Washington Administrative Code

(1) The following definitions and abbreviations and those found in chapter 182-500 WAC apply to this chapter.(a) "Birthing center" means a specialized facility licensed as a childbirth center by the department of health (DOH) under chapter 246-329 WAC.(b) "Bundled services" means…

(1) Client eligibility. The medicaid agency covers planned home births and births in birthing centers for clients who choose to give birth at home or in an agency-approved birthing center and:(a) Are eligible for the alternative benefit package under WAC 182-501-0060, categorical…

WAC 182-533-0610 through 182-533-0680 establish the medicaid agency's provider and documentation requirements and coverage and payment rules for birth doula services when provided to eligible apple health clients. Birth doula services improve and promote healthy pregnancy, birth,…

The following definitions and those found in chapter 182-500 WAC apply to birth doula services."Agency" - See WAC 182-500-0010."Birth doula" - A nonmedical support person certified under chapter 246-835 WAC and trained to provide physical, emotional, and informational support to …

To receive birth doula services, a client must:(1) Be eligible for one of the Washington apple health programs listed in the table in WAC 182-501-0060; and(2) Be within one of the following eligibility periods:(a) During pregnancy;(b) Birth, inclusive of any end of pregnancy outc…

To be eligible to provide birth doula services to Washington apple health clients, a birth doula must:(1) Be 18 years of age or older;(2) Be a resident of the state of Washington or a bordering city as specified in WAC 182-501-0175;(3) Possess current certification as a birth dou…

(1) Providers must fulfill the documentation requirements found in WAC 182-502-0020 and the medicaid agency's current birth doula services billing guide.(2) Each provider must maintain a client health care record for each client that states the services provided and justifies how…

(1) To be covered, birth doula services must:(a) Be preventive in nature according to 42 C.F.R. 440.130(c); and(b) Provide physical, emotional, and informational support to pregnant, birthing, and postpartum people.(2) The medicaid agency covers the birth doula services described…

Under this chapter, the medicaid agency does not cover the following services when provided by birth doulas:(1) Childcare;(2) Chore services including, but not limited to, shopping and cooking;(3) Group services;(4) Phone calls, text messages, and emails;(5) Documentation time; a…

(1) The medicaid agency pays for the birth doula services described in WAC 182-533-0660 when they are:(a) Provided to a client who meets the eligibility requirements in WAC 182-533-0630;(b) Provided to a client during a face-to-face encounter, including audio-visual telemedicine …

The medicaid agency pays for birth doula services provided via telemedicine according to WAC 182-501-0300 and the limitations in this section.(1) The agency pays for birth doula services provided via telemedicine when one of the following are met:(a) The prenatal intake visit is …

The substance-using pregnant people (SUPP) program provides immediate access to medical care in a hospital setting to substance-using or substance-dependent pregnant people and their fetuses. The purpose of the immediate access to medical care is to reduce harm to and improve bir…

(1) To be eligible for the substance-using pregnant people (SUPP) program, a person must be:(a) Pregnant; and(b) Eligible for medicaid.(2) A client eligible under subsection (1) of this section who is enrolled in an agency-contracted managed care plan is eligible for SUPP service…

(1) The agency pays only those providers who:(a) Have been approved by the agency to provide substance-using pregnant people (SUPP) program services;(b) Have been licensed and certified as a behavioral health agency by the department of health (DOH) under chapter 246-341 WAC;(c) …

(1) The agency pays for the following covered services for a pregnant client and their fetus under the substance-using pregnant people (SUPP) program:(a) Primary acute withdrawal management and medical stabilization;(b) Secondary subacute withdrawal management and medical stabili…

The purpose of the early periodic screening, diagnosis, and treatment program is to ensure that children and adolescents receive comprehensive preventive, diagnostic, and treatment services.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-048, s 182-534-0010, filed 6/…

The following definitions and those found in chapter 182-500 WAC apply to this chapter:"Early periodic screening, diagnosis, and treatment (EPSDT)" means the federally mandated health care benefit for clients from birth through age 20 that ensures access to medically necessary se…

(1) People age 20 and younger who are enrolled in medicaid are eligible for coverage through the early periodic screening, diagnosis, and treatment (EPSDT) program. See WAC 182-501-0060, Health care coverage—Program benefit packages—Scope of service categories.(2) Under the EPSDT…

The medicaid agency covers early periodic screening, diagnosis, and treatment (EPSDT) services, as described in WAC 182-534-0100, for children in out-of-home placement to ensure medically necessary needs are promptly addressed.(1) For the purposes of this section, out-of-home pla…

The following definitions and abbreviations and those found in chapter 182-500 WAC apply to this chapter. The medicaid agency also uses dental definitions found in the American Dental Association's Current Dental Terminology (CDT) and the American Medical Association's Physician'…

(1) Refer to WAC 182-501-0060 to see which apple health programs include dental-related services in their benefit package.(2) Managed care clients are eligible under apple health fee-for-service for covered dental-related services not covered by their managed care organization (M…

(1) The following providers are eligible to enroll with the medicaid agency to furnish and bill for dental-related services provided to eligible clients:(a) Persons currently licensed by the state of Washington to:(i) Practice dentistry or specialties of dentistry.(ii) Practice a…

(1) Clients described in WAC 182-535-1060 are eligible to receive the dental-related services described in this chapter, subject to coverage limitations, restrictions, and client age requirements identified for a specific service. The medicaid agency pays for dental-related servi…

Clients described in WAC 182-535-1060 are eligible to receive the dental-related diagnostic services listed in this section, subject to coverage limitations, restrictions, and client age requirements identified for a specific service.(1) Clinical oral evaluations. The medicaid ag…

Clients described in WAC 182-535-1060 are eligible for the dental-related preventive services listed in this section, subject to coverage limitations and client-age requirements identified for a specific service.(1) Prophylaxis. The medicaid agency covers prophylaxis as follows. …

Clients described in WAC 182-535-1060 are eligible for the dental-related restorative services listed in this section, subject to coverage limitations, restrictions, and client age requirements identified for a specific service.(1) Amalgam, resin, and glass ionomer restorations f…

Clients described in WAC 182-535-1060 are eligible to receive the dental-related endodontic services listed in this section, subject to coverage limitations, restrictions, and client age requirements identified for a specific service.(1) Pulp capping. The medicaid agency consider…

Clients described in WAC 182-535-1060 are eligible to receive the dental-related periodontic services listed in this section, subject to coverage limitations, restrictions, and client-age requirements identified for a specified service.(1) Surgical periodontal services. The medic…

Clients described in WAC 182-535-1060 are eligible to receive the prosthodontics (removable) and related services, subject to the coverage limitations, restrictions, and client-age requirements identified for a specific service.(1) Prosthodontics. The medicaid agency requires pri…

Clients described in WAC 182-535-1060 are eligible to receive the maxillofacial prosthetic services listed in this section, subject to the following:(1) Maxillofacial prosthetics are covered on a case-by-case basis and when prior authorized; and(2) The medicaid agency must preapp…

Clients described in WAC 182-535-1060 are eligible to receive the oral and maxillofacial surgery services listed in this section, subject to the coverage limitations, restrictions, and client-age requirements identified for a specific service.(1) Oral and maxillofacial surgery se…

(1) The agency covers orthodontic services, subject to the coverage limitations listed, for clients twenty years of age and younger, according to chapter 182-535A WAC.(2) The agency does not cover orthodontic services for clients twenty-one years of age and older.[Statutory Autho…

Clients described in WAC 182-535-1060 are eligible to receive the adjunctive general services listed in this section, subject to coverage limitations, restrictions, and client-age requirements identified for a specific service.(1) Adjunctive general services. The medicaid agency:…

Subject to coverage limitations and restrictions identified for a specific service, the medicaid agency pays for the additional dental-related services listed in this section that are provided to clients of the developmental disabilities community services division of the departm…

(1) The medicaid agency does not cover the following under the dental program:(a) The dental-related services described in subsection (2) of this section unless the services are covered under the early periodic screening, diagnostic, and treatment (EPSDT) program described in cha…

(1) The medicaid agency uses the determination process for payment described in WAC 182-501-0165 for covered dental-related services that require prior authorization.(2) The agency requires a dental provider who is requesting prior authorization to submit sufficient, current (wit…

The access to baby and child dentistry (ABCD) program increases access to dental services for certain medicaid-eligible clients.(1) A client is eligible for the ABCD program if the client is:(a) Eligible for one of the following medical assistance programs:(i) Categorically needy…

(1) The oral health connections pilot project is effective for dates of service from January 1, 2019, through December 31, 2023.(2) The purpose of the oral health connections pilot project is to test the effect that enhanced oral health services have on the overall health of diab…

The agency uses the description of dental services described in the American Dental Association's Current Dental Terminology (CDT), and the American Medical Association's Physician's Current Procedural Terminology (CPT).(1) For covered dental-related services provided to eligible…

(1) The agency considers that a provider who furnishes covered dental services to an eligible client has accepted the agency's rules and fees.(2) Participating providers must bill the agency their usual and customary fees.(3) Payment for dental services is based on the agency's s…

This section applies to payment for denture laboratory services. The agency does not directly reimburse denture laboratories. The agency's reimbursement for complete dentures, partial dentures, and overdentures includes laboratory fees. The provider is responsible to pay a dentur…

The agency pays for medically necessary dental-related services provided in an inpatient or outpatient hospital setting according to WAC 182-550-1100.[Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1500, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as…

See WAC 182-501-0180, 182-501-0182, and 182-501-0184 for services provided outside the state of Washington. See WAC 182-501-0175 for designated bordering cities.[Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1550, filed 3/25/14, effecti…

The following definitions and those found in chapter 182-500 WAC apply to this chapter."Adolescent dentition" means teeth that are present after the loss of primary teeth and prior to the cessation of growth that affects orthodontic treatment."Appliance placement" means the appli…

(1) Subject to the limitations of this chapter, the medicaid agency covers medically necessary orthodontic treatment and orthodontic-related services for severe handicapping malocclusions, craniofacial anomalies, or cleft lip or palate, for eligible clients through age twenty. Re…

The following provider types may furnish and be paid for providing covered orthodontic treatment and orthodontic-related services to eligible medical assistance clients:(1) Orthodontists;(2) Pediatric dentists;(3) General dentists; and(4) Agency-recognized craniofacial teams or o…

Orthodontic treatment and orthodontic-related services require prior authorization.(1) The medicaid agency covers orthodontic treatment and orthodontic-related services for a client who has one of the medical conditions listed in (a) and (b) of this subsection. Treatment and foll…

When the medicaid agency authorizes a limited orthodontic treatment, full orthodontic treatment, or orthodontic-related services for a client, including a client eligible for services under the EPSDT program, that authorization indicates only that the specific service is medicall…

(1) The medicaid agency pays providers for furnishing covered orthodontic treatment and orthodontic-related services described in WAC 182-535A-0040 according to this section and other applicable WAC.(2) A provider who furnishes covered orthodontic treatment and orthodontic-relate…

The medicaid agency pays contracted school districts, educational service districts, charter schools, and tribal schools for school-based health care services provided to medicaid-eligible children who require early intervention or special education and related services consisten…