PDFWAC 182-501-0065
Health care coverage—Description of service categories.
This rule provides a brief description of the medical, dental, mental health, and substance use disorder (SUD) service categories listed in the table in WAC 182-501-0060. The description of services under each category is not intended to be all inclusive.
(1) For alternative benefits plan (ABP), 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.
(2) The following service categories are subject to the exclusions, limitations, restrictions, and eligibility requirements contained in agency rules:
(a) Ambulance - Emergency medical transportation and ambulance transportation for nonemergency medical needs. (WAC 182-546-0001 through 182-546-4000.)
(b) Applied behavior analysis (ABA) - (Chapter 182-531A WAC.)
(c) Behavioral health services - (Chapter 182-538D WAC, Behavioral health services, WAC 182-531-1400 Psychiatric physician-related services and other professional mental health services, and chapter 246-341 WAC, Behavioral health services administrative requirements.)
(d) Blood, blood products, and related services - Blood and/or blood derivatives, including synthetic factors, plasma expanders, and their administration. (WAC 182-550-1400 and 182-550-1500.)
(e) Community behavioral health support services (CBHS) - (Chapter 182-561 WAC.)
(f) Dental services - Diagnosis and treatment of dental problems including emergency treatment and preventive care. (Chapters 182-535 and 182-535A WAC.)
(g) Diagnostic services - Clinical testing and imaging services. (WAC 182-531-0100; WAC 182-550-1400 and 182-550-1500.)
(h) Early and periodic screening, diagnosis, and treatment (EPSDT) - (Chapter 182-534 WAC and WAC 182-501-0050(10).)
(i) Enteral nutrition program - Enteral nutrition products, equipment, and related supplies. (Chapter 182-554 WAC.)
(j) Habilitative services - (Chapter 182-545 WAC.)
(k) Health care professional services - The following services found in chapter 182-531 WAC:
(i) Office visits and vaccinations;
(ii) Screening/brief intervention/referral to treatment (SBIRT), emergency room, and nursing facility services;
(iii) Home-based and hospital-based services;
(iv) Surgery, anesthesia, pathology, radiology, and laboratory services;
(v) Obstetric services;
(vi) Kidney dialysis and renal disease services;
(vii) Advanced registered nurse practitioner, naturopathy, osteopathy, podiatry, physiatry, and pulmonary/respiratory services; and
(viii) Allergen immunotherapy services.
(l) Health homes - (Chapter 182-557 WAC.)
(m) Hearing evaluations - The following services found in WAC 182-531-0375:
(i) Audiology;
(ii) Diagnostic evaluations; and
(iii) Hearing exams and testing.
(n) Hearing aids - (Chapter 182-547 WAC.)
(o) Home health services - Intermittent, short-term skilled nursing care, occupational therapy, physical therapy, speech therapy, home infusion therapy, and health aide services, provided in the home. (WAC 182-551-2000 through 182-551-2220.)
(p) Home infusion therapy/parenteral nutrition program - Supplies and equipment necessary for parenteral infusion of therapeutic agents. (Chapter 182-553 WAC.)
(q) 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 182-551-1210 through 182-551-1850.)
(r) 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 182-550 WAC.)
(s) Intermediate care facility/services for persons with intellectual disabilities - Habilitative training, health-related care, supervision, and residential care. (Chapter 388-835 WAC.)
(t) Maternity care and delivery services - Community health nurse visits, nutrition visits, behavioral health visits, midwife services, maternity and infant case management services, family planning services and community health worker visits. (WAC 182-533-0330.)
(u) Medical equipment, supplies, and appliances - Medical equipment and appliances, including wheelchairs, hospital beds, respiratory equipment; casts, splints, crutches, trusses, and braces. Medical supplies, including antiseptics, germicides, bandages, dressings, tape, blood monitoring/testing supplies, braces, belts, supporting devices, decubitus care products, ostomy supplies, syringes, needles, and urological supplies. (Chapter 182-543 WAC.)
(v) Medical nutrition therapy – Outpatient medical nutrition therapy and associated follow-ups. (Chapter 182-555 WAC.)
(w) Nursing facility services - Nursing, therapies, dietary, and daily care services delivered in a licensed nursing facility. (Chapter 388-97 WAC.)
(x) 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 182-550-1900 and 182-556-0400.)
(y) Orthodontic services - (Chapter 182-535A WAC.)
(z) Out-of-state services - (WAC 182-502-0120.)
(aa) Outpatient rehabilitation services (OT, PT, ST) - Evaluations, assessments, and treatment. (WAC 182-545-200.)
(bb) 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). (Chapters 388-106 and 388-845 WAC.)
(cc) 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 182-530-2000.) Additional coverage for medications and prescriptions is addressed in specific program WAC sections.
(dd) Private duty nursing - Continuous skilled nursing services provided in a private residence, including client assessment, administration of treatment, and monitoring of medical equipment and client care. For benefits for clients age 17 and younger, see WAC 182-551-3000 through 182-551-3400. For benefits for clients age 18 and older, see WAC 388-106-1000 through 388-106-1055.
(ee) Prosthetic/orthotic devices - Artificial limbs and other external body parts; devices that prevent, support, or correct a physical deformity or malfunction. (WAC 182-543-5000.)
(ff) Reproductive health services - Gynecological exams; contraceptives, drugs, and supplies, including prescriptions; sterilization; screening and treatment of sexually transmitted diseases; and educational services. (WAC 182-532-001 through 182-532-140.)
(gg) Respiratory care (oxygen) - All services, oxygen, equipment, and supplies related to respiratory care. (Chapter 182-552 WAC.)
(hh) School-based health care services - Early intervention services or special education health-related services provided in schools to medicaid-eligible children ages birth through 20 who have an individualized education program (IEP) or individualized family service plan (IFSP). (Chapter 182-537 WAC.)
(ii) Vision care - Eye exams, refractions, fittings, visual field testing, vision therapy, ocular prosthetics, and surgery. (WAC 182-531-1000.)
(jj) Vision hardware - Frames and lenses. (Chapter 182-544 WAC.)
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-10-081, § 182-501-0065, filed 4/30/24, effective 7/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, 2018 c 159. WSR 19-14-020, § 182-501-0065, filed 6/24/19, effective 7/25/19. Statutory Authority: RCW 41.05.021, 2013 2nd sp.s. c 4, and Patient Protection and Affordable Care Act (P.L. 111-148). WSR 14-06-045, § 182-501-0065, filed 2/26/14, effective 3/29/14. Statutory Authority: RCW 41.05.021. WSR 13-15-044, § 182-501-0065, filed 7/11/13, effective 8/11/13. WSR 11-14-075, recodified as § 182-501-0065, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-501-0065, filed 11/30/06, effective 1/1/07.]