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).

WAC 182-501-0060 Health care coverage--Program benefit packages--Scope of service categories.

Effective April 17, 2015

  1. This rule provides a table that lists:
    1. The following Washington apple health (WAH) programs:
      1. The alternative benefits plan (ABP) medicaid;
      2. Categorically needy (CN) medicaid;
      3. Medically needy (MN) medicaid; and
      4. Medical care services (MCS) programs (includes incapacity-based and aged, blind, and disabled medical care services), as described in WAC 182-508-0005; and
    2. The benefit packages showing what service categories are included for each program.
  2. Within a service category included in a benefit package, some services may be covered and others noncovered.
  3. Services covered within each service category included in a benefit package:
    1. Are determined in accordance with WAC 182-501-0050 and 182-501-0055 when applicable.
    2. May be subject to limitations, restrictions, and eligibility requirements contained in agency rules.
    3. May require prior authorization (see WAC 182-501-0165), or expedited authorization when allowed by the agency.
    4. Are paid for by the agency or its designee and subject to review both before and after payment is made. The agency or the client's managed care organization may deny or recover payment for such services, equipment, and supplies based on these reviews.
  4. The agency does not pay for covered services, equipment, or supplies that:
    1. Require prior authorization from the agency or its designee, if prior authorization was not obtained before the service was provided;
    2. Are provided by providers who are not contracted with the agency as required under chapter 182-502 WAC;
    3. Are included in an agency or its designee waiver program identified in chapter 182-515 WAC; or
    4. Are covered by a third-party payor (see WAC 182-501-0200), including medicare, if the third-party payor has not made a determination on the claim or has not been billed by the provider.
  5. Programs not addressed in the table:
    1. Alien emergency medical (AEM) services (see chapter 182-507 WAC); and
    2. TAKE CHARGE program (see WAC 182-532-700 through 182-532-790);
    3. Postpartum and family planning extension (see WAC 182-523-0130(4) and 182-505-0115(5));
    4. Eligibility for pregnant minors (see WAC 182-505-0117); and
    5. Kidney disease program (see chapter 182-540 WAC).
  6. Scope of service categories. The following table lists the agency's categories of health care services.
    1. Under the ABP, CN, and MN headings there are two columns. One addresses clients twenty years of age and younger and the other addresses clients twenty-one years of age and older.
    2. The letter "Y" means 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.
    3. The letter "N" means a service category is not included for that program.
    4. Refer to WAC 182-501-0065 for a description of each service category and for the specific program rules containing the limitations and restrictions to services.
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
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

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.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

*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)

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.

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