WAC 182-501-0055 Health care coverage—How the agency determines coverage of services for its health care programs using health technology assessments.

Effective August 9, 2015

  1. The medicaid agency uses health technology assessments to determine whether a new technology, new indication, or existing technology approved by the Food and Drug Administration (FDA) is a covered service under agency health care programs. The agency only uses health technology assessments when coverage is not mandated by federal or state law. A health technology assessment may be conducted by or on behalf of:
    1. The agency; or
    2. The health technology assessment clinical committee (HTACC) under RCW 70.14.080 through 70.14.140.
  2. The agency reviews available evidence relevant to a medical or dental service or health care-related equipment and uses a technology evaluation matrix to:
    1. Determine its efficacy, effectiveness, and safety;
    2. Determine its impact on health outcomes;
    3. Identify indications for use;
    4. Identify potential for misuse or abuse; and
    5. Compare to alternative technologies to assess benefit vs. harm and cost effectiveness.
  3. The agency may determine the technology, device, or technology-related supply is:
    1. Covered (see WAC 182-501-0060 for the scope of coverage under Washington apple health (WAH) programs);
    2. Covered with authorization (see WAC 182-501-0165 for the process on how authorization is determined);
    3. Covered with limitations (see WAC 182-501-0169 for how limitations can be extended); or
    4. Noncovered (see WAC 182-501-0070 for noncovered services).
  4. The agency may periodically review existing technologies, devices, or technology-related supplies and reassign authorization requirements as necessary using the provisions in this section for new technologies, devices, or technology-related supplies.
  5. The agency evaluates the evidence and criteria from HTACC to determine whether a service is covered under WAC 182-501-0050 (9) and (10) and this section.

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.