Health Care Coverage Program Benefit Packages and Scope of Service Categories

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

Note: The Health Care Authority (Agency) 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 lists services that may be provided under the specific services/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 plan, or the Department of Social and Health Services (DSHS), as applicable. This table is provided for general information only and does not in any way guarantee that any 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, and agency Medicaid provider guides (MPGs).

Service ABP 20- ABP 21+ CN 20- CN 21+ MN 20- MN 21+ MCS FP/TC
LEGEND:
Y=Yes, service is usually included
N=No, service is not included
R=Restricted with coverage limitations; please see footnotes 1-5, as applicable, for more information, or refer to individual program MPGs
*Medicare recipients receive outpatient prescriptions through their Medicare Part D plan.
1. Services limited by program (i.e., TAKE CHARGE, Family Planning sterilization services)
2. Coverage limited to children age 20 years old and younger if done through an EPSDT screening referral, or as required by the enteral nutrition program
3. Coverage limited to recipients age 19 through 20 years of age
4. Border cities are considered "in state" for MCS coverage
5. Service is covered directly through the Division of Behavioral Health and Recovery (DBHR)
Ambulance (Ground/Air) Y   Y Y Y Y Y R1
Ambulatory Surgery (Center Based) Y Y Y Y Y Y Y R1
Applied Behavior Analysis (ABA) R3 N Y N Y N N N
Blood/Blood Administration Y Y Y Y Y Y Y R1
Behavioral Health Services                
     Mental health (MH) inpatient care Y Y Y Y Y Y Y N
     MH outpatient community care Y Y Y Y Y Y R N
     MH psychiatric visits Y Y Y Y Y Y R N
     MH medication management Y Y Y Y Y Y Y N
     Substance use disorder (SUD) detoxification Y Y Y Y Y Y Y N
     SUD diagnostic assessment Y Y Y Y Y Y Y N
     SUD residential treatment Y Y Y Y Y Y Y N
     SUD outpatient treatment Y Y Y Y Y Y Y N
Chiropractic R3 R3 Y N Y N N N
Dental Y Y Y Y Y Y R N
Dentures Y Y Y Y Y Y N N
Detoxification Y Y Y Y Y Y R N
Diabetes Education Y Y Y Y Y Y Y N
Dialysis Y Y Y Y Y Y Y N
Early Periodic Screening Diagnosis & Treatment (EPSDT) R3 N Y N Y N N N
Family Planning Services Y Y Y Y Y Y Y Y
Habilitative Services R R N N N N N N
Health Home Care Coordination ​Y ​Y ​Y ​Y ​N ​N ​N ​N
Hearing Aid R3 N Y N Y N N N
     Hearing Evaluations Y Y Y Y Y Y Y N
HIV/AIDS Case Management Y Y Y Y Y Y N N
Home Health Services Y Y Y Y Y Y Y N
Home Infusion Therapy/Parental Nutrition Y Y Y Y Y Y Y N
Hospice Y Y Y Y Y Y N N
     Pediatric Palliative Care Services R3 R3 Y N Y N N N
Hospital Services -
Inpatient and Outpatient
Y Y Y Y Y Y Y R1
Intermediate care facility/services for persons with intellectual disabilities Y Y Y Y Y Y Y N
Maternity Care & Delivery Services Y Y Y Y Y Y N N
Medical Equipment                
     Enteral Nutrition Services R3 R3 Y R Y R R N
     Nondurable Medical Supplies and Equipment (MSE) Y Y Y Y Y Y Y N
     Wheelchairs, Durable Medical Equipment and Supplies (DME), Complex Rehabilitation Technology Y Y Y Y Y Y Y N
Medical Nutrition Program
(RD Consult)
R3 R3 R2 R R2 N R2 N
Nursing Facility Services Y Y Y Y Y Y Y N
Organ Transplants Y Y Y Y Y Y Y N
Orthodontics R3 N Y N Y N N N
Out of State Services (Excludes Border Cities) Y Y Y Y Y Y N4 N
Oxygen Respiratory Services Y Y Y Y Y Y Y N
Personal Care Services R R R R R R N N
Physician Related Services Y Y Y Y Y Y Y R1
Prenatal Diagnosis Genetic Counseling Y Y Y Y Y Y N N
Prescription Drugs* Y Y Y Y Y Y Y R1
Private Duty Nursing for Children R3 R3 Y N Y N N N
Prosthetic/Orthotic Devices Y Y Y Y Y Y Y N
School Based Health Care Services R3 N Y N Y N N N
Smoking Cessation Y Y Y Y Y Y Y N
Substance Abuse Services (Chemical Dependency) Y Y Y Y Y Y Y5 N
Therapy (Outpatient Rehab)-
Occupational
Physical
Speech
R R Y Y Y N Y N
Vaccinations Y R Y R Y R R R1
Vision hardware Y N Y N Y N N N

Other Services

  • Alien Medical Programs
    • Alien Emergency Medical (AEM)
      The agency covers services only necessary to treat the client's emergency medical condition.
    • Medical for Dialysis and Cancer Treatment
      The agency covers services only necessary to treat the client's end stage renal disease or cancer.
    • State-Funded Long-Term Care Services
      The agency covers services only necessary to treat nursing facility clients under very limited conditions.
  • QMB Medicare Only
    The agency covers only the Medicare coinsurance and deductible up to the Medicare or the agency allowed amount, whichever is less.
  • Nonemergency Medical Transportation (Brokered Transport)
    The agency covers nonemergency medical transportation for eligible clients to or from covered services through contracted brokers. The brokers arrange and pay for trips for qualifying agency clients. Currently, eligible clients include those on the following programs: Medicaid, Children's Health Insurance Program, Washington Apple Health, Medical Care Services, and Alien Emergency Medical.
  • Interpreter Services - Spoken and Sign Languages
    The agency covers the cost of interpreter services for eligible clients through a competitively procured interpreter service contract (currently with CTS Language Link). Requests for interpreter services must be placed by Medicaid providers or authorized agency staff when the appointment is for a Medicaid-covered service according to the Medicaid client's benefits package.

Customer Service Phone Numbers

Agency clients may call 1-800-562-3022 (option 6) for more information.

Providers may call 1-800-562-3022 (option 5) for more information.