Scope of Care
Revised April 4, 2017
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).
*Medicare recipients receive outpatient prescriptions through their Medicare Part D plan.
- Services limited by program (i.e., TAKE CHARGE, Family Planning sterilization services)
- 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
- Coverage limited to recipients age 19 through 20 years of age
- Border cities are considered "in state" for MCS coverage
- Service is covered directly through the Division of Behavioral Health and Recovery (DBHR)
- 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.
- Alien Emergency Medical (AEM)
- 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.