(1) This rule provides a list (see subsection (5)) of medical, dental, mental health, and substance abuse categories of service covered by the department under categorically needy (CN) medicaid, medically needy (MN) medicaid, Alien Emergency Medical (AEM), and medical care services (MCS) programs. MCS means the limited scope of care financed by state funds and provided to general assistance and Alcohol and Drug Addiction Treatment and Support Act (ADATSA) program clients.
(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
(c) Are included in a department waiver program identified in chapter 388-515
(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 health care 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 only 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) Health care 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.
[11-14-075, recodified as § 182-501-0060, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-501-0060, filed 11/30/06, effective 1/1/07.]