Washington Administrative Code

(1) The agency's health home program provides patient-centered care to participants who:(a) Have at least one chronic condition as defined in WAC 182-557-0100; and(b) Are at risk of a second chronic condition as evidenced by a minimum predictive risk score of 1.5.(2) The health h…

The following terms and definitions and those found in chapter 182-500 WAC apply to this chapter:Action - For the purposes of this chapter, means one or more of the following:(a) The denial of eligibility for health home services.(b) The denial or limited authorization by the qua…

(1) To be eligible for the health home program, a client must:(a) Be a recipient of categorically needy health care coverage or be eligible for services under an alternative benefits plan (ABP), as described in WAC 182-501-0060, through:(i) Fee-for-service, including full dual el…

The agency uses eight steps to calculate a person's risk score.(1) Step 1. Collect paid claims and health plan encounter data. The agency obtains a set of paid fee-for-service claims and managed care encounters for a client.(a) For clients age 17 and younger, the agency uses all …

(1) Qualified health homes must comply with the confidentiality and data sharing requirements that apply to participants eligible under medicare and Title XIX medicaid programs and as specified in the health home contract.(2) The agency and the department of social and health ser…

(1) Qualified health homes must have a grievances and appeals process in place that complies with the requirements of this section and must maintain records of all grievances and appeals.(a) This section contains information about the grievance system for fee-for-service clients,…

Only an agency-contracted qualified health home may bill and be paid for providing health home services described in this chapter. Billing requirements and payment methodology are described in the contract between the agency and the qualified health home.[Statutory Authority: RCW…

(1) Involuntary disenrollment for health and safety concerns. If a qualified health home or care coordinator believes there are unresolved health or safety concerns with a health home client, the medicaid agency reviews the health home's written request for involuntary disenrollm…

The medicaid agency may pay a premium assistance subsidy for comprehensive health insurance premiums and other cost-sharing (defined in WAC 182-500-0020) when the agency determines it would be cost-effective to maintain a client's available health care coverage.[Statutory Authori…

The following definitions, and those definitions found in chapter 182-500 WAC, apply to this chapter."Average cost per user" means the average medicaid expenditure for a person of the same age, sex, and eligibility type as the applicant, per fiscal year, as calculated by the agen…

(1) Eligibility. To be eligible for the premium payment program (PPP):(a) A member of the client's medical assistance unit, as described in chapter 182-506 WAC, must be receiving benefits under the medicaid agency's:(i) Alternative benefits plan coverage;(ii) Categorically needy …

(1) General rule. Under section 1905(a) of the Social Security Act, the agency pays a premium assistance subsidy up to an eligible person's individual health insurance premium obligation when the agency determines it is cost effective.(2) Eligible persons. An eligible person is a…

(1) General rule. Under section 1906 of the Social Security Act, the agency pays a premium assistance subsidy:(a) Up to an eligible person's employer-sponsored group health insurance plan premium obligation; and(b) When the agency determines it is cost effective as defined in WAC…

(1) General rule. Under section 1906A of the Social Security Act, the agency pays an eligible person's premium assistance subsidy and other cost-sharing obligations when the agency determines it is cost-effective as defined in WAC 182-558-0020.(2) Eligible persons. An eligible pe…

(1) The agency monitors payments under the premium payment program.(2) Under RCW 41.05A.110, the agency may recover any overpayment of a premium assistance subsidy or cost-sharing amount. Events that may cause an overpayment for purposes of this section include agency administrat…

A client may request an administrative hearing under chapter 182-526 WAC if the client does not agree with an agency decision regarding eligibility for the premium payment program, the amount of a premium assistance subsidy, or an overpayment of a premium assistance subsidy.[Stat…

(1) Under the authority of the medicaid transformation project, RCW 71.24.385, and subject to available funds, the medicaid agency covers targeted foundational community supports to eligible medicaid beneficiaries, which include the following benefits:(a) Community support servic…

The following definitions and those found in chapter 182-500 WAC apply to this chapter."Adverse benefit determination" means one or more of the following:(a) The denial or limited authorization of a requested foundational community support services, including determinations based…

(1) Providers of community support services and supported employment services under this authority must be:(a) Health care professionals, entities, or contractors as defined by WAC 182-502-0002;(b) Agencies, centers, or facilities as defined by WAC 182-502-0002;(c) Health home pr…

To be eligible for community support services, a client must:(1) Be age 16 or older;(2) Be eligible for Washington apple health (medicaid);(3) Meet at least one of the following health criteria and be expected to benefit from community support services:(a) Clients assessed by a l…

To be eligible for supported employment services, a client must:(1) Be age sixteen or older;(2) Be eligible for apple health (medicaid);(3) Desire to obtain employment;(4) Meet at least one of the following health criteria and is expected to benefit from supported employment serv…

The medicaid agency pays for community support services and supported employment described in WAC 182-559-100 when no other public funds are already dedicated to providing comparable services to the client, unless the provider can demonstrate that the client requires services tha…

Nothing in this chapter shall be construed as providing a legal right to any individual to any of the services referenced in this chapter. The services provided under this chapter are strictly limited to the authority granted to the state under the medicaid transformation project…

(1) This section contains information about the third-party administrator (TPA) grievance and appeal system and the medicaid agency's administrative hearing process for clients under the foundational community supports program.(a) The TPA must have a grievance and appeal system a…

This rule describes a qualified achieving a better life experience (ABLE) account and its effect on the determination of eligibility for Washington apple health coverage.(1) A qualified ABLE account:(a) Is established and maintained by a state, or its designated agency or entity;…

(1) Administration. The medicaid agency, in conjunction with the department of social and health services, administers the community behavioral health support services (CBHS) benefit.(2) Services. The CBHS benefit tailors services designed to assist eligible clients to acquire, r…

The following definitions and those found in chapter 182-500 WAC apply to this chapter:"Activities of daily living (ADL)" means the same as in WAC 388-106-0010."Home and community services (HCS)" means the division of the department of social and health services (DSHS) that manag…

To be eligible for the community behavioral health support services (CBHS) benefit, a person must meet all requirements and criteria in this section.(1) General requirements. A person must:(a) Be eligible for apple health under categorically needy or alternate benefit plan scope …

The community behavioral health support services (CBHS) benefit covers supportive supervision and oversight services that:(1) Include direct monitoring, redirection, diversion, and cueing to prevent at-risk behavior that may result in harm to the client or to others.(2) Assist wi…

(1) The agency has established tiers for community behavioral health support services using the needs-based criteria and risk criteria in WAC 182-561-0300.(2) At a minimum, a person determined eligible for supportive supervision qualifies to receive Tier 1 services for an average…

(1) Supportive supervision and oversight services providers. The services described in WAC 182-561-0400(1) must be provided by the following medicaid agency-contracted providers:(a) Adult family homes, as defined in RCW 70.128.010, which are licensed under chapter 388-76 WAC;(b) …

For purposes of this chapter, eligible diagnoses include only the following:• Psychotic disorder with hallucinations due to known physiological condition• Psychotic disorder with delusions due to known physiological condition• Mood disorder due to known physiological condition, u…

(1) The medicaid agency gives the client written notice of an action under chapter 182-518 WAC.(2) The client has the right to appeal the agency's adverse action according to chapter 182-526 WAC.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-10-081, § 182-561-0800, fil…

This chapter contains rules regarding community health worker (CHW) services.(1) For the purpose of this chapter, CHWs are frontline public health workers who are trusted members, or have a close understanding, or both, of the community served. This trusting relationship enables …

The following definitions and those found in chapter 182-500 WAC apply to community health worker (CHW) services."Agency" - See WAC 182-500-0010."Care coordination and health system navigation" - Helping clients to:(a) Identify providers to receive services;(b) Make appointments …

(1) The medicaid agency gives the client written notice of an action under chapter 182-518 WAC.(2) The client has the right to appeal the agency's adverse action according to chapter 182-526 WAC.[Statutory Authority: RCW 41.05.021, 41.05.160, and 2024 c 376 s 211(43). WSR 25-06-0…

To receive community health worker (CHW) services, a person must:(1) Be eligible for one of the Washington apple health programs listed in the table in WAC 182-501-0060, except for the medical care services (MCS) programs; and(2) Be recommended by a physician or other licensed pr…

(1) Community health worker (CHW) services must be initiated and recommended by a physician or other licensed practitioner of the healing arts, as specified in 42 C.F.R. 440.130.(2) During the initiating visit, the health care professional:(a) Identifies that the client exhibits …

(1) To be paid for providing community health worker (CHW) services to Washington apple health clients, a CHW must:(a) Deliver the CHW services under the general supervision of a medicaid-enrolled, licensed practitioner within the scope of their licensure as described in state la…

Community health workers must fulfill the documentation requirements in the medicaid agency's community health worker (CHW) services billing guide including, but not limited to, documenting in the client's health record:(1) Advance client consent. Consent must be obtained by the …

The medicaid agency covers the following services when performed by a community health worker (CHW):(1) Conducting person-centered assessments within their focus to:(a) Identify personal health goals and preferences;(b) Assess for physical, mental, behavioral, and social challeng…

Under this chapter, the medicaid agency does not cover the following services when provided by community health workers (CHW):(1) Clinical care management services that require a state credential;(2) Child care;(3) Chore services, including shopping and cooking;(4) Companion serv…

(1) Under this chapter, a supervising provider must:(a) Be enrolled as a provider with the medicaid agency;(b) Be one of the following licensed practitioners:(i) Health care professional;(ii) Health care entity;(iii) Supplier; or(iv) Contractor of service; and(c) Meet the require…

In addition to the requirements in WAC 182-502-0020, supervising providers must document the following:(1) Required supervision records for community health workers;(2) Continued education verification and renewal of credentials for professional staff; and(3) Consent forms and do…

(1) The medicaid agency pays for the covered community health worker (CHW) services described in this chapter when they are:(a) Initiated and recommended by a physician or other licensed practitioner of the healing arts, as specified in 42 C.F.R. 440.130;(b) Provided and billed a…

This chapter contains rules regarding reentry services.(1) The medicaid agency covers reentry services under the following authorities:(a) Under the authority of the reentry demonstration initiative, which is part of the agency's section 1115 medicaid demonstration waiver known a…

The following definitions and those found in chapter 182-500 WAC apply to this chapter."Adjudication" - A legal process that involves reviewing evidence and arguments to reach a decision. The decision is based on applying a standard set of guidelines to an individual's specific c…

Under this chapter, to provide reentry services, providers must:(1) Be enrolled as a provider with the medicaid agency; and(2) Meet the requirements for an enrolled provider under chapter 182-502 WAC.[Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.715. WSR 25-11-005, s …

(1) The following carceral facilities may provide reentry services when they meet the requirements in this chapter:(a) State prisons operated by the department of corrections (DOC);(b) City, county, and regionally operated adult jails;(c) Tribal jails; and(d) The following youth …

(1) The following reentry benefits available under CAA vary based upon whether the eligible juvenile is preadjudication or postadjudication:(a) Preadjudication benefits (section 5122 of CAA, 2023) include the following for eligible juveniles that are incarcerated in public instit…