Washington Administrative Code

(1) The purpose of the AIDS health insurance premium payment program is to help people who are not eligible for the medicaid agency's Washington apple health medical programs and who are diagnosed with AIDS pay their health insurance premiums.(2) To be eligible for the AIDS healt…

The medicaid agency provides HIV/AIDS case management to assist people infected with HIV to: Live as independently as possible; maintain and improve health; reduce behaviors that put the person and others at risk; and gain access to needed medical, social, and educational service…

(1) The medicaid agency pays HIV/AIDS case management providers for the following three services:(a) Comprehensive assessment. The assessment must cover the areas outlined in WAC 182-539-0300 (1) and (5).(i) The agency pays for only one comprehensive assessment unless the client'…

This chapter (WAC 182-540-001 through 182-540-065) contains rules for the state-funded kidney disease program (KDP) administered by the health care authority (the agency). The KDP is available for persons who have end-stage renal disease requiring dialysis or kidney transplant, o…

The following definitions and those found in chapter 182-500 WAC, apply to this chapter for the purpose of administering the kidney disease program."Affiliate" - A facility, hospital, unit, business, or person having an agreement with a kidney center to provide specified services…

(1) Persons must meet the following criteria to be eligible for the kidney disease program (KDP):(a) Reside in the state of Washington as required under WAC 182-503-0520 or 182-503-0525;(b) Be diagnosed with end-stage renal disease (ESRD) requiring dialysis or kidney transplant a…

(1) Household size is used to determine the appropriate income standard for KDP eligibility and also whose income must be counted or not counted.(2) The following members of a person's household must be included when determining the household size:(a) The applicant's spouse if li…

(1) A household must have countable income at or below two hundred twenty percent of the federal poverty level for a person to be eligible for the kidney disease program (KDP). See WAC 182-540-021 to determine who must be included in the household and whose income counts.(2) The …

(1) A person who is approved for KDP is required to report changes in their circumstances to the KDP contractor within thirty days of the date of the change. The person is required to report the following changes:(a) When total income for household members included in the KDP hou…

When a person applies for the kidney disease program (KDP), the KDP contractor must:(1) Inform the applicant of the requirements for KDP eligibility as defined in this chapter, provide the applicant with the necessary forms and instructions to complete the KDP application, and pr…

(1) An applicant for KDP must:(a) Complete the KDP application form and submit any necessary documentation to the KDP contractor in order to make an eligibility determination;(b) Do one of the following:(i) Provide application documentation from the department of social and healt…

(1) The person's household must have countable resources at or below the limits established in the federal low-income subsidy (LIS) program for the person to be eligible for the kidney disease program. LIS resource standards are listed at https://www.hca.wa.gov/free-or-low-cost-h…

(1) The kidney disease program (KDP) contractor must:(a) Be a medicare-certified end-stage renal disease (ESRD) facility; and(b) Have a valid KDP client services contract with the agency.(2) The KDP contractor must provide, directly or through an affiliate:(a) Professional consul…

(1) The kidney disease program (KDP) covers the cost of health care services essential to the treatment of end-stage renal disease (ESRD) and its complications. Within available funding and at the discretion of the KDP contractor covered services include:(a) Dialysis:(i) Center d…

(1) Clients have the right to appeal:(a) KDP eligibility decisions made by the person's KDP contractor;(b) Coverage decisions made by the contractor or the first decision submitted by the agency for medical services or devices that are not considered to be for the treatment of th…

(1) The agency reimburses KDP contractors:(a) Within the limits of legislative funding for the program;(b) According to the terms of each kidney center's contract with the agency; and(c) According to the provisions of the KDP manual.(2) The KDP contractor must submit the followin…

This section describes the medicaid agency reimbursement rules for free-standing kidney centers providing dialysis and end-stage renal disease services to agency clients.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-040, § 182-540-101, filed 6/24/15, effective 7/25…

The following definitions and those found in chapter 182-500 WAC, apply to this chapter."Affiliate" means a facility, hospital, unit, business, or person having an agreement with a kidney center to provide specified services to end stage renal disease (ESRD) patients."Agreement" …

(1) To be eligible for the kidney center services described in this section, a person must be diagnosed with end-stage renal disease (ESRD) or acute renal failure and be covered under:(a) One of the Washington apple health programs listed in the table in WAC 182-501-0060;(b) Alie…

To receive reimbursement from the medicaid agency for providing care to agency clients, a kidney center must:(1) Be a medicare-certified end-stage renal disease (ESRD) facility and have a signed core provider agreement with the agency (see chapter 182-502 WAC);(2) Meet requiremen…

(1) The medicaid agency covers the following services and supplies subject to the restrictions and limitations in this section and other applicable published WAC:(a) In-facility dialysis;(b) Home dialysis;(c) Training for self-dialysis;(d) Home dialysis helpers;(e) Dialysis suppl…

(1) The medicaid agency does not reimburse kidney centers for the following:(a) Blood and blood products (refer to WAC 182-540-190);(b) Personal care items such as slippers and toothbrushes; or(c) Additional staff time or personnel costs. Staff time is paid through the composite …

(1) Kidney center services described in this section are paid by one of two methods:(a) Composite rate payments - This is a payment method in which all standard equipment, supplies, and services are calculated into a blended rate.(i) A single dialysis session and related services…

(1) The following equipment, supplies, and services for in-facility and home dialysis are included in the composite rate:(a) Medically necessary dialysis equipment;(b) All dialysis services furnished by the facility's staff;(c) Standard end-stage renal disease laboratory tests (r…

The following items and services are not included in the composite rate and must be billed separately, subject to the restrictions or limitations in this section and other applicable published WAC:(1) Drugs related to treatment including, but not limited to, epoetin alpha (EPO) a…

(1) Laboratory services included in the composite rate, performed by either the facility or an independent laboratory, must not be billed separately except as provided for in (b) of this subsection:(a) Standard end-stage renal disease (ESRD) lab tests are included in the composit…

(1) The medicaid agency reimburses free-standing kidney centers for:(a) Blood processing and other fees assessed by nonprofit blood centers that do not charge for the blood or blood products themselves; and(b) Costs incurred by the center to administer its in-house blood procurem…

The medicaid agency reimburses the kidney center for EPO therapy when:(1) Administered in the kidney center to a client:(a) With a hematocrit less than 33 percent or a hemoglobin less than 11 when therapy is initiated;(b) Continuing EPO therapy with a hematocrit between 30 and 36…

Injectable drugs administered in the kidney center are reimbursed up to the medicaid agency published maximum fees.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-040, § 182-540-210, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-540-210, filed …

(1) The federal government considers medical equipment, supplies, and appliances, which the medicaid agency refers to throughout this chapter as medical equipment, services under the medicaid program.(2) The agency pays for medical equipment, including modifications, accessories,…

The following definitions and abbreviations and those found in chapter 182-500 WAC apply to this chapter."By-report (BR)" - See WAC 182-500-0015."Complex needs patient" - An individual with a diagnosis or medical condition that results in significant physical or functional needs …

(1) Refer to the table in WAC 182-501-0060 to see which Washington apple health programs include home health services, including medical equipment and related services, in their benefit package.(2) For clients eligible under an alien emergency medical (AEM) program, see WAC 182-5…

(1) The medicaid agency pays, on a fee-for-service basis, providers (including providers who supply medical equipment and supplies in an outpatient clinical setting), pharmacies, and suppliers, for medical equipment, medical supplies, complex rehabilitation technology (CRT), and …

(1) An interested party may request the medicaid agency to include new medical equipment in the agency's medical equipment billing guide.(2) The request must include credible evidence, including but not limited to:(a) Manufacturer's literature;(b) Manufacturer's pricing;(c) Clini…

(1) When a provider delivers an item directly to the client or the client's authorized representative, the provider must furnish the proof of delivery when the medicaid agency requests that information. All of the following apply:(a) The agency requires a delivery slip as proof o…

(1) The medicaid agency bases its decision to rent or purchase medical equipment on the length of time the client needs the equipment.(2) A provider must not bill the agency for the rental or purchase of equipment supplied to the provider at no cost by suppliers/manufacturers.(3)…

(1) Hospital beds.(a) The medicaid agency covers, with prior authorization, one hospital bed in a ten-year period, per client, with the following limitations:(i) A manual hospital bed as the primary option when the client has full-time caregivers; or(ii) A semi-electric hospital …

The medicaid agency covers the purchase of the following, with the stated limitations, without prior authorization:(1) Patient lift, hydraulic, with seat or sling - One per client in a five-year period.(2) Traction equipment - One per client in a five-year period.(3) Trapeze bars…

(1) The medicaid agency covers, with prior authorization, noninvasive osteogenesis electrical stimulators, also known as bone growth stimulators, limited to one per client, in a five-year period.(2) The agency pays for the purchase of nonspinal bone growth stimulators, only when:…

(1) The medicaid agency covers:(a) One artificial larynx, any type, without prior authorization, per client in a five-year period; and(b) One speech generating device (SGD), with prior authorization, per client every two years.(2) The agency pays only for those approved SGDs that…

(1) The medicaid agency covers the purchase of the following ambulatory aids with stated limitations, without prior authorization:(a) Canes - One per client in a five-year period.(b) Crutches - One per client in a five-year period.(c) Walkers - One per client in a five-year perio…

(1) The medicaid agency covers, with prior authorization, manual and power-drive wheelchairs for clients who reside at home. For clients who reside in a skilled nursing facility, see WAC 182-543-5700.(2) For manual or power-drive wheelchairs for clients who reside at home, reques…

The medicaid agency covers the rental or purchase of a manual wheelchair for a home client who is nonambulatory or has limited mobility and requires a wheelchair to participate in normal daily activities. For clients who reside in a skilled nursing facility, see WAC 182-543-5700.…

The medicaid agency pays for medically necessary power-drive wheelchairs when prior authorized.(1) Adults. The medicaid agency pays for power-drive wheelchairs for clients age twenty-one and older when the prescribing physician certifies that the following clinical criteria are m…

(1) The medicaid agency pays for, with prior authorization, wheelchair accessories and modifications that are specifically identified by the manufacturer as separate line item charges. To receive payment, providers must submit the following to the agency:(a) A completed General I…

(1) The medicaid agency pays for, with prior authorization, individually configured, complex rehabilitation technology (CRT) products.(2) CRT must be supplied by a CRT supplier with the appropriate taxonomy number to bill for the items.(3) Each site that a company operates must e…

(1) The medicaid agency pays for, without prior authorization (PA), the following prosthetics and orthotics. Items that meet the definition of medical equipment may be covered under the requirements for medical equipment. Prosthetics and orthotics that do not meet those definitio…

The medicaid agency pays for the following medical supplies and related services without prior authorization unless otherwise specified:(1) Antiseptics and germicides:(a) Alcohol (isopropyl) or peroxide (hydrogen) - One pint per month;(b) Alcohol wipes (box of two hundred) - One …

(1) The medicaid agency's skilled nursing facility per diem rate, established in chapters 74.46 RCW, 388-96, and 388-97 WAC, includes any reusable and disposable medical supplies that may be required for a skilled nursing facility client, unless otherwise specified within this se…

(1) The medicaid agency requires providers to obtain authorization for medical equipment as required in this chapter, in chapters 182-501 and 182-502 WAC, and in published billing guides and provider notices or when the clinical criteria required in this chapter are not met.(a) T…