WAC 182-532-790 TAKE CHARGE program - Good cause exemption from billing third party insurance.

Effective September 1, 2013

1. Under the TAKE CHARGE program, two groups of clients may request an exemption from the medicaid requirement to bill third-party insurance due to "good cause." The two groups are:
   1. TAKE CHARGE applicants who:
      1. Are eighteen years of age or younger;
      2. Are covered under their parents' health insurance; and
      3. Do not want their parents to know that they are seeking and/or receiving family planning services.
   2. Individuals who are domestic violence victims and are covered under the perpetrator's health insurance.
2. "Good cause" means that the use of the third-party coverage would violate a client's confidentiality because the third party:
   1. Routinely sends verification of services to the third-party subscriber and that subscriber is someone other than the applicant; and/or
   2. Requires the applicant to use a primary care provider who is likely to report the applicant's request for family planning services to the subscriber.

WAC 182-501-0165 Medical and dental coverage—Fee-for-service (FFS) prior authorization—Determination process for payment.

Effective August 9, 2015

1. This section applies to fee-for-service (FFS) requests for medical or dental services and medical equipment that:
   1. Are identified as covered services or early and periodic screening, diagnosis, and treatment services; and
   2. Require prior authorization by the medicaid agency.
2. The following definitions and those found in chapter 182-500 WAC apply to this section:

           "Controlled studies" - Studies in which defined groups are compared with each other to reduce bias.

           "Credible evidence" - Type I-IV evidence or evidence-based information from any of the following sources:

           • Clinical guidelines

           • Government sources

          • Independent medical evaluation (IME)

          • Independent review organization (IRO)

          • Independent technology assessment organizations

          • Medical and hospital associations

         • Policies of other health plans

         • Regulating agencies (for example, the Federal Drug Administration or Department of Health)

         • Treating provider

          • Treatment pathways

        "Evidence-based" - The ordered and explicit use of the best evidence available (see "hierarchy of evidence" in subsection (6)(a) of this section) when making health care decisions.

        "Health outcome" - Changes in health status (mortality and morbidity) which result from the provision of health care services.

         "Institutional review board (IRB)" - A board or committee responsible for reviewing research protocols and determining whether:

         (1) The rights and welfare of human subjects are adequately protected;

         (2) The risks to people are minimized and are not unreasonable;

         (3)The risks to people are outweighed by the potential benefit to them or by the knowledge to be gained; and

         (4)The proposed study design and methods are adequate and appropriate in the light of stated study objectives.

"Independent review organization (IRO)" - A panel of medical and benefit experts intended to provide unbiased, independent, clinical, evidence-based reviews of adverse decisions.

"Independent medical evaluation (IME)" - An objective medical examination of the client to establish the medical facts.

"Provider" - The person who is responsible for diagnosing, prescribing, and providing medical, dental, or mental health services to agency clients.

(3) The agency authorizes, on a case-by-case basis, requests described in subsection (1) of this section when the agency determines the service or equipment is medically necessary as defined in WAC 182-500-070. The process the agency uses to assess medical necessity is based on:

(a) The evaluation of submitted and obtainable medical, dental, or mental health evidence as described in subsections (4) and (5) of this section; and

(b) The application of the evidence-based rating process described in subsection (6) of this section.

(4) The agency reviews available evidence relevant to a medical, dental, or mental health service or equipment to:

(a) Determine its efficacy, effectiveness, and safety;

(b) Determine its impact on health outcomes;

(c) Identify indications for use;

(d) Evaluate pertinent client information;

(e) Compare to alternative technologies; and

(f) Identify sources of credible evidence that use and report evidence-based information.

(5) The agency considers and evaluates all available clinical information and credible evidence relevant to the client's condition. The provider responsible for the client's diagnosis, or treatment, or both, must submit with the request credible evidence specifically related to the client's condition including, but not limited to:

(a) A physiological description of the client's disease, injury, impairment, or other ailment;

(b) Pertinent laboratory findings;

(c) Pertinent X-ray and/or imaging reports;

(d) Individual patient records pertinent to the case or request;

(e) Photographs, or videos, or both, if requested; and

(f) Objective medical/dental/mental health information such as medically/dentally acceptable clinical findings and diagnoses resulting from physical or mental examinations.

(6) The agency uses the following processes to determine whether a requested service described in subsection (1) is medically necessary:

(a) Hierarchy of evidence - How defined. The agency uses a hierarchy of evidence to determine the weight given to available data. The weight of medical evidence depends on objective indicators of its validity and reliability including the nature and source of the evidence, the empirical characteristics of the studies or trials upon which the evidence is based, and the consistency of the outcome with comparable studies. The hierarchy (in descending order with Type I given the greatest weight) is:

(i) Type I: Meta-analysis done with multiple, well-designed controlled studies;

(ii) Type II: One or more well-designed experimental studies;

(iii) Type III: Well-designed, quasi-experimental studies such as nonrandomized controlled, single group pre-post, cohort, time series, or matched case-controlled studies;

(iv) Type IV: Well-designed, nonexperimental studies, such as comparative and correlation descriptive, and case studies (uncontrolled); and

(v) Type V: Credible evidence submitted by the provider.

(b) Hierarchy of evidence - How classified. Based on the quality of available evidence, the agency determines if the requested service is effective and safe for the client by classifying it as an "A,""B,""C," or "D" level of evidence:

(i) "A" level evidence: Shows the requested service or equipment is a proven benefit to the client's condition by strong scientific literature and well-designed clinical trials such as Type I evidence or multiple Type II evidence or combinations of Type II, III or IV evidence with consistent results (An "A" rating cannot be based on Type III or Type IV evidence alone).

(ii) "B" level evidence: Shows the requested service or equipment has some proven benefit supported by:

(A) Multiple Type II or III evidence or combinations of Type II, III or IV evidence with generally consistent findings of effectiveness and safety (A "B" rating cannot be based on Type IV evidence alone); or

(B) Singular Type II, III, or IV evidence in combination with agency-recognized:

(I) Clinical guidelines;

(II) Treatment pathways; or

(III) Other guidelines that use the hierarchy of evidence in establishing the rationale for existing standards.

(iii) "C" level evidence: Shows only weak and inconclusive evidence regarding safety, or efficacy, or both. For example:

(A) Type II, III, or IV evidence with inconsistent findings; or

(B) Only Type V evidence is available.

(iv) "D" level evidence: Is not supported by any evidence regarding its safety and efficacy, for example that which is considered investigational or experimental.

(c) Hierarchy of evidence - How applied. After classifying the available evidence, the agency:

(i) Approves "A" and "B" rated requests if the service or equipment:

(A) Does not place the client at a greater risk of mortality or morbidity than an equally effective alternative treatment; and

(B) Is not more costly than an equally effective alternative treatment.

(ii) Approves a "C" rated request only if the provider shows the requested service is the optimal intervention for meeting the client's specific condition or treatment needs, and:

(A) Does not place the client at a greater risk of mortality or morbidity than an equally effective alternative treatment;

(B) Is less costly to the agency than an equally effective alternative treatment; and

(C) Is the next reasonable step for the client in a well-documented tried-and-failed attempt at evidence-based care.

(iii) Denies "D" rated requests unless:

(A) The requested service or equipment has a humanitarian device exemption from the Food and Drug Administration (FDA); or

(B) There is a local institutional review board (IRB) protocol addressing issues of efficacy and safety of the requested service that satisfies both the agency and the requesting provider.

(7) Within fifteen days of receiving the request from the client's provider, the agency reviews all evidence submitted and:

(a) Approves the request;

(b) Denies the request if the requested service is not medically necessary; or

(c) Requests the provider submit additional justifying information. The agency sends a copy of the request to the client at the same time.

(i) The provider must submit the additional information within thirty days of the agency's request.

(ii) The agency approves or denies the request within five business days of the receipt of the additional information.

(iii) If the provider fails to provide the additional information, the agency will deny the requested service.

(8) When the agency denies all or part of a request for a covered service or equipment, the agency sends the client and the provider written notice, within ten business days of the date the information is received, that:

(a) Includes a statement of the action the agency intends to take;

(b) Includes the specific factual basis for the intended action;

(c) Includes reference to the specific WAC provision upon which the denial is based;

(d) Is in sufficient detail to enable the recipient to:

(i) Learn why the agency's action was taken; and

(ii) Prepare an appropriate response.

(e) Is in sufficient detail to determine what additional or different information might be provided to challenge the agency's determination;

(f) Includes the client's administrative hearing rights;

(g) Includes an explanation of the circumstances under which the denied service is continued or reinstated if a hearing is requested; and

(h) Includes examples(s) of "lesser cost alternatives" that permit the affected party to prepare an appropriate response.

(9) If an administrative hearing is requested, the agency or the client may request an independent review organization (IRO) or independent medical examination (IME) to provide an opinion regarding whether the requested service or equipment is medically necessary. The agency pays for the independent assessment if the agency agrees that it is necessary, or an administrative law judge orders the assessment.

WAC 182-501-0055 Health care coverage—How the agency determines coverage of services for its health care programs using health technology assessments.

Effective August 9, 2015

1. The medicaid agency uses health technology assessments to determine whether a new technology, new indication, or existing technology approved by the Food and Drug Administration (FDA) is a covered service under agency health care programs. The agency only uses health technology assessments when coverage is not mandated by federal or state law. A health technology assessment may be conducted by or on behalf of:
   1. The agency; or
   2. The health technology assessment clinical committee (HTACC) under RCW 70.14.080 through 70.14.140.
2. The agency reviews available evidence relevant to a medical or dental service or health care-related equipment and uses a technology evaluation matrix to:
   1. Determine its efficacy, effectiveness, and safety;
   2. Determine its impact on health outcomes;
   3. Identify indications for use;
   4. Identify potential for misuse or abuse; and
   5. Compare to alternative technologies to assess benefit vs. harm and cost effectiveness.
3. The agency may determine the technology, device, or technology-related supply is:
   1. Covered (see WAC 182-501-0060 for the scope of coverage under Washington apple health (WAH) programs);
   2. Covered with authorization (see WAC 182-501-0165 for the process on how authorization is determined);
   3. Covered with limitations (see WAC 182-501-0169 for how limitations can be extended); or
   4. Noncovered (see WAC 182-501-0070 for noncovered services).
4. The agency may periodically review existing technologies, devices, or technology-related supplies and reassign authorization requirements as necessary using the provisions in this section for new technologies, devices, or technology-related supplies.
5. The agency evaluates the evidence and criteria from HTACC to determine whether a service is covered under WAC 182-501-0050 (9) and (10) and this section.

WAC 182-524-0600 Payments.

Revised June 17, 2019

1. We pay your silver level qualified health plan (QHP) premium costs directly to the QHP carrier unless we determine good cause exists to reimburse you for the premium costs.
2. We pay your mandatory out-of-pocket costs separate from your premium costs through cost-sharing funds.
3. Cost-sharing funds are only for your out-of-pocket costs.
4. We will not pay for, or reimburse you for, costs not considered as out-of-pocket costs or expenses incurred by people not covered under COFA islander health care.
5. You are responsible for ensuring the services you receive are covered under your QHP and rendered as in-network.
6. We may stop payments of your silver level QHP premium costs and your cost-sharing funds when you:
   1. Fail to provide verification of payments through us or an agency-contracted vendor;
   2. Fail to respond to a request for information from us or an agency-contracted vendor;
   3. Misuse your cost-sharing funds by:
      1. Purchasing anything not considered an out-of-pocket cost; or
      2. Allowing another person access to your cost-sharing funds.
   4. Are no longer eligible for COFA islander health care as de-scribed under WAC 182-524-0300.
7. You must follow the requirements of any agency-contracted vendor that provides services enabling you to access your cost-sharing funds.
8. We monitor payments and cost-sharing transactions under COFA islander health care.

WAC 182-524-0500 Notice requirements.

Revised June 17, 2019

1. The provisions in chapter 182-518 WAC apply to COFA islander health care, where applicable. This section applies only to notices and letters that we send regarding COFA islander health care.
2. We send you written notices (letters) when we:
   1. Approve you for COFA islander health care;
   2. Deny you for COFA islander health care;
   3. Change or terminate your eligibility from COFA islander health care;
   4. Ask you for more information; and
   5. Reimburse you for premium costs, as determined by WAC 182-524-0600.
3. All written notices we send to you include:
   1. The date of the notice;
   2. Specific contact information for you to use if you have questions or need help with the notice;
   3. The nature of the action;
   4. The effective date of the action;
   5. The facts and reasons for the action;
   6. The specific regulation on which the action is based;
   7. Your appeal rights, if an appeal is available; and
   8. Other information required by the state.
4. If we request information from you, we allow at least ten calendar days for you to submit requested information. If you ask, we may allow you more time to get us the information.
   1. If the due date falls on a weekend or a legal holiday as described in RCW 1.16.050, the due date is the next business day.
   2. We do not deny or terminate your eligibility when we ask you to provide information.
   3. If we do not receive your information by the due date, we make a determination based on all the information available.
5. We send a written notice to you at least ten days before taking any adverse action. The ten-day notice period starts on the day we send the notice.
6. We may send a notice fewer than ten days before the date of the adverse action if:
   1. You request the action;
   2. You request termination;
   3. A change in statute, federal regulation, or administrative rule is the sole cause of the action;
   4. You are incarcerated and expect to remain incarcerated at least thirty days;
   5. Mail sent to you is returned without a forwarding address and we do not have a more current address for you;
   6. You move out-of-state;
   7. Your plan ends because you move to a county where your current silver level qualified health plan (QHP) is not available and you fail to select a new plan;
   8. You die;
   9. You begin receiving other state or federal medical assistance that provides minimum essential coverage; or
   10. Your silver level QHP is closed and you do not enroll in another silver level QHP.

WAC 182-524-0400 Residency requirements.

Revised June 17, 2019

1. This section applies only to residency requirement for COFA islander health care.
2. A resident is a person who currently lives in Washington and:
   1. Intends to reside here, including people without a fixed address; or
   2. Entered the state looking for a job; or
   3. Entered the state with a job commitment.
3. You do not need to live in the state for a specific period of time to meet the requirements in subsection (2) of this section.
4. You can be temporarily out-of-state and remain on COFA islander health care if you:
   1. Intend to return once the purpose of your absence concludes; and
   2. Meet the eligibility requirements as described under WAC 182-524-0300.

WAC 182-524-0300 Eligibility.

Effective June 17, 2019

In order to be eligible for state-funded COFA islander health care, you must enroll in a silver level qualified health plan (QHP) through the Washington health benefit exchange (HBE) during open enrollment or when you qualify for a special enrollment period as described in 45 C.F.R. 155.410 and 45 C.F.R. 155.420.

1. You are eligible for state-funded COFA islander health care administered by us no earlier than January 1, 2019, if you:
   1. Are a COFA islander;
   2. Meet the residency requirements as described under WAC 182-524-0400;
   3. Have household income, as defined under 26 C.F.R. 1.36B-1(e), under one hundred thirty-three percent of the federal poverty level (FPL);
   4. Do not qualify for another federal or state medical assistance programs under chapter 74.09 RCW, that provides minimum essential coverage;
   5. Qualify for, and accept, the maximum advance premium tax credit available under 45 C.F.R. 155.305(f); and
   6. Are enrolled in a silver level QHP.
2. Eligibility for COFA islander health care is subject to the availability of amounts appropriated for the program.
3. You will be terminated from COFA islander health care if you:
   1. Do not meet the eligibility criteria under subsection (1) of this section; or
   2. Request termination.
4. You may be terminated from COFA islander health care if you:
   1. Perform an act, practice, or omission that constitutes fraud, and an insurer rescinds your QHP policy; or
   2. Use your COFA islander health care cost-sharing funds to pay for anything other than out-of-pocket costs.
5. We will reinstate your COFA islander health care if you were:
   1. Terminated in error; or
   2. Successful in your appeal of a termination.
6. Your COFA islander health care begins the first day of the month your silver level QHP coverage begins and you meet the other eligibility requirements as described in subsection (1) of this section.
7. If you report a change that makes you eligible for COFA islander health care, your sponsorship begins either:
   1. The first day of the following month if the change was reported before the fifteenth of the month; or
   2. The first day of the second month if the change was reported after the fifteenth of the month.
8. Your COFA islander health care ends the day your enrollment in a silver level QHP ends or the last day of the month your COFA islander health care eligibility ends, whichever is earlier.

WAC 182-524-0200 Definitions.

Effective June 17, 2019

This section defines terms used in this chapter. See chapter 182-500 WAC for additional definitions.

"Advance premium tax credit (APTC)" - A tax credit taken in advance to lower a monthly health insurance payment (or premium).

"COFA islander" – A person who is a citizen of the Federated States of Micronesia, the Republic of the Marshall Islands, or the Republic of Palau.

"COFA islander health care" – An agency-administered program that pays the premium and out-of-pocket costs for a silver level qualified health plan for eligible COFA islanders.

"Compact of Free Association (COFA)" – A legal agreement between the government of the United States and the governments of the Federated States of Micronesia (U.S. Pub. L. 108-188); the Republic of the Marshall Islands (U.S. Pub. L. 108-188); and the Republic of Palau (U.S. Pub. L. 99-658).

"Cost-sharing funds" – Agency-provided funds for out-of-pocket costs.

"Out-of-pocket costs" – Copayments, coinsurance, deductibles, and other cost-sharing requirements imposed under a qualified health plan for services, pharmaceuticals, devices, and other health benefits covered by the plan and rendered as in-network. Excludes premiums, balance billing amounts for out-of-network providers, and spending for noncovered services.

"Premium cost" – A person's premium for a qualified health plan, minus the amount of the person's advanced premium tax credit.

"Silver level qualified health plan (QHP)" – Silver level indicates the category of a qualified health plan (QHP) offered by the Washington health benefit exchange (HBE). For a definition of QHP, see WAC 182-500-0090.

WAC 182-524-0100 General.

Effective June 17, 2019

1. Compact of Free Association (COFA) islander health care is a state-funded program administered by the health care authority (the agency) to pay the monthly premiums and out-of-pocket expenses for silver level qualified health plans for eligible COFA islanders.
2. For the purpose of this chapter, "our," "us," and "we" refer to the agency or the agency's designee and "you" refers to the applicant for, or recipient of, COFA islander health care.
3. You have the right to appeal any adverse agency action regarding COFA islander health care as described in chapter 182-526 WAC. For coordinated appeals with the Washington health benefit exchange, as described under WAC 182-526-0102, we treat appeals made to either the Washington health benefit exchange or us as filed on the same day. You will not have to submit any information that you have previously submitted to either the Washington health benefit exchange or us.