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

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

Effective June 11, 2025

1. This rule provides a table that lists:
   1. The following Washington apple health programs:
      1. The alternative benefits plan (ABP) medicaid;
      2. Categorically needy (CN) medicaid;
      3. Medically needy (MN) medicaid; 
      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
      5. Washington apple health expansion (AHE); 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 prior authorization when allowed by the agency.
   4. Are paid for by the agency or the agency's 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 the agency's 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 the agency's 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. Medical assistance programs for noncitizens (see chapter 182-507 WAC); and
   2. Family planning only programs (see WAC 182-532-500 through 182-532-570);
   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.

¹ Clients enrolled in the Washington apple health for kids and Washington apple health for kids with premium programs, which includes the children's health insurance program (CHIP), receive CN-scope of health care services.
* Medically necessary nursing facility services are covered when the enrollee's condition meets the criteria for rehabilitative or skilled care.
** Only for age 20 and younger.