Washington Administrative Code

Providers must fulfill the documentation requirements found in:(1) WAC 182-502-0020; and(2) Applicable medicaid agency billing guides.[Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.715. WSR 25-11-005, s 182-563-500, filed 5/8/25, effective 7/1/25.]

(1) The medicaid agency pays for the reentry services described in this chapter when they are:(a) Provided and billed according to the agency's rules, reentry policy and operations guide, and applicable agency billing guides; and(b) Documented in the client's record or chart per …

(1) The medicaid agency gives fee-for-service (FFS) clients written notice of an agency action under chapter 182-518 WAC.(2) FFS clients have the right to appeal the agency's adverse action according to chapter 182-526 WAC.(3) Refer to WAC 182-538-110 for information about the gr…

(1) The medicaid agency pays for reentry targeted case management (RTCM):(a) As part of a limited set of services under:(i) CAA reentry preadjudication (section 5122 of CAA, 2023) for eligible juveniles that are incarcerated in public institutions pending disposition; and(ii) CAA…

(1) The medicaid agency pays for outpatient diabetes education for an eligible client when:(a) The department of health (DOH) has approved the billing facility to provide diabetes education services; and(b) The client is referred by a licensed health care provider.(2) The agency …

(1) The Washington state health-related social needs (HRSN) program allows qualifying Washington apple health clients to receive limited, evidence-based, nonmedical services to address a client's unmet, adverse social conditions that contribute to poor health.(2) Subject to avail…

The following definitions and those found in chapter 182-500 WAC apply to this chapter:(1) "Activities of daily living" has the same meaning as defined in 24 C.F.R. § 700.105 and WAC 388-106-0010.(2) "Adverse benefit determination" means one or more of the following:(a) The denia…

(1) To be eligible for housing transition navigation services, a person must be:(a) Enrolled in foundational community supports as described in WAC 182-559-100;(b) Determined by the third-party administrator as having met at least one of the following health needs-based criteria …

(1) The services described in WAC 182-565-0140 are short term and limited to a maximum of six months.(2) The medicaid agency authorizes payment for approved housing transition navigation services for as long as it has funding through the health-related social needs program.(3) Ho…

Subject to the limitations in WAC 182-565-0130, the medicaid agency pays for short-term housing transition and moving costs necessary to establish a client's basic household, to include:(1) Security deposits;(2) Application fees;(3) Background checks;(4) The first month's rent as…

A service provider must be contracted with the foundational community supports (FCS) third-party administrator(s) specifically for FCS services, including payment of transition assistance funds, and meet the requirements of WAC 182-559-200. Other contracted models may be consider…

(1) Nothing in this chapter is intended to provide a legal right to any person to any service referenced in this chapter.(2) The services provided under this chapter are strictly limited to the authority granted to the medicaid agency under the medicaid transformation project and…

(1) General requirements. This section contains information about the third-party administrator (TPA) grievance and appeal process and the medicaid agency's administrative hearing process for clients relating to housing transition navigation services.(a) The TPA must have a griev…

(1) Rent and temporary housing payments provide stable independent living situations for clients in housing transitions who are homeless or at risk of homelessness. The payments may cover rent for up to six months per demonstration period.(2) Subject to available funds, allowable…

The definitions in WAC 182-565-0110 and those found in chapter 182-500 WAC apply to this chapter.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0210, filed 6/11/25, effective 7/12/25.]

To be eligible for rental services, a person must meet the requirements identified in WAC 182-565-0120.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0220, filed 6/11/25, effective 7/12/25.]

(1) The services described in WAC 182-565-0240 are short term and limited to a maximum of six months.(2) The medicaid agency reimburses rental payments only for residences that meet housing habitability standards for safety, sanitation, and habitability.(3) Rental services are su…

Subject to the limitations in WAC 182-565-0230, the medicaid agency may pay for past-due or future rent payments.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0240, filed 6/11/25, effective 7/12/25.]

(1) The rental payments identified in WAC 182-565-0240 must be used only for independent living situations, such as in-home and interim housing settings that meet the housing habitability standards found on the agency's website.(2) The medicaid agency does not reimburse for facil…

Rental service providers must meet the requirements in WAC 182-565-0150.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0260, filed 6/11/25, effective 7/12/25.]

Rental services are subject to the limitation of scope of benefits described in WAC 182-565-0160.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0270, filed 6/11/25, effective 7/12/25.]

Grievances and appeals related to rental services follow the process described in WAC 182-565-0170.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0280, filed 6/11/25, effective 7/12/25.]

Medical respite programs offer a lower-intensity care setting for patients who are homeless or at risk of homelessness and who would otherwise require a hospital stay or lack a safe option for discharge and recovery. Medical respite programs must meet the minimum operating standa…

The following definitions and those found in chapter 182-500 WAC apply to this chapter:"Behavioral health need" - See WAC 182-565-0110."Demonstration period" - See WAC 182-565-0110."Facility" - The physical location where the medical respite program provides medical respite care …

(1) A person must have or be eligible for apple health coverage before entering a medical respite program. If a person does not have coverage and wants to participate in the medical respite program, the program can help them register for coverage.(2) To receive medical respite ca…

A client is eligible for admission to a medical respite program when the client:(1) Is experiencing homelessness or is at risk of becoming homeless;(2) Is experiencing medical and behavioral health needs and meets one of the following:(a) Has recently been discharged from a hospi…

(1) The medical respite program will discharge the client when the client meets one of the following:(a) No longer benefits from medical respite care services;(b) Reaches the 90-day utilization limit for their current admission or the six-month utilization during the demonstratio…

(1) Medical respite programs must provide or arrange for the provision of the following services:(a) Room and board which must include, at a minimum:(i) A dedicated bed that is available to the client 24 hours a day, seven days a week;(ii) Three meals a day in accordance with med…

The medical respite program must provide coordination such that the client can access the following services:(1) Clinical assessments;(2) Behavioral health screenings for psychosocial needs;(3) Medical case management;(4) Case management support in accessing benefits and housing;…

Medical respite care services are short-term, limited to 90 consecutive days and no more than six months (180 days) during the demonstration period. See WAC 182-565-0340.[Statutory Authority: RCW 41.05.021, 41.05.160, and 2023 c 475 s 215(64). WSR 25-19-039, s 182-565-0370, filed…

A medical respite program may provide medical respite care services when the medical respite program:(1) Is enrolled as a Washington apple health medicaid provider for claims to be paid and be able to provide documentation of proof of service;(2) Meets the standards for medical r…

Grievance and appeals related to medical respite care services follow the process described in chapter 182-526 WAC.[Statutory Authority: RCW 41.05.021, 41.05.160, and 2023 c 475 s 215(64). WSR 25-19-039, s 182-565-0390, filed 9/9/25, effective 10/10/25.]

(1) Washington state has nine accountable communities of health (ACHs), as defined in RCW 82.04.43395, each of which operates a regional community care hub. In addition, the federally recognized tribes in Washington operate a statewide native hub to support the delivery of whole-…

"Clinical-risk factor" means physiological conditions that increase the likelihood of poor health outcomes."Community care hub (CCH)" means one of the nine regional centers managed and operated by one of the nine accountable communities of health (ACH). Each CCH organizes and sup…

To be eligible to receive covered services through community care hubs, a person must be enrolled in Washington apple health and:(1) Meet one or more of the following social risk factors:(a) Be homeless or at risk of homelessness, as defined by 24 C.F.R. § 91.5, except for the an…

Community care hubs provide the following covered services:(1) Screen clients for health needs and health-related social needs (HRSN);(2) Check clients' eligibility to receive the case management, outreach, and education service;(3) Refer clients to providers, community partners,…

Under RCW 7.70.060(4), the agency's medical director is authorized to independently assess and certify patient decision aids.[Statutory Authority: RCW 7.70.060 and 2012 c 101. WSR 12-24-052, § 182-60-005, filed 11/30/12, effective 1/1/13.]

When used in this chapter:(1) "Agency" means the Washington state health care authority (HCA), created pursuant to chapter 41.05 RCW.(2) "Certification fee" means a fee assessed by the agency to an individual or organization applicant requesting certification or recertification o…

The agency's medical director:(1) Maintains a list of recognized national certifying organizations so that individuals or organizations seeking certification may identify organizations recognized by the agency's medical director. (2) Considers organizations recommended by applica…

(1) When independently reviewing decision aids under RCW 7.70.060 (4)(a)(ii), the agency's medical director uses agency certification criteria, which are based on criteria developed by the International Patient Decision Aid Standards (IPDAS) Collaboration, for evaluation of a pat…

(1) The agency's medical director has the authority to establish one or more expert advisory panels to review patient decision aids using established criteria under WAC 182-60-025.(2) The panel may include the following as necessary:(a) Practicing physicians or other relevant lic…

The agency charges one or more fees to an applicant to defray the costs of assessments, certifications, recertifications, and any opportunities to remedy deficiencies in the application, according to this chapter. (1) Fees are based on the reasonable projected or actual cost of t…

(1) The agency may, at the medical director's discretion, give preference to certification of patient decision aids identified as priority topics for shared decision making by the Healthier Washington Initiative, the Robert Bree collaborative, or other topics that are important t…

(1) Decisions.(a) The agency's medical director, with input as determined necessary by an advisory review team, or contracted experts, or both, makes a written determination to:(i) Certify the decision aid;(ii) Notify the developer of areas of deficiency and provide an opportunit…

(1) The agency's medical director may suspend the certification or recertification process if the medical director determines there are deficiencies in an application, including the decision aid and supporting materials.(2) The agency provides the developer with a written notice …

The agency posts the following information on its website:(1) Priority certification topics and the timeline for application and consideration of submitted decision aids;(2) Certification forms and criteria;(3) A complete listing of certified decision aids and certification effec…

(1) This chapter establishes the responsibilities of the health care authority in the long-term services and supports program known as WA cares fund program as identified in RCW 50B.04.020(2).(2) Department of social and health services program rules can be found under chapter 38…

The definitions in this section apply throughout this chapter.Approved services has the same meaning as defined in WAC 388-116-1010.Benefit unit has the same meaning as defined in RCW 50B.04.010.Eligible beneficiary has the same meaning as defined in RCW 50B.04.010.Long-term serv…

(1) The health care authority (HCA) tracks and ensures that payments for LTSS services do not exceed an eligible beneficiary's total available program benefit units. (2) HCA pays a claim for approved services that have been preauthorized by the eligible beneficiary, when the LTSS…

If an eligible beneficiary is also an apple health (medicaid) client, the provider must first seek timely payment from the beneficiary's WA cares benefit units before billing apple health (medicaid) for approved services.[Statutory Authority: RCW 50B.04.020 (2)(e), 41.05.021, and…