WAC 182-500-0095 Medical assistance definitions -- R.

Effective November 25, 2023

"Reasonably compatible" means the amount of a person's self-attested income or resources (as defined in WAC 182-500-0100) and the amount of a person's income or resources verified via electronic data sources are either both above or both below the applicable income or resources standard for Washington apple health (WAH). When self-attested income or resources is less than the standard for WAH, but income or resources from available data sources is more than the WAH standard, or when the self-attested income or resources cannot be verified via electronic data sources, the self-attested income or resources are considered not reasonably compatible.

"Retroactive period" means approval of medical coverage for any or all of the retroactive period. A client may be eligible only in the retroactive period or may have both current eligibility and a separate retroactive period of eligibility approved.

WAC 182-500-0090 Medical assistance definitions -- Q.

Effective January 9, 2014

"Qualified health plan (QHP)" means a health insurance plan that has been certified by the Washington health benefit exchange to meet at minimum the standards described in 45 C.F.R. Part 156, Subpart C and RCW 43.71.065 and offered in accordance with the process described in 45 C.F.R. Part 155, Subpart K and RCW 43.71.065.

WAC 182-500-0085 Medical assistance definitions -- P.

Effective November 19, 2015

"Patient transportation" means client transportation to or from covered health care services under federal and state health care programs.

"Physician" means a doctor of medicine, osteopathy, naturopathy, or podiatry who is legally authorized to perform the functions of the profession by the state in which the services are performed.

"Prescribing provider" means a health care professional authorized by law or rule to prescribe drugs to Washington apple health (WAH) clients.

"Prior authorization" is the requirement that a provider must request, on behalf of a client and when required by rule or agency billing instructions, the agency or the agency's designee's approval to provide a health care service before the client receives the health care service, prescribed drug, device, or drug-related supply. The agency or the agency's designee's approval is based on medical necessity. Receipt of prior authorization does not guarantee payment. Expedited prior authorization and limitation extension are types of prior authorization.

"Prosthetic device" means a preventive, replacement, corrective, or supportive device prescribed by a physician or other licensed practitioner, within the scope of his or her practice under state law.

"Provider" means an institution, agency, or person that is licensed, certified, accredited, or registered according to Washington state law, and has:

(a) A signed core provider agreement or contract with the agency or the agency's designee, and is authorized to provide health care, goods, and services to WAH clients; or

(b) Authorization from a managed care organization (MCO) that contracts with the agency or the agency's designee to provide health care, goods, and services to eligible WAH clients enrolled in the MCO plan.

"Provider guide" means an agency publication that describes a specific benefit covered under WAH, which includes client eligibility verification instructions, provider responsibilities, authorization requirements, coverage, billing, and how to complete and submit claims.

"Public institution" see "institution" in WAC 182-500-0050.

WAC 182-532-500  Family Planning only program - Purpose.

Effective October 1, 2019

The purpose of the family planning only programs is to provide family planning services to:

1. Improve access to family planning and family planning-related services;
2. Reduce unintended pregnancies; and
3. Promote healthy intervals between pregnancies and births.

WAC 182-500-0080 Medical assistance definitions -- O.

Effective October 12, 2013

"Ordering and referring provider" means any physician or other health care professional who orders or refers items or services for clients eligible for Washington's health care programs administered by the agency.

"Outpatient" means a patient receiving care in a hospital outpatient setting or a hospital emergency department, or away from a hospital such as in a physician's office or clinic, the patient's own home, or a nursing facility.

"Overhead costs" means those costs that have been incurred for common or joint objectives and cannot be readily identified with a particular final cost objective. Overhead costs that are allocated must be clearly distinguished from other functions and identified as a benefit to a direct service.

WAC 182-534-0100  EPSDT

Effective August 24, 2014

1. Persons who are eligible for medicaid are eligible for coverage through the early and periodic screening, diagnosis, and treatment (EPSDT) program up through the day before their twenty-first birthday.
2. Access and services for EPSDT are governed by federal rules at 42 C.F.R., Part 441, Subpart B which were in effect as of January 1, 1998.
   1. The standard for coverage for EPSDT is that the services, treatment or other measures are:
      1. Medically necessary;
      2. Safe and effective; and
      3. Not experimental.
   2. EPSDT services are exempt from specific coverage or service limitations which are imposed on the rest of the CN and MN program. Examples of service limits which do not apply to the EPSDT program are the specific numerical limits in WAC 182-545-200.
   3. Services not otherwise covered under the medicaid program are available to children under EPSDT. The services, treatments and other measures which are available include but are not limited to:
      1. Nutritional counseling;
      2. Chiropractic care;
      3. Orthodontics; and
      4. Occupational therapy (not otherwise covered under the MN program).
   4. Prior authorization and referral requirements are imposed on medical service providers under EPSDT. Such requirements are designed as tools for determining that a service, treatment or other measure meets the standards in subsection (2)(a) of this section.
3. Transportation requirements of 42 C.F.R. 441, Subpart B are met through a contract with transportation brokers throughout the state.

WAC 182-500-0075 Medical assistance definitions -- N.

Effective January 1, 2019

"National correct coding initiative (NCCI)" is a national standard for the accurate and consistent description of medical goods and services using procedural codes. The standard is based on coding conventions defined in the American Medical Association's Current Procedural Terminology (CPT®) manual, current standards of medical and surgical coding practice, input from specialty societies, and analysis of current coding practices. The Centers for Medicare and Medicaid Services (CMS) maintain NCCI policy. Information can be found at: http://www.cms.hhs.gov/NationalCorrectCodInitEd/.

"National provider indicator (NPI)" is a federal system for uniquely identifying all providers of health care services, supplies, and equipment.

"NCCI edit" is a software step used to determine if a claim is billing for a service that is not in accordance with federal and state statutes, federal and state regulations, agency or the agency's designee's fee schedules, billing instructions, and other publications. The agency or the agency's designee has the final decision whether the NCCI edits allow automated payment for services that were not billed in accordance with governing law, NCCI standards or agency or agency's designee policy.

"Nonapplying spouse" see "spouse" in WAC 182-500-0100.

"Nonbilling provider" is a health care professional enrolled with the agency only as an ordering, referring, prescribing provider for the Washington medicaid program and who is not otherwise enrolled as a medicaid provider with the agency.

"Noncovered service" see "covered service" in WAC 182-500-0020.

"Nonphysician practitioner" means the following professionals who work in collaboration with an ordering physician: Nurse practitioner, clinical nurse specialist, certified nurse midwife, or physician assistant.

"Nursing facility" see "institution" in WAC 182-500-0050.

"Nursing facility long-term care services" are services in a nursing facility when a person does not meet the criteria for rehabilitation. Most long-term care assists people with support services. (Also called custodial care.)

"Nursing facility rehabilitative services" are the planned interventions and procedures which constitute a continuing and comprehensive effort to restore a person to the person's former functional and environmental status, or alternatively, to maintain or maximize remaining function.

WAC 182-538-050  Definitions

Effective April 23, 2022

The following definitions and abbreviations and those found in chapter 182-500 WAC apply to this chapter. If conflict exists, this chapter takes precedence.

"Administrative hearing" means an evidentiary adjudicative proceeding before an administrative law judge or presiding officer that is available to an enrollee under chapter 182-526 WAC according to RCW 74.09.741.

"Adverse benefit determination" means one or more of the following:

(a) The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit;

(b) The reduction, suspension, or termination of a previously authorized service;

(c) The denial, in whole or in part, of payment for a service;

(d) The failure to provide services in a timely manner, as defined by the state;

(e) The failure of a managed care organization (MCO) to act within the time frames provided in 42 C.F.R. Sec. 438.408 (a), (b)(1) and (2) for standard resolution of grievances and appeals; or

(f) For a resident of a rural area with only one MCO, the denial of an enrollee's request to exercise the enrollee's right to obtain services outside the network under 42 C.F.R. Sec. 438.52 (b)(2)(ii).

"Agency" - See WAC 182-500-0010.

"Appeal" means a review by an MCO of an adverse benefit determination.

"Apple health foster care (AHFC)" means the managed care program developed by the agency and the department of social and health services to serve children and youth in foster care and adoption support and young adult alumni of the foster care program.

"Assign" or "assignment" means the agency selects an MCO to serve a client who has not selected an MCO.

"Auto enrollment" means the agency has automatically enrolled a client into an MCO in the client's area of residence.

"Behavioral health" - See WAC 182-538D-0200.

"Behavioral health administrative service organization (BH-ASO)" means an entity selected by the medicaid agency to administer behavioral health services and programs, including crisis services for all people in an integrated managed care regional service area. The BH-ASO administers crisis services for all people in its defined regional service area, regardless of a person's ability to pay.

"Behavioral health services only (BHSO)" means the program in which enrollees only receive behavioral health benefits through a managed care delivery system.

 "Child or youth with special health care needs" means a client under age 19 who is:
(a) Eligible for supplemental security income under Title XVI of the Social Security Act;
(b) Eligible for medicaid under section 1902(e)(3) of the Social Security Act;
(c) In foster care or other out-of-home placement;
(d) Receiving foster care or adoption assistance; or 
(e) Receiving services through a family-centered, community based, coordinated care system that receives grant funds under section 501(a)(1)(D) of Title V of the Social Security Act. 

"Client" - See WAC 182-500-0020.

"Disenrollment" - See "end enrollment."

"Emergency medical condition" means a condition meeting the definition in 42 C.F.R. Sec. 438.114(a).

"Emergency services" means services defined in 42 C.F.R. Sec. 438.114(a).

"End enrollment" means ending the enrollment of an enrollee for one of the reasons outlined in WAC 182-538-130.

"Enrollee" means a person eligible for any Washington apple health program enrolled in managed care with an MCO or PCCM provider that has a contract with the state.

"Enrollee's representative" means a person with a legal right or written authorization from the enrollee to act on behalf of the enrollee in making decisions.

"Enrollees with special health care needs" means enrollees having chronic and disabling conditions and the conditions:

(a) Have a biologic, psychologic, or cognitive basis;

(b) Have lasted or are virtually certain to last for at least one year; and

(c) Produce one or more of the following conditions stemming from a disease:

(i) Significant limitation in areas of physical, cognitive, or emotional function;

(ii) Dependency on medical or assistive devices to minimize limitation of function or activities; or

(iii) In addition, for children, any of the following:

(A) Significant limitation in social growth or developmental function;

(B) Need for psychological, educational, medical, or related services over and above the usual for the child's age; or

(C) Special ongoing treatments, such as medications, special diet, interventions, or accommodations at home or school.

"Exemption" means agency approval of a client's preenrollment request to remain in the fee-for-service delivery system for one of the reasons outlined in WAC 182-538-130.

"Fully integrated managed care (FIMC)" - See integrated managed care.

"Grievance" means an expression of dissatisfaction about any matter other than an adverse benefit determination.

"Grievance and appeal system" means the processes the MCO implements to handle appeals of adverse benefit determinations and grievances, as well as the processes to collect and track information about them.

"Health care service" or "service" means a service or item provided for the prevention, cure, or treatment of an illness, injury, disease, or condition.

"Integrated managed care (IMC)" means the program under which a managed care organization provides:

(a) Physical health services funded by medicaid; and

(b) Behavioral health services funded by medicaid, and other available resources provided for in chapters 182-538B, 182-538C, and 182-538D WAC.

"Managed care" means a comprehensive health care delivery system that includes preventive, primary, specialty, and ancillary services. These services are provided through either an MCO or PCCM provider.

"Managed care contract" means the agreement between the agency and an MCO to provide prepaid contracted services to enrollees.

"Managed care organization" or "MCO" means an organization having a certificate of authority or certificate of registration from the office of insurance commissioner that contracts with the agency under a comprehensive risk contract to provide prepaid health care services to enrollees under the agency's managed care programs.

"Mandatory enrollment" means the agency's requirement that a client enroll in managed care.

"Mandatory service area" means a service area in which eligible clients are required to enroll in an MCO.

"Nonparticipating provider" means a person, health care provider, practitioner, facility, or entity acting within their scope of practice and licensure that:

(a) Provides health care services to enrollees; and

(b) Does not have a written agreement with the managed care organization (MCO) to participate in the MCO's provider network.

"Participating provider" means a person, health care provider, practitioner, or entity acting within their scope of practice and licensure with a written agreement with the MCO to provide services to enrollees.

"Patient days of care" means all voluntary patients and involuntarily committed patients under chapter 71.05 RCW, regardless of where in the state hospital the patients reside. Patients who are committed to the state hospital under chapter 10.77 RCW are not included in the patient days of care. Patients who are committed under RCW 10.77.088 by municipal or district courts after failed competency restoration and dismissal of misdemeanor charges are not counted in the patient days of care until a petition for 90 days of civil commitment under chapter 71.05 RCW has been filed in court. Patients who are committed under RCW 10.77.086 by a superior court after failed competency restoration and dismissal of felony charges are not counted in the patient days of care until the patient is civilly committed under chapter 71.05 RCW.

"Primary care case management" or "PCCM" means the health care management activities of a provider that contracts with the agency to provide primary health care services and to arrange and coordinate other preventive, specialty, and ancillary health services.

"Primary care provider" or "PCP" means a person licensed or certified under Title 18 RCW including, but not limited to, a physician, an advanced registered nurse practitioner (ARNP), naturopath, or a physician assistant who supervises, coordinates, and provides health services to a client or an enrollee, initiates referrals for specialist and ancillary care, and maintains the client's or enrollee's continuity of care.

"Regional service area (RSA)" means a single county or multi-county grouping formed for the purpose of health care purchasing and designated by the agency and the department of social and health services.

"Timely" concerning the provision of services, means an enrollee has the right to receive medically necessary health care as expeditiously as the enrollee's health condition requires. Concerning authorization of services and grievances and appeals, "timely" means according to the agency's managed care program contracts and the time frames stated in this chapter.

"Wraparound with intensive services (WISe)" is a program that provides comprehensive behavioral health services and support to:

(a) Medicaid-eligible people age 20 or younger with complex behavioral health needs; and

(b) Their families.

WAC 182-500-0070 Medical assistance definitions -- M.

Effective July 1, 2019

"Medicaid" means the federal medical aid program under Title XIX of the Social Security Act that provides health care to eligible people.

"Medicaid agency" means the state agency that administers the medicaid program. The Washington state health care authority (HCA) is the state's medicaid agency.

"Medicaid transformation project" refers to the demonstration granted to the state by the federal government under section 1115 of the Social Security Act. Under this demonstration, the federal government allows the state to engage in a five-year demonstration to support health care systems, to implement reform, and to provide new targeted medicaid services to eligible clients with significant needs.

"Medical assistance" is the term the agency and its predecessors use to mean all federal or state-funded health care programs, or both, administered by the agency or its designees. Medical assistance programs are referred to as Washington apple health.

"Medical care services (MCS)" means the limited scope health care program financed by state funds for clients who are eligible for the aged, blind, or disabled (ABD) cash assistance (see WAC 388-400-0060) or the housing and essential needs (HEN) referral program (see WAC 388-400-0065) and not eligible for other full-scope programs due to their citizenship or immigration status.

"Medical consultant" means a physician employed by or contracted with the agency or the agency's designee.

"Medical facility" means a medical institution or clinic that provides health care services.

"Medical institution" See "institution" in WAC 182-500-0050.

"Medical services card" or "services card" means the card the agency issues at the initial approval of a person's Washington apple health benefit. The card identifies the person's name and medical services identification number but is not proof of eligibility. The card may be replaced upon request if it is lost or stolen, but is not required to access health care through Washington apple health.

"Medically necessary" is a term for describing requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the client that endanger life, or cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the client requesting the service. For the purposes of this section, "course of treatment" may include mere observation or, where appropriate, no medical treatment at all.

"Medically needy (MN)" or "medically needy program (MNP)" means the state and federally funded health care program available to specific groups of people who would be eligible as categorically needy (CN), except their monthly income is above the CN standard. Some long-term care clients with income or resources above the CN standard may also qualify for MN.

"Medically needy income level (MNIL)" means the standard the agency uses to determine eligibility under the medically needy program. See WAC 182-519-0050.

"Medicare" is the federal government health insurance program under Titles II and XVIII of the Social Security Act. For additional information, see www.Medicare.gov.

"Medicare assignment" means the process by which a provider agrees to provide services to a medicare beneficiary and accept medicare's payment for the services.

"Medicare cost-sharing" means out-of-pocket medical expenses related to services provided by medicare. For clients enrolled in medicare, cost-sharing may include Part A and Part B premiums, coinsurance, deductibles, and copayments for medicare services. See chapter 182-517 WAC.

"Minimum essential coverage" means coverage under 26 U.S.C Sec. 5000A (f).

"Modified adjusted gross income (MAGI)" means the adjusted gross income as determined by the Internal Revenue Service under the Internal Revenue Code of 1986 (IRC) increased by:

       (a) Any amount excluded from gross income under 26 U.S.C. Sec. 911;

       (b) Any amount of interest received or accrued by the client during the taxable year which is exempt from tax; and

       (c) Any amount of Title II Social Security income or Tier 1 railroad retirement benefits excluded from gross income under 26 U.S.C. Sec. 86. See chapter 182-509 WAC for additional rules regarding MAGI.

WAC 182-538-060 Managed care choice and assignment.

Effective October 25, 2020

1. The medicaid agency requires a client to enroll in integrated managed care (IMC) when that client:
   1. Is eligible for one of the Washington apple health programs for which enrollment is mandatory;
   2. Resides in an area where enrollment is mandatory; and
   3. Is not exempt from IMC enrollment and the agency has not ended the client's managed care enrollment, consistent with WAC 182-538-130.
2. American Indian and Alaska native (AI/AN) clients and their descendants may choose one of the following:
   1. Enrollment with a managed care organization (MCO) available in their regional service area;
   2. Enrollment with a PCCM provider through a tribal clinic or urban Indian center available in their area; or
   3. The agency's fee-for-service system for physical health or behavioral health or both.
3. To enroll with an MCO or PCCM provider, a client may:
   1. Enroll online via the Washington Healthplanfinder at https://www.wahealthplanfinder.org ;
   2. Call the agency's toll-free enrollment line at 800-562-3022; or
   3. Go to the ProviderOne client portal at https://www.waproviderone.org/client and follow the instructions.
4. An enrollee in IMC must enroll with an MCO available in the regional service area where the enrollee resides.
5. All family members will be enrolled with the same MCO, except family members of an enrollee placed in the patient review and coordination (PRC) program under WAC 182-501-0135 need not enroll in the same MCO as the family member placed in the PRC program.
6. An enrollee may be placed into the PRC program by the MCO or the agency. An enrollee placed in the PRC program must follow the enrollment requirements of the program as stated in WAC 182-501-0135.
7. When a client requests enrollment with an MCO or PCCM provider, the agency enrolls a client effective the earliest possible date given the requirements of the agency's enrollment system.
8. The agency assigns a client who does not choose an MCO or PCCM provider as follows:
   1. If the client was enrolled with an MCO or PCCM provider within the previous six months, the client is reenrolled with the same MCO or PCCM provider;
   2. If (a) of this subsection does not apply and the client has a family member enrolled with an MCO, the client is enrolled with that MCO;
   3. The client is reenrolled within the previous six months with their prior MCO plan if:
      1. The agency identifies the prior MCO and the program is available; and
      2. The client does not have a family member enrolled with an agency-contracted MCO or PCCM provider.
   4. If the client has a break in eligibility of less than two months, the client will be automatically reenrolled with his or her previous MCO or PCCM provider and no notice will be sent; or
   5. If the client cannot be assigned according to (a), (b), (c), or (d) of this subsection, the agency:
      1. Assigns the client according to agency policy, or this rule, or both;
      2. Does not assign clients to any MCO that has a total statewide market share of forty percent or more of clients who are enrolled in apple health IMC. On a quarterly basis, the agency reviews enrollment data to determine each MCO's statewide market share in apple health IMC;
      3. Applies performance measures associated with increasing or reducing assignment consistent with this rule and agency policy or its contracts with MCOs.
   6. If the client cannot be assigned according to (a) or (b) of this subsection, the agency assigns the client as follows:
      1. If a client who is not AI/AN does not choose an MCO, the agency assigns the client to an MCO available in the area where the client resides. The MCO is responsible for primary care provider (PCP) choice and assignment.
      2. For clients who are newly eligible or who have had a break in eligibility of more than six months, the agency sends a written notice to each household of one or more clients who are assigned to an MCO. The assigned client has ten calendar days to contact the agency to change the MCO assignment before enrollment is effective. The notice includes:
         1. The agency's toll-free number;
         2. The toll-free number and name of the MCO to which each client has been assigned;
         3. The effective date of enrollment; and
         4. The date by which the client must respond in order to change the assignment.
9. An MCO enrollee's selection of a PCP or assignment to a PCP occurs as follows:
   1. An MCO enrollee may choose:
      1. A PCP or clinic that is in the enrollee's MCO and accepting new enrollees; or
      2. A different PCP or clinic participating with the enrollee's MCO for different family members.
   2. The MCO assigns a PCP or clinic that meets the access standards set forth in the relevant managed care contract if the enrollee does not choose a PCP or clinic.
   3. An MCO enrollee may change PCPs or clinics in an MCO for any reason, with the change becoming effective no later than the beginning of the month following the enrollee's request.
   4. An MCO enrollee may file a grievance with the MCO if the MCO does not approve an enrollee's request to change PCPs or clinics.
   5. MCO enrollees required to participate in the agency's PRC program may be limited in their right to change PCPs (see WAC 182-501-0135).