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Program benefit packages and scope of services
The Health Care Authority provides funding for a wide range of medical services. The level of medical coverage for any given client depends on the medical program for which the client is eligible.
This table is found in WAC 182-501-0060. It lists services that may be provided under the specific services or programs if the individual meets all the criteria required to receive the service. Some services may require prior authorization from:
- The agency.
- An agency-contracted managed care organization.
- The Department of Social and Health Services (DSHS).
This table is provided for general information only. It does not guarantee that a service will actually be covered. Benefits, coverage, and interpretation of benefits and coverage may change at any time. Coverage limitations can be found in:
- Federal statutes and regulations.
- State statutes and regulations.
- State budget provisions
- Agency billing guides.
Abbreviations used in table
- ABP - Alternative Benefit Plan
- CN - Categorically Needy Program
- MCS - Medical Care Services
- MN - Medically Needy Program
- AHE - Apple Health Expansion
Effective 6/20/2024
| Service categories | ABP 20- | ABP 21+ | CN1 20- | CN 21+ | MN 20- | MN 21+ | MCS | AHE |
|---|---|---|---|---|---|---|---|---|
| Ambulance (ground and air) | Y | Y | Y | Y | Y | Y | Y | Y |
| Applied behavior analysis (ABA) | Y | Y | Y | Y | Y | Y | N | Y |
| Behavioral health services | Y | Y | Y | Y | Y | Y | Y | Y |
| Blood/blood products/related services | Y | Y | Y | Y | Y | Y | Y | Y |
| Dental services | Y | Y | Y | Y | Y | Y | Y | Y |
| Diagnostic services (lab and X-ray) | Y | Y | Y | Y | Y | Y | Y | Y |
| Early and periodic screening, diagnosis, and treatment (EPSDT) services | Y | N | Y | N | Y | N | N | N |
| Enteral nutrition program | Y | Y | Y | Y | Y | Y | Y | Y |
| Habilitative services | Y | Y | N | N | N | N | N | N |
| Health care professional services | Y | Y | Y | Y | Y | Y | Y | Y |
| Health homes | Y | Y | Y | Y | N | N | N | N |
| Hearing evaluations | Y | Y | Y | Y | Y | Y | Y | Y |
| Hearing aids | Y | Y | Y | Y | Y | Y | Y | Y |
| Home health services | Y | Y | Y | Y | Y | Y | Y | Y |
| Home infusion therapy/parenteral nutrition program | Y | Y | Y | Y | Y | Y | Y | Y |
| Hospice services | Y | Y | Y | Y | Y | Y | N | Y |
| Hospital services Inpatient/outpatient | Y | Y | Y | Y | Y | Y | Y | Y |
| Intermediate care facility/services for persons with intellectual disabilities | Y | Y | Y | Y | Y | Y | Y | N |
| Maternity care and delivery services | Y | Y | Y | Y | Y | Y | Y | Y |
| Medical equipment, supplies, and appliances | Y | Y | Y | Y | Y | Y | Y | Y |
| Medical nutrition therapy | Y | Y | Y | Y | Y | Y | Y | Y |
| Nursing facility services | Y | Y | Y | Y | Y | Y | Y | Y* |
| Organ transplants | Y | Y | Y | Y | Y | Y | Y | Y |
| Orthodontic services | Y | N | Y | N | Y | N | N | Y** |
| Out-of-state services | Y | Y | Y | Y | Y | Y | N | Y |
| Outpatient rehabilitation services (OT, PT, ST) | Y | Y | Y | Y | Y | Y | Y | Y |
| Personal care services | Y | Y | Y | Y | N | N | N | N |
| Prescription drugs | Y | Y | Y | Y | Y | Y | Y | Y |
| Private duty nursing | Y | Y | Y | Y | Y | Y | N | N |
| Prosthetic/orthotic devices | Y | Y | Y | Y | Y | Y | Y | Y |
| Reproductive health services | Y | Y | Y | Y | Y | Y | Y | Y |
| Respiratory care (oxygen) | Y | Y | Y | Y | Y | Y | Y | Y |
| School-based medical services | Y | N | Y | N | Y | N | N | Y** |
| Vision care Exams, refractions, and fittings | Y | Y | Y | Y | Y | Y | Y | Y |
| Vision hardware Frames and lenses | Y | N | Y | N | Y | N | N | Y** |
LEGEND
Y = A service category is included for that program. Services within each service category are subject to limitations and restrictions listed in the specific medical assistance program rules and agency issuances.
N = A service category is not included for that program.
1 Clients enrolled in the Apple Health for Kids programs (with and without premium) receive CN-scope of health care services. The Apple Health for Kids programs includes the children's health insurance program (CHIP).
*Medically necessary nursing facility services are covered when the enrollee's condition meets the criteria for rehabilitative or skilled care.
** Only for age 20 and younger.