(1) The department pays for health care services provided outside the state of Washington only when the service meets the provisions set forth in WAC 388-501-0180
, and specific program WAC.
(2) With the exception of hospital services and nursing facilities, the department pays the provider of service in designated bordering cities as if the care was provided within the state of Washington (see WAC 388-501-0175
(3) With the exception of designated bordering cities, the department does not pay for health care services provided to clients in medical care services (MCS) programs outside the state of Washington (see WAC 388-556-0500
(4) With the exception of hospital services (see subsection (5) of this section), the department pays for health care services provided outside the state of Washington at the lower of:
(a) The billed amount; or
(b) The rate established by the Washington state medical assistance programs.
(5) The department pays for hospital services provided in designated bordering cities and outside the state of Washington in accordance with the provisions of WAC 388-550-3900
(6) The department pays nursing facilities located outside the state of Washington when approved by the aging and disability services administration (ADSA) at the lower of the billed amount or the adjusted statewide average reimbursement rate for in-state nursing facility care, only in the following limited circumstances:
(a) Emergency situations; or
(b) When the client intends to return to Washington state and the out-of-state stay is for:
(i) Thirty days or less; or
(ii) More than thirty days if approved by ADSA.
(7) To receive payment from the department, an out-of-state provider must:
(a) Have a signed agreement with the department;
(b) Meet the functionally equivalent licensing requirements of the state or province in which care is rendered;
(c) Meet the conditions in WAC 388-502-0100
(d) Satisfy all medicaid conditions of participation;
(e) Accept the department's payment as payment in full according to 42 C.F.R. 447.15; and
(f) If a Canadian provider, bill at the U.S. exchange rate in effect at the time the service was provided.
(8) For covered services for eligible clients, the department reimburses other approved out-of-state providers at the lower of:
(a) The billed amount; or
(b) The rate paid by the Washington state Title XIX medicaid program.
[11-14-075, recodified as § 182-502-0120, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. 10-19-057, § 388-502-0120, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035. 08-08-064, § 388-502-0120, filed 3/31/08, effective 5/1/08. Statutory Authority: RCW 74.08.090. 01-02-076, § 388-502-0120, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.04.050 and 74.08.090. 00-01-088, § 388-502-0120, filed 12/14/99, effective 1/14/00.]