WSR 16-06-109 PERMANENT RULES HEALTH CARE AUTHORITY (Washington Apple Health) [Filed March 2, 2016, 8:14 a.m., effective April 2, 2016] Effective Date of Rule: Thirty-one days after filing.
Purpose: The agency is striking the definition for "Medical assistance administration," adding definitions for "Medicaid agency" and ["]Medically needy income level,["] and making other changes to improve clarity.
Citation of Existing Rules Affected by this Order: Amending WAC 182-500-0070.
Adopted under notice filed as WSR 16-01-178 on December 22, 2015.
Changes Other than Editing from Proposed to Adopted Version: "Medicaid" means the federal medical aid program under Title XIX of the Social Security Act that provides health care to eligible persons people.
"Medical assistance" is the term the agency and its predecessors use to mean all federal or state-funded health care programs, or both, administered by the agency or its designees. Medical assistance programs are referred to as Washington apple health (WAH).
"Medical care services (MCS)" means the limited scope health care program financed by state funds for clients who are eligible for the aged, blind, or disabled (ABD) cash assistance (see WAC 388-400-0060) or the housing and essential needs (HEN) referral program (see WAC 388-500-0065) and not eligible for other full-scope WAH programs due to their citizenship or immigration status.
"Medical services card" or "services card" means the card the agency issues at the initial approval of a person's WAH Washington apple health benefit. The card identifies the person's name and medical services identification number but is not proof of WAH eligibility. The card may be replaced upon request if it is lost or stolen, but is not required to access health care through WAH Washington apple health.
"Medically needy (MN)" or "medically needy program (MNP)" means the state and federally funded health care program available to specific groups of people who would be eligible as categorically needy (CN), except their monthly income is above the CN standard. Some long-term care clients with income or resources above the CN standard may also qualify for MN.
"Medicare" means is the medical aid federal government health insurance program under Titles II and XVIII of the Social Security Act. For additional information, see www.Medicare.gov.
"Medicare assignment" means the process by which a provider agrees to provide services to a medicare beneficiary client and accept medicare's payment for the services.
"Medicare cost-sharing" means out-of-pocket medical expenses related to services provided by medicare. For WAH clients enrolled in medicare, cost-sharing may include Part A and Part B premiums, co-insurance, deductibles, and copayments for medicare services. See chapter 182-517 WAC.
"Modified adjusted gross income (MAGI)" means the adjusted gross income as determined by the Internal Revenue Service under the Internal Revenue Code of 1986 (IRC) increased by:
(1) Any amount excluded ... ;
(2) Any amount of interest ... ; and
(3) Any amount of Title II Social Security income or Tier 1 railroad retirement benefits excluded from gross income under 26 U.S.C. Sec. 86. See chapter 182-509 WAC for additional rules regarding MAGI.
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 0, Amended 1, Repealed 0.
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 1, Repealed 0.
Date Adopted: March 2, 2016.
Wendy Barcus
Rules Coordinator
AMENDATORY SECTION (Amending WSR 14-01-021, filed 12/9/13, effective 1/9/14)
WAC 182-500-0070 Medical assistance definitions—M.
"Medicaid" ((is)) means the federal medical aid program under Title XIX of the Social Security Act ((under which)) that provides health care ((is provided)) to eligible ((persons)) people.
"Medicaid agency" means the state agency that administers the medicaid program. The Washington state health care authority (HCA) is the state's medicaid agency.
"Medical assistance" is the term the agency and its predecessors ((used prior to the implementation of the Affordable Care Act in Washington state)) use to mean all federal ((and/or)) or state-funded health care programs, or both, administered by the agency or its ((designee that are now known)) designees. Medical assistance programs are referred to as Washington apple health.
(("Medical assistance administration (MAA)" is the former organization within the department of social and health services authorized to administer the federally funded and/or state-funded health care programs that are now administered by the agency, formerly the medicaid purchasing administration (MPA), of the health and recovery services administration (HRSA).))
"Medical care services (MCS)" means the limited scope health care program financed by state funds for clients ((who meet the incapacity criteria defined in chapter 182-508 WAC or)) who are eligible for the ((Alcohol and Drug Addiction Treatment and Support Act (ADATSA) program)) aged, blind, or disabled (ABD) cash assistance (see WAC 388-400-0060) or the housing and essential needs (HEN) referral program (see WAC 388-400-0065) and not eligible for other full-scope programs due to their citizenship or immigration status.
"Medical consultant" means a physician employed by or contracted ((by)) with the agency or the agency's designee.
"Medical facility" means a medical institution or clinic that provides health care services.
"Medical institution" See "institution" in WAC 182-500-0050.
"Medical services card" or "services card" means the card ((issued by)) the agency issues at the initial approval of a person's Washington apple health (((WAH))) benefit. The card identifies the person's name and medical services identification number((,)) but is not proof of eligibility ((for WAH)). The card may be replaced upon request if it is lost or stolen, but is not required to access health care through ((WAH)) Washington apple health.
"Medically necessary" is a term for describing requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the client that endanger life, or cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the client requesting the service. For the purposes of this section, "course of treatment" may include mere observation or, where appropriate, no medical treatment at all.
"Medically needy (MN)" or "medically needy program (MNP)" ((is)) means the state((-)) and federally funded health care program available to specific groups of ((persons)) people who would be eligible as categorically needy (CN), except their monthly income is above the CN standard. Some long-term care clients with income ((and/or)) or resources above the CN standard may also qualify for MN.
"Medically needy income level (MNIL)" means the standard the agency uses to determine eligibility under the medically needy program. See WAC 182-519-0050.
"Medicare" is the federal government health insurance program ((for certain aged or disabled persons)) under Titles II and XVIII of the Social Security Act. ((Medicare has four parts:
(1) "Part A" - Covers medicare inpatient hospital services, post-hospital skilled nursing facility care, home health services, and hospice care.
(2) "Part B" - The supplementary medical insurance benefit (SMIB) that covers medicare doctors' services, outpatient hospital care, outpatient physical therapy and speech pathology services, home health care, and other health services and supplies not covered under Part A of medicare.
(3) "Part C" - Covers medicare benefits for clients enrolled in a medicare advantage plan.
(4) "Part D" - The medicare prescription drug insurance benefit.)) For additional information, see www.Medicare.gov.
"Medicare assignment" means the process by which a provider agrees to provide services to a medicare beneficiary and accept medicare's payment for the services.
"Medicare cost-sharing" means out-of-pocket medical expenses related to services provided by medicare. For ((medical assistance)) clients ((who are)) enrolled in medicare, cost-sharing may include Part A and Part B premiums, co-insurance, deductibles, and copayments for medicare services. See chapter 182-517 WAC ((for more information)).
"Minimum essential coverage" means coverage ((defined in Section 5000A(f) of Subtitle D of the Internal Revenue Code of 1986, as added by Section 1401 of the Affordable Care Act)) under 26 U.S.C. Sec. 5000A(f).
"Modified adjusted gross income (MAGI)" means the adjusted gross income ((())as determined by the Internal Revenue Service under the Internal Revenue Code of 1986 (IRC)(())) increased by:
(1) Any amount excluded from gross income under ((Section 911 of the IRC)) 26 U.S.C. Sec. 911;
(2) Any amount of interest received or accrued by the ((taxpayer)) client during the taxable year which is exempt from tax; and
(3) Any amount of Title II Social Security income or Tier 1 railroad retirement ((income which is)) benefits excluded from gross income under ((Section 86 of the IRC. See WAC 182-509-0300 through 182-509-0375 for additional rules regarding MAGI)) 26 U.S.C. Sec. 86. See chapter 182-509 WAC for additional rules regarding MAGI.
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