WAC 182-501-0050 Health care general coverage.

WAC 182-501-0050 Health care general coverage.

Effective August 11, 2013

WAC 182-501-0050 through 182-501-0065 describe the health care services available to a client on a fee-for-service basis or to a client enrolled in a managed care organization (MCO) (defined in WAC 182-538-050). For the purposes of this section, health care services includes treatment, equipment, related supplies, and drugs. WAC 182-501-0070 describes noncovered services.

1. Health care service categories listed in WAC 182-501-0060 do not represent a contract for health care services.
2. For the provider to receive payment, the client must be eligible for the covered health care service on the date the health care service is performed or provided.
3. Under the agency's fee-for-service programs, providers must be enrolled with the agency or its designee and meet the requirements of chapter 182-502 WAC to be paid for furnishing health care services to clients.
4. The agency or its designee pays only for the health care services that are:
   1. Included in the client's health care benefits package as described in WAC 182-501-0060;
   2. Covered - See subsection (9) of this section;
   3. Ordered or prescribed by a health care provider who meets the requirements of chapter 182-502 WAC;
   4. Medically necessary as defined in WAC 182-500-0070;
   5. Submitted for authorization, when required, in accordance with WAC 182-501-0163;
   6. Approved, when required, in accordance with WAC 182-501-0165;
   7. Furnished by a provider according to chapter 182-502 WAC; and
   8. Billed in accordance with agency or its designee program rules and the agency's current published billing instructions.
5. The agency does not pay for any health care service requiring prior authorization from the agency or its designee, if prior authorization was not obtained before the health care service was provided; unless:
   1. The client is determined to be retroactively eligible for medical assistance; and
   2. The request meets the requirements of subsection (4) of this section.
6. The agency does not reimburse clients for health care services purchased out-of-pocket.
7. The agency does not pay for the replacement of agency-purchased equipment, devices, or supplies which have been sold, gifted, lost, broken, destroyed, or stolen as a result of the client's carelessness, negligence, recklessness, deliberate intent, or misuse unless:
   1. Extenuating circumstances exist that result in a loss or destruction of agency-purchased equipment, devices, or supplies, through no fault of the client that occurred while the client was exercising reasonable care under the circumstances; or
   2. Otherwise allowed under specific agency program rules.
8. The agency's refusal to pay for replacement of equipment, device, or supplies will not extend beyond the limitations stated in specific agency program rules.
9. Covered health care services.
   1. Covered health care services are either:
      1. "Federally mandated" - Means the state of Washington is required by federal regulation (42 C.F.R. 440.210 and 220) to cover the health care service for medicaid clients; or
      2. "State-option" - Means the state of Washington is not federally mandated to cover the health care service but has chosen to do so at its own discretion.
   2. The agency may limit the scope, amount, duration, and/or frequency of covered health care services. Limitation extensions are authorized according to WAC 182-501-0169.
10. Noncovered health care services.
    1. The agency does not pay for any health care service listed as noncovered in WAC 182-501-0070 or in any other agency program rule, unless the agency grants a request for an exception to rule allowing payment for the noncovered service. The agency evaluates a request for a noncovered health care service only if an exception to rule is requested according to the provisions in WAC 182-501-0160.
    2. When a noncovered health care service is recommended during the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) exam and then ordered by a provider, the agency evaluates the health care service according to the process in WAC 182-501-0165 to determine if it is medically necessary, safe, effective, and not experimental (see WAC 182-534-0100 for EPSDT rules).