Washington Administrative Code

(Effective January 1, 2027)(1) Except for hospitals primarily engaged in the care and treatment of children in King or Pierce counties, for the purpose of calculating any payment thresholds set in this chapter:(a) The authority calculates the amount of benchmark reimbursement for…

(Effective January 1, 2027)(1) Contractors must provide the authority with the following in the form and manner prescribed by the authority:(a) Cost and quality of care information; and(b) Data on all claims and encounters.(2) Except for hospitals primarily engaged in the care an…

(Effective January 1, 2027)(1) The authority conducts an annual measurement as described in WAC 182-40-0300 and 182-40-0400 following the end of a plan year to ensure compliance with this chapter. Failure to comply with the reimbursement requirements in this chapter will result i…

(Effective January 1, 2027)(1) When the authority determines a contractor has reimbursed a hospital an amount in excess of the payment threshold for any plan year, as specified in WAC 182-40-0300, it is an overpayment. When the authority identifies an overpayment, the authority p…

(Effective January 1, 2027)(1) When the authority determines a contractor reimbursed primary care, behavioral health providers, or critical access hospitals below the required payment threshold for any plan year, as specified in WAC 182-40-0300 and 182-40-0400, the authority prov…

(Effective January 1, 2027)Contractors are responsible for ensuring any reimbursements to providers and provider networks comply with reimbursement requirements established in WAC 182-40-0300 and 182-40-0400. This includes provider reimbursements resulting from arrangements with …

(Effective January 1, 2027)(1) In addition to any action described in this chapter, the authority may require the contractor to create and comply with a corrective action plan and demonstrate corrective action. A copy of the corrective action plan must be provided to the authorit…

(Effective January 1, 2027)(1) An in-state, out-of-network hospital that is reimbursed in accordance with WAC 182-40-0300(2) may not charge to or collect from the patient, for a service covered by the patient's health plan, or a person who is financially responsible for the patie…

(Effective January 1, 2027)(1) When the authority determines that a contractor or hospital failed to comply with a requirement in this chapter, the authority provides written notice of noncompliance to the contractor or hospital explaining the nature of the violation.(2) The auth…

(Effective January 1, 2027)(1) A contractor or hospital may appeal a written notice of noncompliance by timely filing an appeal, and the authority will schedule an administrative hearing.(2) To file an appeal, the contractor or hospital must send a written request to the authorit…

(1) The Washington health benefit exchange, in partnership with the health care authority, administers public purchasing of the Washington state public option plans known as Cascade Care Select.(2) Each hospital should consider all valid offers from public option plans to ensure …

For the purposes of this chapter:"Authority" means the Washington state health care authority."Carrier" is defined in RCW 48.43.005."Health benefit exchange" means the Washington state health benefit exchange established in RCW 43.71.020."Hospital" means any hospital licensed und…

(1) Compliance. The authority conducts investigations, as needed, to ensure compliance with this chapter.(2) Investigations. The authority may open an investigation:(a) When the authority receives information from a carrier that a hospital failed to contract with that carrier to …

(1) The process described in this section applies only if a party receives a written sanction notice from the authority for noncompliance with this chapter.(2) The authority must receive a party's appeal within 28 calendar days of the date the party received the notice of sanctio…

RCW 41.05.021 (1)(b)(iii) and 70.14.050 authorize the director to establish an independent Washington state pharmacy and therapeutics committee within the health care authority to evaluate available evidence of the relative safety, efficacy and the effectiveness of prescription d…

When used in this chapter:(1) "Appointing authority" means the following people acting jointly: The director of the health care authority and the director of the department of labor and industries.(2) "Committee" means the independent Washington state pharmacy and therapeutics co…

The purpose of the committee is to evaluate the available evidence of the relative safety, efficacy, and effectiveness of prescription drugs within a class of prescription drugs and make recommendations to the appointing authority for its deliberation in the development of the Wa…

(1) Meetings of the pharmacy and therapeutics committee comply with the provisions of the Open Public Meetings Act, chapter 42.30 RCW, and are subject to the provisions of the Administrative Procedure Act, chapter 34.05 RCW, as applicable.(2) The pharmacy and therapeutics committ…

(1) The committee consists of no fewer than ten members appointed by the appointing authority.(2) The appointing authority has the sole right to appoint committee members and may terminate appointment of any member at any time during the term.(3) The appointing authority makes ap…

(1) Members are appointed to a term of three years and serve until a successor is appointed. A member may be reappointed for up to two additional three-year terms for a total of nine years.(2) Committee members serve staggered three-year terms. Of the initial appointees, in order…

Committee members:(1) Select a chair and a vice chair from among the committee membership.(2) Meet at least quarterly and may meet at other times at the discretion of the chair.(3) Adopt a plan of operation that sets forth the policies and procedures established by the committee …

(1) When filling prescriptions for participating state purchased health care programs, pharmacists must make a therapeutic interchange if the prescription is prescribed by an endorsing practitioner except:(a) If the endorsing practitioner indicates "dispense as written" on the no…

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 Tabe…

"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 …

"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 …

"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, si…

"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…

"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 da…

"Fee-for-service (FSS)" - The general payment method the agency or agency's designee uses to pay for covered medical services provided to clients, except those services covered under the agency's prepaid managed care programs."Fiscal intermediary" means an organization having an …

"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 …

"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 insuranc…

"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 a Washington apple health program…

"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 ag…

"Managed care organization (MCO)" see WAC 182-538-050."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 Washi…

"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 Termin…

"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 outpatien…

"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 profess…

"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…

"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 s…

"Self-attestation" means a person's written, verbal, or electronic declaration of the person's income, resources, or circumstances made under penalty of perjury, confirming a statement to be true. (See also "attested income" or "attested resources.")"Spenddown" is a term used in …

"Tax dependent" means a person for whom a tax filer claims an exemption on his or her federal income tax return. A tax dependent may be either a qualifying child or a qualifying relative under 26 U.S.C. Sec. 152 for a taxable year."Tax filer" means a person who expects to file a …

"Urgent care" means an unplanned appointment for a covered medical service with verification from an attending physician or facility that the client must be seen that day or the following day."Usual and customary charge" means the amount a provider typically charges to fifty perc…

"Washington apple health" means the public health insurance programs for eligible Washington residents. Washington apple health is the name used in Washington state for medicaid, the children's health insurance program (CHIP), and state-only funded health care programs."Washingto…

WAC 182-501-0050 through 182-501-0065 describe the health care services available to a client on a fee-for-service basis or to a client enrolled in a managed care organization (MCO) (defined in WAC 182-538-050). For the purposes of this section, health care services includes trea…

(1) The medicaid agency uses health technology assessments to determine whether a new technology, new indication, or existing technology approved by the Food and Drug Administration (FDA) is a covered service under agency health care programs. The agency only uses health technolo…

(1) This rule provides a table that lists:(a) The following Washington apple health programs:(i) The alternative benefits plan (ABP) medicaid;(ii) Categorically needy (CN) medicaid;(iii) Medically needy (MN) medicaid; and(iv) Medical care services (MCS) programs (includes incapac…

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 benef…

(1) The medicaid agency or the agency's 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…

(1) For the purpose of this section, "liable third party" means:(a) The tort-feasor, or insurer of the tort-feasor, or both; and(b) Any person, entity or program that is or may be liable to provide coverage for the illness or injuries for which the medicaid agency is providing as…

In this section "advance directive" means a written instruction, recognized under state law, relating to the provision of health care when an individual is incapacitated.(1) All agencies, health maintenance organizations (HMOs), and facilities including hospitals, critical access…