Section 182-501-0184. Health care services provided outside of the United States and U.S. territories or in a foreign country.

For the purposes of this section, the term "health care services" does not include the diagnosis and treatment for alcohol, substance abuse, and mental health services.

(1) The provisions of WAC 182-501-0182 apply to this section.

(2) The medicaid agency does not pay for health care services furnished in a foreign country, except for medical services furnished in the province of British Columbia, Canada, under this section. The agency pays for medical services furnished in British Columbia, Canada, to Washington apple health (WAH) clients only when those clients:

(a) Reside in Point Roberts, Washington;

(b) Reside in Washington communities along the border with British Columbia, Canada (see subsection (3) of this section for further clarification); or

(c) Are members of the Canadian First Nations who live in Washington state.

(3) For WAH clients identified in subsection (2) of this section, the agency covers emergency and nonemergency medical services provided in British Columbia, Canada, when the services are:

(a) Within the scope of the client's health care program as specified in chapter 182-501 WAC;

(b) Allowed to be provided outside the United States and U.S. territories by specific program WAC; and

(c) Medically necessary as defined in WAC 182-500-0070.

(4) For WAH clients identified in subsection (2) of this section, the agency covers nonemergency medical services in British Columbia, Canada, only when:

(a) It is general practice for WAH clients to use medically necessary resources across the Canadian border; or

(b) The medical services in British Columbia, Canada, are closer or more readily accessible to the client's Washington state residence. As applied to nonemergency medical services, the phrase "closer or more readily accessible to the client's Washington state residence" means:

(i) There is not a United States provider for the service within twenty-five miles of the client's Washington state residence; and

(ii) The closest Canadian provider of the service is closer than the closest U.S. provider of the service.

(5) The agency does not cover services provided in British Columbia, Canada, under the Involuntary Treatment Act (chapter 71.05 RCW and chapter 388-865 WAC).

(6) The agency's payment for covered medical services furnished to a WAH client in British Columbia, Canada, is payment in full according to 42 C.F.R. 447.15.

(7) A British Columbia, Canada, provider who furnished health care services or covered items to a WAH client receives payment from the agency only when:

(a) The reimbursement is made to a financial institution or entity located within the United States in U.S. dollars; and

(b) The participating British Columbia, Canada, provider:

(i) Has signed a core provider agreement with the agency;

(ii) Satisfies all medicaid conditions of participation;

(iii) Meets functionally equivalent licensing requirements; and

(iv) Complies with the same utilization control standards as in-state providers.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-15-053, § 182-501-0184, filed 7/9/15, effective 8/9/15. WSR 11-14-075, recodified as § 182-501-0184, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.04.057 and 74.09.510. WSR 11-14-054, § 388-501-0184, filed 6/29/11, effective 7/30/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035. WSR 08-08-064, § 388-501-0184, filed 3/31/08, effective 5/1/08.]

RCW 41.05.021 and 41.05.160. WSR 15-15-053, § 182-501-0184, filed 7/9/15, effective 8/9/15. WSR 11-14-075, recodified as § 182-501-0184, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.04.057 and 74.09.510. WSR 11-14-054, § 388-501-0184, filed 6/29/11, effective 7/30/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035. WSR 08-08-064, § 388-501-0184, filed 3/31/08, effective 5/1/08.

Rules

182-501-0182,182-501,182-500-0070,388-865,