Washington Administrative Code

(1) The health care authority's physician trauma care fund (TCF) is an amount that is legislatively appropriated to the medicaid agency each biennium for the purpose of increasing the agency's payment to physicians and other clinicians (those who are performing services within th…

(1) Effective for dates of service July 1, 2013, through December 31, 2014, the agency is authorized by the legislature to increase reimbursement rates to medicare levels for independent ARNPs who provide qualified primary care services to eligible medicaid clients.(2) For the pu…

(1) Effective for dates of service on or after September 1, 2015, the medicaid agency pays enhanced rates for physician procedure codes directly related to insertion or implant of long-acting reversible contraceptives (LARC).(2) The agency pays the enhanced rate as a set amount a…

(1) Subject to available funds, the medicaid agency pays an enhanced rate for covered pediatric care services and the administration of vaccines provided to clients age 20 and younger.(2) For the purposes of this section, pediatric care services are defined as covered evaluation …

(1) The medicaid agency pays an enhanced reimbursement using the medicare rate when medication for opioid use disorder (MOUD) is part of the visit for selected evaluation and management (E/M) codes and the provider meets the criteria in this section.(2) The purpose of this enhanc…

Applied behavior analysis (ABA) assists clients and their families to improve the core symptoms associated with autism spectrum disorders and intellectual or developmental disabilities for which there is evidence ABA is effective, per WAC 182-501-0165. ABA services support learni…

The following definitions and those found in chapter 182-500 WAC, medical definitions, and chapter 182-531 WAC, physician-related services, apply throughout this chapter.Applied behavior analysis or ABA - Applied behavior analysis (ABA) is an empirically validated approach to imp…

The medicaid agency pays for ABA services when the services are:(1) Covered;(2) Medically necessary;(3) Within the scope of the eligible client's medical care program;(4) Provided to clients who meet the criteria in WAC 182-531A-0400;(5) Within currently accepted standards of evi…

To be eligible for applied behavior analysis (ABA) services, a client must:(1) Be covered under Washington apple health (WAH);(2) Provide documentation created by a COE provider that:(a) Establishes the presence of functional impairment; delay in communication, behavior, or socia…

(1) Any person may refer a client suspected of meeting the criteria in WAC 182-531A-0400 to a center of excellence (COE) provider for an evaluation.(2) The individual COE provider must complete a comprehensive diagnostic evaluation and provide:(a) Documentation showing how the au…

(1) If the center of excellence (COE) provider has prescribed applied behavior analysis (ABA) services, the client may begin stage two - ABA assessment, functional analysis, and ABA therapy treatment plan development.(2) Prior authorization must be obtained from the agency prior …

(1) A provider must obtain prior authorization before delivery of applied behavior analysis (ABA) services. To request prior authorization, a provider must submit the following documents to the medicaid agency or follow the managed care organization (MCO) process:(a) The comprehe…

Center of excellence.(1) For the purposes of this chapter, center of excellence (COE) refers to an individual provider, not a facility.(2) A center of excellence (COE) must be an evaluating and prescribing provider.(3) The COE provider must be:(a) A person licensed under Title 18…

(1) The medicaid agency covers only the following applied behavior analysis (ABA) services, delivered in settings described in WAC 182-531A-0600, for eligible clients:(a) The ABA assessments that determine the relationship between environmental events and the client's behaviors;(…

The medicaid agency does not cover certain services under the applied behavior analysis (ABA) program include, but are not limited to:(1) Autism camps;(2) Dolphin therapy;(3) Equine therapy or hippo therapy;(4) Primarily educational services;(5) Recreational therapy;(6) Respite c…

(1) The medicaid agency requires prior authorization (PA) and recertification of the medical necessity of applied behavior analysis (ABA) services.(2) Requirements for PA requests are described in WAC 182-531A-0700.(3) The agency may reduce or deny services requested based on med…

Applied behavior analysis (ABA) services delivered using telemedicine may be reimbursed by the agency when billed in accordance with the rules regarding telemedicine and store-and-forward technology in WAC 182-501-0300 and the agency's published billing instructions.[Statutory Au…

The following definitions and those found in chapter 182-500 WAC apply to this chapter.340B dispensing fee - The medicaid agency's established fee paid to a registered and medicaid-participating 340B drug program provider under the public health service (PHS) act for expenses inv…

WAC 182-532-050 through 182-532-130 describe reproductive health services and related services covered by the medicaid agency. For maternity-related services, see chapter 182-533 WAC. For other related services, see chapter 182-531 WAC.[Statutory Authority: RCW 41.05.021, 41.05.1…

(1) The medicaid agency covers reproductive health services, as described under WAC 182-532-120, for clients covered by one of the Washington apple health programs as listed in the table in WAC 182-501-0060.(2) A client enrolled in an agency-contracted managed care organization (…

To receive payment for reproductive health services, a provider must:(1) Meet the requirements under this chapter and chapters 182-501 and 182-502 WAC;(2) Provide only those services that are within the scope of their licenses;(3) Bill the agency according to the agency's publish…

In addition to the services listed in WAC 182-531-0100, the medicaid agency covers all of the following reproductive health services:(1) For a client capable of reproducing, one comprehensive preventive family planning visit once every twelve months, based on nationally recognize…

Noncovered reproductive health services are described in WAC 182-501-0070 and 182-531-0150.[Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-130, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05…

(1) The medicaid agency reimburses providers for covered reproductive health services using the medicaid agency's published fee schedules.(2) Family planning pharmacy services, family planning lab services, and sterilization services are reimbursed by the medicaid agency under th…

The purpose of family planning only programs is to provide family planning services to all clients capable of reproducing, regardless of gender, to:(1) Improve access to family planning and family planning-related services; and(2) Reduce unintended pregnancies.[Statutory Authorit…

For the purposes of this section, "full-scope coverage" means coverage under either the categorically needy (CN) program, the broadest, most comprehensive scope of health care services covered or the alternative benefits plan (ABP), the same scope of care as CN, applicable to the…

To be paid by the medicaid agency for services provided to clients eligible for family planning only programs, providers must:(1) Comply with the requirements under this chapter and chapters 182-501 and 182-502 WAC;(2) Provide only those services that are within the scope of thei…

The medicaid agency covers all of the following services:(1) One comprehensive preventive family planning visit once every 12 months, based on nationally recognized clinical guidelines. This visit must have a primary focus and diagnosis of family planning and include counseling, …

(1) The medicaid agency limits payment under the family planning only programs to services that:(a) Have a primary focus and diagnosis of family planning as determined by a qualified licensed medical practitioner;(b) Are medically necessary for the client to safely and effectivel…

In addition to the requirements in WAC 182-502-0020, providers must document the following in the client's medical record:(1) Primary focus and diagnosis of the visit is family planning or family planning-related;(2) Contraceptive methods discussed;(3) Plan for use of a contracep…

(1) For the purposes of this section, "good cause" means that the use of the third-party coverage would violate a client's confidentiality because the third party:(a) Routinely sends written, verbal, or electronic communications, as defined in RCW 48.43.505, to the third-party su…

(1) Under the 1989 Maternity Care Access Act, and RCW 74.09.760 through 74.09.900, the agency established First Steps to provide access to services for eligible people and their infants.(2) The rules for the:(a) Maternity support services (MSS) component of First Steps are found …

The purpose of maternity support services (MSS) is to:(1) Improve and promote healthy birth outcomes. Services are delivered by an MSS interdisciplinary team to eligible pregnant and post-pregnant people and their infants.(2) Help eligible clients to access:(a) Prenatal care as e…

The following definitions and those found in WAC 182-500-0005 apply to maternity support services (MSS) and infant case management (ICM) (see WAC 182-533-0360 through 182-533-0386 for ICM rules)."Basic health messages" - For MSS, the preventive health education messages designed …

(1) To receive maternity support services (MSS), a client must:(a) Be covered under the alternative benefit plan, categorically needy, medically needy, or state-funded medical programs under Washington apple health; and(b) Be within the eligibility period of a maternity cycle as …

Maternity support service providers may include community clinics, federally qualified health centers, local health departments, hospitals, nonprofit organizations, tribal health clinics, and private clinics.(1) To be paid for providing maternity support services (MSS) and infant…

(1) MSS providers must use qualified professionals, as specified in this section.(a) Behavioral health specialists who are currently credentialed, certified, or licensed in Washington by the department of health under chapters 246-809, 246-810, 246-811, and 246-924 WAC as one of …

Providers must fulfill the documentation requirements under WAC 182-502-0020 and the medicaid agency's current billing instructions including:(1) Required supervision records for community health workers;(2) Continued education verification and renewal of credentials for professi…

(1) The medicaid agency must cover these maternity support services (MSS) provided by an MSS interdisciplinary team:(a) Screening(s) for risk factors related to pregnancy and birth outcomes;(b) Brief assessment when indicated;(c) Brief counseling;(d) Education that relates to imp…

(1) The medicaid agency must cover only those services listed in WAC 182-533-0330.(2) The medicaid agency must evaluate a request for any noncovered service under the provisions of WAC 182-501-0160.[Statutory Authority: RCW 41.05.021. WSR 14-09-061, § 182-533-0340, filed 4/16/14,…

The medicaid agency pays for the covered maternity support services (MSS) described in WAC 182-533-0330, subject to the requirements in this section:(1) MSS are:(a) Provided to a client who meets the eligibility requirements in WAC 182-533-0320.(b) Provided to a client during an …

The purpose of infant case management (ICM) is to improve the welfare of infants by providing their parent(s) with information and assistance to access needed medical, social, educational, and other services.[Statutory Authority: RCW 41.05.021. WSR 14-09-061, § 182-533-0360, file…

The definitions in WAC 182-533-0315 also apply to infant case management (ICM).[Statutory Authority: RCW 41.05.021. WSR 14-09-061, § 182-533-0365, filed 4/16/14, effective 5/17/14. WSR 11-14-075, recodified as § 182-533-0365, filed 6/30/11, effective 7/1/11. Statutory Authority: …

(1) To be eligible to receive infant case management (ICM), an infant must meet all the following criteria:(a) Be covered under categorically needy, medically needy, or state-funded medical programs under Washington apple health.(b) Meet the age requirement for ICM, which is the …

(1) Infant case management (ICM) services may be provided only by a qualified infant case manager who is employed by a provider meeting the requirements in WAC 182-533-0325.(2) The infant case manager must meet at least one of the following qualifications under (a), (b), or (c) o…

Providers must fulfill the documentation requirements under WAC 182-502-0020 and the medicaid agency's current billing instructions including:(1) Required supervision records for infant case managers;(2) Continued education verification and renewal of credentials for professional…

(1) The medicaid agency must cover infant case management (ICM) services subject to the restrictions and limitations in this section and other applicable WAC.Covered services include:(a) An initial in-person screening for ICM services, which includes an assessment of risk factors…

(1) The medicaid agency must cover only those services that are listed in WAC 182-533-0380.(2) The medicaid agency must evaluate a request for any noncovered service under the provisions of WAC 182-501-0160.[Statutory Authority: RCW 41.05.021. WSR 14-09-061, § 182-533-0385, filed…

(1) The medicaid agency must pay for the covered infant case management (ICM) services described in WAC 182-533-0380 on a fee-for-service basis subject to the following requirements.ICM services must be:(a) Provided to a client who meets the eligibility requirements in WAC 182-53…

(1) Purpose. The purpose of childbirth education (CBE) classes is to help prepare the client and the client's support person(s):(a) For the physiological, emotional, and psychological changes experienced during and after pregnancy;(b) To develop self-advocacy skills;(c) To increa…