WAC 182-500-0065 Definitions -- L.

Effective September 24, 2022

"Limitation extension" see WAC 182-501-0169.

"Limited casualty program (LCP)" means the medically needy (MN) program.

"Long-term civil commitment" means inpatient mental health treatment for clients on 90-day or 180-day court orders whose treatment is authorized by the agency in agency-contracted beds.

WAC 182-500-0050 Washington apple health definitions -- I.

Effective April 23, 2022

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

"Institution" means an entity that furnishes (in single or multiple facilities) food, shelter, and some treatment or services to four or more people unrelated to the proprietor. Eligibility for Washington apple health program may vary depending upon the type of institution in which an individual resides. For the purposes of apple health programs, "institution" includes all the following:

1. "Institution for mental diseases (IMD)" -- A hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment or care of people with mental diseases, including medical attention, nursing care and related services. An IMD may include inpatient substance use disorder (SUD) facilities of more than 16 beds which provide residential treatment for SUD.
2. "Intermediate care facility for individuals with intellectual disabilities (ICF/IID)" -- An institution or distinct part of an institution that is:
   1. Defined in 42 CFR 440.150;
   2. Certified to provide ICF/IID services under 42 CFR 483, Subpart I; and
   3. Primarily for the diagnosis, treatment, or rehabilitation for people with intellectual disabilities or a related condition.
3. "Medical institution" -- An entity that is organized to provide medical care, including nursing and convalescent care. The terms "medical facility" and "medical institution" are sometimes used interchangeably throughout Title 182 WAC.
   1. To meet the definition of medical institution, the entity must:
      1. Be licensed as a medical institution under state law;
      2. Provide medical care, with the necessary professional personnel, equipment, and facilities to manage the health needs of the patient on a continuing basis under acceptable standards; and
      3. Include adequate physician and nursing care.
   2. Medical institutions include:
      1. "Hospice care center"--An entity licensed by the department of health (DOH) to provide hospice services. Hospice care centers must be medicare-certified, and approved by the agency or the agency's designee to be considered a medical institution.
      2. "Hospital"--Defined in WAC 182-500-0045.
      3. "Nursing facility (NF)"--An entity certified to provide skilled nursing care and long-term care services to medicaid recipients under Social Security Act Sec. 1919(a), 42 U.S.C. Sec. 1396r. Nursing facilities that may become certified include nursing homes licensed under chapter 18.51 RCW, and nursing facility units within hospitals licensed by DOH under chapter 70.41 RCW. This includes the nursing facility section of a state veteran's facility.
      4. "Psychiatric hospital"--An institution, or a psychiatric unit located in a hospital, licensed as a hospital under applicable Washington state laws and rules, that is primarily engaged to provide psychiatric services for the diagnosis and treatment of mentally ill people under the supervision of a physician.
      5. "Psychiatric residential treatment facility (PRTF)" -- A nonhospital residential treatment center licensed by DOH, and certified by the agency or the agency's designee to provide psychiatric inpatient services to medicaid-eligible people age 21 and younger. A PRTF must be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or any other accrediting organization with comparable standards recognized by Washington state. A PRTF must meet the requirements in 42 CFR 483, Subpart G, regarding the use of restraint and seclusion.
      6. "Residential habilitation center (RHC)"--A residence operated by the state under chapter 71A.20 RCW that serves people who have exceptional care and treatment needs due to their developmental disabilities by providing residential care designed to develop individual capacities to their optimum. RHCs provide residential care and may be certified to provide ICF/MR services and nursing facility services.
   3. Medical institutions do not include entities licensed by the agency or the agency's designee as adult family homes (AFHs) and boarding homes. AFHs and boarding homes include assisted living facilities, adult residential centers, enhanced adult residential centers, and developmental disability group homes.
4. "Public institution" means an entity that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control.
   1. Public institutions include:
      1. Correctional facility -- An entity such as a state prison, or city, county, or tribal jail, or juvenile rehabilitation or juvenile detention facility.
      2. Eastern and Western State mental hospitals. (Medicaid coverage for these institutions is limited to people age 21 and younger, and people age 65 and older.)
      3. Certain facilities administered by Washington state's department of veteran's affairs (see (b) of this subsection for facilities that are not considered public institutions).
   2. Public institutions do not include intermediate care facilities, entities that meet the definition of medical institution (such as Harborview Medical Center and University of Washington Medical Center), or facilities in Retsil, Orting, and Spokane that are administered by the department of veteran's affairs and licensed as nursing facilities.

"Institution for mental diseases (IMD)" see "institution" in this section.
"Institution review board" - A board or committee responsible for reviewing research protocols and determining whether:

1. Risks to subjects are minimized;
2. Risks to subjects are reasonable in relation to anticipated benefits, if any, to subjects, and the importance of the knowledge that may reasonably be expected to result;
3. Selection of subjects is equitable;
4. Informed consent will be sought from each prospective subject or the subject's legally authorized representative;
5. Informed consent will be appropriately documented;
6. When appropriate, the research plan makes adequate provision for monitoring the data collected to ensure the safety of subjects;
7. When appropriate, there are adequate provisions to protect the privacy of subjects and to maintain the confidentiality of data; and
8. When some or all of the subjects are likely to be vulnerable to coercion or undue influence, such as children, prisoners, pregnant people, mentally disabled persons, or economically or educationally disadvantaged persons, additional safeguards have been included in the study to protect the rights and welfare of these subjects.

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

"Intermediate care facility for individuals with intellectual disabilities (ICF/IID)" see "institution" in this section.

WAC 182-500-0045 Medical assistance definitions -- H.

Effective January 9, 2014

"Health benefit exchange" means the public-private partnership created pursuant to chapter 43.71 RCW.

"Health insurance premium tax credit (HIPTC)" is a premium tax credit that is refundable and can also be paid in advance from the Internal Revenue Service to a taxpayer's insurance company to help cover the cost of premiums for a taxpayer enrolled in a qualified health plan (QHP) through the health benefit exchange. This tax credit is specified in Section 36B of the Internal Revenue Code of 1986.

"Health maintenance organization (HMO)" means an entity licensed by the office of the insurance commissioner to provide comprehensive medical services directly to an eligible enrolled client in exchange for a premium paid by the agency on a prepaid capitation risk basis.

"Health care professional" means a provider of health care services licensed or certified by the state in which they practice.

"Health care service category" means a grouping of health care services listed in the table in WAC 182-501-0060. A health care service category is included or excluded depending on the client's medical assistance benefits package.

"Home health agency" means an agency or organization certified under medicare to provide comprehensive health care on a part-time or intermittent basis to a patient in the patient's place of residence.

"Hospital" means an entity that is licensed as an acute care hospital in accordance with applicable state laws and rules, or the applicable state laws and rules of the state in which the entity is located when the entity is out-of-state, and is certified under Title XVIII of the federal Social Security Act. The term "hospital" includes a medicare or state-certified distinct rehabilitation unit or a psychiatric hospital.

WAC 182-500-0040 Medical assistance definitions -- G.

Effective July 1, 2011

"Grandfathered client" means a noninstitutionalized person who meets all current requirements for medicaid eligibility except the criteria for blindness or disability; and:

1. Was eligible for medicaid in December 1973 as blind or disabled whether or not the person was receiving cash assistance in December 1973;
2. Continues to meet the criteria for blindness or disability and other conditions of eligibility used under the medicaid plan in December 1973; or
3. Was an institutionalized person who:
   1. Was eligible for medicaid in December 1973, or any part of that month, as an inpatient of a medical institution or a resident of a facility that is known as an intermediate care facility that was participating in the medicaid program and for each consecutive month after December 1973; and
   2. Continues to meet the requirements for medicaid eligibility that were in effect under the state's plan in December 1973 for institutionalized persons and remains institutionalized.

WAC 182-500-0030 Definitions -- E.

Effective November 21, 2025

"Early periodic screening, diagnosis, and treatment (EPSDT)" is defined under WAC 182-534-0050.

"Early elective delivery" means any nonmedically necessary induction or cesarean section before 39 weeks of gestation. Thirty-nine weeks of gestation is greater than 38 weeks and six days.

"Electronic signature" means a signature in electronic form attached to or associated with an electronic record including, but not limited to, a digital signature.

"Emergency medical condition" means the sudden onset of a medical condition (including labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

(a) Placing the patient's health in serious jeopardy;

(b) Serious impairment to bodily functions; or

(c) Serious dysfunction of any bodily organ or part.

"Employer-sponsored dependent coverage" means creditable health coverage for dependents offered by a family member's employer or union, for which the employer or union may contribute in whole or in part towards the premium. Extensions of such coverage (e.g., COBRA extensions) also qualify as employer-sponsored dependent coverage as long as there remains a contribution toward the premiums by the employer or union.

"Evidence-based medicine (EBM)" means the application of a set of principles and a method for the review of well-designed studies and objective clinical data to determine the level of evidence that proves to the greatest extent possible, that a health care service is safe, effective, and beneficial when making:

(a) Population-based health care coverage policies (WAC 182-501-0055 describes how the agency or its designee determines coverage of services for its health care programs by using evidence and criteria based on health technology assessments); and

(b) Individual medical necessity decisions (WAC 182-501-0165 describes how the agency or its designee uses the best evidence available to determine if a service is medically necessary as defined in WAC 182-500-0030).

"Exception to rule." See WAC 182-501-0160 for exceptions to noncovered health care services, supplies, and equipment. See WAC 182-503-0090 for exceptions to program eligibility.

"Expedited prior authorization (EPA)" means the process for obtaining authorization for selected health care services in which providers use a set of numeric codes to indicate to the agency or the agency's designee which acceptable indications, conditions, or agency or agency's designee-defined criteria are applicable to a particular request for authorization. EPA is a form of "prior authorization."

"Extended care services" means nursing and rehabilitative care in a skilled nursing facility provided to a recently hospitalized medicare patient.

WAC 182-500-0025 Definitions -- D.

Effective January 27, 2019

"Delayed certification" means agency or the agency's designee approval of a person's eligibility for medical assistance made after the established application processing time limits.

"Dental consultant" means a dentist employed or contracted by the agency or the agency's designee.

"Department" means the state department of social and health services.

"Disabled" means unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that:

       a. Can be expected to result in death;

       b. Has lasted or can be expected to last for a continuous period of not less than twelve months; or

       c. In the case of a child age seventeen or younger, means any physical or mental impairment of comparable severity.

Decisions on SSI-related disability are subject to the authority of federal statutes and rules codified at 42 USC Sec 1382c and 20 CFR, parts 404 and 416, as amended, and controlling federal court decisions, which define the old-age, survivors, and disability insurance (OASDI) and SSI disability standard and determination process. See WAC 182-500-0015 for definition of "blind."

"Domestic partner" means an adult who meets the requirements for a valid state registered domestic partnership as established by RCW 26.60.030 and who has been issued a certificate of state registered domestic partnership from the Washington secretary of state.

"Dual eligible client" means a client who has been found eligible as a categorically needy (CN) or medically needy (MN) medicaid client and is also a medicare beneficiary. This does not include a client who is only eligible for a medicare savings program as described in chapter 182-517 WAC.

WAC 182-500-0020 Definitions -- C.

Effective November 14, 2022

"Caretaker relative" means a relative of a dependent child by blood, adoption, or marriage with whom the child is living, who assumes primary responsibility for the child's care, and who is one of the following:

(a) The child's father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece.

(b) The spouse of such parent or relative (including same sex marriage or domestic partner), even after the marriage is terminated by death or divorce.

(c) Other relatives including relatives of half-blood, first cousins once removed, people of earlier generations (as shown by the prefixes of great, great-great, or great-great-great), and natural parents whose parental rights were terminated by a court order.

"Carrier" means an organization that contracts with the federal government to process claims under medicare Part B.

"Categorically needy (CN) or categorically needy program (CNP)" is the state and federally funded health care program established under Title XIX of the Social Security Act for people within medicaid-eligible categories, whose income and/or resources are at or below set standards.

"Categorically needy income level (CNIL)" is the standard used by the agency to determine eligibility under a categorically needy program.

"Categorically needy (CN) scope of care" is the range of health care services included within the scope of service categories described in WAC 182-501-0060 available to people eligible to receive benefits under a CN program. Some state-funded health care programs provide CN scope of care.

"Center of excellence" - A hospital, medical center, or other health care provider that meets or exceeds standards set by the agency for specific treatments or specialty care.

"Centers for Medicare and Medicaid Services (CMS)" - The federal agency that runs the medicare, medicaid and children's health insurance programs, and the federally facilitated marketplace.

"Children's health program or children's health care programs" See "Apple health for kids."

"Client" means a person who is an applicant for, or recipient of, any Washington apple health program, including managed care and long-term care. See definitions for "applicant" and "recipient" in RCW 74.09.741.

"Community spouse." See "spouse" in WAC 182-500-0100.

"Continuous eligibility" means a person continues to receive their apple health coverage without interruption throughout their certification period regardless of changes in income, household size, immigration or citizenship status, or any other factor of eligibility other than moving out-of-state or death.

"Core provider agreement" is a written contract whose terms and conditions bind each provider in the fee-for-service program to applicable federal laws, state laws, and the agency's rules, provider alerts, billing guides, and other subregulatory guidance. See WAC 182-502-0005. The core provider agreement is a unilateral contract.

"Cost-sharing" means any expenditure required by or on behalf of an enrollee with respect to essential health benefits; such term includes deductibles, coinsurance, copayments, or similar charges, but excludes premiums, balance billing amounts for nonnetwork providers, and spending for noncovered services.

"Cost-sharing reductions" means reductions in cost-sharing for an eligible person enrolled in a silver level plan in the health benefit exchange or for a person who is an American Indian or Alaska native enrolled in a qualified health plan (QHP) in the exchange.

"Couple." See "spouse" in WAC 182-500-0100.

"Covered service" is a health care service contained within a "service category" that is included in a Washington apple health (WAH) benefits package described in WAC 182-501-0060. For conditions of payment, see WAC 182-501-0050(5). A noncovered service is a specific health care service (for example, cosmetic surgery), contained within a service category that is included in a WAH benefits package, for which the agency or the agency's designee requires an approved exception to rule (ETR) (see WAC 182-501-0160). A noncovered service is not an excluded service (see WAC 182-501-0060).

"Creditable coverage" means most types of public and private health coverage, except Indian health services, that provide access to physicians, hospitals, laboratory services, and radiology services. This term applies to the coverage whether or not the coverage is equivalent to that offered under premium-based programs included in Washington apple health (WAH). Creditable coverage is described in 42 U.S.C. 300gg-3 (c)(1).

WAC 182-500-0015 Medical assistance definitions -- B.

Effective October 23, 2021

"Benefit package" means the set of health care service categories included in a client's health care program. See WAC 182-501-0060.

"Benefit period" means the time period used to determine whether medicare can pay for covered Part A services. A benefit period begins the first day a beneficiary receives inpatient hospital or extended care services from a qualified provider. The benefit period ends when the beneficiary has not been an inpatient of a hospital or other facility primarily providing skilled nursing or rehabilitation services for sixty consecutive days. There is no limit to the number of benefit periods a beneficiary may receive. Benefit period also means a "spell of illness" for medicare payments.

"Billing instructions" means provider guides. See WAC 182-500-0085.

"Blind" is a category of medical program eligibility that requires:

1. 1. A central visual acuity of 20/200 or less in the better eye with the use of a correcting lens; or
   2. A field of vision limitation so the widest diameter of the visual field subtends an angle no greater than twenty degrees from central.

"By report (BR)" means a method of payment in which the agency or the agency's designee determines the amount it will pay for a service when the rate for that service is not included in the agency's published fee schedules. The provider must submit a report which describes the nature, extent, time, effort and equipment necessary to deliver the service.

WAC 182-500-0010 Medical assistance definitions -- A.

Effective November 25, 2023

"Administrative renewal" means the agency uses electronically available income and resources data sources to verify and recertify a person's Washington apple health benefits for a subsequent certification period. A case is administratively renewed when the person's self-attested income and resources are reasonably compatible (as defined in WAC 182-500-0095) with the information available to the agency from the electronic data sources and the person meets citizenship, immigration, Social Security number, and age requirements.

"After-pregnancy coverage (APC)" means full-scope Washington apple health (medicaid) health care coverage for people up to 12 months after the month their pregnancy ends under WAC 182-505-0115.

"Agency" or "medicaid agency" means the Washington state health care authority (HCA).

"Agency's designee" means any entity expressly designated by the agency to act on its behalf.

"Allowable costs" are the documented costs as reported after any cost adjustment, cost disallowances, reclassifications, or reclassifications to nonallowable costs which are necessary, ordinary and related to the outpatient care of medical care clients or not expressly declared nonallowable by applicable statutes or regulations. Costs are ordinary if they are of the nature and magnitude which prudent and cost-conscious management would pay.

"Alternative benefits plan" means the range of health care services included within the scope of service categories described in WAC 182-501-0060 available to persons eligible to receive health care coverage under the Washington apple health modified adjusted gross income (MAGI)-based adult coverage described in WAC 182-505-0250.

"Ancillary services" means additional services ordered by the provider to support the core treatment provided to the patient. These services may include, but are not limited to, laboratory services, radiology services, drugs, physical therapy, occupational therapy, and speech therapy.

"Apple health for kids" is the umbrella term for health care coverage for certain groups of children that is funded by the state and federal governments under Title XIX medicaid programs, Title XXI Children's Health Insurance Program, or solely through state funds (including the program formerly known as the children's health program). Funding for any given child depends on the program for which the child is determined to be eligible. Apple health for kids programs are included in the array of health care programs available through Washington apple health (WAH).

"Attested income" or "attested resources" means a self-declared statement of a person's income or resources made under penalty of perjury to be true. (See also "self-attestation.")

"Authorization" means the agency's or the agency's designee's determination that criteria are met, as one of the preconditions to the agency's or the agency's designee's decision to provide payment for a specific service or device. (See also "expedited prior authorization" and "prior authorization.")

"Authorized representative" is defined under WAC 182-503-0130.

WAC 182-500-0005 Definitions.

Effective August 29, 2016

Chapter 182-500 WAC contains definitions of words and phrases used in rules for medical assistance and other health care programs. When a term is not defined in this chapter, other agency or agency's designee WAC, or state or federal law, the medical definitions found in the Taber's Cyclopedic Medical Dictionary will apply. For general terms not defined in this chapter, other agency or agency's designee WAC, or state or federal law, the definitions in Webster's New World Dictionary apply. If a definition in this chapter conflicts with a definition in another chapter of Title 182 WAC, the definition in the specific WAC prevails.