WAC 182-500-0015 Medical assistance definitions -- B.

Effective October 23, 2021

"Benefit package" means the set of health care service categories included in a client's health care program. See WAC 182-501-0060.

"Benefit period" means the time period used to determine whether medicare can pay for covered Part A services. A benefit period begins the first day a beneficiary receives inpatient hospital or extended care services from a qualified provider. The benefit period ends when the beneficiary has not been an inpatient of a hospital or other facility primarily providing skilled nursing or rehabilitation services for sixty consecutive days. There is no limit to the number of benefit periods a beneficiary may receive. Benefit period also means a "spell of illness" for medicare payments.

"Billing instructions" means provider guides. See WAC 182-500-0085.

"Blind" is a category of medical program eligibility that requires:

1. 1. A central visual acuity of 20/200 or less in the better eye with the use of a correcting lens; or
   2. A field of vision limitation so the widest diameter of the visual field subtends an angle no greater than twenty degrees from central.

"By report (BR)" means a method of payment in which the agency or the agency's designee determines the amount it will pay for a service when the rate for that service is not included in the agency's published fee schedules. The provider must submit a report which describes the nature, extent, time, effort and equipment necessary to deliver the service.

WAC 182-500-0010 Medical assistance definitions -- A.

Effective November 25, 2023

"Administrative renewal" means the agency uses electronically available income and resources data sources to verify and recertify a person's Washington apple health benefits for a subsequent certification period. A case is administratively renewed when the person's self-attested income and resources are reasonably compatible (as defined in WAC 182-500-0095) with the information available to the agency from the electronic data sources and the person meets citizenship, immigration, Social Security number, and age requirements.

"After-pregnancy coverage (APC)" means full-scope Washington apple health (medicaid) health care coverage for people up to 12 months after the month their pregnancy ends under WAC 182-505-0115.

"Agency" or "medicaid agency" means the Washington state health care authority (HCA).

"Agency's designee" means any entity expressly designated by the agency to act on its behalf.

"Allowable costs" are the documented costs as reported after any cost adjustment, cost disallowances, reclassifications, or reclassifications to nonallowable costs which are necessary, ordinary and related to the outpatient care of medical care clients or not expressly declared nonallowable by applicable statutes or regulations. Costs are ordinary if they are of the nature and magnitude which prudent and cost-conscious management would pay.

"Alternative benefits plan" means the range of health care services included within the scope of service categories described in WAC 182-501-0060 available to persons eligible to receive health care coverage under the Washington apple health modified adjusted gross income (MAGI)-based adult coverage described in WAC 182-505-0250.

"Ancillary services" means additional services ordered by the provider to support the core treatment provided to the patient. These services may include, but are not limited to, laboratory services, radiology services, drugs, physical therapy, occupational therapy, and speech therapy.

"Apple health for kids" is the umbrella term for health care coverage for certain groups of children that is funded by the state and federal governments under Title XIX medicaid programs, Title XXI Children's Health Insurance Program, or solely through state funds (including the program formerly known as the children's health program). Funding for any given child depends on the program for which the child is determined to be eligible. Apple health for kids programs are included in the array of health care programs available through Washington apple health (WAH).

"Attested income" or "attested resources" means a self-declared statement of a person's income or resources made under penalty of perjury to be true. (See also "self-attestation.")

"Authorization" means the agency's or the agency's designee's determination that criteria are met, as one of the preconditions to the agency's or the agency's designee's decision to provide payment for a specific service or device. (See also "expedited prior authorization" and "prior authorization.")

"Authorized representative" is defined under WAC 182-503-0130.

WAC 182-500-0005 Definitions.

Effective August 29, 2016

Chapter 182-500 WAC contains definitions of words and phrases used in rules for medical assistance and other health care programs. When a term is not defined in this chapter, other agency or agency's designee WAC, or state or federal law, the medical definitions found in the Taber's Cyclopedic Medical Dictionary will apply. For general terms not defined in this chapter, other agency or agency's designee WAC, or state or federal law, the definitions in Webster's New World Dictionary apply. If a definition in this chapter conflicts with a definition in another chapter of Title 182 WAC, the definition in the specific WAC prevails.

WAC 182-527-2734 Liens during a client's lifetime.

Effective July 1, 2017

For the pur­poses of this section, the term "agency" includes the agency's desig­nee.

1. When the agency may file.
   1. The agency may file a lien against the property of a Washing­ton apple health client during the client's lifetime if:
      1. The client resides in a skilled nursing facility, intermedi­ate care facility for individuals with an intellectual disability, or other medical institution under WAC 182-500-0050;
      2. The agency determines that a client cannot reasonably be expected to return home because:
         1. The agency receives a physician's verification that the client will not be able to return home; or
         2. The client has resided for six months or longer in an institution as defined in WAC 182-500-0050; and
      3. None of the following people lawfully reside in the client's home:
         1. The client's spouse or state-registered domestic partner;
         2. The client's child who is age twenty or younger, or is blind or permanently disabled as defined in WAC 182-512-0050; or
         3. A client's sibling who has an equity interest in the home and who has been residing in the home for at least one year immediately before the client's admission to the medical institution.
   2. If the client returns home from the medical institution, the agency releases the lien.
2. Amount of the lien.
   1. The agency may file a lien to recoup the cost of all non-MAGI-based and deemed eligible services under WAC 182-503-0510 it correctly purchased on the client's behalf, regardless of the client's age on the date of service.
   2. Services provided under the medicaid transformation project, defined in WAC 182-500-0070, are excluded when determining the amount of the lien.
3. Notice requirement.
   1. Before the agency may file a lien under this section, it sends notice via first class mail to:
      1. The client's last known address;
      2. The client's authorized representative, if any;
      3. The address of the property subject to the lien; and
      4. Any other person known to hold title to the property.
   2. The notice states:
      1. The client's name;
      2. The agency's intent to file a lien against the client's property;
      3. The county in which the property is located; and
      4. How to request an administrative hearing.
4. Interest assessed on past-due debt.
   1. Interest on a past-due debt accrues at a rate of one percent per month under RCW 43.17.240.
   2. A lien under this section becomes a past-due debt when the agency has recorded the lien in the county where the property is loca­ted and:
      1. Thirty days have passed since the property was transferred or
      2. Nine months have passed since the lien was filed.
   3. The agency may waive interest if reasonable efforts to sell the property have failed.
5. Administrative hearing. An administrative hearing under this section is governed by WAC 182-527-2753.

WAC 182-520-0015 Long-term services and supports client overpay­ments.

Effective July 14, 2016

1. General right to recover.
   1. A long-term services and supports (LTSS) client overpayment is any payment for LTSS made by the agency or the agency's designee on a client's behalf in excess of that to which the client is legally en­titled.
   2. An LTSS client overpayment may be caused by:
      1. A client or a client's authorized representative misstating or failing to reveal a fact affecting eligibility under WAC 182-503-0505;
      2. A client or a client's authorized representative failing to timely report a change required under WAC 182-504-0105; or
      3. The agency or the agency's designee's error.
   3. The agency or the agency's designee may recoup an LTSS client overpayment:
      1. Up to six years after the date of the notice in subsection (2) of this section; and
      2. Regardless of whether the program is state-funded, federally funded, or both.
   4. The amount of the LTSS client overpayment equals the amount the agency or the agency's designee paid on the client's behalf minus the amount to which the client was legally entitled.
2. Notice.
   1. The agency notifies the client or the client's authorized representative by:
      1. Personal service under RCW 4.28.080; or
      2. Certified mail, return receipt requested.
   2. The agency or the agency's designee may prove that it noti­fied the client by providing:
      1. A sworn statement;
      2. An affidavit or certificate of mailing; or
      3. The certified mail receipt signed by the client or the cli­ent's authorized representative.
   3. The notice states:
      1. The client's name;
      2. The client's address;
      3. The date the agency or the agency's designee issued the no­tice;
      4. The amount of the LTSS client overpayment;
      5. How the agency calculated the LTSS client overpayment;
      6. How the client may request an administrative hearing; and
      7. How the client may make a payment.
3. Response.
   1. The client must respond to the notice within ninety days of the date the agency or the agency's designee served the client with the notice of the LTSS client overpayment by:
      1. Paying the agency or the agency's designee;
      2. Establishing a payment plan with the agency or the agency's designee; or
      3. Requesting an administrative hearing.
   2. If the client does not respond to the notice within ninety days of the date the agency or the agency's designee served the client with the notice, the agency or the agency's designee may initiate col­lection action.
4. Hearings. A person who disagrees with agency or the agency's designee's action under this section may request an administrative hearing under chapter 182-526 WAC.

WAC 182-501-0200 Third-party resources.

Effective August 6, 2021

1. The medicaid agency requires a provider to seek timely reimbursement from a third party when a client has available third-party resources, except as described under subsections (2) and (3) of this section.
2. The agency pays for medical services and seeks reimbursement from a liable third party when the claim is for preventive pediatric services as covered under the early and periodic screening, diagnosis and treatment (EPSDT) program.
3. The agency pays for medical services and seeks reimbursement from any liable third party when both of the following apply:
   1. The provider submits to the agency documentation of billing the third party and the provider has not received payment after one hundred days from the date of services; and
   2. The claim is for a covered service provided to a client on whose behalf the office of support enforcement is enforcing a noncustodial parent to pay support. For the purpose of this section, "is enforcing" means the noncustodial parent either:
      1. Is not complying with an existing court order; or
      2. Received payment directly from the third party and did not pay for the medical services.
4. The provider may not bill the agency or the client for a covered service when a third party pays a provider the same amount as or more than the agency rate.
5. When the provider receives payment from a third party after receiving reimbursement from the agency, the provider must refund to the agency the amount of the:
   1. Third-party payment when the payment is less than the agency's maximum allowable rate; or
   2. Agency payment when the third-party payment is equal to or more than the agency's maximum allowable rate.
6. The agency does not pay for medical services if third-party benefits are available to pay for the client's medical services when the provider bills the agency, except under subsections (2) and (3) of this section.
7. The client is liable for charges for covered medical services that would be paid by the third-party payment when the client either:
   1. Receives direct third-party reimbursement for the services; or
   2. Fails to execute legal signatures on insurance forms, billing documents, or other forms necessary to receive insurance payments for services rendered. See WAC 182-503-0540 for assignment of rights.
8. The agency considers an adoptive family to be a third-party resource for the medical expenses of the birth mother and child only when there is a written contract between the adopting family and either the birth mother, the attorney, the provider, or the adoption service. The contract must specify that the adopting family will pay for the medical care associated with the pregnancy.
9. A provider cannot refuse to furnish covered services to a client because of a third-party's potential liability for the services.
10. For third-party liability on personal injury litigation claims, the agency or managed care organization (MCO) is responsible for providing medical services under WAC 182-501-0100.

WAC 182-554-500 Covered orally administered enteral nutrition products, equipment and related supplies - Clients age twenty and younger only.

Effective May 1, 2017

1. Subject to the prior authorization requirements and limitations in this section, and in the Enteral Nutrition Program Billing Guide, the agency covers orally administered enteral nutrition products for clients age twenty and younger.
2. The agency's enteral nutrition program is not a food benefit. All clients under age five who qualify for supplemental nutrition from the women, infants, and children (WIC) nutrition program must receive products and formulas directly from that program. The agency may cover orally administered enteral nutrition products for a client under age five if the client has a WIC information form that verifies:
   1. The client is not eligible for the WIC program;
   2. The client is eligible for the WIC program, but the client's need for an oral enteral nutrition product or formula exceeds the amount allowed by WIC rules; or
   3. The client is eligible for the WIC program, but a medically necessary product or formula is not available through the WIC program.
3. With expedited prior authorization, the agency covers orally administered enteral nutrition products for a one-time, initial one-month supply if the client:
   1. Has or is at risk of growth or nutrient deficits due to a condition that prevents the client from meeting their needs using food, over-the-counter nutrition products, standard infant formula, or standard toddler formula; and
   2. Has completed the agency's enteral nutrition products prescription form (HCA 13-961).
4. With prior authorization (PA), the agency covers a monthly supply of orally administered enteral nutrition products if the client:
   1. Has or is at risk of growth or nutrient deficits due to a condition that prevents the client from meeting their needs using food, over-the-counter nutrition products, standard infant formula, or standard toddler formula;
   2. Has a valid prescription that states the product is medically necessary as defined in WAC 182-500-0070; and
   3. Has a nutrition assessment from a registered dietitian (RD) that includes all of the following:
      1. Evaluation of the client's nutritional status, including growth and nutrient analysis;
      2. An explanation about why the product is medically necessary as defined in WAC 182-500-0070;
      3. A nutrition care plan that monitors the client's nutrition status, and includes plans for transitioning the client to food or food products, if possible; and
      4. Recommendations, as necessary, for the primary care provider to refer the client to other health care providers (for example, gastrointestinal specialists, allergists, speech therapists, occupational therapists, applied behavioral analysis providers, and mental health providers) who will address the client's growth or nutrient deficits as described in (a) of this subsection, and facilitate the client's transition to food or food products.
5. If a client requires orally administered enteral nutrition products for longer than one month, the client must continue to meet criteria in subsection (4) of this section and receive periodic reevaluations from an RD. Periodic reevaluations:
   1. Must be performed at least three times a year for a client age three or younger;
   2. Must be performed at least two times a year for a client older than age three; and
   3. May be performed face-to-face, or by medical record and growth data review and phone contact with the client or the client's caregiver.
6. If a client requires orally administered enteral nutrition products for longer than one month, the DME or pharmacy provider must obtain PA from the agency. The request for PA must include all of the following:
   1. Documentation of the client's diagnosis that supports the client's need for the orally administered enteral nutrition product;
   2. The client's nutrition care plan, which must monitor the client's nutrition status, and transition the client to food or food products, if possible, or document why the client cannot transition to food or food products;
   3. Updates to the client's nutrition care plan resulting from subsequent reevaluations;
   4. Updates to the client's growth chart;
   5. Documentation that shows through regular follow up and weight checks how the prescribed product is treating the client's growth or nutrient deficits, or is necessary to maintain the client's growth or nutrient status;
   6. Referrals, if necessary, to other health care providers (for example, gastrointestinal specialists, allergists, speech therapists, occupational therapists, applied behavioral analysis providers, and mental health providers) and show communication of recommendations and treatment plans for the client; and
   7. Documentation of any communication the treating provider has had with other providers, such as those in subsection (4)(c)(iv) of this section, directly or indirectly treating the client's growth or nutrient deficits while the client is receiving orally administered enteral nutrition products.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page