Apple Health (Medicaid) rulemaking

HCA is amending WAC 182-550-4400 to change a reference to the chemical-using pregnant (CUP) women program to the substance-using pregnant people (SUPP) program in subsection (2)(b). HCA is also amending subsection (2)(g) to reflect that HCA no longer denies payment for claims grouped to DRG 469 or DRG 470.

The agency is amending WAC 182-550-6400 to apply it to all eligible providers and update diabetes education provider criteria and billing requirements.

The agency is amending WAC 182-550-4550 to provide hospitals an administrative day rate for days in which a postpartum client does not meet criteria for acute inpatient level of care but their infant is still an inpatient being observed for potential neonatal abstinence/opioid withdrawal syndrome and the primary and appropriate first line treatment for the infant is continuous care by the parent.

The agency is amending this rule to remove the website link referencing where QMB resource standards for an individual and a couple are listed. Under recent legislation, ESSB 5693, Chapter 297, Laws of 2022, Sec. 205 (26), countable resources are no longer required for other eligibility programs. As a result, HCA removed the QMB resource standards chart from its website. The kidney disease program, however, still requires these resource standards which can be found on Medicare’s website.

HCA deleted subsections (9) and (10) within WAC 182-538-070 to be consistent with the integrated managed care contract standards for delivery case rate payments.

This rule establishes eligibility criteria for the Civil Transition Program, which is a state-funded, fee-for-service program that requires the Department of Social and Health Services (DSHS) to provide wraparound services and supports in community-based settings, which may include residential supports, to persons who have been found not competent to stand trial due to an intellectual or developmental disability, dementia, or traumatic brain injury. This Apple Health program is for persons who are not eligible for any other Apple Health program and will provide state-funded categorically needy coverage. This program implements a portion of RCW 10.77.202, which became effective December 1, 2023. The agency established WAC 182-538B-180 through an emergency rule filed under WSR 23-24-052. The purpose of this rulemaking is to make that rule permanent. DSHS is engaged in rulemaking on this subject. DSHS filed a preproposal statement of inquiry under WSR 23-24-046 and established emergency rules under WSR 24-05-046.

The agency is amending this rule to update medical equipment, supplies, & appliances definitions to align with industry standard.

HCA is amending these rules to change the medical necessity criteria for hospital beds and to clarify the process for submitting prior authorization requests to HCA.

The agency is amending
this rule to correct a typographical error.

The agency is revising this rule in accordance with the Settlement Agreement in the case of National Association
of Chain Drug Stores, et al., v. Washington State Health Care Authority, et al. (Case No. 51489-3-II) and for the
purpose of ensuring the continuation of federal Medicaid funding.