Apple Health (Medicaid) rulemaking

The agency is updating the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) chapter to align with guidance from the Centers for Medicare & Medicaid Services.

The agency is amending its rules to increase the income standards for pregnancy and postpartum groups from 193% to 210% of the federal poverty level. This
increase is consistent with legislative directives in chapter 213, Laws of 2024 (2E2SSB 5580).

The State Supplemental Operating budget (section 211 (34), Chapter 376, Laws of 2024, (ESSB 5950)), included funding for the Health Care Authority (HCA) to implement a birth doula benefit for Apple Health (Medicaid) clients. HCA is developing rules in Chapter 182-533 WAC and amending WAC 182-502-0002 to accomplish this.

The agency is amending this rule to expand screening and preventative services for certain sexually transmitted infections during a client visit focused on family planning.

RCW 74.09.830 provides full-scope coverage for 12 months postpartum for pregnant or postpartum persons. This coverage is more generous than and thus replaces the limited scope “Family planning only – Pregnancy related program.” The agency intends to remove language related to this superseded program from chapter 182-532 WAC.

The agency is adding a new section describing system requirements for electronic visit verification (EVV) for home health care services.

The agency is revising these rules to allow for reimbursements of professional services for home infusions.

The agency is revising these two sections to update outdated terminology (fair hearings to administrative hearings) and also to remove the outdated options for requesting prior authorization.

The agency is amending these rules as an overall housekeeping project. Additionally, the agency is removing definitions for “base year” and “uninsured patient”, removing “with special needs” language from low-income clients, updating the abbreviation of the medicaid inpatient utilization rate from MIPUR to MIUR to align with CMS, updating WAC cross referencing, standardizing language, removing language that the DSH application is posted to the agency’s website, updating that the agency will use the medicare cost report rather than the DRDF to determine a hospital’s MUIR, removing DSH programs no longer funded and not part of the program, and audit requests for additional information must be received 10 days from the initial notification. Also updating the
name of the “provider data summary schedule (PDSS)” to “schedule of annual reporting requirements (SARR).”