Section 182-501-0055. Health care coverage—How the agency determines coverage of services for its health care programs using health technology assessments.

(1) The medicaid agency uses health technology assessments to determine whether a new technology, new indication, or existing technology approved by the Food and Drug Administration (FDA) is a covered service under agency health care programs. The agency only uses health technology assessments when coverage is not mandated by federal or state law. A health technology assessment may be conducted by or on behalf of:

(a) The agency; or

(b) The health technology assessment clinical committee (HTACC) under RCW 70.14.080 through 70.14.140.

(2) The agency reviews available evidence relevant to a medical or dental service or health care-related equipment and uses a technology evaluation matrix to:

(a) Determine its efficacy, effectiveness, and safety;

(b) Determine its impact on health outcomes;

(c) Identify indications for use;

(d) Identify potential for misuse or abuse; and

(e) Compare to alternative technologies to assess benefit vs. harm and cost effectiveness.

(3) The agency may determine the technology, device, or technology-related supply is:

(a) Covered (see WAC 182-501-0060 for the scope of coverage under Washington apple health (WAH) programs);

(b) Covered with authorization (see WAC 182-501-0165 for the process on how authorization is determined);

(c) Covered with limitations (see WAC 182-501-0169 for how limitations can be extended); or

(d) Noncovered (see WAC 182-501-0070 for noncovered services).

(4) The agency may periodically review existing technologies, devices, or technology-related supplies and reassign authorization requirements as necessary using the provisions in this section for new technologies, devices, or technology-related supplies.

(5) The agency evaluates the evidence and criteria from HTACC to determine whether a service is covered under WAC 182-501-0050 (9) and (10) and this section.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-15-053, § 182-501-0055, filed 7/9/15, effective 8/9/15. WSR 11-14-075, recodified as § 182-501-0055, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-07-116, § 388-501-0055, filed 3/22/10, effective 4/22/10. Statutory Authority: RCW 74.08.090 and 70.14.090. WSR 09-17-004, § 388-501-0055, filed 8/6/09, effective 9/6/09.]

RCW 41.05.021 and 41.05.160. WSR 15-15-053, § 182-501-0055, filed 7/9/15, effective 8/9/15. WSR 11-14-075, recodified as § 182-501-0055, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-07-116, § 388-501-0055, filed 3/22/10, effective 4/22/10. Statutory Authority: RCW 74.08.090 and 70.14.090. WSR 09-17-004, § 388-501-0055, filed 8/6/09, effective 9/6/09.

Rules

182-501-0060,182-501-0165,182-501-0169,182-501-0070,182-501-0050,