WAC 182-500-0030 Definitions -- E.

Effective August 18, 2025

"Early and periodic screening, diagnosis and treatment (EPSDT)" is defined under QAC 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.

WAC 182-527-2734 Liens during a client's lifetime.

Effective July 1, 2017

For the pur­poses of this section, the term "agency" includes the agency's desig­nee.

1. When the agency may file.
   1. The agency may file a lien against the property of a Washing­ton apple health client during the client's lifetime if:
      1. The client resides in a skilled nursing facility, intermedi­ate care facility for individuals with an intellectual disability, or other medical institution under WAC 182-500-0050;
      2. The agency determines that a client cannot reasonably be expected to return home because:
         1. The agency receives a physician's verification that the client will not be able to return home; or
         2. The client has resided for six months or longer in an institution as defined in WAC 182-500-0050; and
      3. None of the following people lawfully reside in the client's home:
         1. The client's spouse or state-registered domestic partner;
         2. The client's child who is age twenty or younger, or is blind or permanently disabled as defined in WAC 182-512-0050; or
         3. A client's sibling who has an equity interest in the home and who has been residing in the home for at least one year immediately before the client's admission to the medical institution.
   2. If the client returns home from the medical institution, the agency releases the lien.
2. Amount of the lien.
   1. The agency may file a lien to recoup the cost of all non-MAGI-based and deemed eligible services under WAC 182-503-0510 it correctly purchased on the client's behalf, regardless of the client's age on the date of service.
   2. Services provided under the medicaid transformation project, defined in WAC 182-500-0070, are excluded when determining the amount of the lien.
3. Notice requirement.
   1. Before the agency may file a lien under this section, it sends notice via first class mail to:
      1. The client's last known address;
      2. The client's authorized representative, if any;
      3. The address of the property subject to the lien; and
      4. Any other person known to hold title to the property.
   2. The notice states:
      1. The client's name;
      2. The agency's intent to file a lien against the client's property;
      3. The county in which the property is located; and
      4. How to request an administrative hearing.
4. Interest assessed on past-due debt.
   1. Interest on a past-due debt accrues at a rate of one percent per month under RCW 43.17.240.
   2. A lien under this section becomes a past-due debt when the agency has recorded the lien in the county where the property is loca­ted and:
      1. Thirty days have passed since the property was transferred or
      2. Nine months have passed since the lien was filed.
   3. The agency may waive interest if reasonable efforts to sell the property have failed.
5. Administrative hearing. An administrative hearing under this section is governed by WAC 182-527-2753.

WAC 182-520-0015 Long-term services and supports client overpay­ments.

Effective July 1, 2025

1. General right to recover.
   1. A long-term services and supports (LTSS) client overpayment is any payment for LTSS made by the agency or the agency's designee on a client's behalf in excess of that to which the client is legally en­titled.
   2. An LTSS client overpayment may be caused by:
      1. A client or a client's authorized representative misstating or failing to reveal a fact affecting eligibility under WAC 182-503-0505;
      2. A client or a client's authorized representative failing to timely report a change required under WAC 182-504-0105; or
      3. The agency or the agency's designee's error.
   3. The agency or the agency's designee may recoup an LTSS client overpayment:
      1. Up to six years after the date of the notice in subsection (2) of this section; and
      2. Regardless of whether the program is state-funded, federally funded, or both.
   4. The amount of the LTSS client overpayment equals the amount the agency or the agency's designee paid on the client's behalf minus the amount to which the client was legally entitled.
   5. When the agency or the agency's designee determines it caused the overpayment, the agency or the agency's designee may grant exceptions to client recovery.
2. Notice.
   1. The agency notifies the client or the client's authorized representative by:
      1. Personal service under RCW 4.28.080; or
      2. Certified mail, return receipt requested.
   2. The agency or the agency's designee may prove that it noti­fied the client by providing:
      1. A sworn statement;
      2. An affidavit or certificate of mailing; or
      3. The certified mail receipt signed by the client or the cli­ent's authorized representative.
   3. The notice states:
      1. The client's name;
      2. The client's address;
      3. The date the agency or the agency's designee issued the no­tice;
      4. The amount of the LTSS client overpayment;
      5. How the agency calculated the LTSS client overpayment;
      6. How the client may request an administrative hearing; and
      7. How the client may make a payment.
3. Response.
   1. The client must respond to the notice within 90 days of the date the agency or the agency's designee served the client with the notice of the LTSS client overpayment by:
      1. Paying the agency or the agency's designee;
      2. Establishing a payment plan with the agency or the agency's designee; or
      3. Requesting an administrative hearing.
   2. If the client does not respond to the notice within 90 days of the date the agency or the agency's designee served the client with the notice, the agency or the agency's designee may initiate col­lection action.
4. Hearings. A person who disagrees with agency or the agency's designee's action under this section may request an administrative hearing under chapter 182-526 WAC.

WAC 182-501-0200 Third-party resources.

Effective August 6, 2021

1. The medicaid agency requires a provider to seek timely reimbursement from a third party when a client has available third-party resources, except as described under subsections (2) and (3) of this section.
2. The agency pays for medical services and seeks reimbursement from a liable third party when the claim is for preventive pediatric services as covered under the early and periodic screening, diagnosis and treatment (EPSDT) program.
3. The agency pays for medical services and seeks reimbursement from any liable third party when both of the following apply:
   1. The provider submits to the agency documentation of billing the third party and the provider has not received payment after one hundred days from the date of services; and
   2. The claim is for a covered service provided to a client on whose behalf the office of support enforcement is enforcing a noncustodial parent to pay support. For the purpose of this section, "is enforcing" means the noncustodial parent either:
      1. Is not complying with an existing court order; or
      2. Received payment directly from the third party and did not pay for the medical services.
4. The provider may not bill the agency or the client for a covered service when a third party pays a provider the same amount as or more than the agency rate.
5. When the provider receives payment from a third party after receiving reimbursement from the agency, the provider must refund to the agency the amount of the:
   1. Third-party payment when the payment is less than the agency's maximum allowable rate; or
   2. Agency payment when the third-party payment is equal to or more than the agency's maximum allowable rate.
6. The agency does not pay for medical services if third-party benefits are available to pay for the client's medical services when the provider bills the agency, except under subsections (2) and (3) of this section.
7. The client is liable for charges for covered medical services that would be paid by the third-party payment when the client either:
   1. Receives direct third-party reimbursement for the services; or
   2. Fails to execute legal signatures on insurance forms, billing documents, or other forms necessary to receive insurance payments for services rendered. See WAC 182-503-0540 for assignment of rights.
8. The agency considers an adoptive family to be a third-party resource for the medical expenses of the birth mother and child only when there is a written contract between the adopting family and either the birth mother, the attorney, the provider, or the adoption service. The contract must specify that the adopting family will pay for the medical care associated with the pregnancy.
9. A provider cannot refuse to furnish covered services to a client because of a third-party's potential liability for the services.
10. For third-party liability on personal injury litigation claims, the agency or managed care organization (MCO) is responsible for providing medical services under WAC 182-501-0100.