WAC 182-526-0500  Hearing record.

Effective March 16, 2017

1. Before the record is closed, the administrative law judge (ALJ) may:
   1. Set another hearing date;
   2. If needed, enter orders addressing limited issues before issuing a hearing decision resolving all issues in the proceeding; or
   3. Give the parties more time to file exhibits or written argument.
2. The record is closed:
   1. At the end of the hearing if the ALJ does not allow more time to file evidence or argument; or
   2. After the deadline for filing evidence or argument is over.
3. After the record is closed:
   1. No more evidence may be admitted without good cause;
   2. The (ALJ) must enter an initial order and the office of administrative hearings (OAH) must serve copies on all of the parties; and
   3. OAH must send the official record of the proceedings to the board of appeals. The record must be complete when it is sent, and include all parts required by WAC 182-526-0512.

WAC 182-501-0070 Health care coverage--Noncovered services.

Effective April 24, 2022

1. The medicaid agency or its designee does not pay for any health care service not listed or referred to as a covered health care service under the medical programs described in WAC 182-501-0060, regardless of medical necessity. For the purposes of this section, health care services includes treatment, equipment, related supplies, and drugs. Circumstances in which clients are responsible for payment of health care services are described in WAC 182-502-0160.
2. This section does not apply to health care services provided as a result of the early and periodic screening, diagnosis, and treatment (EPSDT) program as described in chapter 182-534 WAC.
3. The agency or its designee does not pay for any ancillary health care service(s) provided in association with a noncovered health care service.
4. The following list of noncovered health care services is not intended to be exhaustive. Noncovered health care services include, but are not limited to:
   1. Any health care service specifically excluded by federal or state law;
   2. Acupuncture, Christian Science practice, faith healing, herbal therapy, homeopathy, massage, massage therapy, naturopathy, and sanipractice;
   3. Chiropractic care for adults;
   4. Cosmetic, reconstructive, or plastic surgery, and any related health care services, not specifically allowed under WAC 182-531-0100(4);
   5. Discography;
   6. Ear or other body piercing;
   7. Face lifts or other facial cosmetic enhancements;
   8. Fertility, infertility or sexual dysfunction testing, and related care, drugs, and/or treatment including but not limited to:
      1. Artificial insemination;
      2. Donor ovum, donor sperm, or gestational carrier;
      3. In vitro fertilization;
      4. Penile implants;
      5. Reversal of sterilization; and
      6. Sex therapy.
   9. Hair transplants;
   10. Epilation (hair removal) and electrolysis not specifically allowed under WAC 182-531-1675;
   11. Marital counseling;
   12. Motion analysis, athletic training evaluation, work hardening condition, high altitude simulation test, and health and behavior assessment;
   13. Nonmedical equipment;
   14. Penile implants;
   15. Prosthetic testicles not specifically allowed under WAC 182-531-1675;
   16. Psychiatric sleep therapy;
   17. Subcutaneous injection filling;
   18. Tattoo removal;
   19. Transport of Involuntary Treatment Act (ITA) clients to or from out-of-state treatment facilities, including those in bordering cities;
   20. Upright magnetic resonance imaging (MRI); and
   21. Vehicle purchase - New or used vehicle.
5. For a specific list of noncovered health care services in the following service categories, refer to the WAC citation:
   1. Ambulance transportation and nonemergent transportation as described in chapter 182-546 WAC;
   2. Dental services as described in chapter 182-535 WAC;
   3. Durable medical equipment as described in chapter 182-543 WAC;
   4. Hearing care services as described in chapter 182-547 WAC;
   5. Home health services as described in WAC 182-551-2130;
   6. Hospital services as described in WAC 182-550-1600;
   7. Health care professional services as described in WAC 182-531-0150;
   8. Prescription drugs as described in chapter 182-530 WAC;
   9. Vision care hardware for clients 20 years of age and younger as described in chapter 182-544 WAC; and
   10. Vision care exams as described in WAC 182-531-1000.
6. A client has a right to request an administrative hearing, if one is available under state and federal law. When the agency or its designee denies all or part of a request for a noncovered health care service(s), the agency or its designee sends the client and the provider written notice, within 10 business days of the date the decision is made, that includes:
   1. A statement of the action the agency or its designee intends to take;
   2. Reference to the specific WAC provision upon which the denial is based;
   3. Sufficient detail to enable the recipient to:
      1. Learn why the agency's or its designee's action was taken; and
      2. Prepare a response to the agency's or its designee's decision to classify the requested health care service as noncovered.
   4. The specific factual basis for the intended action; and
   5. The following information:
      1. Administrative hearing rights;
      2. Instructions on how to request the hearing;
      3. Acknowledgment that a client may be represented at the hearing by legal counsel or other representative;
      4. Instructions on how to request an exception to rule (ETR);
      5. Information regarding agency-covered health care services, if any, as an alternative to the requested noncovered health care service; and
      6. Upon the client's request, the name and address of the nearest legal services office.
7. A client can request an exception to rule (ETR) as described in WAC 182-501-0160.

WAC 182-501-0065 Health care coverage -- Description of service categories.

Effective July 25, 2019

This rule provides a brief description of the medical, dental, mental health, and substance use disorder (SUD) service categories listed in the table in WAC 182-501-0060. The description of services under each category is not intended to be all inclusive.

1. For alternative benefits plan (ABP), categorically needy (CN), medically needy (MN), and medical care services (MCS), refer to the WAC citations listed in the following descriptions for specific details regarding each service category.
2. The following service categories are subject to the exclusions, limitations, restrictions, and eligibility requirements contained in agency rules:
   1. Ambulance - Emergency medical transportation and ambulance transportation for nonemergency medical needs. (WAC 182-546-0001 through 182-546-4000.)
   2. Applied behavior analysis (ABA) – (Chapter 182-531A WAC).
   3. Behavioral health services - (Chapter 182-538D​ WAC, Behavioral health services, WAC 182-531-1400 Psychiatric physician-related services and other professional mental health services, and chapter 246-341 WAC, Behavioral health services administrative requirements).
   4. Blood, blood products, and related services - Blood and/or blood derivatives, including synthetic factors, plasma expanders, and their administration. (WAC 182-550-1400 and 182-550-1500.
   5. Dental services - Diagnosis and treatment of dental problems including emergency treatment and preventive care. (Chapters 182-535 and 182-535A WAC.)
   6. Diagnostic services - Clinical testing and imaging services. (WAC 182-531-0100; WAC 182-550-1400 and 182-550-1500.)
   7. Early and periodic screening, diagnosis, and treatment (EPSDT) – (Chapter 182-534 WAC and WAC 182-501-0050(10).)
   8. Enteral nutrition program - Enteral nutrition products, equipment, and related supplies. (Chapter 182-554 WAC.)​
   9. Habilitative services – (Chapter 182-545 WAC).
   10. Health care professional services - The following services found in chapter 182-531 WAC:
       1. Office visits and vaccinations;
       2. Screening/brief intervention/referral to treatment (SBIRT), emergency room and nursing facility services;
       3. Home-based and hospital-based services;
       4. Surgery, anesthesia, pathology, radiology, and laboratory services;
       5. Obstetric services;
       6. Kidney dialysis and renal disease services;
       7. Advanced registered nurse practitioner, naturopathy, osteopathy, podiatry, physiatry, and pulmonary/respiratory services; and
       8. Allergen immunotherapy services. 
   11. Health homes - (Chapter 182-557 WAC).
   12. Hearing evaluations - The following services found in WAC 182-531-0375:
       1. Audiology;
       2. Diagnostic evaluations; and
       3. Hearing exams and testing. ​
   13. Hearing aids - (Chapter 182-547 WAC).
   14. Home health services - Intermittent, short-term skilled nursing care, occupational therapy, physical therapy, speech therapy, home infusion therapy, and health aide services, provided in the home. (WAC 182-551-2000 through 182-551-2220.)
   15. Home infusion therapy/parenteral nutrition program - Supplies and equipment necessary for parenteral infusion of therapeutic agents. (Chapter 182-553 WAC.)
   16. Hospice services - Physician services, skilled nursing care, medical social services, counseling services for client and family, drugs, medications (including biologicals), medical equipment and supplies needed for palliative care, home health aide, homemaker, personal care services, medical transportation, respite care, and brief inpatient care. This benefit also includes services rendered in a hospice care center and pediatric palliative care services. (WAC 182-551-1210 through 182-551-1850.)
   17. Hospital services - Inpatient/outpatient - Emergency room; hospital room and board (includes nursing care); inpatient services, supplies, equipment, and prescription drugs; surgery, anesthesia; diagnostic testing, laboratory work, blood/blood derivatives; radiation and imaging treatment and diagnostic services; and outpatient or day surgery, and obstetrical services. (Chapter 182-550 WAC.)
   18. Intermediate care facility/services for persons with intellectual disabilities - Habilitative training, health-related care, supervision, and residential care. (Chapter 388-835 WAC.)
   19. Maternity care and delivery services - Community health nurse visits, nutrition visits, behavioral health visits, midwife services, maternity and infant case management services, family planning services and community health worker visits. (WAC 182-533-0330.)
   20. Medical equipment, supplies, and appliances - Medical equipment and appliances, including wheelchairs, hospital beds, respiratory equipment; casts, splints, crutches, trusses, and braces. Medical supplies, including antiseptics, germicides, bandages, dressings, tape, blood monitoring/testing supplies, braces, belts, supporting devices, decubitus care products, ostomy supplies, syringes, needles, and urological supplies. (Chapter 182-543 WAC.)
   21. Medical nutrition therapy - Outpatient medical nutrition therapy and associated follow-ups. (Chapter 182-555 WAC.)
   22. Nursing facility services - Nursing, therapies, dietary, and daily care services delivered in a licensed nursing facility. (Chapter 388-97 WAC.)
   23. Organ transplants - Solid organs, e.g., heart, kidney, liver, lung, pancreas, and small bowel; bone marrow and peripheral stem cell; skin grafts; and corneal transplants. (WAC 182-550-1900 and 182-556-0400.)
   24. Orthodontic services – (Chapter 182-535A WAC).
   25. Out-of-state services -  (WAC 182-502-0120).
   26. Outpatient rehabilitation services (OT, PT, ST) - Evaluations, assessments, and treatment. (WAC 182-545-200.)
   27. Personal care services - Assistance with activities of daily living (e.g., bathing, dressing, eating, managing medications) and routine household chores (e.g., meal preparation, housework, essential shopping, transportation to medical services). (Chapters 388-106 and 388-845 WAC).

                 bb. Prescription drugs - Outpatient drugs (including in nursing facilities), both generic and brand name; drug devices and supplies; some over-the-counter drugs; oral, topical, injectable drugs;                           vaccines, immunizations, and biologicals; and family planning drugs, devices, and supplies. (WAC 182-530-2000.) Additional coverage for medications and prescriptions is addressed in                                     specific program WAC sections.
                 cc. Private duty nursing - Continuous skilled nursing services provided in a private residence, including client assessment, administration of treatment, and monitoring of medical equipment                             and client care for clients age seventeen and younger, see WAC 182-551-3000 - 182-551-3400. For benefits for clients eighteen and older, see WAC 388-106-1000 through 388-106-1055.
                 dd. Prosthetic/orthotic devices - Artificial limbs and other external body parts; devices that prevent, support, or correct a physical deformity or malfunction. (WAC 182-543-5000.)
                 ee. Reproductive health services - Gynecological exams; contraceptives, drugs, and supplies, including prescriptions; sterilization; screening and treatment of sexually transmitted diseases;                                 and educational services. (WAC 182-532-001 through 182-532-140.)
                 ff. Respiratory care (oxygen) - All services, oxygen, equipment, and supplies related to respiratory care. (Chapter 182-552 WAC.)
                 gg. School-based health care services - Early intervention services or special education health-related services provided in schools to medicaid-eligible children ages birth through twenty who                           have an individualized education program (IEP) or individualized family service plan (IFSP). (Chapter 182-537 WAC.)
                 hh. Vision care - Eye exams, refractions, fittings, visual field testing, vision therapy, ocular prosthetics, and surgery. (WAC 182-531-1000.)
                 ii. Vision hardware - Frames and lenses. (Chapter 182-544 WAC.)

WAC 182-526-0650  Service of petition for judicial review.

Effective March 16, 2017

1. The party requesting judicial review must:
   1. File a petition for judicial review with the court;
   2. File and serve the petition for judicial review of a final order within thirty days after the date it was mailed to the parties; and
   3. Serve copies of its petition on the health care authority (HCA), the office of the attorney general, and all other parties.
2. To serve HCA, the petitioning party must deliver a copy of the petition for judicial review to the director of HCA and send a copy to the board of appeals (BOA). The party may hand deliver the petition or send it by mail that gives proof of receipt.

   The physical location of the director is:

   Director
   Health Care Authority
   626 8th Avenue S.E.
   Olympia, WA 98501

   The mailing address of the director is:

   Director
   Health Care Authority
   P.O. Box 45502
   Olympia, WA 98504-5502

   The physical and mailing addresses for BOA are in WAC 182-526-0030.

3. To serve the office of the attorney general and other parties, the petitioning party may send a copy of the petition for judicial review by regular mail. The party may send a petition to the address for the attorney of record to serve a party. The party may serve the office of the attorney general by hand delivery to:

          Office of the Attorney General
          7141 Cleanwater Drive S.W.
          Tumwater, WA 98501

         The mailing address of the attorney general is:

         Office of the Attorney General
         P.O. Box 40124
         Olympia, WA 98504-0124

WAC 182-526-0647 Exhaustion of administrative remedies required.

Effective February 1, 2013

Generally, a party may file a petition for judicial review only after it has completed the administrative hearing process. See RCW 34.05.534.

WAC 182-526-0645 Deadline for petition for judicial review and filing requirements.

Effective February 1, 2013

A party must file a petition for judicial review with the superior court within thirty calendar days after the final order is served to the parties.

WAC 182-526-0640  Judicial review of a final order.

Effective March 16, 2017

1. Judicial review is the process of appealing a final order to a court.
2. The party that requested the hearing may appeal a final order by filing a written petition for judicial review that meets the requirements of RCW 34.05.546. HCA may not request judicial review.
3. The party seeking judicial review must consult RCW 34.05.510 to 34.05.598 for further details of the judicial review process.

WAC 182-526-0635 Process after a party requests reconsideration.

Effective February 1, 2013

1. After the review judge receives a reconsideration request, the review judge has twenty calendar days to enter and serve a reconsideration decision unless the review judge serves notice allowing more time.
2. After BOA receives a reconsideration request, the review judge must either:
   1. Write a reconsideration decision; or
   2. Serve all parties an order denying the request.
3. If the review judge does not serve an order or notice granting more time within twenty days of receipt of the reconsideration request, the request is denied.

WAC 182-526-0630 Responding to a reconsideration request.

Effective February 1, 2013

1. A party does not have to respond to a request for reconsideration of a final order. A response is optional.
2. If a party responds, that party must file a response with the board of appeals (BOA) by or before the seventh business day after the date the review judge mailed the request to the party.
3. A party should send a copy of the response to any other party or representative.
4. If a party needs more time to respond, the review judge may extend its deadline if the party gives a good reason within the deadline in subsection (2) of this section.

WAC 182-526-0620 Deadline for requesting reconsideration.

Effective February 1, 2013

1. To request reconsideration of a final order entered by a review judge, the BOA must receive a written reconsideration request on or before the tenth calendar day after the final order was served.
2. The review judge may extend its deadline for filing a request for reconsideration if a party:
   1. Asks for more time before the deadline expires; and
   2. Gives a good reason for the extension. 
3. If a reconsideration request is filed after the deadline, the final order will not be reconsidered and the deadline to ask for judicial review of the final HCA decision continues to run.
4. If a party does not request reconsideration or fails to ask for an extension within the deadline, the final order may not be reconsidered and it becomes the final HCA decision.