describe the health care 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, health care services includes treatment, equipment, related supplies, and drugs. WAC 388-501-0070
describes noncovered services.
(1) Health care service categories listed in WAC 388-501-0060
do not represent a contract for health care services.
(2) For the provider to receive payment, the client must be eligible for the covered health care service on the date the health care service is performed or provided.
(3) 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 health care services to clients.
(4) The department pays only for the health care services that are:
(a) Within the scope of the client's medical program;
(b) Covered - See subsection (9) of this section;
(c) Ordered or prescribed by a health care provider who meets the requirements of chapter 388-502
(d) Medically necessary as defined in WAC 388-500-0005
(e) Submitted for authorization, when required, in accordance with WAC 388-501-0163
(f) Approved, when required, in accordance with WAC 388-501-0165
(g) Furnished by a provider according to chapter 388-502
(h) Billed in accordance with department program rules and the department's current published billing instructions and numbered memoranda.
(5) The department does not pay for any health care service requiring prior authorization from the department, if prior authorization was not obtained before the health care 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 department does not reimburse clients for health care services purchased out-of-pocket.
(7) 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:
(a) 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
(b) Otherwise allowed under chapter 388-500
(8) The department's refusal to pay for replacement of equipment, device, or supplies will not extend beyond the limitations stated in specific department program rules.
(9) Covered health care services
(a) Covered health care services are either:
(i) "Federally mandated" - Means the state of Washington is required by federal regulation (42 C.F.R. 440.210 and 220) to cover the health care service for medicaid clients; or
(ii) "State-option" - Means the state of Washington is not federally mandated to cover the health care 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 health care services. Limitation extensions are authorized according to WAC 388-501-0169
(10) Noncovered health care services
(a) The department does not pay for any health care service:
(i) That federal or state laws or regulations prohibit the department from covering; or
(ii) Listed as noncovered in WAC 388-501-0070
or in any other program rule. The department evaluates a request for a noncovered health care service only if an exception to rule is requested according to the provisions in WAC 388-501-0160
(b) When a noncovered health care service is recommended during the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) exam and then ordered by a provider, the department evaluates the health care 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).
[11-14-075, recodified as § 182-501-0050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. 10-07-116, § 388-501-0050, filed 3/22/10, effective 4/22/10. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 09-23-112, § 388-501-0050, filed 11/18/09, effective 12/19/09; 06-24-036, § 388-501-0050, filed 11/30/06, effective 1/1/07. 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.]