Section 182-501-0065. Health care coverage—Description of service categories.

This rule provides a brief description of the medical, dental, mental health, and substance use disorder (SUD) service categories listed in the table in WAC 182-501-0060. The description of services under each category is not intended to be all inclusive.

(1) For categorically needy (CN), medically needy (MN), and medical care services (MCS), refer to the WAC citations listed in the following descriptions for specific details regarding each service category.

(2) The following service categories are subject to the exclusions, limitations, restrictions, and eligibility requirements contained in agency rules:

(a) Ambulance - Emergency medical transportation and ambulance transportation for nonemergency medical needs. (WAC 182-546-0001 through 182-546-4000.)

(b) Applied behavior analysis (ABA) - (WAC 182-531-1410 through 182-531-1434).

(c) Behavioral health services - 

(i) Mental health inpatient care - Voluntary and involuntary admissions for psychiatric services. (WAC 182-550-2600.)

(ii) Mental health outpatient (community mental health) services - Nonemergency, psychological evaluation, nonurgent counseling. (WAC 182-531-1400, 388-865-0215, 388-865-0230, and 388-865-0610 (1)(d)(i).)

(iii) Psychiatric visits. (WAC 182-531-1400 and 388-865-0230.)

(iv) Mental health medication management. (WAC 182-531-1400.)

(v) Substance use disorder (SUD) detoxification. (WAC 388-877B-0100 through 388-877B-0130 and 182-550-1100; WAC 182-556-0400(3).)

(vi) SUD diagnostic assessment. (WAC 388-877B-0500 through 388-877B-0550.)

(vii) SUD residential treatment. (WAC 388-877B-0200 through 388-877B-0280.)

(viii) SUD outpatient treatment. (WAC 388-877B-0300 through 388-877B-0370; WAC 182-533-0701 through 182-533-0730.)

(d) Blood, blood products, and related services - Blood and/or blood derivatives, including synthetic factors, plasma expanders, and their administration. (WAC 182-550-1400 and 182-550-1500.)

(e) Dental services - Diagnosis and treatment of dental problems including emergency treatment and preventive care. (Chapters 182-535 and 182-535A WAC.)

(f) Diagnostic services - Clinical testing and imaging services. (WAC 182-531-0100; WAC 182-550-1400 and 182-550-1500.)

(g) Early and periodic screening, diagnosis, and treatment (EPSDT) - (Chapter 182-534 WAC and WAC 182-501-0050(10).)

(h) Habilitative services - (Chapter 182-545 WAC).

(i) Health care professional services - Office visits, vaccinations, screening/brief intervention/referral to treatment (SBIRT), emergency room, nursing facility, home-based, and hospital-based care; surgery, anesthesia, pathology, radiology, and laboratory services; obstetric services; kidney dialysis and renal disease services; osteopathic care, podiatry services, physiatry, and pulmonary/respiratory services; and allergen immunotherapy. (Chapter 182-531 WAC.)

(j) Hearing evaluations - Audiology; diagnostic evaluations; hearing exams and testing. (WAC 182-531-0100 and 182-531-0375.)

(k) Hearing aids - (Chapter 182-547 WAC).

(l) Home health services - Intermittent, short-term skilled nursing care, occupational therapy, physical therapy, speech therapy, home infusion therapy, and health aide services, provided in the home. (WAC 182-551-2000 through 182-551-2220.)

(m) Hospice services - Physician services, skilled nursing care, medical social services, counseling services for client and family, drugs, medications (including biologicals), medical equipment and supplies needed for palliative care, home health aide, homemaker, personal care services, medical transportation, respite care, and brief inpatient care. This benefit also includes services rendered in a hospice care center and pediatric palliative care services. (WAC 182-551-1210 through 182-551-1850.)

(n) Hospital services—Inpatient/outpatient - Emergency room; hospital room and board (includes nursing care); inpatient services, supplies, equipment, and prescription drugs; surgery, anesthesia; diagnostic testing, laboratory work, blood/blood derivatives; radiation and imaging treatment and diagnostic services; and outpatient or day surgery, and obstetrical services. (Chapter 182-550 WAC.)

(o) Intermediate care facility/services for persons with intellectual disabilities - Habilitative training, health-related care, supervision, and residential care. (Chapter 388-835 WAC.)

(p) Maternity care and delivery services - Community health nurse visits, nutrition visits, behavioral health visits, midwife services, maternity and infant case management services, family planning services and community health worker visits. (WAC 182-533-0330.)

(q) Medical equipment, durable (DME) - Wheelchairs, hospital beds, respiratory equipment; casts, splints, crutches, trusses, and braces. (Chapter 182-543 WAC.)

(r) Medical equipment, nondurable (MSE) - Antiseptics, germicides, bandages, dressings, tape, blood monitoring/testing supplies, braces, belts, supporting devices, decubitus care products, ostomy supplies, pregnancy test kits, syringes, needles, and urological supplies. (Chapter 182-543 WAC.)

(s) Medical nutrition services - Enteral and parenteral nutrition, including supplies. (Chapters 182-553 and 182-554 WAC.)

(t) Nursing facility services - Nursing, therapies, dietary, and daily care services. (Chapter 388-97 WAC.)

(u) Organ transplants - Solid organs, e.g., heart, kidney, liver, lung, pancreas, and small bowel; bone marrow and peripheral stem cell; skin grafts; and corneal transplants. (WAC 182-550-1900 and 182-556-0400.)

(v) Orthodontic services - (Chapter 182-535A WAC).

(w) Out-of-state services - (WAC 182-502-0120).

(x) Outpatient rehabilitation services (OT, PT, ST) - Evaluations, assessments, and treatment. (WAC 182-545-200.)

(y) Personal care services - Assistance with activities of daily living (e.g., bathing, dressing, eating, managing medications) and routine household chores (e.g., meal preparation, housework, essential shopping, transportation to medical services). (WAC 388-106-0010, 388-106-0200, 388-106-0300, 388-106-0600, 388-106-0700, 388-106-0745, and 388-106-0900.)

(z) Prescription drugs - Outpatient drugs (including in nursing facilities), both generic and brand name; drug devices and supplies; some over-the-counter drugs; oral, topical, injectable drugs; vaccines, immunizations, and biologicals; and family planning drugs, devices, and supplies. (WAC 182-530-2000.) Additional coverage for medications and prescriptions is addressed in specific program WAC sections.

(aa) Private duty nursing - Continuous skilled nursing services provided in the home, including client assessment, administration of treatment, and monitoring of medical equipment and client care for clients seventeen years of age and under. (WAC 182-551-3000.) For benefits for clients eighteen years of age and older, see WAC 388-106-1000 through 388-106-1055.

(bb) Prosthetic/orthotic devices - Artificial limbs and other external body parts; devices that prevent, support, or correct a physical deformity or malfunction. (WAC 182-543-5000.)

(cc) Reproductive health services - Gynecological exams; contraceptives, drugs, and supplies, including prescriptions; sterilization; screening and treatment of sexually transmitted diseases; and educational services. (WAC 182-532-001 through 182-532-140.)

(dd) Respiratory care (oxygen) - All services, oxygen, equipment, and supplies related to respiratory care. (Chapter 182-552 WAC.)

(ee) School-based medical services - Medical services provided in schools to children with disabilities under the Individuals with Disabilities Education Act (IDEA). (Chapter 182-537 WAC.)

(ff) Vision care - Eye exams, refractions, fittings, visual field testing, vision therapy, ocular prosthetics, and surgery. (WAC 182-531-1000.)

(gg) Vision hardware - Frames and lenses. (Chapter 182-544 WAC.)

[Statutory Authority: RCW 41.05.021, 2013 2nd sp.s. c 4, and Patient Protection and Affordable Care Act (P.L. 111-148). WSR 14-06-045, § 182-501-0065, filed 2/26/14, effective 3/29/14. Statutory Authority: RCW 41.05.021. WSR 13-15-044, § 182-501-0065, filed 7/11/13, effective 8/11/13. WSR 11-14-075, recodified as § 182-501-0065, 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 06-24-036, § 388-501-0065, filed 11/30/06, effective 1/1/07.]

RCW 41.05.021, 2013 2nd sp.s. c 4, and Patient Protection and Affordable Care Act (P.L. 111-148). WSR 14-06-045, § 182-501-0065, filed 2/26/14, effective 3/29/14. Statutory Authority: RCW 41.05.021. WSR 13-15-044, § 182-501-0065, filed 7/11/13, effective 8/11/13. WSR 11-14-075, recodified as § 182-501-0065, 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 06-24-036, § 388-501-0065, filed 11/30/06, effective 1/1/07.

Rules

182-501-0060,182-546-0001,182-546-4000,182-531-1410,182-531-1434,182-550-2600,182-531-1400,388-865-0215,388-865-0230,388-865-0610,182-531-1400,388-865-0230,182-531-1400,388-877B-0100,388-877B-0130,182-550-1100,182-556-0400,388-877B-0500,388-877B-0550,388-877B-0200,388-877B-0280,388-877B-0300,388-877B-0370,182-533-0701,182-533-0730,182-550-1400,182-550-1500,182-535,182-535A,182-531-0100,182-550-1400,182-550-1500,182-534,182-501-0050,182-545,182-531,182-531-0100,182-531-0375,182-547,182-551-2000,182-551-2220,182-551-1210,182-551-1850,182-550,388-835,182-533-0330,182-543,182-543,182-553,182-554,388-97,182-550-1900,182-556-0400,182-535A,182-502-0120,182-545-200,388-106-0010,388-106-0200,388-106-0300,388-106-0600,388-106-0700,388-106-0745,388-106-0900,182-530-2000,182-551-3000,388-106-1000,388-106-1055,182-543-5000,182-552,182-537,182-544,