare; and
(B) Medicare has not made a determination on the claim or has not been billed by the provider.
(2) Noncovered services
(a) MAA does not cover services, equipment or supplies to which any of the following apply:
(i) The service or equipment is not included as a covered service in the state plan;
(ii) Federal or state laws or regulations prohibit coverage;
(iii) The service or equipment is considered experimental or investigational by the Food and Drug Administration or the Health Care Financing Administration; or
(iv) MAA rules do not list the service or equipment as covered.
(b) MAA reviews all initial requests for noncovered services based on WAC 388-501-0165.
(c) If a noncovered service, equipment or supply is prescribed under the EPSDT program, it will be evaluated as a covered service and reviewed for medical necessity)) The following rules, WAC 388-501-0050 through WAC 388-501-0065, describe the healthcare services available to a client on a fee-for-service basis or as an enrollee in a managed care organization (MCO)(defined in WAC 388-538-050). Noncovered services are described in WAC 388-501-0070.
(1) Service categories listed in WAC 388-501-0060 do not represent a contract for services.
(2) The client must be eligible for the covered service on the date the service is performed or provided.
(3) The department pays only for medical or dental services, equipment, or supplies that are:
(a) Within the scope of the client's medical program;
(b) Covered - see subsection (5);
(c) Medically necessary;
(d) Ordered or prescribed by a healthcare provider meeting the requirements of chapter 388-502 WAC; and
(e) Furnished by a provider according to the requirements of chapter 388-502 WAC.
(4) The department's fee-for-service program pays only for services furnished by enrolled providers who meet the requirements of chapter 388-502 WAC.
(5) The department does not pay for any service, treatment, equipment, drug, or supply requiring prior authorization from the department, if prior authorization was not obtained before the service was provided.
(6) Covered services
(a) Covered 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 service for Medicaid clients; or
(ii) "State-option" - means the State of Washington is not federally-mandated to cover the service but has chosen to do so at its own discretion.
(b) The department may limit the scope, amount, duration, and/or frequency of covered services. Limitation extensions are authorized according to WAC 388-501-0169.
(7) Noncovered services
(a) The department does not pay for any service, equipment, or supply:
(i) That federal or state law or regulations prohibit the department from covering;
(ii) Listed as noncovered in WAC 388-501-0070 or in any other program rule. The department evaluates a request for a noncovered service only if an exception to rule is requested according to the provisions in WAC 388-501-0160.
(b) When Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) applies, a noncovered service, equipment, or supply will be evaluated 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).
[Statutory Authority: RCW 74.08.090. 01-12-070, § 388-501-0050, filed 6/4/01, effective 7/5/01. Statutory Authority: RCW 74.04.050 and 74.08.090. 00-01-088, § 388-501-0050, filed 12/14/99, effective 1/14/00.]
(2) Not all categories of service listed in this section are covered under every medical program, nor do they represent a contract for services. Services are subject to the exclusions, limitations, and eligibility requirements contained in department rules.
(3) Services covered under each listed category:
(a) Are determined by the department after considering available evidence relevant to the service or equipment to:
(i) Determine efficacy, effectiveness, and safety;
(ii) Determine impact on health outcomes;
(iii) Identify indications for use;
(iv) Compare alternative technologies; and
(v) Identify sources of credible evidence that use and report evidence-based information.
(b) May require prior authorization (see WAC 388-501-0165), or expedited authorization when allowed by the department.
(c) Are paid for by the department and subject to review both before and after payment is made. The department or the client's managed care organization may deny or recover payment for such services, equipment, and supplies based on these reviews.
(4) The department does not pay for covered services, equipment, or supplies that:
(a) Require prior authorization from the department, if prior authorization was not obtained before the service was provided;
(b) Are provided by providers who are not contracted with the department as required under chapter 388-502 WAC;
(c) Are included in a department waiver program identified in chapter 388-515 WAC; or
(d) Are covered by a third-party payer (see WAC 388-501-0200), including Medicare, if the third-party payer has not made a determination on the claim or has not been billed by the provider.
(5) Scope of covered service categories. The following table lists the department's covered categories of healthcare services.
• Under the four program columns (CN, MN, MCS, and AEM), the letter "C" means a service category is covered for that program, subject to any limitations listed in the specific medical assistance program WAC and department issuances.
• The letter "N" means a service category is not covered under that program.
• The letter "E" means the service category is available on ly if it is necessary to treat the client's emergency medical condition and may require prior authorization from the department.
• Refer to WAC 388-501-0065 for a description of each service category and for the specific program WAC containing the limitations and exclusions to services.
| Service Categories | CN* | MN | MCS | AEM |
| (a) Adult day health | C | C | N | E |
| (b) Ambulance (ground and air) | C | C | C | E |
| (c) Blood processing/administration | C | C | C | E |
| (d) Dental services | C | C | C | E |
| (e) Detoxification | C | C | C | E |
| (f) Diagnostic services (lab & x-ray) | C | C | C | E |
| (g) Family planning services | C | C | C | E |
| (h) Healthcare professional services | C | C | C | E |
| (i) Hearing care (audiology/hearing exams/aids) | C | C | C | E |
| (j) Home health services | C | C | C | E |
| (k) Hospice services | C | C | N | E |
| (l) Hospital services -inpatient/outpatient | C | C | C | E |
| (m) Intermediate care facility/services for mentally retarded | C | C | C | E |
| (n) Maternity care and delivery services | C | C | N | E |
| (o) Medical equipment, durable (DME) | C | C | C | E |
| (p) Medical equipment, nondurable (MSE) | C | C | C | E |
| (q) Medical nutrition services | C | C | C | E |
| (r) Mental health services | C | C | C | E |
| (s) Nursing facility services | C | C | C | E |
| (t) Organ transplants | C | C | C | N |
| (u) Out-of-state services | C | C | N | E |
| (v) Oxygen/respiratory services | C | C | C | E |
| (w) Personal care services | C | C | N | N |
| (x) Prescription drugs | C | C | C | E |
| (y) Private duty nursing | C | C | N | E |
| (z) Prosthetic/orthotic devices | C | C | C | E |
| (aa) School medical services | C | C | N | N |
| (bb) Substance abuse services | C | C | C | E |
| (cc) Therapy -occupational/physical/speech | C | C | C | E |
| (dd) Vision care (exams/lenses) | C | C | C | E |
*Clients enrolled in the State Children's Health Insurance Program and the Children's Health Program receive CN scope of medical care.
[]
(1) For categorically needy (CN), medically needy (MN), and medical care services (MCS), refer to the WAC citations listed in the following descriptions for specific details regarding each service category. For Alien Emergency Medical (AEM) services, refer to WAC 388-438-0110.
(2) The following service categories are subject to the exclusions, limitations, and eligibility requirements contained in department rules:
(a) Adult day health - Skilled nursing services, counseling, therapy (physical, occupational, speech, or audiology), personal care services, social services, general therapeutic activities, health education, nutritional meals and snacks, supervision, and protection. [WAC 388-71-0702 through WAC 388-71-0776]
(b) Ambulance - Emergency medical transportation and ambulance transportation for nonemergency medical needs. [WAC 388-546-0001 through WAC 388-546-4000]
(c) Blood processing/administration - Blood and/or blood derivatives, including synthetic factors, plasma expanders, and their administration. [WAC 388-550-1400 and WAC 388-550-1500]
(d) Dental services - Diagnosis and treatment of dental problems including emergency treatment and preventive care. [Chapter 388-535 WAC and Chapter 388-535A WAC]
(e) Detoxification - Inpatient treatment performed by a certified detoxification center or in an inpatient hospital setting. [WAC 388-800-0020 through WAC 388-800-0035; and WAC 388-550-1100]
(f) Diagnostic services - Clinical testing and imaging services. [WAC 388-531-0100; WAC 388-550-1400 and WAC 388-550-1500]
(g) Family planning services - Gynecological exams; contraceptives, drugs, and supplies, including prescriptions; sterilization; screening and treatment of sexually transmitted diseases; and educational services. [WAC 388-532-530]
(h) Healthcare professional services - Office visits, emergency room, nursing facility, home-based, and hospital-based care; surgery, anesthesia, pathology, radiology, and laboratory services; obstetric services; kidney dialysis and renal disease services; osteopathic care, podiatry services, physiatry, and pulmonary/respiratory services; and allergen immunotherapy. [Chapter 388-531 WAC]
(i) Hearing care - Audiology; diagnostic evaluations; hearing exams and testing; and hearing aids. [WAC 388-544-1200 and WAC 388-544-1300; WAC 388-545-700; and WAC 388-531-0100]
(j) Home health services - Intermittent, short-term skilled nursing care, physical therapy, speech therapy, home infusion therapy, and health aide services, provided in the home. [WAC 388-551-2000 through WAC 388-551-2220]
(k) Hospice services - Physician services, skilled nursing care, medical social services, counseling services for client and family, drugs, medications (including biologicals), medical equipment and supplies needed for palliative care, home health aide, homemaker, personal care services, medical transportation, respite care, and brief inpatient care. This benefit also includes services rendered in a hospice care center and pediatric palliative care services. [WAC 388-551-1210 through WAC 388-551-1850]
(l) Hospital services - inpatient/outpatient - Emergency room; hospital room and board (includes nursing care); inpatient services, supplies, equipment, and prescription drugs; surgery, anesthesia; diagnostic testing, laboratory work, blood/blood derivatives; radiation and imaging treatment and diagnostic services; and outpatient or day surgery, and obstetrical services. [Chapter 388-550 WAC]
(m) Intermediate care facility/services for mentally retarded - Habilitative training, health-related care, supervision, and residential care. [Chapter 388-835 WAC]
(n) Maternity care and delivery services - Community health nurse visits, nutrition visits, behavioral health visits, midwife services, maternity and infant case management services, and community health worker visits. [WAC 388-533-0330]
(o) Medical equipment, durable (DME) - Wheelchairs, hospital beds, respiratory equipment; prosthetic and orthotic devices; casts, splints, crutches, trusses, and braces. [WAC 388-543-1100]
(p) Medical equipment, nondurable (MSE) - Antiseptics, germicides, bandages, dressings, tape, blood monitoring/testing supplies, braces, belts, supporting devices, decubitus care products, ostomy supplies, pregnancy test kits, syringes, needles, transcutaneous electrical nerve stimulators (TENS) supplies, and urological supplies. [WAC 388-543-2800]
(q) Medical nutrition services - Enteral and parenteral nutrition, including supplies. [Chapter 388-553 WAC and Chapter 388-554 WAC]
(r) Mental health services - Inpatient and outpatient psychiatric services and community mental health services. [Chapter 388-865 WAC]
(s) Nursing facility services - Nursing, therapies, dietary, and daily care services. [Chapter 388-97 WAC]
(t) Organ transplants - Solid organs, e.g., heart, kidney, liver, lung, pancreas, and small bowel; bone marrow and peripheral stem cell; skin grafts; and corneal transplants. [WAC 388-550-1900 and WAC 388-550-2000, and WAC 388-556-0400]
(u) Out-of-state services - Emergency services; prior authorized care. Services provided in bordering cities are treated as if they were provided in state. [WAC 388-501-0175 and WAC 388-501-0180; WAC 388-531-1100; and WAC 388-556-0500]
(v) Oxygen/respiratory services - Oxygen, oxygen equipment and supplies; oxygen and respiratory therapy, equipment, and supplies. [Chapter 388-552 WAC]
(w) Personal care services - Assistance with activities of daily living (e.g., bathing, dressing, eating, managing medications) and routine household chores (e.g., meal preparation, housework, essential shopping, transportation to medical services). [WAC 388-106-0010, 0300, 0400, 0500, 0600, 0700, 0720 and 0900]
(x) Prescription drugs - Outpatient drugs (including in nursing facilities), both generic and brand name; drug devices and supplies; some over-the-counter drugs; oral, topical, injectable drugs; vaccines, immunizations, and biologicals; and family planning drugs, devices, and supplies. [WAC 388-530-1100] Additional coverage for medications and prescriptions is addressed in specific program WAC sections.
(y) Private duty nursing - Continuous skilled nursing services provided in the home, including client assessment, administration of treatment, and monitoring of medical equipment and client care for clients seventeen years of age and under. [WAC 388-551-3000.] For benefits for clients eighteen years of age and older, see WAC 388-106-1000 through WAC 388-106-1055.
(z) Prosthetic/orthotic devices - Artificial limbs and other external body parts; devices that prevent, support, or correct a physical deformity or malfunction. [WAC 388-543-1100]
(aa) School medical services - Medical services provided in schools to children with disabilities under the Individuals with Disabilities Education Act (IDEA). [Chapter 388-537 WAC]
(bb) Substance abuse services - Chemical dependency assessment, case management services, and treatment services. [WAC 388-533-0701 through WAC 388-533-0730; WAC 388-556-0100 and WAC 388-556-0400; and WAC 388-800-0020]
(cc) Therapy - occupational/physical/speech - Evaluations, assessments, and treatment. [WAC 388-545-300, WAC 388-545-500, and WAC 388-545-700]
(dd) Vision care - Eye exams, refractions, frames, lenses, ocular prosthetics, and surgery. [WAC 388-544-0250 through WAC 388-544-0550]
[]
Reviser's note: The brackets and enclosed material in the text of the above section occurred in the copy filed by the agency and appear in the Register pursuant to the requirements of RCW 34.08.040.
AMENDATORY SECTION(Amending WSR 00-03-035, filed 1/12/00,
effective 2/12/00)
WAC 388-501-0160
Exception to rule -- Request for a
noncovered ((medical or dental)) healthcare service((, or
related equipment)).
A client and/or ((their)) the client's
provider may request ((prior authorization for MAA)) the
department to pay for a noncovered ((medical or dental))
healthcare service((, or related equipment)). This is called
an exception to rule.
(1) ((MAA)) The department cannot approve an exception to
rule if the ((exception violates)) requested service is
excluded under state ((or federal law or federal regulation))
statute.
(2) The item or service(s) for which an exception is requested must be of a type and nature which falls within accepted standards and precepts of good medical practice;
(3) All exception requests must represent cost-effective utilization of medical assistance program funds as determined by the department;
(4) A request for an exception to rule must be submitted
to the department in writing within ninety days of the date of
the written notification denying authorization for the
noncovered service. For ((MAA)) the department to consider
the exception to rule request((,)):
(a) The client and/or the client's healthcare provider
must submit sufficient client-specific information and
documentation ((must be submitted for the MAA)) to Health and
Recovery Services Administration's medical director or
designee ((to determine if:
(a))) which demonstrate the client's clinical condition
is so different from the majority that there is no equally
effective, less costly covered service or equipment that meets
the client's need(s)((; and))
(b) ((The requested service or equipment will result in
lower overall costs of care for the client)) The client's
healthcare professional must certify that medical treatment or
items of service which are covered under the client's medical
assistance program and which, under accepted standards of
medical practice, are indicated as appropriate for the
treatment of the illness or condition, have been found to be:
(i) Medically ineffective in the treatment of the client's condition; or
(ii) Inappropriate for that specific client.
(((3) The MAA medical director or designee evaluates and
considers requests on a case-by-case basis according to the
information and documentation submitted from the provider.
(4) Within fifteen working days of MAA's receipt of the request, MAA notifies the provider and the client, in writing, of MAA's decision to grant or deny the exception to rule)) (5) Within fifteen business days of receiving the request, the department sends written notification to the provider and the client:
(a) Approving the exception to rule request;
(b) Denying the exception to rule request; or
(c) Requesting additional information.
(i) The additional information must be received by the department within thirty days of the date the information was requested.
(ii) The department approves or denies the exception to rule request within five business days of receiving the additional information.
(iii) If the requested information is insufficient or not provided within thirty days, the department denies the exception to rule request.
(6) The HRSA medical director or designee evaluates and considers requests on a case-by-case basis. The HRSA medical director has final authority or approve or deny a request for exception to rule.
(((5))) (7) Clients do not have a right to a fair hearing
on exception to rule decisions.
[Statutory Authority: RCW 74.08.090, 74.04.050, 74.09.035. 00-03-035, § 388-501-0160, filed 1/12/00, effective 2/12/00. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-501-0160, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-030.]
(1) No extension of covered services will be authorized when prohibited by specific program rules.
(2) When an extension is not prohibited by specific program rules, a client or the client's provider may request a limitation extension.
(3) Under fee-for-service (FFS), the department evaluates requests for limitation extensions using the process described in WAC 388-501-0165. For a managed care enrollee, the client's managed care organization (MCO) evaluates requests for limitation extensions according to the MCO's prior authorization process.
(4) In addition to subsection (3), both the department and MCO consider the following in evaluating a request for a limitation extension:
(a) The level of improvement the client has shown to date related to the requested service and the reasonably calculated probability of continued improvement if the requested service is extended; and
(b) The reasonably calculated probability the client's condition will worsen if the requested service is not extended.
[]
(a) Within the scope of an eligible client's medical
((care)) assistance program. Refer to ((chapter 388-529)) WAC
388-501-0060 and WAC 388-501-0065; and
(b) Medically necessary as defined in 388-500-0005.
(2) ((MAA evaluates a request for any service that is
listed as noncovered in WAC 388-531-0150 under the provisions
of WAC 388-501-0165.
(3) MAA)) The department evaluates a request for a
service that is in a covered category((, but has been
determined to be experimental or investigational under WAC 388-531-0550,)) under the provisions of WAC 388-501-0165
((which related to medical necessity)).
(((4) MAA)) (3) The department evaluates requests for
covered services that are subject to limitations or other
restrictions and approves such services beyond those
limitations or restrictions ((when medically necessary, under
the standards for covered services in WAC 388-501-0165)) as
described in WAC 388-501-0169.
(((5) MAA)) (4) The department covers the following
physician-related services, subject to the conditions in
subsections (1), (2), and (3)((, and (4))) of this section:
(a) Allergen immunotherapy services;
(b) Anesthesia services;
(c) Dialysis and end stage renal disease services (refer to chapter 388-540 WAC);
(d) Emergency physician services;
(e) ENT (ear, nose, and throat) related services;
(f) Early and periodic screening, diagnosis, and treatment (EPSDT) services (refer to WAC 388-534-0100);
(g) ((Gender dysphoria surgery and related procedures,
treatment, prosthetics, or supplies when recommended after a
multidisciplinary evaluation including at least urology,
endocrinology, and psychiatry;
(h))) Family planning services (refer to chapter 388-532 WAC);
(((i))) (h) Hospital inpatient services (refer to chapter 388-550 WAC);
(((j))) (i) Maternity care, delivery, and newborn care
services (refer to chapter 388-533 WAC);
(((k))) (j) Office visits;
(((l))) (k) Vision-related services, ((per)) refer to
chapter 388-544 WAC;
(((m))) (l) Osteopathic treatment services;
(((n))) (m) Pathology and laboratory services;
(((o))) (n) Physiatry and other rehabilitation services
(refer to chapter 388-550 WAC);
(((p))) (o) Podiatry services;
(((q))) (p) Primary care services;
(((r))) (q) Psychiatric services, provided by a
psychiatrist;
(((s))) (r) Pulmonary and respiratory services;
(((t))) (s) Radiology services;
(((u))) (t) Surgical services;
(((v) Surgery)) (u) Cosmetic, reconstructive, or plastic
surgery, and related services and supplies to correct
physiological defects from birth, illness, or physical trauma,
or for mastectomy reconstruction for post cancer treatment;
and
(((w))) (v) Other outpatient physician services.
(((6) MAA)) (5) The department covers physical
examinations for ((MAA)) medical assistance clients only when
the physical examination is one or more of the following:
(a) A screening exam covered by the EPSDT program (see WAC 388-534-0100);
(b) An annual exam for clients of the division of developmental disabilities; or
(c) A screening pap smear, mammogram, or prostate exam.
(((7))) (6) By providing covered services to a client
eligible for a medical ((care)) assistance program, a provider
who has signed an agreement with ((MAA)) the department
accepts ((MAA's)) the department's rules and fees as outlined
in the agreement, which includes federal and state law and
regulations, billing instructions, and ((MAA)) department
issuances.
[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-0100, filed 12/6/00, effective 1/6/01.]
3794.4(2) For a child eligible for the newborn medical program, the certification period begins on the child's date of birth and continues through the end of the month of the child's first birthday.
(3) For a woman eligible for a medical program based on pregnancy, the certification period ends the last day of the month that includes the sixtieth day from the day the pregnancy ends.
(4) For families the certification period is twelve months with a six-month report required as a condition of eligibility as described in WAC 388-418-0011.
(5) For children, the certification period is twelve months. Eligibility is continuous without regard to changes in circumstances other than aging out of the program, moving out of state or death. When the medical assistance unit is also receiving benefits under a cash or food assistance program, the medical certification period is updated to begin anew at each:
(a) Approved application for cash or food assistance; or
(b) Completed eligibility review.
(6) For an SSI-related person the certification period is twelve months.
(7) When the child turns nineteen the certification period ends even if the twelve-month period is not over. The certification period may be extended past the end of the month the child turns nineteen when:
(a) The child is receiving inpatient services on the last day of the month the child turns nineteen;
(b) The inpatient stay continues into the following month or months; and
(c) The child remains eligible except for exceeding age nineteen.
(8) A retroactive certification period can begin up to three months immediately before the month of application when:
(a) The client would have been eligible for medical assistance if the client had applied; and
(b) The client received covered medical services as
described in WAC ((388-529-0100)) 388-501-0060 and WAC 388-501-0065.
(9) If the client is eligible only during the three-month retroactive period, that period is the only period of certification.
(10) Any months of a retroactive certification period are added to the designated certification periods described in this section.
(11) For a child determined eligible for SCHIP medical benefits as described in chapter 388-542 WAC:
(a) The certification periods are described in subsections (1), (5), and (7) of this section;
(b) There is not a retroactive eligibility period as described in subsections (8), (9), and (10); and
(c) For a child who has creditable coverage at the time of application, the certification period begins on the first of the month after the child's creditable coverage is no longer in effect, if:
(i) All other SCHIP eligibility factors are met; and
(ii) An eligibility decision is made per WAC 388-406-0035.
[Statutory Authority: RCW 74.08.090, 74.09.530, and 74.09.415. 05-19-031, § 388-416-0015, filed 9/12/05, effective 10/13/05. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.04.510, and 2004 c 54. 04-21-064, § 388-416-0015, filed 10/18/04, effective 11/18/04. Statutory Authority: RCW 74.08.090, 74.09.530, and 2003 c 10. 04-03-019, § 388-416-0015, filed 1/12/04, effective 2/12/04. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090 and 74.09.450. 00-08-002, § 388-416-0015, filed 3/22/00, effective 5/1/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-416-0015, filed 7/31/98, effective 9/1/98. Formerly 388-509-0970, 388-521-2105, 388-522-2210 and 388-522-2230.]
(1) The HWD program provides categorically needy (CN)
((Medicaid services)) scope of care as described in WAC
((388-529-0200)) 388-501-0060.
(2) The department approves HWD coverage for twelve months effective the first of the month in which a person applies and meets program requirements. See WAC 388-475-1100 for "retroactive" coverage for months before the month of application.
(3) A person who is eligible for another Medicaid program may choose not to participate in the HWD program.
(4) A person is not eligible for HWD coverage for a month in which the person received Medicaid benefits under the medically needy (MN) program.
(5) The HWD program does not provide long-term care (LTC) services described in chapters 388-513 and 388-515 WAC. LTC services include institutional, waivered, and hospice services. To receive LTC services, a person must qualify and participate in the cost of care according to the rules of those programs.
[Statutory Authority: RCW 74.08.090, Section 1902 (a)(10)(A)(ii) of the Social Security Act, and 2001 c 7 § 209(5), Part II. 02-01-073, § 388-475-1000, filed 12/14/01, effective 1/14/02.]
(a) Medical care coverage under all medical programs
administered by the ((medical assistance administration
(MAA))) department; and
(b) Reimbursement purposes.
(2) The department does not cover out-of-state medical care for clients under the following state-administered (Washington state medical care only) medical programs:
(a) General assistance-unemployable (GA-U); or
(b) Alcohol and Drug Addiction Treatment and Support Act
(ADATSA)((; or
(c) Medically indigent program (MIP))).
(3) Subject to the exceptions and limitations in this section, the department covers out-of-state medical care provided to eligible clients when the services are:
(a) Within the scope of the client's medical care program
as specified ((under chapter 388-529)) in WAC 388-501-0060;
and
(b) Medically necessary as defined in WAC 388-500-0005.
(4) If the client travels out-of-state expressly to obtain medical care, the medical services must have prior authorization through the department's determination process described in WAC 388-501-0165.
(5) See WAC 388-501-0165 for the department's determination process for requests for:
(a) ((Any service that is listed in any Washington
Administrative Code section as noncovered;
(b))) A service that is in a covered category, but has
been determined to be experimental or investigational under
WAC 388-531-0550; ((and)) or
(((c))) (b) A covered service that is subject to the
department's limitations or other restrictions and the request
for the service exceeds those limitations or restrictions (see
also WAC 388-501-0169).
(6) The department evaluates a request for a noncovered service if an exception to rule is requested according to the provisions in WAC 388-501-0160.
(7) The department determines out-of-state coverage for transportation services, including ambulance services, according to chapter 388-546 WAC.
(((7))) (8) The department reimburses an out-of-state
provider for medical care provided to an eligible client if
the provider:
(a) Meets the licensing requirements of the state in which care is provided;
(b) Contracts with the department to be an enrolled provider; and
(c) Meets the same criteria for payment as in-state providers.
[Statutory Authority: RCW 74.08.090 and 74.09.035. 01-01-011, § 388-501-0180, filed 12/6/00, effective 1/6/01. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-501-0180, filed 5/3/94, effective 6/3/94. Formerly parts of WAC 388-82-135 and 388-92-015.]
(2) A person's base period begins on the first day of the month of application, subject to the exceptions in subsection (4) of this section.
(3) A separate base period may be made for a retroactive period. The retroactive base period is made up of the three calendar months immediately prior to the month of application.
(4) A base period may vary from the terms in subsections (1), (2), or (3) of this section if:
(a) A three month base period would overlap a previous eligibility period; or
(b) A client is not or will not be resource eligible for the required base period; or
(c) The client is not or will not be able to meet the TANF-related or SSI-related requirement for the required base period; or
(d) The client is or will be eligible for categorically needy (CN) coverage for part of the required base period; or
(e) The client was not otherwise eligible for MN coverage for each of the months of the retroactive base period.
(5) The amount of a person's "spenddown" is calculated by the department. The MN countable income from each month of the base period is compared to the MNIL. The excess income from each of the months in the base period is added together to determine the "spenddown" for the base period.
(6) If income varies and a person's MN countable income falls below the MNIL for one or more months, the difference is used to offset the excess income in other months of the base period. If this results in a spenddown amount of zero dollars and cents, see WAC 388-519-0100(5).
(7) Once a person's spenddown amount is known, their qualifying medical expenses are subtracted from that spenddown amount to determine the date of eligibility. The following medical expenses are used to meet spenddown:
(a) First, Medicare and other health insurance deductibles, coinsurance charges, enrollment fees, or copayments;
(b) Second, medical expenses which would not be covered by the MN program;
(c) Third, hospital expenses paid by the person during the base period;
(d) Fourth, hospital expenses, regardless of age, owed by the applying person;
(e) Fifth, other medical expenses, potentially payable by the MN program, which have been paid by the applying person during the base period; and
(f) Sixth, other medical expenses, potentially payable by the MN program which are owed by the applying person.
(8) If a person meets the spenddown obligation at the time of application, they are eligible for MN medical coverage for the remainder of the base period. The beginning date of eligibility would be determined as described in WAC 388-416-0020.
(9) If a person's spenddown amount is not met at the time of application, they are not eligible until they present evidence of additional expenses which meets the spenddown amount.
(10) To be counted toward spenddown, medical expenses must:
(a) Not have been used to meet a previous spenddown; and
(b) Not be the confirmed responsibility of a third party. The entire expense will be counted unless the third party confirms its coverage within:
(i) Forty-five days of the date of the service; or
(ii) Thirty days after the base period ends; and
(c) Meet one of the following conditions:
(i) Be an unpaid liability at the beginning of the base period and be for services for:
(A) The applying person; or
(B) A family member legally or blood-related and living in the same household as the applying person.
(ii) Be for medical services either paid or unpaid and incurred during the base period; or
(iii) Be for medical services paid and incurred during a previous base period if that client payment was made necessary due to delays in the certification for that base period.
(11) An exception to the provisions in subsection (10) of this section exists. Medical expenses the person owes are applied to spenddown even if they were paid by or are subject to payment by a publicly administered program during the base period. To qualify, the program cannot be federally funded or make the payments of a person's medical expenses from federally matched funds. The expenses do not qualify if they were paid by the program before the first day of the base period.
(12) The following medical expenses which the person owes are applied to spenddown. Each dollar of an expense or obligation may count once against a spenddown cycle that leads to eligibility for MN coverage:
(a) Charges for services which would have been covered by
the department's medical programs as described in ((chapter
388-529)) WAC 388-501-0060 and WAC 388-501-0065, less any
confirmed third party payments which apply to the charges; and
(b) Charges for some items or services not typically covered by the department's medical programs, less any third party payments which apply to the charges. The allowable items or services must have been provided or prescribed by a licensed health care provider; and
(c) Medical insurance and Medicare copayments or coinsurance (premiums are income deductions under WAC 388-519-0100(4)); and
(d) Medical insurance deductibles including those Medicare deductibles for a first hospitalization in sixty days.
(13) Medical expenses may be used more than once if:
(a) The person did not meet their total spenddown amount and did not become eligible in that previous base period; and
(b) The medical expense was applied to that unsuccessful spenddown and remains an unpaid bill.
(14) To be considered toward spenddown, written proof of medical expenses for services rendered to the client must be presented to the department. The deadline for presenting medical expense information is thirty days after the base period ends unless good cause for delay can be documented.
(15) The medical expenses applied to the spenddown amount are the client's financial obligation and are not reimbursed by the department (see WAC 388-502-0100).
(16) Once a person meets their spenddown and they are issued a medical identification card for MN coverage, newly identified expenses cannot be considered toward that spenddown. Once the application is approved and coverage begins the beginning date of the certification period cannot be changed due to a clients failure to identify or list medical expenses.
[Statutory Authority: RCW 71.05.560, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530. 06-13-042, § 388-519-0110, filed 6/15/06, effective 7/16/06. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, and 74.08.090. 05-08-093, § 388-519-0110, filed 4/1/05, effective 5/2/05; 98-16-044, § 388-519-0110, filed 7/31/98, effective 9/1/98. Formerly WAC 388-518-1830, 388-518-1840, 388-519-1905, 388-519-1910, 388-519-1930 and 388-522-2230.]
(2) ((MAA)) The department reimburses only pharmacies
that:
(a) Are ((MAA-enrolled)) department-enrolled providers;
and
(b) Meet the general requirements for providers described under WAC 388-502-0020.
(3) To be both covered and reimbursed under this chapter, prescription drugs must be:
(a) Medically necessary as defined in WAC 388-500-0005;
(b) Within the scope of coverage of an eligible client's
medical assistance program. Refer to ((chapter 388-529)) WAC
388-501-0060 and WAC 388-501-0065 for scope of coverage
information;
(c) For a medically accepted indication appropriate to the client's condition;
(d) Billed according to the conditions under WAC 388-502-0150 and 388-502-0160; and
(e) Billed according to the conditions and requirements of this chapter.
(4) Acceptance and filling of a prescription for a client
eligible for a medical care program constitutes acceptance of
((MAA's)) the department's rules and fees. See WAC 388-502-0100 for general conditions of payment.
[Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1000, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-028, § 388-530-1000, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1000, filed 10/9/96, effective 11/9/96.]
(a) Brand or generic drugs, when the manufacturer has not signed a rebate agreement with the federal Department of Health and Human Services. Refer to WAC 388-530-1125 for information on the drug rebate program.
(b) A drug prescribed:
(i) For weight loss or gain;
(ii) For infertility, frigidity, impotency, or sexual dysfunction;
(iii) For cosmetic purposes or hair growth; or
(iv) To promote tobacco cessation, except as described in WAC 388-533-0345 (3)(d) tobacco cessation for pregnant women.
(c) Over-the-counter (OTC) drugs and supplies, except as described under WAC 388-530-1100.
(d) Prescription vitamins and mineral products, except:
(i) When prescribed for clinically documented deficiencies;
(ii) Prenatal vitamins, only when prescribed and dispensed to pregnant women; or
(iii) Fluoride preparations for children under the early and periodic screening, diagnosis, and treatment (EPSDT) program.
(e) A drug prescribed for an indication or dosing that is not evidence based as determined by:
(i) ((MAA)) The department in consultation with federal
guidelines; or
(ii) The drug use review (DUR) board; and
(iii) ((MAA)) The department's medical consultants and
((MAA)) the department's pharmacist(s).
(f) Drugs listed in the federal register as "less-than-effective" ("DESI" drugs) or which are identical, similar, or related to such drugs.
(g) Drugs that are:
(i) Not approved by the Food and Drug Administration (FDA); or
(ii) Prescribed for non-FDA approved indications or dosing, unless prior authorized; or
(iii) Unproven for efficacy or safety.
(h) Outpatient drugs for which the manufacturer requires as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or manufacturer's designee.
(i) Drugs requiring prior authorization for which ((MAA))
department authorization has been denied.
(j) Preservatives, flavoring and/or coloring agents.
(k) Less than a one-month supply of drugs for long-term therapy.
(l) A drug with an obsolete national drug code (NDC) more than two years from the date the NDC is designated obsolete by the manufacturer.
(m) Products or items that do not have an eleven-digit NDC.
(n) Nonpreferred drugs when a therapeutic equivalent is on the preferred drug list(s) (PDL), according to WAC 388-530-1100, and subject to the dispense as written (DAW) provisions of WAC 388-530-1280, and 388-530-1290.
(o) Less than a three-month supply of contraceptive patches, contraceptive rings, or oral contraceptives (excluding emergency contraceptive pills), unless otherwise directed by the prescriber.
(2) ((MAA)) The department does not reimburse enrolled
providers for:
(a) Outpatient drugs, biological products, insulin, supplies, appliances, and equipment included in other reimbursement methods including, but not limited to:
(i) Diagnosis-related group (DRG);
(ii) Ratio of costs-to-charges (RCC);
(iii) Nursing facility ((per diem)) daily rate;
(iv) Managed care capitation rates;
(v) Block grants; or
(vi) Drugs prescribed for clients who are on the ((MAA))
department's hospice program when the drugs are related to the
client's terminal illness and related condition(s).
(b) Any drug regularly supplied as an integral part of program activity by other public agencies (e.g., immunization vaccines for children).
(c) Prescriptions written on pre-signed prescription
blanks filled out by nursing facility operators or
pharmacists. ((MAA)) The department may terminate the core
provider agreement of pharmacies involved in this practice.
(d) Drugs used to replace those taken from nursing facility emergency kits.
(e) Drugs used to replace a physician's stock supply.
(f) Free pharmaceutical samples.
(g) A drug product after the product's national drug code (NDC) termination date.
(h) A drug product whose shelf life has expired.
(3) ((MAA)) The department evaluates each request for
authorization of a noncovered drug ((under WAC 388-530-1100(5)
and under the provisions of WAC 388-501-0165)), device, or
pharmaceutical supply as an exception to rule according to WAC 388-501-0160.
[Statutory Authority: RCW 74.08.090, 70.14.050, 69.41.150, 69.41.190, chapter 41.05 RCW. 05-02-044, § 388-530-1150, filed 12/30/04, effective 1/30/05. Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1150, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-028, § 388-530-1150, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1150, filed 10/9/96, effective 11/9/96.]
(2) Bariatric surgery must be performed in a hospital with a bariatric surgery program, and the hospital must be:
(a) Located in the state of Washington or approved border cities (see WAC 388-501-0175); and
(b) Meet the requirements of WAC 388-550-2301.
(3) If bariatric surgery is requested or prescribed under
the EPSDT program, ((MAA)) the department evaluates it as a
covered service under EPSDT's standard of coverage that
requires the service to be:
(a) Medically necessary;
(b) Safe and effective; and
(c) Not experimental.
(4) ((MAA)) The department authorizes payment for
bariatric surgery and bariatric surgery-related services in
three stages:
(a) Stage one -- Initial assessment of client;
(b) Stage two -- Evaluations for bariatric surgery and successful completion of a weight loss regimen; and
(c) Stage three -- Bariatric surgery.
Stage one -- Initial assessment
(5) Any ((MAA)) department-enrolled provider who is
licensed to practice medicine in the state of Washington may
examine a client requesting bariatric surgery to ascertain if
the client meets the criteria listed in subsection (6) of this
section.
(6) The client meets the preliminary conditions of stage one when:
(a) The client is between twenty-one and fifty-nine years of age;
(b) The client has a body mass index (BMI) of thirty-five or greater;
(c) The client is not pregnant. (Pregnancy within the
first two years following bariatric surgery is not
recommended. When applicable, a family planning consultation
is highly recommended prior to bariatric surgery((.)));
(d) The client is diagnosed with one of the following:
(i) Diabetes mellitus;
(ii) Degenerative joint disease of a major weight bearing joint(s) (the client must be a candidate for joint replacement surgery if weight loss is achieved); or
(iii) Other rare comorbid conditions (such as pseudo tumor cerebri) in which there is medical evidence that bariatric surgery is medically necessary and that the benefits of bariatric surgery outweigh the risk of surgical mortality; and
(e) The client has an absence of other medical conditions such as multiple sclerosis (MS) that would increase the client's risk of surgical mortality or morbidity from bariatric surgery.
(7) If a client meets the criteria in subsection (6) of
this section, the provider must request prior authorization
from ((MAA)) the department before referring the client to
stage two of the bariatric surgery authorization process. The
provider must attach a medical report to the request for prior
authorization with supporting documentation that the client
meets the stage one criteria in subsections (5) and (6) of
this section.
(8) ((MAA)) The department evaluates requests for covered
services that are subject to limitations or other restrictions
and approves such services beyond those limitations or
restrictions when medically necessary, under the ((standards
for covered services in)) provisions of WAC 388-501-0165 and
WAC 388-501-0169.
Stage two -- Evaluations for bariatric surgery and successful completion of a weight loss regimen
(9) After receiving prior authorization from ((MAA)) the
department to begin stage two of the bariatric surgery
authorization process, the client must:
(a) Undergo a comprehensive psychosocial evaluation
performed by a psychiatrist, licensed psychiatric ARNP, or
licensed independent social worker with a minimum of two years
postmasters' experience in a mental health setting. Upon
completion, the results of the evaluation must be forwarded to
((MAA)) the department. The comprehensive psychosocial
evaluation must include:
(i) An assessment of the client's mental status or illness to:
(A) Evaluate the client for the presence of substance abuse problems or psychiatric illness which would preclude the client from participating in presurgical dietary requirements or postsurgical lifestyle changes; and
(B) If applicable, document that the client has been successfully treated for psychiatric illness and has been stabilized for at least six months and/or has been rehabilitated and is free from any drug and/or alcohol abuse and has been drug and/or alcohol free for a period of at least one year.
(ii) An assessment and certification of the client's ability to comply with the postoperative requirements such as lifelong required dietary changes and regular follow-up.
(b) Undergo an internal medicine evaluation performed by
an internist to assess the client's preoperative condition and
mortality risk. Upon completion, the internist must forward
the results of the evaluation to ((MAA)) the department.
(c) Undergo a surgical evaluation by the surgeon who will
perform the bariatric surgery (see subsection (13) of this
section for surgeon requirements). Upon completion, the
surgeon must forward the results of the surgical evaluation to
((MAA)) the department and to the licensed medical provider
who is supervising the client's weight loss regimen (refer to
WAC 388-531-1600 (9)(d)(ii)).
(d) Under the supervision of a licensed medical provider,
the client must participate in a weight loss regimen prior to
surgery. The client must, within one hundred and eighty days
from the date of ((MAA's)) the department's stage one
authorization, lose at least five percent of his or her
initial body weight. If the client does not meet this weight
loss requirement within one hundred and eighty days from the
date of ((MAA's)) the department's initial authorization,
((MAA)) the department will cancel the authorization. The
client or the client's provider must reapply for prior
authorization from ((MAA)) the department to restart stage
two. For the purpose of this section, "initial body weight"
means the client's weight at the first evaluation appointment.
(i) The purpose of the weight loss regimen is to help the client achieve the required five percent loss of initial body weight prior to surgery and to demonstrate the client's ability to adhere to the radical and lifelong behavior changes and strict diet that are required after bariatric surgery.
(ii) The weight loss regimen must:
(A) Be supervised by a licensed medical provider who has
a core provider agreement with ((MAA)) the department;
(B) Include monthly visits to the medical provider;
(C) Include counseling twice a month by a registered dietician referred to by the treating provider or surgeon; and
(D) Be at least six months in duration.
(iii) Documentation of the following requirements must be
retained in the client's medical file. Copies of the
documentation must be forwarded to ((MAA)) the department upon
completion of stage two. ((MAA)) The department will evaluate
the documentation and authorize the client for bariatric
surgery if the stage two requirements were successfully
completed.
(A) The provider must document the client's compliance in keeping scheduled appointments and the client's progress toward weight loss by serial weight recordings. Clients must lose at least five percent loss of initial body weight and must maintain the five percent weight loss until surgery;
(B) For diabetic clients, the provider must document the efforts in diabetic control or stabilization;
(C) The registered dietician must document the client's compliance (or noncompliance) in keeping scheduled appointments, and the client's weight loss progress;
(D) The client must keep a journal of active participation in the medically structured weight loss regimen including the activities under (d)(iii)(A), (d)(iii)(B) if appropriate, and (d)(iii)(C) of this subsection.
(10) If the client fails to complete all of the
requirements of subsection (9) of this section, ((MAA)) the
department will not authorize stage three -- Bariatric surgery.
(11) If the client is unable to meet all of the stage two
criteria, the client or the client's provider must reapply for
prior authorization from ((MAA)) the department to re-enter
stage two.
Stage three -- Bariatric surgery
(12) ((MAA)) The department may withdraw authorization of
payment for bariatric surgery at any time up to the actual
surgery if ((MAA)) the department determines that the client
is not complying with the requirements of this section.
(13) A surgeon who performs bariatric surgery for medical assistance clients must:
(a) Have a signed core provider agreement with ((MAA))
the department;
(b) Have a valid medical license in the state of Washington; and
(c) Be affiliated with a bariatric surgery program that meets the requirements of WAC 388-550-2301.
(14) For hospital requirements for stage three -- Bariatric surgery, see WAC 388-530-2301.
[Statutory Authority: RCW 74.08.090,