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
  • FP/TC - Family Planning Only/TAKE CHARGE
  • MCS - Medical Care Services
  • MN - Medically Needy Program
Service categories ABP 20- ABP 21+ CN1 20- CN 21+ MN 20- MN 21+ MCS
Ambulance (ground and air) Y Y Y Y Y Y Y
Applied behavior analysis (ABA) Y N Y N Y N N
Behavioral health services              
  • Mental health (MH) inpatient care
Y Y Y Y Y Y Y
  • MH outpatient community care
Y Y Y Y Y Y Y2
  • MH psychiatric visits
Y Y Y Y Y Y Y3
  • MH medication management
Y Y Y Y Y Y Y
  • Substance use disorder (SUD) detoxification
Y Y Y Y Y Y Y
  • SUD diagnostic assessment
Y Y Y Y Y Y Y
  • SUD residential treatment
Y Y Y Y Y Y Y
  • SUD outpatient treatment
Y Y Y Y Y Y Y
Blood/blood products/related services Y Y Y Y Y Y Y
Dental services Y Y Y Y Y Y Y
Diagnostic services (lab and X-ray) Y Y Y Y Y Y Y
Early and periodic screening, diagnosis, and treatment (EPSDT) services Y N Y N Y N N
Habilitative services Y Y N N N N N
Health care professional services Y Y Y Y Y Y Y
Hearing evaluations Y Y Y Y Y Y Y
Hearing aids Y N Y N Y N N
Home health services Y Y Y Y Y Y Y
Hospice services Y Y Y Y Y Y N
Hospital services Inpatient/outpatient Y Y Y Y Y Y Y
Intermediate care facility/services for persons with intellectual disabilities Y Y Y Y Y Y Y
Maternity care and delivery services Y Y Y Y Y Y Y
Medical equipment, durable (DME) Y Y Y Y Y Y Y
Medical equipment, nondurable (MSE) Y Y Y Y Y Y Y
Medical nutrition services Y Y Y Y Y Y Y
Nursing facility services Y Y Y Y Y Y Y
Organ transplants Y Y Y Y Y Y Y
Orthodontic services Y N Y N Y N N
Out-of-state services Y Y Y Y Y Y N
Outpatient rehabilitation services (OT, PT, ST) Y Y Y Y Y N Y
Personal care services Y Y Y Y N N N
Prescription drugs Y Y Y Y Y Y Y
Private duty nursing Y Y Y Y Y Y N
Prosthetic/orthotic devices Y Y Y Y Y Y Y
Reproductive health services Y Y Y Y Y Y Y
Respiratory care (oxygen) Y Y Y Y Y Y Y
School-based medical services Y N Y N Y N N
Vision care Exams, refractions, and fittings Y Y Y Y Y Y Y
Vision hardware Frames and lenses Y N Y N Y N N

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).

2 Restricted to incapacity-based MCS clients enrolled in managed care.

3 Each year, incapacity-based MCS clients can receive one psychiatric diagnostic evaluation per year and eleven monthly visits per year for medication management.