Apple Health (Medicaid) rulemaking

The agency is removing the outdated clinical criteria for coverage of oxygen and is also revising other criteria. The clinical criteria in the current rules are more restrictive than Medicare’s current clinical criteria, which causes providers to request prior authorization more frequently than necessary. Under this rulemaking, the agency plans to align the rules with Medicare’s current requirements.

In response to SB 5228, Section 2, Chapter 113, Laws of 2023, HCA is amending WAC 182-545-200 to state that HCA pays for outpatient rehabilitation services provided to eligible clients when provided by licensed or certified behavioral health agencies as part of a mental health or substance use disorder treatment program. HCA is also amending this rule to add separate limits for clients needing occupational therapy to treat behavioral health conditions.

The agency is amending these rules to provide medical nutrition therapy for eligible adult Medicaid clients. The agency is also updating the program names for alien emergency medical (AEM) and Take Charge referenced in WAC 182-501-0060, consistent with the current names for those programs.

The agency is amending these rules to provide more precise language to define the program parameters and ensure consistency. Specifically, the agency is proposing to amend:
• 182-546-5000(4) to clarify this section pertains to a client’s freedom of access to health care, but that doesn’t require the agency to cover transportation at a higher cost in order to meet the client’s personal choice of medical provider.
• 182-546-5100 to add a definition for Against Medical Advice (AMA), fix WAC reference in Ambulance definition, and remove definitions for extended stay and short stay.
• 182-546-5550 to add in a new subsection (1)(b) regarding against medical advice discharges and a new subsection (1)(k) for standalone pharmacy trips.
• 182-546-5600(3)(b) to clarify the agency may pay for transportation for a client to a pharmacy to obtain Medicare Part D prescriptions if the prescriptions are billable to Medicaid and not paid for by Medicare Part D
• 182-546-5800(1) to clarify that out of state requests require a minimum of 7 days’ notice before the client’s travel.
• 182-546-5900(4) to clarify the reasonable cost of lodging and meals is measured against the state per diem of the location where the client is receiving covered medical services and striking subsections (4)(a), (4)(b), and (4)(c).

The agency is amending WAC 182-527-2742 to add a new subsection (1)(e) to except from estate recovery state-only funded Guardianship and Conservatorship Assistance Program services.

The agency intends to lower the minimum eligibility age for community support services from age eighteen to age sixteen. This will allow more people to receive supportive housing services that aim to reduce homelessness and improve health outcomes.

The agency is amending this rule to clarify: 1) which Medicaid recipients are eligible for the health home program; and 2) that people with third-party medical coverage are ineligible for this program.

HCA is amending WAC 182-557-0225 (7) to update the risk score weights specifically pertaining to children of various age groups outlined and the weights for health diagnoses for children. This update aligns with the release of version 6.5 of the University of San Diego’s Chronic Illness and Disability Payment System (CDPS).

The agency is revising these rules to include coverage for adult cochlear implants for Apple Health (Medicaid) clients. The legislature provided funding for adult cochlear implants in the 2023-2025 Omnibus Operating Budget.

The agency intends to amend this chapter to update eligibility requirements for clients enrolled in a Qualified Health Plan (QHP). The agency also plans to revise the overpayments and administrative hearings sections to clarify when and how the agency can recover overpayments from PPP clients.