Current through Register Vol. 24-18, September 15, 2024
(1) The medicaid agency or its designee does
not pay for any health care service not listed or referred to as a covered
health care service under the medical programs described in WAC
182-501-0060,
regardless of medical necessity. For the purposes of this section, health care
services includes treatment, equipment, related supplies, and drugs.
Circumstances in which clients are responsible for payment of health care
services are described in WAC
182-502-0160.
(2) This section does not apply to health
care services provided as a result of the early and periodic screening,
diagnosis, and treatment (EPSDT) program as described in chapter 182-534
WAC.
(3) The agency or its designee
does not pay for any ancillary health care service(s) provided in association
with a noncovered health care service.
(4) The following list of noncovered health
care services is not intended to be exhaustive. Noncovered health care services
include, but are not limited to:
(a) Any
health care service specifically excluded by federal or state law;
(b) Acupuncture, Christian Science practice,
faith healing, herbal therapy, homeopathy, massage, massage therapy,
naturopathy, and sanipractice;
(c)
Chiropractic care for adults;
(d)
Cosmetic, reconstructive, or plastic surgery, and any related health care
services, not specifically allowed under WAC
182-531-0100(4)
or
182-531-1675;
(e) Discography;
(f) Ear or other body piercing;
(g) Face lifts or other facial cosmetic
enhancements;
(h) Fertility,
infertility or sexual dysfunction testing, and related care, drugs, and/or
treatment including but not limited to:
(i)
Artificial insemination;
(ii) Donor
ovum, donor sperm, or gestational carrier;
(iii) In vitro fertilization;
(iv) Penile implants;
(v) Reversal of sterilization; and
(vi) Sex therapy.
(i) Hair transplants;
(j) Epilation (hair removal) and electrolysis
not specifically allowed under WAC
182-531-1675;
(k) Marital counseling;
(l) Motion analysis, athletic training
evaluation, work hardening condition, high altitude simulation test, and health
and behavior assessment;
(m)
Nonmedical equipment;
(n) Penile
implants;
(o) Prosthetic testicles
not specifically allowed under WAC
182-531-1675;
(p) Psychiatric sleep therapy;
(q) Subcutaneous injection filling;
(r) Tattoo removal;
(s) Transport of Involuntary Treatment Act
(ITA) clients to or from out-of-state treatment facilities, including those in
bordering cities;
(t) Upright
magnetic resonance imaging (MRI); and
(u) Vehicle purchase - New or used
vehicle.
(5) For a
specific list of noncovered health care services in the following service
categories, refer to the WAC citation:
(a)
Ambulance transportation and nonemergent transportation as described in chapter
182-546 WAC;
(b) Dental services as
described in chapter 182-535 WAC;
(c) Durable medical equipment as described in
chapter 182-543 WAC;
(d) Hearing
care services as described in chapter 182-547 WAC;
(e) Home health services as described in WAC
182-551-2130;
(f) Hospital services as described in WAC
182-550-1600;
(g) Health care professional services as
described in WAC
182-531-0150;
(h) Prescription drugs as described in
chapter 182-530 WAC;
(i) Vision
care hardware for clients 20 years of age and younger as described in chapter
182-544 WAC; and
(j) Vision care
exams as described in WAC
182-531-1000.
(6) A client has a right to request an
administrative hearing, if one is available under state and federal law. When
the agency or its designee denies all or part of a request for a noncovered
health care service(s), the agency or its designee sends the client and the
provider written notice, within 10 business days of the date the decision is
made, that includes:
(a) A statement of the
action the agency or its designee intends to take;
(b) Reference to the specific WAC provision
upon which the denial is based;
(c)
Sufficient detail to enable the recipient to:
(i) Learn why the agency's or its designee's
action was taken; and
(ii) Prepare
a response to the agency's or its designee's decision to classify the requested
health care service as noncovered.
(d) The specific factual basis for the
intended action; and
(e) The
following information:
(i) Administrative
hearing rights;
(ii) Instructions
on how to request the hearing;
(iii) Acknowledgment that a client may be
represented at the hearing by legal counsel or other representative;
(iv) Instructions on how to request an
exception to rule (ETR);
(v)
Information regarding agency-covered health care services, if any, as an
alternative to the requested noncovered health care service; and
(vi) Upon the client's request, the name and
address of the nearest legal services office.
(7) A client can request an exception to rule
(ETR) as described in WAC
182-501-0160.
Statutory Authority:
RCW
41.05.021 and section 1927 of the Social
Security Act. WSR 12-18-062, §182-501-0070, filed 8/31/12, effective
10/1/12. WSR 11-14-075, recodified as §182-501-0070, filed 6/30/11,
effective 7/1/11. Statutory Authority:
RCW
74.04.050,
74.08.090,
74.09.530, and
74.09.700. WSR 09-23-112, §
388-501-0070, filed 11/18/09, effective 12/19/09; WSR 07-04-036, §
388-501-0070, filed 1/29/07, effective
3/1/07.
