RCW 74.09.520
Medical assistance
—
Care and services included
—
Funding limitations.
(1) The term "medical assistance" may include the following care and services subject to rules adopted by the authority or department: (a) Inpatient hospital services; (b) outpatient hospital services; (c) other laboratory and X-ray services; (d) nursing facility services; (e) physicians' services, which shall include prescribed medication and instruction on birth control devices; (f) medical care, or any other type of remedial care as may be established by the secretary or director; (g) home health care services; (h) private duty nursing services; (i) dental services; (j) physical and occupational therapy and related services; (k) prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist, whichever the individual may select; (l) personal care services, as provided in this section; (m) hospice services; (n) other diagnostic, screening, preventive, and rehabilitative services; and (o) like services when furnished to a child by a school district in a manner consistent with the requirements of this chapter. For the purposes of this section, neither the authority nor the department may cut off any prescription medications, oxygen supplies, respiratory services, or other life-sustaining medical services or supplies.
"Medical assistance," notwithstanding any other provision of law, shall not include routine foot care, or dental services delivered by any health care provider, that are not mandated by Title XIX of the social security act unless there is a specific appropriation for these services.
(2) The department shall adopt, amend, or rescind such administrative rules as are necessary to ensure that Title XIX personal care services are provided to eligible persons in conformance with federal regulations.
(a) These administrative rules shall include financial eligibility indexed according to the requirements of the social security act providing for medicaid eligibility.
(b) The rules shall require clients be assessed as having a medical condition requiring assistance with personal care tasks. Plans of care for clients requiring health-related consultation for assessment and service planning may be reviewed by a nurse.
(c) The department shall determine by rule which clients have a health-related assessment or service planning need requiring registered nurse consultation or review. This definition may include clients that meet indicators or protocols for review, consultation, or visit.
(3) The department shall design and implement a means to assess the level of functional disability of persons eligible for personal care services under this section. The personal care services benefit shall be provided to the extent funding is available according to the assessed level of functional disability. Any reductions in services made necessary for funding reasons should be accomplished in a manner that assures that priority for maintaining services is given to persons with the greatest need as determined by the assessment of functional disability.
(4) Effective July 1, 1989, the authority shall offer hospice services in accordance with available funds.
(5) For Title XIX personal care services administered by the department, the department shall contract with area agencies on aging or may contract with a federally recognized Indian tribe under RCW 74.39A.090
(3):
(a) To provide case management services to individuals receiving Title XIX personal care services in their own home; and
(b) To reassess and reauthorize Title XIX personal care services or other home and community services as defined in RCW 74.39A.009
in home or in other settings for individuals consistent with the intent of this section:
(i) Who have been initially authorized by the department to receive Title XIX personal care services or other home and community services as defined in RCW 74.39A.009
; and
(ii) Who, at the time of reassessment and reauthorization, are receiving such services in their own home.
(6) In the event that an area agency on aging or federally recognized Indian tribe is unwilling to enter into or satisfactorily fulfill a contract or an individual consumer's need for case management services will be met through an alternative delivery system, the department is authorized to:
(a) Obtain the services through competitive bid; and
(b) Provide the services directly until a qualified contractor can be found.
(7) Subject to the availability of amounts appropriated for this specific purpose, the authority may offer medicare part D prescription drug copayment coverage to full benefit dual eligible beneficiaries.
(8) Effective January 1, 2016, the authority shall require universal screening and provider payment for autism and developmental delays as recommended by the bright futures guidelines of the American academy of pediatrics, as they existed on August 27, 2015. This requirement is subject to the availability of funds.
(9) Subject to the availability of amounts appropriated for this specific purpose, effective January 1, 2018, the authority shall require provider payment for annual depression screening for youth ages twelve through eighteen as recommended by the bright futures guidelines of the American academy of pediatrics, as they existed on January 1, 2017. Providers may include, but are not limited to, primary care providers, public health nurses, and other providers in a clinical setting. This requirement is subject to the availability of funds appropriated for this specific purpose.
(10) Subject to the availability of amounts appropriated for this specific purpose, effective January 1, 2018, the authority shall require provider payment for maternal depression screening for mothers of children ages birth to six months. This requirement is subject to the availability of funds appropriated for this specific purpose.
(11) Subject to the availability of amounts appropriated for this specific purpose, the authority shall:
(a) Allow otherwise eligible reimbursement for the following related to mental health assessment and diagnosis of children from birth through five years of age:
(i) Up to five sessions for purposes of intake and assessment, if necessary;
(ii) Assessments in home or community settings, including reimbursement for provider travel; and
(b) Require providers to use the current version of the DC:0-5 diagnostic classification system for mental health assessment and diagnosis of children from birth through five years of age.
(12) Effective January 1, 2024, the authority shall require coverage for noninvasive preventive colorectal cancer screening tests assigned either a grade of A or grade of B by the United States preventive services task force and shall require coverage for colonoscopies performed as a result of a positive result from such a test.
(13)(a) The authority shall require or provide payment to the hospital for any day of a hospital stay in which an adult or child patient enrolled in medical assistance, including home and community services or with a medicaid managed care organization, under this chapter:
(i) Does not meet the criteria for acute inpatient level of care as defined by the authority;
(ii) Meets the criteria for discharge, as defined by the authority or department, to any appropriate placement including, but not limited to:
(A) A nursing home licensed under chapter
18.51
RCW;
(B) An assisted living facility licensed under chapter
18.20
RCW;
(C) An adult family home licensed under chapter
70.128
RCW; or
(D) A setting in which residential services are provided or funded by the developmental disabilities administration of the department, including supported living as defined in RCW 71A.10.020
; and
(iii) Is not discharged from the hospital because placement in the appropriate location described in (a)(ii) of this subsection is not available.
(b) Pharmacy services and pharmaceuticals shall be billed by and paid to the hospital separately.
(c) The requirements of this subsection do not alter requirements for billing or payment for inpatient care.
(d) The authority shall adopt, amend, or rescind such administrative rules as necessary to facilitate calculation and payment of the amounts described in this subsection, including for clients of medicaid managed care organizations.
(e) The authority shall adopt rules requiring medicaid managed care organizations to establish specific and uniform administrative and review processes for payment under this subsection.
(f) For patients meeting the criteria in (a)(ii)(A) of this subsection, hospitals must utilize swing beds or skilled nursing beds to the extent the services are available within their facility and the associated reimbursement methodology prior to the billing under the methodology in (a) of this subsection, if the hospital determines that such swing bed or skilled nursing bed placement is appropriate for the patient's care needs, the patient is appropriate for the existing patient mix, and appropriate staffing is available.
[
2025 c 367 s 1
. Prior:
2023 c 315 s 1
;
2023 c 299 s 1
;
2022 c 255 s 4
;
2021 c 126 s 2
;
2017 c 202 s 4
;
2015 1st sp.s. c 8 s 2
;
2011 1st sp.s. c 15 s 27
;
2007 c 3 s 1
;
2004 c 141 s 2
;
2003 c 279 s 1
;
1998 c 245 s 145
;
1995 1st sp.s. c 18 s 39
;
1994 c 21 s 4
; prior:
1993 c 149 s 10
;
1993 c 57 s 1
;
1991 sp.s. c 8 s 9
; prior:
1991 c 233 s 1
;
1991 c 119 s 1
; prior:
1990 c 33 s 594
;
1990 c 25 s 1
; prior:
1989 c 427 s 10
;
1989 c 400 s 3
;
1985 c 5 s 3
;
1982 1st ex.s. c 19 s 4
;
1981 1st ex.s. c 6 s 21
;
1981 c 8 s 20
;
1979 c 141 s 344
;
1969 ex.s. c 173 s 11
;
1967 ex.s. c 30 s 5
.]
NOTES:
Findings
—
Intent
—
2017 c 202:
See note following RCW 74.09.495
.
Findings
—
2015 1st sp.s. c 8:
"(1) The bright futures guidelines issued by the American academy of pediatrics outline recommended well-child visit schedules and universal screening of children for autism and developmental delays. Private health plans established after March 2010 are required to comply with the bright futures guidelines as the standard for preventive services. The federal law does not require medicaid programs to follow the guidelines; however, thirty states completely cover the bright futures guidelines, six states cover all but one well-child screen, and six additional states cover all but developmental and autism screens as part of their medicaid programs.
(2) The 2012 Washington state legislature directed the Washington state institute for public policy to assess the costs and benefits of implementing the guidelines. The research indicates that fewer than half of children with developmental delays are identified before starting school and roughly half of children with autism spectrum disorder are diagnosed only after entering school, by which time significant delays may have occurred and opportunities for treatment may have been missed. Adopting the universal screening guidelines improves early diagnosis and enables early intervention with appropriate therapies and services. The annual cost to society for caring for children with autism or developmental delays can be significant, including cost of services, special education, informal care, and lost productivity. Early intervention and access to appropriate therapies mitigate long-term societal costs and improve the health and opportunity for the child.
(3) The more adverse experiences a child has, such as the burden of family economic hardship and social bias, the greater the likelihood of developmental delays and later health problems. Over forty-six percent of Washington's children have medicaid apple health for kids and have a much greater likelihood of reporting poor to very poor health compared to children who have commercial insurance. Disparities also exist in the diagnosis and initiation of treatment services for children of color. Research shows that children of color are diagnosed later and begin receiving early intervention services later. This health equity gap can be addressed by identifying and supporting children early through universal screening.
(4) Primary care providers currently see ninety-nine percent of children between birth and three years of age and are uniquely situated to access nearly all children with universal screening." [
2015 1st sp.s. c 8 s 1
.]
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Conflict with federal requirements
—
Severability
—
Effective date
—
1995 1st sp.s. c 18:
See notes following RCW 74.39A.030
.
Conflict with federal requirements
—
Effective date
—
1994 c 21:
See notes following RCW 43.20B.080
.
Conflict with federal requirements
—
Severability
—
Effective dates
—
1993 c 149:
See notes following RCW 28A.150.390
.
Effective date
—
1991 sp.s. c 8:
See note following RCW 18.51.050
.
Purpose
—
Statutory references
—
Severability
—
1990 c 33:
See RCW 28A.900.100
through
28A.900.102
.
Intent
—
1989 c 400:
See note following RCW 28A.150.390
.
Effective date
—
1982 1st ex.s. c 19:
See note following RCW 74.09.035
.
Effective date
—
Severability
—
1981 1st ex.s. c 6:
See notes following RCW 74.04.005
.
Legislative confirmation of effect of 1994 c 21: RCW 43.20B.090
.
RCW 74.09.522
Medical assistance
—
Agreements with managed care organizations for provision of services to medicaid recipients
—
Principles to be applied in purchasing managed health care.
(1) For the purposes of this section, "nonparticipating provider" means a person, health care provider, practitioner, facility, or entity, acting within their scope of practice, that does not have a written contract to participate in a managed care organization's provider network, but provides health care services to enrollees of programs authorized under this chapter or other applicable law whose health care services are provided by the managed care organization.
(2) The authority shall enter into agreements with managed care organizations to provide health care services to recipients of medicaid under the following conditions:
(a) Agreements shall be made for at least thirty thousand recipients statewide;
(b) Agreements in at least one county shall include enrollment of all recipients of programs as allowed for in the approved state plan amendment or federal waiver for Washington state's medicaid program;
(c) To the extent that this provision is consistent with section 1903(m) of Title XIX of the federal social security act or federal demonstration waivers granted under section 1115(a) of Title XI of the federal social security act, recipients shall have a choice of systems in which to enroll and shall have the right to terminate their enrollment in a system: PROVIDED, That the authority may limit recipient termination of enrollment without cause to the first month of a period of enrollment, which period shall not exceed twelve months: AND PROVIDED FURTHER, That the authority shall not restrict a recipient's right to terminate enrollment in a system for good cause as established by the authority by rule;
(d) To the extent that this provision is consistent with section 1903(m) of Title XIX of the federal social security act, participating managed care organizations shall not enroll a disproportionate number of medical assistance recipients within the total numbers of persons served by the managed care organizations, except as authorized by the authority under federal demonstration waivers granted under section 1115(a) of Title XI of the federal social security act;
(e)(i) In negotiating with managed care organizations the authority shall adopt a uniform procedure to enter into contractual arrangements, including:
(A) Standards regarding the quality of services to be provided;
(B) The financial integrity of the responding system;
(C) Provider reimbursement methods that incentivize chronic care management within health homes, including comprehensive medication management services for patients with multiple chronic conditions consistent with the findings and goals established in RCW 74.09.5223
;
(D) Provider reimbursement methods that reward health homes that, by using chronic care management, reduce emergency department and inpatient use;
(E) Promoting provider participation in the program of training and technical assistance regarding care of people with chronic conditions described in RCW 43.70.533, including allocation of funds to support provider participation in the training, unless the managed care organization is an integrated health delivery system that has programs in place for chronic care management;
(F) Provider reimbursement methods within the medical billing processes that incentivize pharmacists or other qualified providers licensed in Washington state to provide comprehensive medication management services consistent with the findings and goals established in RCW 74.09.5223
;
(G) Evaluation and reporting on the impact of comprehensive medication management services on patient clinical outcomes and total health care costs, including reductions in emergency department utilization, hospitalization, and drug costs; and
(H) Established consistent processes to incentivize integration of behavioral health services in the primary care setting, promoting care that is integrated, collaborative, colocated, and preventive.
(ii)(A) Health home services contracted for under this subsection may be prioritized to enrollees with complex, high cost, or multiple chronic conditions.
(B) Contracts that include the items in (e)(i)(C) through (G) of this subsection must not exceed the rates that would be paid in the absence of these provisions;
(f) The authority shall seek waivers from federal requirements as necessary to implement this chapter;
(g) The authority shall, wherever possible, enter into prepaid capitation contracts that include inpatient care. However, if this is not possible or feasible, the authority may enter into prepaid capitation contracts that do not include inpatient care;
(h) The authority shall define those circumstances under which a managed care organization is responsible for out-of-plan services and assure that recipients shall not be charged for such services;
(i) Nothing in this section prevents the authority from entering into similar agreements for other groups of people eligible to receive services under this chapter; and
(j) The authority must consult with the federal center for medicare and medicaid innovation and seek funding opportunities to support health homes.
(3) The authority shall ensure that publicly supported community health centers and providers in rural areas, who show serious intent and apparent capability to participate as managed care organizations are seriously considered as contractors. The authority shall coordinate its managed care activities with activities under chapter
70.47
RCW.
(4) The authority shall work jointly with the state of Oregon and other states in this geographical region in order to develop recommendations to be presented to the appropriate federal agencies and the United States congress for improving health care of the poor, while controlling related costs.
(5) The legislature finds that competition in the managed health care marketplace is enhanced, in the long term, by the existence of a large number of managed care organization options for medicaid clients. In a managed care delivery system, whose goal is to focus on prevention, primary care, and improved enrollee health status, continuity in care relationships is of substantial importance, and disruption to clients and health care providers should be minimized. To help ensure these goals are met, the following principles shall guide the authority in its healthy options managed health care purchasing efforts:
(a) All managed care organizations should have an opportunity to contract with the authority to the extent that minimum contracting requirements defined by the authority are met, at payment rates that enable the authority to operate as far below appropriated spending levels as possible, consistent with the principles established in this section.
(b) Managed care organizations should compete for the award of contracts and assignment of medicaid beneficiaries who do not voluntarily select a contracting system, based upon:
(i) Demonstrated commitment to or experience in serving low-income populations;
(ii) Quality of services provided to enrollees;
(iii) Accessibility, including appropriate utilization, of services offered to enrollees;
(iv) Demonstrated capability to perform contracted services, including ability to supply an adequate provider network;
(v) Payment rates; and
(vi) The ability to meet other specifically defined contract requirements established by the authority, including consideration of past and current performance and participation in other state or federal health programs as a contractor.
(c) Consideration should be given to using multiple year contracting periods.
(d) Quality, accessibility, and demonstrated commitment to serving low-income populations shall be given significant weight in the contracting, evaluation, and assignment process.
(e) All contractors that are regulated health carriers must meet state minimum net worth requirements as defined in applicable state laws. The authority shall adopt rules establishing the minimum net worth requirements for contractors that are not regulated health carriers. This subsection does not limit the authority of the Washington state health care authority to take action under a contract upon finding that a contractor's financial status seriously jeopardizes the contractor's ability to meet its contract obligations.
(f) Procedures for resolution of disputes between the authority and contract bidders or the authority and contracting carriers related to the award of, or failure to award, a managed care contract must be clearly set out in the procurement document.
(6) The authority may apply the principles set forth in subsection (5) of this section to its managed health care purchasing efforts on behalf of clients receiving supplemental security income benefits to the extent appropriate.
(7) Any contract with a managed care organization to provide services to medical assistance enrollees shall require that managed care organizations offer contracts to mental health providers and substance use disorder treatment providers to provide access to primary care services integrated into behavioral health clinical settings, for individuals with behavioral health and medical comorbidities.
(8) Managed care organization contracts effective on or after April 1, 2016, shall serve geographic areas that correspond to the regional service areas established in RCW 74.09.870
.
(9) A managed care organization shall pay a nonparticipating provider that provides a service covered under this chapter or other applicable law to the organization's enrollee no more than the lowest amount paid for that service under the managed care organization's contracts with similar providers in the state if the managed care organization has made good faith efforts to contract with the nonparticipating provider.
(10) For services covered under this chapter or other applicable law to medical assistance or medical care services enrollees, nonparticipating providers must accept as payment in full the amount paid by the managed care organization under subsection (9) of this section in addition to any deductible, coinsurance, or copayment that is due from the enrollee for the service provided. An enrollee is not liable to any nonparticipating provider for covered services, except for amounts due for any deductible, coinsurance, or copayment under the terms and conditions set forth in the managed care organization contract to provide services under this section.
(11) Pursuant to federal managed care access standards, 42 C.F.R. Sec. 438, managed care organizations must maintain a network of appropriate providers that is supported by written agreements sufficient to provide adequate access to all services covered under the contract with the authority, including hospital-based physician services. The authority will monitor and periodically report on the proportion of services provided by contracted providers and nonparticipating providers, by county, for each managed care organization to ensure that managed health care systems are meeting network adequacy requirements. No later than January 1st of each year, the authority will review and report its findings to the appropriate policy and fiscal committees of the legislature for the preceding state fiscal year.
(12) Payments under RCW 74.60.130
are exempt from this section.
[
2023 c 51 s 43
;
2020 c 260 s 1
;
2019 c 325 s 4004
;
2018 c 201 s 7017
;
2015 c 256 s 1
;
2014 c 225 s 55
;
2013 2nd sp.s. c 17 s 13
;
2013 c 261 s 2
. Prior:
2011 1st sp.s. c 15 s 29
;
2011 1st sp.s. c 9 s 2
;
2011 c 316 s 4
; prior:
1997 c 59 s 15
;
1997 c 34 s 1
;
1989 c 260 s 2
;
1987 1st ex.s. c 5 s 21
;
1986 c 303 s 2
.]
NOTES:
Effective date
—
2019 c 325:
See note following RCW 71.24.011
.
Findings
—
Intent
—
Effective date
—
2018 c 201:
See notes following RCW 41.05.018
.
Effective date
—
2013 2nd sp.s. c 17:
See note following RCW 74.60.005
.
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Findings
—
Intent
—
2011 1st sp.s. c 9:
See note following RCW 70.47.020
.
Effective date
—
1997 c 34:
"This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect immediately [April 16, 1997]." [
1997 c 34 s 3
.]
Legislative findings
—
Intent
—
1986 c 303:
"(1) The legislature finds that:
(a) Good health care for indigent persons is of importance to the state;
(b) To ensure the availability of a good level of health care, efforts must be made to encourage cost consciousness on the part of providers and consumers, while maintaining medical assistance recipients within the mainstream of health care delivery;
(c) Managed health care systems have been found to be effective in controlling costs while providing good health care services;
(d) By enrolling medical assistance recipients within managed health care systems, the state's goal is to ensure that medical assistance recipients receive at least the same quality of care they currently receive.
(2) It is the intent of the legislature to develop and implement new strategies that promote the use of managed health care systems for medical assistance recipients by establishing prepaid capitated programs for both inpatient and outpatient services." [
1986 c 303 s 1
.]
RCW 74.09.5222
Medical assistance
—
Section 1115 demonstration waiver request.
(1) The authority shall submit a section 1115 demonstration waiver request to the federal department of health and human services to expand and revise the medical assistance program as codified in Title XIX of the federal social security act. The waiver request should be designed to ensure the broadest federal financial participation under Title XIX and XXI of the federal social security act. To the extent permitted under federal law, the waiver request should include the following components:
(a) Establishment of a single eligibility standard for low-income persons, including expansion of categorical eligibility to include childless adults. The authority shall request that the single eligibility standard be phased in such that incremental steps are taken to cover additional low-income parents and individuals over time, with the goal of offering coverage to persons with household income at or below two hundred percent of the federal poverty level;
(b) Establishment of a single seamless application and eligibility determination system for all state low-income medical programs included in the waiver. Applications may be electronic and may include an electronic signature for verification and authentication. Eligibility determinations should maximize federal financing where possible;
(c) The delivery of all low-income coverage programs as a single program, with a common core benefit package that may be similar to the basic health benefit package or an alternative benefit package approved by the secretary of the federal department of health and human services, including the option of supplemental coverage for select categorical groups, such as children, and individuals who are aged, blind, and disabled;
(d) A program design to include creative and innovative approaches such as: Coverage for preventive services with incentives to use appropriate preventive care; enhanced medical home reimbursement and bundled payment methodologies; cost-sharing options; use of care management and care coordination programs to improve coordination of medical and behavioral health services; application of an innovative predictive risk model to better target care management services; and mandatory enrollment in managed care, as may be necessary;
(e) The ability to impose enrollment limits or benefit design changes for eligibility groups that were not eligible under the Title XIX state plan in effect on the date of submission of the waiver application;
(f) A premium assistance program whereby employers can participate in coverage options for employees and dependents of employees otherwise eligible under the waiver. The waiver should make every effort to maximize enrollment in employer-sponsored health insurance when it is cost-effective for the state to do so, and the purchase is consistent with the requirements of Titles XIX and XXI of the federal social security act. To the extent allowable under federal law, the authority shall require enrollment in available employer-sponsored coverage as a condition of eligibility for coverage under the waiver; and
(g) The ability to share savings that might accrue to the federal medicare program, Title XVIII of the federal social security act, from improved care management for persons who are eligible for both medicare and medicaid. Through the waiver application process, the authority shall determine whether the state could serve, directly or by contract, as a medicare special needs plan for persons eligible for both medicare and medicaid.
(2) The authority shall hold ongoing stakeholder discussions as it is developing the waiver request, and provide opportunities for public review and comment as the request is being developed.
(3) The authority shall identify statutory changes that may be necessary to ensure successful and timely implementation of the waiver request as submitted to the federal department of health and human services as the apple health program for adults.
(4) The legislature must authorize implementation of any waiver approved by the federal department of health and human services under this section.
[
2011 1st sp.s. c 15 s 30
;
2009 c 545 s 4
.]
NOTES:
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Findings
—
2009 c 545:
See note following RCW 43.06.155
.
RCW 74.09.5223
Findings
—
Chronic care management.
The legislature finds that chronic care management, including comprehensive medication management services, provided by licensed pharmacists and qualified providers is a critical component of a collaborative, multidisciplinary, inter-professional approach to the treatment of chronic diseases for targeted individuals, to improve the quality of care and reduce overall cost in the treatment of such diseases.
[
2013 c 261 s 1
.]
RCW 74.09.5225
Medical assistance
—
Payments for services provided by rural hospitals
—
Participation in Washington rural health access preservation pilot.
(1) Payments for recipients eligible for medical assistance programs under this chapter for services provided by hospitals, regardless of the beneficiary's managed care enrollment status, shall be made based on allowable costs incurred during the year, when services are provided by a rural hospital certified by the centers for medicare and medicaid services as a critical access hospital, unless the critical access hospital is participating in the Washington rural health access preservation pilot described in subsection (2)(b) of this section. Any additional payments made by the authority for the healthy options program shall be no more than the additional amounts per service paid under this section for other medical assistance programs.
(2)(a) Beginning on July 24, 2005, except as provided in (b) of this subsection, a moratorium shall be placed on additional hospital participation in critical access hospital payments under this section. However, rural hospitals that applied for certification to the centers for medicare and medicaid services prior to January 1, 2005, but have not yet completed the process or have not yet been approved for certification, remain eligible for medical assistance payments under this section.
(b)(i) The purpose of the Washington rural health access preservation pilot is to develop an alternative service and payment system to the critical access hospital authorized under section 1820 of the social security act to sustain essential services in rural communities.
(ii) For the purposes of state law, any rural hospital approved by the department of health for participation in critical access hospital payments under this section that participates in the Washington rural health access preservation pilot identified by the state office of rural health and ceases to participate in critical access hospital payments may renew participation in critical access hospital associated payment methodologies under this section at any time.
(iii) The Washington rural health access preservation pilot is subject to the following requirements:
(A) In the pilot formation or development, the department of health, health care authority, and Washington state hospital association will identify goals for the pilot project before any hospital joins the pilot project;
(B) Participation in the pilot is optional and no hospital may be required to join the pilot;
(C) Before a hospital enters the pilot program, the health care authority must provide information to the hospital regarding how the hospital could end its participation in the pilot if the pilot is not working in its community;
(D) Payments for services delivered by public health care service districts participating in the Washington rural health access preservation pilot to recipients eligible for medical assistance programs under this chapter must be based on an alternative, value-based payment methodology established by the authority. Subject to the availability of amounts appropriated for this specific purpose, the payment methodology must provide sufficient funding to sustain essential services in the areas served, including but not limited to emergency and primary care services. The methodology must adjust payment amounts based on measures of quality and value, rather than volume. As part of the pilot, the health care authority shall encourage additional payers to use the adopted payment methodology for services delivered by the pilot participants to individuals insured by those payers;
(E) The department of health, health care authority, and Washington state hospital association will report interim progress to the legislature no later than December 1, 2018, and will report on the results of the pilot no later than six months following the conclusion of the pilot. The reports will describe any policy changes identified during the course of the pilot that would support small critical access hospitals; and
(F) Funds appropriated for the Washington rural health access preservation pilot will be used to help participating hospitals transition to a new payment methodology and will not extend beyond the anticipated three-year pilot period.
(3)(a) Beginning January 1, 2015, payments for recipients eligible for medical assistance programs under this chapter for services provided by a hospital, regardless of the beneficiary's managed care enrollment status, shall be increased to one hundred twenty-five percent of the hospital's fee-for-service rates, when services are provided by a rural hospital that:
(i) Was certified by the centers for medicare and medicaid services as a sole community hospital as of January 1, 2013;
(ii) Had a level III adult trauma service designation from the department of health as of January 1, 2014;
(iii) Had less than one hundred fifty acute care licensed beds in fiscal year 2011; and
(iv) Is owned and operated by the state or a political subdivision.
(b) The enhanced payment rates under this subsection shall be considered the hospital's medicaid payment rate for purposes of any other state or private programs that pay hospitals according to medicaid payment rates.
(c) Hospitals participating in the certified public expenditures program may not receive the increased reimbursement rates provided in this subsection (3) for inpatient services.
[
2017 c 198 s 1
; (2023 c 443 s 2 expired January 1, 2024);
2016 sp.s. c 31 s 2
;
2014 c 57 s 2
;
2011 1st sp.s. c 15 s 31
;
2005 c 383 s 1
;
2001 2nd sp.s. c 2 s 2
.]
NOTES:
Reviser's note:
The contingency in 2023 c 443 s 4 occurred, and therefore 2023 c 443 s 2 expired.
Finding
—
Intent
—
2016 sp.s. c 31:
"The legislature finds that small critical access hospitals provide essential services to their communities. The legislature recognizes the need to offer small critical access hospitals the opportunity to pilot different delivery and payment models than may be currently allowed under the critical access hospital program. The legislature also intends to allow these participating hospitals to return to the critical access hospital program if they so choose." [
2016 sp.s. c 31 s 1
.]
Findings
—
2014 c 57:
"The legislature finds that promoting a financially viable health care system in all parts of the state is a critical interest. The federal centers for medicare and medicaid services has recognized the crucial role hospitals play in providing care in rural areas by creating the sole community hospital program, which allows certain small rural hospitals to receive enhanced payments for medicare services. The legislature further finds that creating a similar reimbursement system for the state's medicaid program for sole community hospitals will promote the long-term financial viability of the rural health care system in those communities." [
2014 c 57 s 1
.]
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Findings
—
2001 2nd sp.s. c 2:
"The legislature finds that promoting a financially viable health care system in all parts of the state is a paramount interest. The health care financing administration has recognized the crucial role that hospitals play in providing care in rural areas by creating the critical access hospital program to allow small, rural hospitals that qualify to receive reasonable cost-based reimbursement for medicare services. The legislature further finds that creating a similar reimbursement system for the state's medical assistance programs in small, rural hospitals that qualify will help assure the long-term financial viability of the rural health system in those communities." [
2001 2nd sp.s. c 2 s 1
.]
RCW 74.09.5228
Primary care health homes
—
Children with medically complex conditions.
By January 1, 2025, the authority shall submit a state plan amendment to the federal centers for medicare and medicaid services to allow medicaid-eligible children with medically complex conditions to voluntarily enroll in a health home as provided in section 3 of the medicaid services investment and accountability act of 2019 (P.L. 116-16).
[
2024 c 177 s 2
.]
NOTES:
Findings
—
Intent
—
2024 c 177:
"(1) The legislature finds that:
(a) Children with medical complexity deserve coordinated and effective care delivered in a high quality setting. Families should be able to focus solely on their child's needs and not waste precious time fighting a fragmented care system or the complexities of medicaid;
(b) In 2019, the federal government adopted the advancing care for exceptional kids act to address these concerns. This law created a new health home model that will coordinate prompt care for children with medically complex conditions, develop an individualized, comprehensive, pediatric, family-centered care plan, coordinate access to subspecialized care, and coordinate appropriate care with out-of-state providers; and
(c) The federal law provides health homes with a higher federal matching rate, making this proposal beneficial to Washington's children with medical complexities while also being financially prudent.
(2) The legislature, therefore, intends to actively support these medically complex children by taking the steps necessary to implement health homes in Washington." [
2024 c 177 s 1
.]
RCW 74.09.5229
Primary care health homes
—
Chronic care management
—
Findings
—
Intent.
The legislature finds that:
(1) Health care costs are growing rapidly, exceeding the consumer price index year after year. Consequently, state health programs are capturing a growing share of the state budget, even as state revenues have declined. Sustaining these critical health programs will require actions to effectively contain health care cost increases in the future; and
(2) The primary care health home model has been demonstrated to successfully constrain costs, while improving quality of care. Chronic care management, occurring within a primary care health home, has been shown to be especially effective at reducing costs and improving quality. However, broad adoption of these models has been impeded by a fee-for-service system that reimburses volume of services and does not adequately support important primary care health home services, such as case management and patient outreach. Furthermore, successful implementation will require a broad adoption effort by private and public payers, in coordination with providers.
Therefore the legislature intends to promote the adoption of primary care health homes for children and adults and, within them, advance the practice of chronic care management to improve health outcomes and reduce unnecessary costs. To facilitate the best coordination and patient care, primary care health homes are encouraged to collaborate with other providers currently outside the medical insurance model. Successful chronic care management for persons receiving long-term care services in addition to medical care will require close coordination between primary care providers, long-term care workers, and other long-term care service providers, including area agencies on aging. Primary care providers also should consider oral health coordination through collaboration with dental providers and, when possible, delivery of oral health prevention services. The legislature also intends that the methods and approach of the primary care health home become part of basic primary care medical education.
[
2011 c 316 s 1
.]
RCW 74.09.523
PACE program
—
Definitions
—
Requirements.
(1) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.
(a) "PACE" means the program of all-inclusive care for the elderly, a managed care medicare/medicaid program authorized under sections 1894, 1905(a), and 1934 of the social security act and administered by the department.
(b) "PACE program agreement" means an agreement between a PACE organization, the health care financing administration, and the department.
(2) A PACE program may operate in the state only in accordance with a PACE program agreement with the department.
(3) A PACE program shall at the time of entering into the initial PACE program agreement, and at each renewal thereof, demonstrate cash reserves to cover expenses in the event of insolvency.
(a) The cash reserves at a minimum shall equal the sum of:
(i) One month's total capitation revenue; and
(ii) One month's average payment to subcontractors.
(b) The program may demonstrate cash reserves to cover expenses of insolvency with one or more of the following: Reasonable and sufficient net worth, insolvency insurance, or parental guarantees.
(4) A PACE program must provide full disclosure regarding the terms of enrollment and the option to disenroll at any time to all persons who seek to participate or who are participants in the program.
(5) The department must establish rules to authorize long-term care clients enrolled in a PACE program to elect to continue their enrollment in a PACE program regardless of improved status related to functional criteria for nursing facility level of care, consistent with 42 C.F.R. Sec. 460.160(b) (2013).
(6) The department must develop and implement a coordinated plan to provide education about PACE program site operations under this section. The plan must include:
(a) A strategy to assure that case managers and other staff with responsibilities related to eligibility determinations discuss the option and potential benefits of participating in a PACE program with all eligible long-term care clients;
(b) Requirements that all clients eligible for placement in the community options program entry system waiver program that are age fifty-five or over and reside in a PACE service area be referred to the PACE provider for evaluation. The department's plan must assure that referrals are conducted in a manner that is consistent with federal requirements of Title XIX of the federal social security act; and
(c) Requirements for additional and ongoing training for case managers and other staff with responsibilities related to eligibility determinations in those counties in which a PACE program is operating. The training must include instruction in recognizing the benefits of continued enrollment in a PACE program for those clients who have experienced improved status related to functional criteria for nursing facility level of care.
(7) The department must identify a private entity that operates PACE program sites in Washington to provide the training required under subsection (6) of this section at no cost to the state.
[
2013 c 258 s 1
;
2001 c 191 s 2
.]
NOTES:
Finding
—
2001 c 191:
"The legislature finds that PACE programs provide essential care to the frail elderly in the state of Washington. PACE serves to enhance the quality of life and autonomy for frail, older adults, maximize the dignity of and respect for older adults, enable frail and older adults to live in their homes and their community as long as medically possible, and preserve and support the older adult's family unit." [
2001 c 191 s 1
.]
Effective date
—
2001 c 191:
"This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect immediately [May 7, 2001]." [
2001 c 191 s 4
.]
RCW 74.09.530
Medical assistance
—
Powers and duties of authority.
(1)(a) The authority is designated as the single state agency for purposes of Title XIX of the federal social security act.
(b) The amount and nature of medical assistance and the determination of eligibility of recipients for medical assistance shall be the responsibility of the authority.
(c) The authority shall establish reasonable standards of assistance and resource and income exemptions which shall be consistent with the provisions of the social security act and federal regulations for determining eligibility of individuals for medical assistance and the extent of such assistance to the extent that funds are available from the state and federal government. The authority shall not consider resources in determining continuing eligibility for recipients eligible under section 1931 of the social security act.
(d) The authority is authorized to collaborate with other state or local agencies and nonprofit organizations in carrying out its duties under this chapter or other applicable law and, to the extent appropriate, may enter into agreements with such other entities.
(2) Individuals eligible for medical assistance under RCW 74.09.510
(3) shall be transitioned into coverage under that subsection immediately upon their termination from coverage under RCW 74.09.510
(2)(a). The authority shall use income eligibility standards and eligibility determinations applicable to children placed in foster care. The authority shall provide information regarding basic health plan enrollment and shall offer assistance with the application and enrollment process to individuals covered under RCW 74.09.510
(3) who are approaching their twenty-first birthday.
[
2018 c 201 s 7018
;
2011 1st sp.s. c 15 s 32
;
2007 c 315 s 2
;
2000 c 218 s 2
;
1979 c 141 s 345
;
1967 ex.s. c 30 s 6
.]
NOTES:
Findings
—
Intent
—
Effective date
—
2018 c 201:
See notes following RCW 41.05.018
.
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Conflict with federal requirements
—
2007 c 315:
See note following RCW 74.09.510
.
RCW 74.09.540
Medical assistance
—
Working individuals with disabilities
—
Intent.
(1) It is the intent of the legislature to remove barriers to employment for individuals with disabilities by providing medical assistance to working individuals with disabilities through a buy-in program in accordance with section 1902(a)(10)(A)(ii) of the social security act and eligibility and cost-sharing requirements established by the authority.
(2) The authority shall establish cost-sharing requirements for the buy-in program in accordance with federal law and any conditions or limitations specified in the omnibus appropriations act. The authority shall establish and modify eligibility and cost-sharing requirements in order to administer the program within available funds. The authority may consider a person's income when establishing cost-sharing requirements. The authority may not establish eligibility restrictions for the buy-in program based upon a person's income or maximum age. The authority shall make every effort to coordinate benefits with employer-sponsored coverage available to the working individuals with disabilities receiving benefits under this chapter or other applicable law.
(3) The authority shall seek federal approval to exclude resources accumulated in a separate account that results from earnings during an individual's enrollment in the buy-in program when determining the individual's subsequent eligibility for another medical assistance program.
[
2019 c 70 s 1
;
2018 c 201 s 7019
;
2011 1st sp.s. c 15 s 33
;
2001 2nd sp.s. c 15 s 2
.]
NOTES:
Effective date
—
2019 c 70:
"This act takes effect January 1, 2020." [
2019 c 70 s 2
.]
Findings
—
Intent
—
Effective date
—
2018 c 201:
See notes following RCW 41.05.018
.
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Findings
—
Intent
—
2001 2nd sp.s. c 15:
"The legislature finds that individuals with disabilities face many barriers and disincentives to employment. Individuals with disabilities are often unable to obtain health insurance that provides the services and supports necessary to allow them to live independently and enter or rejoin the workforce. The legislature finds that there is a compelling public interest in eliminating barriers to work by continuing needed health care coverage for individuals with disabilities who enter and maintain employment.
The legislature intends to strengthen the state's policy of supporting individuals with disabilities in leading fully productive lives by supporting the implementation of the federal ticket to work and work incentives improvement act of 1999, Public Law 106-170. This shall include improving incentives to work by continuing coverage for health care and support services, by seeking federal funding for innovative programs, and by exploring options which provide individuals with disabilities a choice in receiving services needed to obtain and maintain employment." [
2001 2nd sp.s. c 15 s 1
.]
RCW 74.09.545
Medical assistance or limited casualty program
—
Eligibility
—
Agreements between spouses to transfer future income
—
Community income.
(1) An agreement between spouses transferring or assigning rights to future income from one spouse to the other shall be invalid for purposes of determining eligibility for medical assistance or the limited casualty program for the medically needy, but this subsection does not affect agreements between spouses transferring or assigning resources, and income produced by transferred or assigned resources shall continue to be recognized as the separate income of the transferee; and
(2) In determining eligibility for medical assistance or the limited casualty program for the medically needy for a married person in need of institutional care, or care under home and community-based waivers as defined in Title XIX of the Social Security Act, if the community income received in the name of the nonapplicant spouse exceeds the community income received in the name of the applicant spouse, the applicant's interest in that excess shall be considered unavailable to the applicant.
[
1986 c 220 s 1
.]
RCW 74.09.555
Medical assistance
—
Reinstatement upon release from confinement
—
Expedited eligibility determinations.
(1) The authority shall adopt rules and policies providing that when persons who were enrolled in medical assistance immediately prior to confinement, or who become enrolled in medical assistance in suspense status during the period of confinement, are released from confinement, their medical assistance coverage shall be fully reinstated no later than at the moment of their release, subject to any expedited review of their continued eligibility for medical assistance coverage that is required under federal or state law. The authority may reinstate medical assistance prior to the day of release provided that no federal funds are expended for any purpose that is not authorized by the state's agreements with the federal government.
(2) The authority, in collaboration with the Washington association of sheriffs and police chiefs, the department of corrections, the department of children, youth, and families, managed care organizations, and behavioral health administrative services organizations, shall establish procedures for coordination between the authority and department field offices, institutions for mental disease, correctional facilities, as defined in RCW 72.09.015
and
70.48.020, and institutions or facilities operated by the department of children, youth, and families, that result in prompt reinstatement of eligibility and speedy eligibility determinations for medical assistance services upon release from confinement. Procedures developed under this subsection must address:
(a) Mechanisms for receiving medical assistance services applications on behalf of confined persons in anticipation of their release from confinement;
(b) Expeditious review of applications filed by or on behalf of confined persons and, to the extent practicable, completion of the review before the person is released;
(c) Mechanisms for providing medical assistance services identity cards to persons eligible for medical assistance services before their release from confinement;
(d) Coordination with the federal social security administration, through interagency agreements or otherwise, to expedite processing of applications for federal supplemental security income or social security disability benefits, including federal acceptance of applications on behalf of confined persons; and
(e) Assuring that notification of the person's release date, current location, and other appropriate information is provided to the person's managed care organization before the person's scheduled release from confinement, or as soon as practicable thereafter.
(3) Where medical or psychiatric examinations during a person's confinement indicate that the person is disabled, the correctional facility, institution for mental diseases, or institution or facility operated by the department of children, youth, and families, shall provide the authority with that information for purposes of making medical assistance eligibility and enrollment determinations prior to the person's release from confinement. The authority shall, to the maximum extent permitted by federal law, use the examination in making its determination whether the person is disabled and eligible for medical assistance.
(4) For purposes of this section, "confined" or "confinement" means incarcerated in a correctional facility, as defined in RCW 72.09.015
and
70.48.020, held in an institution or facility operated by the department of children, youth, and families, or admitted to an institute for mental disease, as defined in 42 C.F.R. part 435, Sec. 1009 on July 24, 2005.
(5) The economic services administration within the department shall adopt standardized statewide screening and application practices and forms designed to facilitate the application of a confined person for medicaid.
[
2025 c 12 s 3
;
2021 c 243 s 3
;
2019 c 325 s 4005
;
2014 c 225 s 102
. Prior:
2011 1st sp.s. c 36 s 32
;
2011 1st sp.s. c 15 s 34
;
2010 1st sp.s. c 8 s 30
;
2005 c 503 s 12
.]
NOTES:
Finding
—
Conflict with federal requirements
—
2025 c 12:
See notes following RCW 74.09.670
.
Findings
—
2021 c 243:
See note following RCW 74.09.670
.
Effective date
—
2019 c 325:
See note following RCW 71.24.011
.
Effective date
—
2014 c 225:
See note following RCW 71.24.016
.
Findings
—
Intent
—
2011 1st sp.s. c 36:
See RCW 74.62.005
.
Effective date
—
2011 1st sp.s. c 36:
See note following RCW 74.62.005
.
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Findings
—
Intent
—
Short title
—
Effective date
—
2010 1st sp.s. c 8:
See notes following RCW 74.04.225
.
Correction of references
—
Savings
—
Severability
—
2005 c 503:
See notes following RCW 71.24.015
.
RCW 74.09.557
Medical assistance
—
Complex rehabilitation technology products.
(1) The authority shall establish a separate recognition for individually configured, complex rehabilitation technology products and services for complex needs patients with the medical assistance program. This separate recognition shall:
(a) Establish a budget and services category separate from other categories, such as durable medical equipment and supplies;
(b) Take into consideration the customized nature of complex rehabilitation technology and the broad range of services necessary to meet the unique medical and functional needs of people with complex medical needs; and
(c) Establish standards for the purchase of complex rehabilitation technology exclusively from qualified complex rehabilitation technology suppliers.
(2) The authority shall require complex needs patients receiving complex rehabilitation technology to be evaluated by:
(a) A licensed health care provider who performs specialty evaluations within his or her scope of practice, including a physical therapist licensed under chapter
18.74
RCW and an occupational therapist licensed under chapter
18.59
RCW, and has no financial relationship with the qualified complex rehabilitation technology supplier; and
(b) A qualified complex rehabilitation technology professional, as identified in subsection (3)(d)(iii) of this section.
(3) As used in this section:
(a) "Complex needs patient" means an individual with a diagnosis or medical condition that results in significant physical or functional needs and capacities. "Complex needs patient" does not negate the requirement that an individual meet medical necessity requirements under authority rules to qualify for receiving a complex rehabilitation product.
(b) "Complex rehabilitation technology" means wheelchairs and seating systems classified as durable medical equipment within the medicare program as of January 1, 2013, that:
(i) Are individually configured for individuals to meet their specific and unique medical, physical, and functional needs and capacities for basic activities of daily living and instrumental activities of daily living identified as medically necessary to prevent hospitalization or institutionalization of a complex needs patient;
(ii) Are primarily used to serve a medical purpose and generally not useful to a person in the absence of an illness or injury; and
(iii) Require certain services to allow for appropriate design, configuration, and use of such item, including patient evaluation and equipment fitting and configuration.
(c) "Individually configured" means a device has a combination of features, adjustments, or modifications specific to a complex needs patient that a qualified complex rehabilitation technology supplier provides by measuring, fitting, programming, adjusting, or adapting the device as appropriate so that the device is consistent with an assessment or evaluation of the complex needs patient by a health care professional and consistent with the complex needs patient's medical condition, physical and functional needs and capacities, body size, period of need, and intended use.
(d) "Qualified complex rehabilitation technology supplier" means a company or entity that:
(i) Is accredited by a recognized accrediting organization as a supplier of complex rehabilitation technology;
(ii) Meets the supplier and quality standards established for durable medical equipment suppliers under the medicare program;
(iii) For each site that it operates, employs at least one complex rehabilitation technology professional, who has been certified by the rehabilitation engineering and assistive technology society of North America as an assistive technology professional, to analyze the needs and capacities of complex needs patients, assist in selecting appropriate covered complex rehabilitation technology items for such needs and capacities, and provide training in the use of the selected covered complex rehabilitation technology items;
(iv) Has the complex rehabilitation technology professional physically present for the evaluation and determination of the appropriate individually configured complex rehabilitation technologies for the complex needs patient;
(v) Provides service and repairs by qualified technicians for all complex rehabilitation technology products it sells; and
(vi) Provides written information to the complex needs patient at the time of delivery about how the individual may receive service and repair.
[
2013 c 178 s 2
.]
NOTES:
Intent
—
2013 c 178:
"The legislature intends to:
(1) Protect access for complex needs patients to important technology and supporting services;
(2) Establish and improve safeguards relating to the delivery and provision of medically necessary complex rehabilitation technology; and
(3) Provide supports for complex needs patients to stay in the home or community setting, prevent institutionalization, and prevent hospitalizations and other costly secondary complications." [
2013 c 178 s 1
.]
Effective date
—
2013 c 178:
"This act takes effect January 1, 2014." [
2013 c 178 s 3
.]
RCW 74.09.559
Long-acting injectable buprenorphine
—
Billing codes
—
Reimbursement.
(1) The authority shall establish appropriate billing codes for hospitals and psychiatric hospitals that administer long-acting injectable buprenorphine on an outpatient basis to use for billing patients enrolled in a medical assistance program.
(2) Upon initiation or renewal of a contract with the authority to administer a medicaid managed care plan, a managed care organization must reimburse a hospital or psychiatric hospital that bills for the administration of long-acting injectable buprenorphine on an outpatient basis as a separate reimbursable expense.
(3) Beginning January 1, 2025, for individuals enrolled in a medical assistance program that is not a medicaid managed care plan, the authority must reimburse a hospital or psychiatric hospital that bills for the administration of long-acting injectable buprenorphine on an outpatient basis administered as a separate reimbursable expense.
(4) Reimbursements provided under this section must be separate from any bundled payment for outpatient hospital or emergency department services.
[
2024 c 366 s 18
.]
NOTES:
Findings
—
Intent
—
2024 c 366:
See note following RCW 71.24.847
.
RCW 74.09.565
Medical assistance for institutionalized persons
—
Treatment of income between spouses.
(1) An agreement between spouses transferring or assigning rights to future income from one spouse to the other shall be invalid for purposes of determining eligibility for medical assistance or the limited casualty program for the medically needy, but this subsection does not affect agreements between spouses transferring or assigning resources, and income produced by transferred or assigned resources shall continue to be recognized as the separate income of the transferee.
(2) In determining eligibility for medical assistance or the limited casualty program for the medically needy for a married person in need of institutional care, or care under home and community-based waivers as defined in Title XIX of the social security act, if the community income received in the name of the nonapplicant spouse exceeds the community income received in the name of the applicant spouse, the applicant's interest in that excess shall be considered unavailable to the applicant.
(3) The department or authority, as appropriate, shall adopt rules consistent with the provisions of section 1924 of the social security act entitled "Treatment of Income and Resources for Certain Institutionalized Spouses," in determining the allocation of income between an institutionalized and community spouse.
(4) The department or authority, as appropriate, shall establish the monthly maintenance needs allowance for the community spouse up to the maximum amount allowed by state appropriation or within available funds and permitted in section 1924 of the social security act. The total monthly needs allowance shall not exceed one thousand five hundred dollars, subject to adjustment provided in section 1924 of the social security act.
[
2011 1st sp.s. c 15 s 35
;
1989 c 87 s 4
.]
NOTES:
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Captions not law
—
1989 c 87:
"Section captions, as found in sections 4 through 8 of this act, constitute no part of the law." [
1989 c 87 s 10
.]
Effective dates
—
1989 c 87:
See note following RCW 74.09.510
.
RCW 74.09.575
Medical assistance for institutionalized persons
—
Treatment of resources.
(1) The department or authority, as appropriate, shall promulgate rules consistent with the treatment of resources provisions of section 1924 of the social security act in determining the allocation of resources between the institutionalized and community spouse.
(2) In the interest of supporting the community spouse the department or authority, as appropriate, shall allow the maximum resource allowance amount permissible under the social security act for the community spouse for persons institutionalized before August 1, 2003.
(3) For persons institutionalized on or after August 1, 2003, the department or authority, as appropriate, in the interest of supporting the community spouse, shall allow up to a maximum of forty thousand dollars in resources for the community spouse. For the fiscal biennium beginning July 1, 2005, and each fiscal biennium thereafter, the maximum resource allowance amount for the community spouse shall be adjusted for economic trends and conditions by increasing the amount allowable by the consumer price index as published by the federal bureau of labor statistics. However, in no case shall the amount allowable exceed the maximum resource allowance permissible under the social security act.
[
2011 1st sp.s. c 15 s 36
;
2003 1st sp.s. c 28 s 1
;
1989 c 87 s 5
.]
NOTES:
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Effective date
—
2003 1st sp.s. c 28:
"This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect July 1, 2003." [
2003 1st sp.s. c 28 s 2
.]
Effective dates
—
1989 c 87:
See note following RCW 74.09.510
.
Captions not law
—
1989 c 87:
See note following RCW 74.09.565
.
RCW 74.09.585
Medical assistance for institutionalized persons
—
Period of ineligibility for transfer of resources.
(1) The department or authority, as appropriate, shall establish standards consistent with section 1917 of the social security act in determining the period of ineligibility for medical assistance due to the transfer of resources.
(2) There shall be no penalty imposed for the transfer of assets that are excluded in a determination of the individual's eligibility for medicaid to the extent such assets are protected by the long-term care insurance policy or contract pursuant to chapter
48.85
RCW.
(3) The department or authority, as appropriate, may waive a period of ineligibility if the department or authority determines that denial of eligibility would work an undue hardship.
[
2011 1st sp.s. c 15 s 37
;
1995 1st sp.s. c 18 s 81
;
1989 c 87 s 7
.]
NOTES:
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Conflict with federal requirements
—
Severability
—
Effective date
—
1995 1st sp.s. c 18:
See notes following RCW 74.39A.030
.
Effective dates
—
1989 c 87:
See note following RCW 74.09.510
.
Captions not law
—
1989 c 87:
See note following RCW 74.09.565
.
RCW 74.09.595
Medical assistance for institutionalized persons
—
Due process procedures.
The department or authority, as appropriate, shall in compliance with section 1924 of the social security act adopt procedures which provide due process for institutionalized or community spouses who request a fair hearing as to the valuation of resources, the amount of the community spouse resource allowance, or the monthly maintenance needs allowance.
[
2011 1st sp.s. c 15 s 38
;
1989 c 87 s 8
.]
NOTES:
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Effective dates
—
1989 c 87:
See note following RCW 74.09.510
.
Captions not law
—
1989 c 87:
See note following RCW 74.09.565
.
RCW 74.09.597
Medical assistance
—
Durable medical equipment and medical supplies
—
Providers.
The following must be medicare providers in order to be paid under the medicaid program: Providers of durable medical equipment and related supplies and providers of medical supplies and related services.
[
2012 c 241 s 105
.]
NOTES:
Intent
—
Finding
—
2012 c 241:
See note following RCW 74.66.010
.
RCW 74.09.600
Post audit examinations by state auditor.
Nothing in this chapter shall preclude the state auditor from conducting post audit examinations of public funds pursuant to RCW 43.09.330
or other applicable law.
[
1977 ex.s. c 260 s 6
.]
NOTES:
Severability
—
1977 ex.s. c 260:
"If any provision of this act, or its application to any person or circumstance is held invalid, the remainder of the act, or the application of the provision to other persons or circumstances is not affected." [
1977 ex.s. c 260 s 8
.]
RCW 74.09.605
Incorporation of outcomes/criteria into contracts with managed care organizations.
The authority shall incorporate the expected outcomes and criteria to measure the performance of service coordination organizations as provided in chapter
70.320
RCW into contracts with managed care organizations that provide services to clients under this chapter.
[
2013 c 320 s 7
.]
RCW 74.09.611
Hospital quality incentive payments
—
Noncritical access hospitals.
(1) If sufficient funds are made available as provided in subsection (2) of this section the authority, in collaboration with the Washington state hospital association, shall design a system of hospital quality incentive payments for noncritical access hospitals. The system must be based upon the following principles:
(a) Evidence-based treatment and processes must be used to improve health care outcomes for hospital patients;
(b) Effective purchasing strategies to improve the quality of health care services should involve the use of common quality improvement measures by public and private health care purchasers, while recognizing that some measures may not be appropriate for application to specialty pediatric, psychiatric, or rehabilitation hospitals;
(c) Quality measures chosen for the system should be consistent with the standards that have been developed by national quality improvement organizations, such as the national quality forum, the federal centers for medicare and medicaid services, or the federal agency for healthcare research and quality. New reporting burdens to hospitals should be minimized by giving priority to measures hospitals are currently required to report to governmental agencies, such as the hospital compare measures collected by the federal centers for medicare and medicaid services;
(d) Benchmarks for each quality improvement measure should be set at levels that are feasible for hospitals to achieve, yet represent real improvements in quality and performance for a majority of hospitals in Washington state; and
(e) Hospital performance and incentive payments should be designed in a manner such that all noncritical access hospitals are able to receive the incentive payments if performance is at or above the benchmark score set in the system established under this section.
(2) If hospital safety net assessment funds under RCW 74.60.020
are made available, such funds must be used to support an additional one percent increase in inpatient hospital rates for noncritical access hospitals that:
(a) Meet the quality incentive benchmarks established under this section; and
(b) Participate in Washington state hospital association collaboratives related to the benchmarks in order to improve care and promote sharing of best practices with other hospitals.
(3) Funds directed from any other lawful source may also be used to support the purposes of this section.
[
2013 2nd sp.s. c 17 s 18
.]
NOTES:
Effective date
—
2013 2nd sp.s. c 17:
See note following RCW 74.60.005
.
RCW 74.09.630
Opioid overdose reversal medications
—
Reimbursement.
Until the opioid overdose reversal medication bulk purchasing and distribution program established in RCW 70.14.170
is operational:
(1) All medicaid managed care organizations must reimburse a hospital or behavioral health agency for dispensing or distributing opioid overdose reversal medication to a covered person under RCW 70.41.485
and
71.24.594
.
(2) If the person is not enrolled in a medicaid managed care organization and does not have any other available insurance coverage, the authority must reimburse a hospital, behavioral health agency, or pharmacy for dispensing or distributing opioid overdose reversal medication under RCW 70.41.485
and
71.24.594
.
[
2023 c 51 s 44
;
2021 c 273 s 5
.]
NOTES:
Findings
—
Intent
—
2021 c 273:
See note following RCW 70.41.480
.
RCW 74.09.632
Opioid overdose reversal medications
—
Technical assistance
—
Written materials.
(1) The authority, in consultation with the department of health, the office of the insurance commissioner, and the addictions, drug, and alcohol institute at the University of Washington, shall provide technical assistance to hospitals and licensed or certified , behavioral health agencies to assist these entities, practitioners, and providers in complying with RCW 70.41.485
and
71.24.594
. The technical assistance provided to behavioral health agencies must include:
(a) Training nonmedical providers on distributing and providing client education and directions for use of opioid overdose reversal medication;
(b) Providing written guidance for billing for opioid overdose reversal medication; and
(c) Analyzing the cost of additional behavioral health agency staff time to carry out the activities in RCW 71.24.594, and providing written guidance no later than January 1, 2022, for funding and billing direct service activities related to assisting clients to obtain opioid overdose reversal medication.
(2) The authority shall develop written materials in all relevant languages for each hospital and applicable licensed or certified behavioral health agency to comply with RCW 70.41.485
and
71.24.594, including directions for the use of opioid overdose reversal medication, and provide them to all hospitals and behavioral health agencies by January 1, 2022.
[
2021 c 273 s 6
.]
NOTES:
Findings
—
Intent
—
2021 c 273:
See note following RCW 70.41.480
.
RCW 74.09.634
Opioid overdose reversal medications
—
Bulk purchasing and distribution program.
(1) All medicaid contracted managed health care organizations must participate in the opioid overdose reversal medication bulk purchasing and distribution program established in RCW 70.14.170
once the program is operational.
(2) The health care authority must participate in the opioid overdose reversal medication bulk purchasing and distribution program established in RCW 70.14.170
once the program is operational for purposes of individuals enrolled in medical assistance under this chapter that are not enrolled in a managed care organization and are uninsured individuals.
[
2023 c 51 s 45
;
2021 c 273 s 12
.]
NOTES:
Rules
—
2021 c 273 ss 7-12:
See note following RCW 70.14.170
.
Findings
—
Intent
—
2021 c 273:
See note following RCW 70.41.480
.
RCW 74.09.640
Opioid use disorder
—
Nonpharmacologic treatments.
(1) In order to support prevention of potential opioid use disorders, the authority must develop and recommend for coverage nonpharmacologic treatments for acute, subacute, and chronic noncancer pain and must report to the governor and the appropriate committees of the legislature, including any requests for funding necessary to implement the recommendations under this section. The recommendations must contain the following elements:
(a) A list of which nonpharmacologic treatments will be covered;
(b) Recommendations as to the duration, amount, and type of treatment eligible for coverage;
(c) Guidance on the type of providers eligible to provide these treatments; and
(d) Recommendations regarding the need to add any provider types to the list of currently eligible medicaid provider types.
(2) The authority must ensure only treatments that are evidence-based for the treatment of the specific acute, subacute, and chronic pain conditions will be eligible for coverage recommendations.
[
2019 c 314 s 35
.]
NOTES:
Declaration
—
2019 c 314:
See note following RCW 18.22.810
.
RCW 74.09.645
Opioid use disorder
—
Coverage without prior authorization.
All medicaid contracted managed care organizations shall provide coverage without prior authorization of at least one federal food and drug administration approved product for the treatment of opioid use disorder in the drug classes opioid agonists, opioid antagonists, and opioid partial agonists.
[
2023 c 51 s 46
;
2019 c 314 s 38
.]
NOTES:
Declaration
—
2019 c 314:
See note following RCW 18.22.810
.
RCW 74.09.650
Prescription drug assistance program.
(1) To the extent funds are appropriated specifically for this purpose, and subject to any conditions placed on appropriations made for this purpose, the authority shall design a medicaid prescription drug assistance program. Neither the benefits of, nor eligibility for, the program is considered to be an entitlement.
(2) The authority shall request any federal waiver necessary to implement this program. Consistent with federal waiver conditions, the department may charge enrollment fees, premiums, or point-of-service cost-sharing to program enrollees.
(3) Eligibility for this program is limited to persons:
(a) Who are eligible for medicare or age sixty-five and older;
(b) Whose family income does not exceed two hundred percent of the federal poverty level as adjusted for family size and determined annually by the federal department of health and human services;
(c) Who lack insurance that provides prescription drug coverage; and
(d) Who are not otherwise eligible under Title XIX of the federal social security act.
(4) The authority shall use a cost-effective prescription drug benefit design. Consistent with federal waiver conditions, this benefit design may be different than the benefit design offered under the medical assistance program. The benefit design may include a deductible benefit that provides coverage when enrollees incur higher prescription drug costs as defined by the department. The authority also may offer more than one benefit design.
(5) The authority shall limit enrollment of persons who qualify for the program so as to prevent an overexpenditure of appropriations for this program or to assure necessary compliance with federal waiver budget neutrality requirements. The authority may not reduce existing medical assistance program eligibility or benefits to assure compliance with federal waiver budget neutrality requirements.
(6) Premiums paid by medicaid enrollees not in the medicaid prescription drug assistance program may not be used to finance the medicaid prescription drug assistance program.
(7) This program will be terminated within twelve months after implementation of a prescription drug benefit under Title XVIII of the federal social security act.
[
2023 c 51 s 47
;
2003 1st sp.s. c 29 s 2
.]
NOTES:
Finding
—
Intent
—
2003 1st sp.s. c 29:
"The legislature finds that prescription drugs are an effective and important part of efforts to maintain and improve the health of Washington state residents. However, their increased cost and utilization is straining the resources of many state health care programs, and is particularly hard on low-income elderly people who lack insurance coverage for such drugs. Furthermore, inappropriate use of prescription drugs can result in unnecessary expenditures and lead to serious health consequences. It is therefore the intent of the legislature to support the establishment by the state of an evidence-based prescription drug program that identifies preferred drugs, develop programs to provide prescription drugs at an affordable price to those in need, and increase public awareness regarding their safe and cost-effective use." [
2003 1st sp.s. c 29 s 1
.]
Severability
—
2003 1st sp.s. c 29:
"If any provision of this act or its application to any person or circumstance is held invalid, the remainder of the act or the application of the provision to other persons or circumstances is not affected." [
2003 1st sp.s. c 29 s 14
.]
Conflict with federal requirements
—
2003 1st sp.s. c 29:
"If any part of this act is found to be in conflict with federal requirements that are a prescribed condition to the allocation of federal funds to the state, the conflicting part of this act is inoperative solely to the extent of the conflict and with respect to the agencies directly affected, and this finding does not affect the operation of the remainder of this act in its application to the agencies concerned. Rules adopted under this act must meet federal requirements that are a necessary condition to the receipt of federal funds by the state." [
2003 1st sp.s. c 29 s 15
.]
Effective date
—
2003 1st sp.s. c 29:
"This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect immediately [June 26, 2003]." [
2003 1st sp.s. c 29 s 16
.]
RCW 74.09.653
Drug reimbursement policy recommendations.
A committee or council required by federal law, within the health care authority, that makes policy recommendations regarding reimbursement for drugs under the requirements of federal law or regulations is subject to chapter
42.30
RCW.
[
2023 c 51 s 48
;
2011 1st sp.s. c 15 s 60
;
1997 c 430 s 2
. Formerly RCW 43.20A.365
.]
NOTES:
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
RCW 74.09.655
Smoking cessation assistance.
The authority shall provide coverage under this chapter for smoking cessation counseling services, as well as prescription and nonprescription agents when used to promote smoking cessation, so long as such agents otherwise meet the definition of "covered outpatient drug" in 42 U.S.C. Sec. 1396r-8(k). However, the authority may initiate an individualized inquiry and determine and implement by rule appropriate coverage limitations as may be required to encourage the use of effective, evidence-based services and prescription and nonprescription agents.
[
2023 c 51 s 49
;
2011 1st sp.s. c 15 s 39
;
2008 c 245 s 1
.]
NOTES:
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
RCW 74.09.657
Findings
—
Family planning services expansion.
The legislature finds that:
(1) Over half of all births in Washington state are covered by public programs;
(2) Research has demonstrated that children of unintended pregnancies receive less prenatal care and are at higher risk for premature birth, low birth weight, neurological disorders, and poor academic performance;
(3) In Washington state, over 50 percent of unintended pregnancies occur in women age 25 years and older;
(4) Washington state's take charge program has been successful in helping women avoid unintended pregnancies; however, when the caseload declined due to federally mandated changes, the rate of unintended pregnancies increased dramatically;
(5) Expanding family planning services to cover women to 260 percent of the federal poverty level would align that program's eligibility standard with income eligibility for publicly funded maternity care service; and
(6) Such an expansion would reduce unintended pregnancies and associated costs to the state.
[
2023 c 51 s 50
;
2011 1st sp.s. c 41 s 1
.]
NOTES:
Funding reduction
—
2011 1st sp.s. c 41:
"Upon implementation of the expansion directed in RCW 74.09.659, the office of financial management shall reduce general fund
—
state allotments for the medical assistance program by one million five hundred thousand dollars for fiscal year 2012 and by two million three hundred fifty thousand dollars for fiscal year 2013. The amounts reduced from allotments shall be placed in reserve status and remain unexpended." [
2011 1st sp.s. c 41 s 3
.]
RCW 74.09.658
Home health
—
Reimbursement
—
Telemedicine.
(1) The home health program shall require registered nurse oversight and intervention, as appropriate. In-person contact between a home health care registered nurse and a patient is not required under the state's medical assistance program for home health services that are: (a) Delivered with the assistance of telemedicine and (b) otherwise eligible for reimbursement as a medically necessary skilled home health nursing visit under the program.
(2) The department or authority, as appropriate, in consultation with home health care service providers shall develop reimbursement rules and, in rule, define the requirements that must be met for a reimbursable skilled nursing visit when services are rendered without a face-to-face visit and are assisted by telemedicine.
(3)(a) The department or authority, as appropriate, shall establish the reimbursement rate for skilled home health nursing services delivered with the assistance of telemedicine that meet the requirements of a reimbursable visit as defined by the department or authority, as appropriate.
(b) Reimbursement is not provided for purchase or lease of telemedicine equipment.
(4) Any home health agency licensed under chapter
70.127
RCW and eligible for reimbursement under the medical programs authorized under this chapter may be reimbursed for services under this section if the service meets the requirements for a reimbursable skilled nursing visit.
(5) Nothing in this section shall be construed to alter the scope of practice of any home health care services provider or authorizes the delivery of home health care services in a setting or manner not otherwise authorized by law.
(6) The use of telemedicine is not intended to replace registered nurse health care visits when necessary.
(7) For the purposes of this section, "telemedicine" means the use of telemonitoring to enhance the delivery of certain home health medical services through:
(a) The provision of certain education related to health care services using audio, video, or data communication instead of a face-to-face visit; or
(b) The collection of clinical data and the transmission of such data between a patient at a distant location and the home health provider through electronic processing technologies. Objective clinical data that may be transmitted includes, but is not limited to, weight, blood pressure, pulse, respirations, blood glucose, and pulse oximetry.
[
2011 1st sp.s. c 15 s 40
;
2009 c 326 s 1
.]
NOTES:
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
RCW 74.09.659
Family planning waiver program request.
(1) The authority shall continue to submit applications for the family planning waiver program.
(2) The authority shall submit a request to the federal department of health and human services to amend the current family planning waiver program as follows:
(a) Provide coverage for sexually transmitted disease testing and treatment; and
(b) Return to the eligibility standards used in 2005 including, but not limited to, citizenship determination based on declaration or matching with federal social security databases, insurance eligibility standards comparable to 2005, and confidential service availability for minors and survivors of domestic and sexual violence.
[
2023 c 51 s 51
. Prior:
2011 1st sp.s. c 41 s 2
;
2011 1st sp.s. c 15 s 41
;
2009 c 545 s 5
.]
NOTES:
Funding reduction
—
2011 1st sp.s. c 41:
See note following RCW 74.09.657
.
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Findings
—
2009 c 545:
See note following RCW 43.06.155
.
RCW 74.09.660
Prescription drug education for seniors
—
Grant qualifications.
Each of the state's area agencies on aging shall implement a program intended to inform and train persons sixty-five years of age and older in the safe and appropriate use of prescription and nonprescription medications. To further this purpose, the department shall award development grants averaging up to twenty-five thousand dollars to each of the agencies upon a showing that:
(1) The agency has the ability to effectively administer such a program, including an understanding of the relevant issues and appropriate outreach and follow-up;
(2) The agency can bring resources to the program in addition to those funded by the grant; and
(3) The program will be a collaborative effort between the agency and other health care programs and providers in the location to be served, including doctors, pharmacists, and long-term care providers.
[
2003 1st sp.s. c 29 s 8
.]
NOTES:
Finding
—
Intent
—
Severability
—
Conflict with federal requirements
—
Effective date
—
2003 1st sp.s. c 29:
See notes following RCW 74.09.650
.
RCW 74.09.665
Human immunodeficiency virus postexposure prophylaxis drugs
—
Coverage
—
Reimbursement.
(1) The authority and all medicaid contracted managed care organizations shall provide coverage without prior authorization for the drugs that comprise at least one regimen recommended by the centers for disease control and prevention for human immunodeficiency virus postexposure prophylaxis.
(2) Notwithstanding the coverage requirements of this section, the authority or a medicaid contracted managed care organization shall reimburse a hospital that bills for a 28-day supply of any human immunodeficiency virus postexposure prophylaxis drugs or therapies dispensed or delivered to a patient in the emergency department for take-home use, pursuant to RCW 70.41.495, as a separate reimbursable expense. This reimbursable expense is separate from any bundled payment for emergency department services.
[
2024 c 251 s 4
.]
NOTES:
Effective date
—
2024 c 251:
See note following RCW 70.41.495
.
RCW 74.09.667
Human immunodeficiency virus antiviral drugs
—
Coverage.
(1) The authority shall provide coverage under this chapter for all federal food and drug administration approved HIV antiviral drugs without prior authorization or step therapy. This coverage must be provided to apple health clients enrolled in both fee-for-service and managed care programs.
(2) Upon initiation or renewal of a contract with the authority to administer a medicaid managed care plan, a managed health care system shall provide coverage without prior authorization or step therapy for all federal food and drug administration approved HIV antiviral drugs.
[
2025 c 11 s 1
.]
RCW 74.09.670
Medical assistance benefits
—
Incarcerated or committed persons
—
Suspension.
(1) Except as provided in subsection (2) of this section, when the authority receives information that a person enrolled in medical assistance is confined in a setting in which federal financial participation is disallowed by the state's agreements with the federal government, the authority shall suspend, rather than terminate, medical assistance benefits for these persons, including those who are: Incarcerated in a correctional facility as defined in RCW 72.09.015
and
70.48.020, confined in an institution or facility operated by the department of children, youth, and families, or committed to a state hospital or other treatment facility. A person who is not currently enrolled in medical assistance must be allowed to apply for medical assistance in suspense status during confinement, and the ability to apply may not depend upon knowledge of the release or discharge date of the person.
(2)(a) During the first 29 days of a person's incarceration or confinement in a correctional facility, as defined in RCW 72.09.015
and
70.48.020, or in an institution or facility operated by the department of children, youth, and families:
(i) A person's incarceration or confinement status may not affect the person's enrollment in medical assistance if the person was enrolled in medical assistance at the time of incarceration or confinement; and
(ii) A person not enrolled in medical assistance at the time of incarceration or confinement must have the ability to apply for medical assistance during incarceration or confinement, which may not depend on knowledge of the release date of the person. If the person is enrolled in medical assistance during the first 29 days of the person's incarceration or confinement, the person's incarceration or confinement status may not affect the person's enrollment in medical assistance.
(b) After the first 29 days of the person's incarceration or confinement, the person's medical assistance status is subject to suspension or application in suspense status under subsection (1) of this section.
[
2025 c 12 s 2
. Prior:
2021 c 243 s 2
;
2021 c 166 s 2
;
2016 c 154 s 2
.]
NOTES:
Finding
—
2025 c 12:
"The legislature recognizes that in 2021, Engrossed Second Substitute Senate Bill 5304 was signed into law to better ensure continuity of coverage for medicaid enrollment of incarcerated youth. The legislature finds that further clarification is required to ensure local and state juvenile facilities are made aware of opportunities for continuity of coverage. The legislature therefore resolves to remove ambiguity in state statute and to direct the health care authority to document its efforts working with local providers to ensure a warm handoff upon release from detention facilities." [
2025 c 12 s 1
.]
Conflict with federal requirements
—
2025 c 12:
"If any part of this act is found to be in conflict with federal requirements that are a prescribed condition to the allocation of federal funds to the state, the conflicting part of this act is inoperative solely to the extent of the conflict and with respect to the agencies directly affected, and this finding does not affect the operation of the remainder of this act in its application to the agencies concerned." [
2025 c 12 s 8
.]
Findings
—
2021 c 243:
"The legislature finds that when considering releasing persons from state and local institutions, realizing the safety of the public is the primary concern. The legislature also finds that the success of persons with behavioral health needs being released from confinement in a prison, jail, juvenile rehabilitation facility, state hospital, and other state and local institutions can be increased with access to continuity of medical assistance, supportive services, and other targeted assistance. The legislature finds that this act provides strategies to prevent interruption of medical assistance benefits and to allow for a seamless transfer between systems of care. The legislature further finds that this act removes stigmatizing language from the program created under RCW 72.09.370
and
71.24.470
and creates a work group to study how to expand the cost-effective strategies of this program to other populations and settings to enhance recovery, reduce recidivism, and improve safety." [
2021 c 243 s 1
.]
Amendments
—
Waivers
—
2021 c 166 s 2:
"The health care authority is authorized to seek any necessary state plan amendments or waivers from the federal department of health and human services that are necessary to implement section 2 of this act." [
2021 c 166 s 4
.]
Findings
—
Intent
—
2021 c 166:
"(1) The legislature finds that:
(a) Having access to same day and next day physical and behavioral health services is imperative to facilitate successful reentry for individuals releasing from jails;
(b) The overwhelming majority of individuals in jails are incarcerated for less than 30 days;
(c) Suspending medicaid for individuals on short-term jail stays causes significant delays in medicaid reinstatement upon release; and
(d) Delays in medicaid reinstatement impede access to physical and behavioral health appointments and prescription medications upon release.
(2) The legislature intends to facilitate successful jail reentry by not suspending medicaid for individuals who are incarcerated for less than 30 days." [
2021 c 166 s 1
.]
Conflict with federal requirements
—
2021 c 166:
"If any part of this act is found to be in conflict with federal requirements that are a prescribed condition to the allocation of federal funds to the state, the conflicting part of this act is inoperative solely to the extent of the conflict and with respect to the agencies directly affected, and this finding does not affect the operation of the remainder of this act in its application to the agencies concerned. Rules adopted under this act must meet federal requirements that are a necessary condition to the receipt of federal funds by the state." [
2021 c 166 s 5
.]
Intent
—
2016 c 154:
"Persons with mental illness and persons with substance use disorders in the custody of the criminal justice system need seamless access to community treatment networks and medical assistance upon release from custody to prevent gaps in treatment and reduce barriers to accessing care. Access to care is critical to reduce recidivism and reduce costs associated with relapse, decompensation, and crisis care. In accord with the recommendations of the adult behavioral health system task force, persons should be allowed to apply or retain their enrollment in medical assistance during periods of incarceration. The legislature intends for the Washington state health care authority and the department of social and health services to raise awareness of best clinical practices to engage persons with behavioral health disorders and other chronic conditions during periods of incarceration and confinement to highlight opportunities for good preventive care and standardize reporting and payment practices for services reimbursable by federal law that support the safe transition of the person back into the community." [
2016 c 154 s 1
.]
RCW 74.09.671
Incarcerated persons
—
Local jails
—
Behavioral health services
—
Federal funding.
The authority shall collaborate with the department, the Washington state association of counties, the Washington association of sheriffs and police chiefs, and accountable communities of health to improve population health and reduce avoidable use of intensive services and settings by requesting expenditure authority from the federal government to provide behavioral health services to persons who are incarcerated in local jails. The authority in consultation with its partners may narrow its submission to discrete programs or regions of the state as deemed advisable to effectively demonstrate the potential to achieve savings by integrating medical assistance across community and correctional settings.
[
2016 c 154 s 4
.]
NOTES:
Intent
—
2016 c 154:
See note following RCW 74.09.670
.
RCW 74.09.672
Inmates of a public institution
—
Exclusion from medicaid coverage
—
Work release and partial confinement programs.
It is the understanding of the legislature that persons participating in a work release program or other partial confinement programs at the state, county, or city level which allow regular freedom during the day to pursue rehabilitative community activities such as participation in work, treatment, or medical care should not be considered "inmates of a public institution" for the purposes of exclusion from medicaid coverage under the social security act. The authority is instructed to obtain any permissions from the federal government necessary to confirm this understanding, and report back to the governor and relevant committees of the legislature.
[
2016 c 154 s 5
.]
NOTES:
Intent
—
2016 c 154:
See note following RCW 74.09.670
.
RCW 74.09.675
Gender-affirming care services
—
Prohibited discrimination.
(1) In the provision of gender-affirming care services through programs under this chapter, the authority, managed care plans, and providers that administer or deliver such services may not discriminate in the delivery of a service provided through a program of the authority based on the covered person's gender identity or expression.
(2) Beginning January 1, 2022:
(a) The authority and any managed care plans delivering or administering services purchased or contracted for by the authority may not apply categorical cosmetic or blanket exclusions to gender-affirming treatment.
(b) Facial feminization surgeries and facial gender-affirming treatment, such as tracheal shaves, hair electrolysis, and other care such as mastectomies, breast reductions, breast implants, or any combination of gender-affirming procedures, including revisions to prior treatment, when prescribed as gender-affirming treatment, may not be excluded as cosmetic.
(c) The authority and managed care plans administering services purchased or contracted for by the authority may not issue an adverse benefit determination denying or limiting access to gender-affirming treatment, unless a health care provider with experience prescribing or delivering gender-affirming treatment has reviewed and confirmed the appropriateness of the adverse benefit determination.
(d) If the authority and managed care plans administering services purchased or contracted for by the authority do not have an adequate network for gender-affirming treatment, they shall ensure the delivery of timely and geographically accessible medically necessary gender-affirming treatment at no greater expense than if they had an in-network, geographically accessible provider available. This includes, but is not limited to, providing case management services to secure out-of-network gender-affirming treatment options that are available to the enrollee in a timely manner within their geographic region. The enrollee shall pay no more than the same cost sharing that the enrollee would pay for the same covered services received from an in-network provider.
(3) For the purposes of this section, "gender-affirming treatment" means a service or product that a health care provider, as defined in RCW 70.02.010, prescribes to an individual to support and affirm the individual's gender identity. Gender-affirming treatment includes, but is not limited to, treatment for gender dysphoria. Gender-affirming treatment can be prescribed to two spirit, transgender, nonbinary, and other gender diverse individuals.
(4) Nothing in this section may be construed to mandate coverage of a service that is not medically necessary.
(5) The authority shall adopt rules necessary to implement this section.
[
2021 c 280 s 4
.]
NOTES:
Short title
—
2021 c 280:
See note following RCW 49.60.178
.
RCW 74.09.700
Medical care
—
Limited casualty program.
(1) To the extent of available funds and subject to any conditions placed on appropriations made for this purpose, medical care may be provided under the limited casualty program to persons not eligible for medical assistance or medical care services who are medically needy as defined in the social security Title XIX state plan and medical indigents in accordance with eligibility requirements established by the authority. The eligibility requirements may include minimum levels of incurred medical expenses. This includes residents of nursing facilities, residents of intermediate care facilities for persons with intellectual disabilities, and individuals who are otherwise eligible for section 1915(c) of the federal social security act home and community-based waiver services, administered by the department who are aged, blind, or disabled as defined in Title XVI of the federal social security act and whose income exceeds three hundred percent of the federal supplement security income benefit level.
(2) Determination of the amount, scope, and duration of medical coverage under the limited casualty program shall be the responsibility of the authority, subject to the following:
(a) Only the following services may be covered:
(i) For persons who are medically needy as defined in the social security Title XIX state plan: Inpatient and outpatient hospital services, and home and community-based waiver services;
(ii) For persons who are medically needy as defined in the social security Title XIX state plan, and for persons who are medical indigents under the eligibility requirements established by the authority: Rural health clinic services; physicians' and clinic services; prescribed drugs, dentures, prosthetic devices, and eyeglasses; nursing facility services; and intermediate care facility services for persons with intellectual disabilities; home health services; hospice services; other laboratory and X-ray services; rehabilitative services, including occupational therapy; medically necessary transportation; and other services for which funds are specifically provided in the omnibus appropriations act;
(b) Medical care services provided to the medically indigent and received no more than seven days prior to the date of application shall be retroactively certified and approved for payment on behalf of a person who was otherwise eligible at the time the medical services were furnished: PROVIDED, That eligible persons who fail to apply within the seven-day time period for medical reasons or other good cause may be retroactively certified and approved for payment.
(3) The authority shall establish standards of assistance and resource and income exemptions. All nonexempt income and resources of limited casualty program recipients shall be applied against the cost of their medical care services.
[
2011 1st sp.s. c 15 s 42
;
2010 c 94 s 25
;
2001 c 269 s 1
;
1993 c 57 s 2
. Prior:
1991 sp.s. c 9 s 7
;
1991 sp.s. c 8 s 10
;
1991 c 233 s 2
;
1989 c 87 s 3
;
1985 c 5 s 4
;
1983 1st ex.s. c 43 s 1
;
1982 1st ex.s. c 19 s 1
;
1981 2nd ex.s. c 10 s 6
;
1981 2nd ex.s. c 3 s 6
;
1981 1st ex.s. c 6 s 22
.]
NOTES:
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Purpose
—
2010 c 94:
See note following RCW 44.04.280
.
Effective dates
—
1991 sp.s. c 9:
"This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and shall take effect on July 1, 1991, except sections 1 through 6 and 9 of this act which shall take effect on September 1, 1991." [
1991 sp.s. c 9 s 11
.]
Effective date
—
1991 sp.s. c 8:
See note following RCW 18.51.050
.
Effective dates
—
1989 c 87:
See note following RCW 74.09.510
.
Effective date
—
1983 1st ex.s. c 43:
"This act is necessary for the immediate preservation of the public peace, health, and safety, the support of the state government and its existing public institutions, and shall take effect on July 1, 1983." [
1983 1st ex.s. c 43 s 3
.]
Effective date
—
1982 1st ex.s. c 19:
See note following RCW 74.09.035
.
Severability
—
1981 2nd ex.s. c 3:
See note following RCW 74.09.510
.
Effective date
—
Severability
—
1981 1st ex.s. c 6:
See notes following RCW 74.04.005
.
RCW 74.09.705
Family medicine workforce development account.
The family medicine workforce development account is created in the state treasury. All receipts from funding available for the family medicine residency network pursuant to RCW 74.60.090
and
70.112.060
and any other funds collected for the medicaid direct payment program established in chapter 376, Laws of 2024 must be deposited into the account. Moneys in the account may be spent only after appropriation. Expenditures from the account may be used only to supplement primary care graduate medical education.
[
2024 c 168 s 8
.]
NOTES:
Effective dates
—
2024 c 168 ss 4-13:
See note following RCW 41.05.155
.
RCW 74.09.710
Chronic care management programs
—
Medical homes
—
Definitions.
(1) The authority, in collaboration with the department of health and the department of social and health services, shall:
(a) Design and implement medical homes for its aged, blind, and disabled clients in conjunction with chronic care management programs to improve health outcomes, access, and cost-effectiveness. Programs must be evidence based, facilitating the use of information technology to improve quality of care, must acknowledge the role of primary care providers and include financial and other supports to enable these providers to effectively carry out their role in chronic care management, and must improve coordination of primary, acute, and long-term care for those clients with multiple chronic conditions. The authority shall consider expansion of existing medical home and chronic care management programs and build on the Washington state collaborative initiative. The authority shall use best practices in identifying those clients best served under a chronic care management model using predictive modeling through claims or other health risk information; and
(b) Evaluate the effectiveness of current chronic care management efforts in the authority and the department, comparison to best practices, and recommendations for future efforts and organizational structure to improve chronic care management.
(2) For purposes of this section:
(a) "Medical home" means a site of care that provides comprehensive preventive and coordinated care centered on the patient needs and assures high quality, accessible, and efficient care.
(b) "Chronic care management" means the authority's program that provides care management and coordination activities for medical assistance clients determined to be at risk for high medical costs. "Chronic care management" provides education and training and/or coordination that assist program participants in improving self-management skills to improve health outcomes and reduce medical costs by educating clients to better utilize services.
[
2011 1st sp.s. c 15 s 43
;
2007 c 259 s 4
.]
NOTES:
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Subheadings not law
—
2007 c 259:
See note following RCW 7.70.060
.
RCW 74.09.715
Access to dental care.
Within funds appropriated for this purpose, the authority shall establish two dental access projects to serve seniors and other adults who are categorically needy blind or disabled. The projects shall provide:
(1) Enhanced reimbursement rates for certified dentists for specific procedures, to begin no sooner than July 1, 2009;
(2) Reimbursement for trained medical providers for preventive oral health services, to begin no sooner than July 1, 2009;
(3) Training, development, and implementation through a partnership with the University of Washington school of dentistry;
(4) Local program coordination including outreach and case management; and
(5) An evaluation that measures the change in utilization rates and cost savings.
[
2011 1st sp.s. c 15 s 44
;
2008 c 146 s 13
.]
NOTES:
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Findings
—
Intent
—
Severability
—
2008 c 146:
See notes following RCW 74.41.040
.
RCW 74.09.717
Dental health aide therapist services
—
Federal funding.
(1) It is the intent of the legislature to provide that dental health aide therapist services are eligible for medicaid funding in order to promote increased dental care access for persons served in settings operated by Indian tribes, tribal organizations, and urban Indian organizations.
(2) The health care authority is directed to coordinate with the centers for medicare and medicaid services to provide that dental health aide therapist services authorized in chapter
70.350
RCW are eligible for federal funding of up to one hundred percent.
[
2017 c 5 s 8
.]
RCW 74.09.719
Compact of free association islander dental care program.
(1) The COFA islander dental care program is established to provide dental services to COFA citizens who meet the requirements in subsection (2) of this section. The authority shall begin administering this program by January 1, 2020.
(2) Subject to the availability of amounts appropriated for this specific purpose, the program shall provide dental services as covered under RCW 74.09.520
to an individual who is eligible for the COFA premium assistance program under RCW 43.71A.020, or:
(a) Is a resident;
(b) Is a COFA citizen;
(c) Has income that is less than one hundred thirty-three percent of the federal poverty level; and
(d) Is enrolled in medicare coverage under Title XVIII of the social security act (42 U.S.C. Sec. 1395 et seq., as amended).
(3) The authority may disqualify a participant from the program if the participant:
(a) No longer meets the eligibility criteria in subsection (2) of this section;
(b) Fails, without good cause, to comply with procedural or documentation requirements established by the authority in accordance with subsection (4) of this section;
(c) Fails, without good cause, to notify the authority of a change of address in a timely manner; or
(d) Withdraws the participant's application or requests termination of coverage.
(4) The authority shall establish:
(a) Application, enrollment, and renewal processes for the COFA islander dental care program; and
(b) Procedural requirements for continued participation in the program, including participant documentation requirements that are necessary for the authority to administer the program.
(5) For the purposes of this section, "COFA citizen" has the same meaning as in RCW 43.71A.010
.
[
2019 c 311 s 4
.]
NOTES:
Findings
—
Intent
—
2019 c 311:
"(1) The legislature finds that:
(a) The legislature recognized the important relationship between the citizens of the compact of free association (COFA) nations and the United States by enacting the COFA premium assistance program in 2018 to pay for premiums and out-of-pocket expenses for COFA citizens who purchase qualifying health coverage;
(b) While other Washingtonians who are income-eligible for medicaid receive dental coverage through apple health, individuals enrolled in the COFA premium assistance program do not currently have affordable access to dental coverage;
(c) Affordable access to dental care, including preventative care, is critical to treating the whole body health of an individual and preventing systemic health problems such as stroke, heart attack, and diabetes. Poor oral health is also associated with a wide range of hardships including difficulty obtaining employment, work absences due to pain, and decreased productivity; and
(d) Research shows that people living in households in which the primary language spoken at home is not English, seniors, people with disabilities, and people who identify as Native Hawaiian or Pacific Islanders are disproportionately impacted by oral health inequities.
(2) The legislature therefore intends to increase access to dental services for COFA islanders residing in Washington by establishing a dental services program that provides dental coverage to income-eligible members of this population." [
2019 c 311 s 1
.]
RCW 74.09.725
Prostate cancer screening.
(Effective until June 30, 2027.)
The authority shall provide coverage for prostate cancer screening under this chapter, provided that the screening is delivered upon the recommendation of the patient's physician, *advanced registered nurse practitioner, or physician assistant.
[
2011 1st sp.s. c 15 s 46
;
2006 c 367 s 8
.]
NOTES:
*Reviser's note:
The term "advanced registered nurse practitioner" was changed to "advanced practice registered nurse" by 2024 c 239 s 1, effective June 30, 2027.
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
PDF
RCW 74.09.725
Prostate cancer screening.
(Effective June 30, 2027.)
The authority shall provide coverage for prostate cancer screening under this chapter, provided that the screening is delivered upon the recommendation of the patient's physician, advanced practice registered nurse, or physician assistant.
[
2025 c 58 s 5168
;
2011 1st sp.s. c 15 s 46
;
2006 c 367 s 8
.]
NOTES:
Effective date
—
2025 c 58 ss 5058-5170:
See note following RCW 7.68.030
.
Explanatory note
—
2025 c 58:
See note following RCW 1.16.050
.
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
RCW 74.09.730
Disproportionate share hospital adjustment.
(1) In establishing Title XIX payments for inpatient hospital services:
(a) To the extent funds are appropriated specifically for this purpose, and subject to any conditions placed on appropriations made for this purpose, the authority shall provide a disproportionate share hospital adjustment considering the following components:
(i) A low-income care component based on a hospital's medicaid utilization rate, its low-income utilization rate, its provision of obstetric services, and other factors authorized by federal law;
(ii) A medical indigency care component based on a hospital's services to persons who are medically indigent; and
(iii) A state-only component, to be paid from available state funds to hospitals that do not qualify for federal payments under (a)(ii) of this subsection, based on a hospital's services to persons who are medically indigent;
(b) The payment methodology for disproportionate share hospitals shall be specified by the authority in regulation.
(2) Nothing in this section shall be construed as a right or an entitlement by any hospital to any payment from the authority.
[
2018 c 201 s 7020
;
2011 1st sp.s. c 15 s 47
;
2009 c 538 s 1
;
1991 sp.s. c 9 s 8
;
1989 c 260 s 1
;
1987 1st ex.s. c 5 s 20
.]
NOTES:
Findings
—
Intent
—
Effective date
—
2018 c 201:
See notes following RCW 41.05.018
.
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Effective dates
—
1991 sp.s. c 9:
See note following RCW 74.09.700
.
RCW 74.09.741
Adjudicative proceedings.
(1) The following persons have the right to an adjudicative proceeding:
(a) Any applicant or recipient who is aggrieved by a decision of the authority or an authorized agency of the authority; or
(b) A current or former recipient who is aggrieved by the authority's claim that he or she owes a debt for overpayment of assistance.
(2) For purposes of this section:
(a) "Applicant" means any person who has made a request, or on behalf of whom a request has been made to the authority for any medical services program established under this chapter.
(b) "Recipient" means a person who is receiving benefits from the authority for any medical services program established in this chapter.
(3) An applicant or recipient has no right to an adjudicative proceeding when the sole basis for the authority's decision is a federal or state law requiring an assistance adjustment for a class of applicants or recipients.
(4) An applicant or recipient may file an application for an adjudicative proceeding with either the authority or the department and must do so within 90 calendar days after receiving notice of the aggrieving decision unless good cause is shown, to the extent allowable under federal law. The authority shall determine which agency is responsible for representing the state of Washington in the hearing, in accordance with agreements entered pursuant to RCW 41.05.021
.
(a) For the purpose of this subsection, good cause is defined as a substantive reason or legal justification for failing to meet a hearing deadline. Good cause to fail to meet a hearing deadline may include, but is not limited to: Military deployment, medical reasons, housing instability, language barriers, or domestic violence.
(b) The authority or the department shall not grant a request for a hearing for good cause if the request is filed more than one year after the aggrieving decision.
(5)(a) The adjudicative proceeding is governed by the administrative procedure act, chapter
34.05
RCW, and this subsection. The following requirements shall apply to adjudicative proceedings in which an appellant seeks review of decisions made by more than one agency. When an appellant files a single application for an adjudicative proceeding seeking review of decisions by more than one agency, this review shall be conducted initially in one adjudicative proceeding. The presiding officer may sever the proceeding into multiple proceedings on the motion of any of the parties, when:
(i) All parties consent to the severance; or
(ii) Either party requests severance without another party's consent, and the presiding officer finds there is good cause for severing the matter and that the proposed severance is not likely to prejudice the rights of an appellant who is a party to any of the severed proceedings.
(b) If there are multiple adjudicative proceedings involving common issues or parties where there is one appellant and both the authority and the department are parties, upon motion of any party or upon his or her own motion, the presiding offer may consolidate the proceedings if he or she finds that the consolidation is not likely to prejudice the rights of the appellant who is a party to any of the consolidated proceedings.
(c) The adjudicative proceeding shall be conducted at the local community services office or other location in Washington convenient to the applicant or recipient and, upon agreement by the applicant or recipient, may be conducted telephonically.
(d) The applicant or recipient, or his or her representative, has the right to inspect his or her file from the authority and, upon request, to receive copies of authority documents relevant to the proceedings free of charge.
(e) The applicant or recipient has the right to a copy of the audio recording of the adjudicative proceeding free of charge.
(f) If a final adjudicative order is issued in favor of an applicant, medical services benefits must be provided from the date of earliest eligibility, the date of denial of the application for assistance, or 45 days following the date of application, whichever is soonest. If a final adjudicative order is issued in favor of a recipient, medical services benefits must be provided from the effective date of the authority's decision.
(g) The authority is limited to recovering an overpayment arising from assistance being continued pending the adjudicative proceeding to the amount recoverable up to the 60th day after the director's receipt of the application for an adjudicative proceeding.
(6) If the director requires that a party seek administrative review of an initial order to an adjudicative proceeding governed by this section, in order for the party to exhaust administrative remedies pursuant to RCW 34.05.534, the director shall adopt and implement rules in accordance with this subsection.
(a) The director, in consultation with the secretary, shall adopt rules to create a process for parties to seek administrative review of initial orders issued pursuant to RCW 34.05.461
in adjudicative proceedings governed by this subsection when multiple agencies are parties.
(b) This process shall seek to minimize any procedural complexities imposed on appellants that result from multiple agencies being parties to the matter, without prejudicing the rights of parties who are public assistance applicants or recipients.
(c) Nothing in this subsection shall impose or modify any legal requirement that a party seek administrative review of initial orders in order to exhaust administrative remedies pursuant to RCW 34.05.534
.
(7) This subsection only applies to an adjudicative proceeding in which the appellant is an applicant for or recipient of medical services programs established under this chapter and the issue is his or her eligibility or ineligibility due to the assignment or transfer of a resource. The burden is on the authority or its authorized agency to prove by a preponderance of the evidence that the person knowingly and willingly assigned or transferred the resource at less than market value for the purpose of qualifying or continuing to qualify for medical services programs established under this chapter. If the prevailing party in the adjudicative proceeding is the applicant or recipient, he or she is entitled to reasonable attorneys' fees.
(8) When an applicant or recipient files a petition for judicial review as provided in RCW 34.05.514
of an adjudicative order entered with respect to the medical services program, no filing fee may be collected from the person and no bond may be required on any appeal. In the event that the superior court, the court of appeals, or the supreme court renders a decision in favor of the applicant or recipient, the person is entitled to reasonable attorneys' fees and costs. If a decision of the court is made in favor of an applicant, assistance shall be paid from the date of earliest eligibility, the date of the denial of the application for assistance, or 45 days following the date of application, whichever is soonest. If a decision of the court is made in favor of a recipient, assistance shall be paid from the effective date of the authority's decision.
(9) The provisions of RCW 74.08.080
do not apply to adjudicative proceedings requested or conducted with respect to the medical services program pursuant to this section.
(10) The authority shall adopt any rules it deems necessary to implement this section.
[
2022 c 163 s 2
;
2011 1st sp.s. c 15 s 53
.]
NOTES:
Conflict with federal requirements
—
Effective date
—
2022 c 163:
See notes following RCW 74.08.080
.
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
RCW 74.09.745
Medicaid funding for home visiting services
—
Recommendations to legislature.
(1) The authority shall collaborate with the department of children, youth, and families to identify opportunities to leverage medicaid funding for home visiting services.
(2) The authority must provide a set of recommendations relevant to subsection (1) of this section to the legislature by December 1, 2018, that builds upon the research and strategies developed in the Washington state home visiting and medicaid financing strategies report submitted by the authority to the department of early learning in August 2017.
[
2018 c 175 s 4
.]
NOTES:
Findings
—
Intent
—
2018 c 175:
See note following RCW 74.09.495
.
RCW 74.09.748
Regional service areas
—
Certain reimbursements required or allowed upon adoption of fully integrated managed health care system.
Upon adoption of a fully integrated managed health care system pursuant to chapter
71.24
RCW, regional service areas:
(1) Must allow reimbursement for time spent supervising persons working toward satisfying supervision requirements established for the relevant practice areas pursuant to RCW 18.225.090
; and
(2) May allow reimbursement for services delivered through a partial hospitalization or intensive outpatient program as described in RCW 71.24.385
.
[
2018 c 175 s 8
.]
NOTES:
Findings
—
Intent
—
2018 c 175:
See note following RCW 74.09.495
.
RCW 74.09.758
Medicaid procurement of services
—
Value-based contracting for medicaid and public employee purchasing.
(1) The authority and the department may restructure medicaid procurement of health care services and agreements with managed care systems on a phased basis to better support integrated physical health, mental health, and substance use disorder treatment, consistent with assumptions in Second Substitute Senate Bill No. 6312, Laws of 2014, and recommendations provided by the behavioral health task force. The authority and the department may develop and utilize innovative mechanisms to promote and sustain integrated clinical models of physical and behavioral health care.
(2) The authority and the department may incorporate the following principles into future medicaid procurement efforts aimed at integrating the delivery of physical and behavioral health services:
(a) Medicaid purchasing must support delivery of integrated, person-centered care that addresses the spectrum of individuals' health needs in the context of the communities in which they live and with the availability of care continuity as their health needs change;
(b) Accountability for the client outcomes established in RCW 71.24.435
and
71.36.025
and performance measures linked to those outcomes;
(c) Medicaid benefit design must recognize that adequate preventive care, crisis intervention, and support services promote a recovery-focused approach;
(d) Evidence-based care interventions and continuous quality improvement must be enforced through contract specifications and performance measures that provide meaningful integration at the patient care level with broadly distributed accountability for results;
(e) Active purchasing and oversight of medicaid managed care contracts is a state responsibility;
(f) A deliberate and flexible system change plan with identified benchmarks to promote system stability, provide continuity of treatment for patients, and protect essential existing behavioral health system infrastructure and capacity; and
(g) Community and organizational readiness are key determinants of implementation timing; a phased approach is therefore desirable.
(3) The principles identified in subsection (2) of this section are not intended to create an individual entitlement to services.
(4) The authority shall increase the use of value-based contracting, alternative quality contracting, and other payment incentives that promote quality, efficiency, cost savings, and health improvement, for medicaid and public employee purchasing. The authority shall also implement additional chronic disease management techniques that reduce the subsequent need for hospitalization or readmissions. It is the intent of the legislature that the reforms the authority implements under this subsection are anticipated to reduce extraneous medical costs, across all medical programs, when fully phased in by fiscal year 2017 to generate budget savings identified in the omnibus appropriations act.
[
2019 c 325 s 5029
;
2014 c 223 s 7
.]
NOTES:
Effective date
—
2019 c 325:
See note following RCW 71.24.011
.
Finding
—
2014 c 223:
See note following RCW 41.05.690
.
RCW 74.09.7585
Changes in services
—
Adjustments to medicaid managed care rates.
(1) The authority shall consult with the department of commerce and the department of health quarterly for all agencies to plan and prepare for new or expanded services in each regional service area, which must include, but are not limited to, incorporating regional capacity changes reported to the authority by managed care organizations, behavioral health administrative services organizations, providers including Indian health services providers, Indian health care providers, urban Indian health organizations, or provider networks. When programs or facilities including, but not limited to, those programs and facilities described in RCW 71.24.045
(1)(e) are newly established or closed or existing services are expanded or reduced in a region the authority shall direct the state's medicaid contractor for actuarial services to promptly and prospectively adjust medicaid managed care rates to include a programmatic adjustment related to the new or expanded service prior to the facility opening or the service expansion, consistent with the rate-setting cycles directed by the authority. If a facility closes or services are reduced, managed care and fee-for-service rates must be adjusted accordingly in the rate-setting cycle following the facility closure.
(2) Within existing funds, the authority's preparation for the reprocurement of services to enrollees of medical assistance programs authorized under this chapter shall include the opportunity for comment by key stakeholders, to the extent allowed by applicable state and federal procurement standards, including tribes, patient groups, health care providers and facilities, counties, and behavioral health administrative services organizations. Preparation for the reprocurement of services must also include:
(a) Methodologies for measuring network access and adequacy for each provider type subject to network access and adequacy standards and tailored to the particular needs of the regional service areas, to be implemented in the reprocurement to assure access to appropriate and timely behavioral health services in each region; and
(b) Opportunities to amend managed care contract requirements to further streamline and standardize processes to reduce administrative burden for providers.
[
2025 c 216 s 1
.]
RCW 74.09.760
Short title
—
1989 1st ex.s. c 10.
This act may be known and cited as the "maternity care access act of 1989."
[
1989 1st ex.s. c 10 s 1
.]
RCW 74.09.770
Maternity care access system established.
(1) The legislature finds that Washington state and the nation as a whole have a high rate of infant illness and death compared with other industrialized nations. This is especially true for minority and low-income populations. Premature and low weight births have been directly linked to infant illness and death. The availability of adequate maternity care throughout the course of pregnancy has been identified as a major factor in reducing infant illness and death. Further, the investment in preventive health care programs, such as maternity care, contributes to the growth of a healthy and productive society and is a sound approach to health care cost containment. The legislature further finds that access to maternity care for low-income women in the state of Washington has declined significantly in recent years and has reached a crisis level.
(2) It is the purpose of this subchapter to provide, consistent with appropriated funds, maternity care necessary to ensure healthy birth outcomes for low-income families. To this end, a maternity care access system is established based on the following principles:
(a) The family is the fundamental unit in our society and should be supported through public policy.
(b) Access to maternity care for eligible persons to ensure healthy birth outcomes should be made readily available in an expeditious manner through a single service entry point.
(c) Unnecessary barriers to maternity care for eligible persons should be removed.
(d) Access to preventive and other health care services should be available for low-income children.
(e) Each woman should be encouraged to and assisted in making her own informed decisions about her maternity care.
(f) Unnecessary barriers to the provision of maternity care by qualified health professionals should be removed.
(g) The system should be sensitive to cultural differences among eligible persons.
(h) To the extent possible, decisions about the scope, content, and delivery of services should be made at the local level involving a broad representation of community interests.
(i) The maternity care access system should be evaluated at appropriate intervals to determine effectiveness and need for modification.
(j) Maternity care services should be delivered in a cost-effective manner.
[
2011 1st sp.s. c 15 s 48
;
1989 1st ex.s. c 10 s 2
.]
NOTES:
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
RCW 74.09.780
Reservation of legislative power.
The legislature reserves the right to amend or repeal all or any part of this subchapter at any time and there shall be no vested private right of any kind against such amendment or repeal. All rights, privileges, or immunities conferred by this subchapter or any acts done pursuant thereto shall exist subject to the power of the legislature to amend or repeal this subchapter at any time.
[
2018 c 201 s 7021
;
1989 1st ex.s. c 10 s 3
.]
NOTES:
Findings
—
Intent
—
Effective date
—
2018 c 201:
See notes following RCW 41.05.018
.
RCW 74.09.790
Definitions.
Unless the context clearly requires otherwise, the definitions in this section apply throughout RCW 74.09.760
through
74.09.820
and
74.09.510
:
(1) "At-risk eligible person" means an eligible person determined by the authority to need special assistance in applying for and obtaining maternity care, including pregnant women who are substance abusers, pregnant and parenting adolescents, pregnant minority women, and other eligible persons who need special assistance in gaining access to the maternity care system.
(2) "Authority" means the Washington state health care authority.
(3) "County authority" means the board of county commissioners, county council, or county executive having the authority to participate in the maternity care access program or its designee. Two or more county authorities may enter into joint agreements to fulfill the requirements of this chapter.
(4) "Department" means the department of social and health services.
(5) "Eligible person" means a woman in need of maternity care or a child, who is eligible for medical assistance pursuant to this chapter or the prenatal care program administered by the authority.
(6) "Family planning services" means planning the number of one's children by use of contraceptive techniques.
(7) "Maternity care services" means inpatient and outpatient medical care, case management, and support services necessary during prenatal, delivery, and postpartum periods.
(8) "Support services" means, at least, public health nursing assessment and follow-up, health and childbirth education, psychological assessment and counseling, outreach services, nutritional assessment and counseling, needed vitamin and nonprescriptive drugs, transportation, family planning services, and child care. Support services may include alcohol and substance abuse treatment for pregnant women who are addicted or at risk of being addicted to alcohol or drugs to the extent funds are made available for that purpose.
[
2011 1st sp.s. c 15 s 49
;
1993 c 407 s 9
;
1990 c 151 s 4
;
1989 1st ex.s. c 10 s 4
.]
NOTES:
Reviser's note:
The definitions in this section have been alphabetized pursuant to RCW 1.08.015
(2)(k).
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
RCW 74.09.800
Maternity care access program established.
The authority shall, consistent with the state budget act, develop a maternity care access program designed to ensure healthy birth outcomes as follows:
(1) Provide maternity care services to low-income pregnant women and health care services to children in poverty to the maximum extent allowable under the medical assistance program, Title XIX of the federal social security act;
(2) Provide maternity care services to low-income women who are not eligible to receive such services under the medical assistance program, Title XIX of the federal social security act;
(3) Have the following procedures in place to improve access to maternity care services and eligibility determinations for pregnant women applying for maternity care services under the medical assistance program, Title XIX of the federal social security act:
(a) Use of a shortened and simplified application form;
(b) Outstationing authority staff to make eligibility determinations;
(c) Establishing local plans at the county and regional level, coordinated by the authority; and
(d) Conducting an interview for the purpose of determining medical assistance eligibility within five working days of the date of an application by a pregnant woman and making an eligibility determination within fifteen working days of the date of application by a pregnant woman;
(4) Establish a maternity care case management system that shall assist at-risk eligible persons with obtaining medical assistance benefits and receiving maternity care services, including transportation and child care services;
(5) Within available resources, establish appropriate reimbursement levels for maternity care providers;
(6) Implement a broad-based public education program that stresses the importance of obtaining maternity care early during pregnancy;
(7) Refer persons eligible for maternity care services under the program established by this section to persons, agencies, or organizations with maternity care service practices that primarily emphasize healthy birth outcomes;
(8) Provide family planning services including information about the synthetic progestin capsule implant form of contraception, for twelve months immediately following a pregnancy to women who were eligible for medical assistance under the maternity care access program during that pregnancy or who were eligible only for emergency labor and delivery services during that pregnancy; and
(9) Within available resources, provide family planning services to women who meet the financial eligibility requirements for services under subsections (1) and (2) of this section.
[
2011 1st sp.s. c 15 s 50
;
1993 c 407 s 10
;
1989 1st ex.s. c 10 s 5
.]
NOTES:
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
RCW 74.09.810
Alternative maternity care service delivery system established
—
Remedial action report.
(1) The authority shall establish an alternative maternity care service delivery system, if it determines that a county or a group of counties is a maternity care distressed area. A maternity care distressed area shall be defined by the authority, in rule, as a county or a group of counties where eligible women are unable to obtain adequate maternity care. The authority shall include the following factors in its determination:
(a) Higher than average percentage of eligible persons in the distressed area who receive late or no prenatal care;
(b) Higher than average percentage of eligible persons in the distressed area who go out of the area to receive maternity care;
(c) Lower than average percentage of obstetrical care providers in the distressed area who provide care to eligible persons;
(d) Higher than average percentage of infants born to eligible persons per obstetrical care provider in the distressed area; and
(e) Higher than average percentage of infants that are of low birth weight, five and one-half pounds or two thousand five hundred grams, born to eligible persons in the distressed area.
(2) If the authority determines that a maternity care distressed area exists, it shall notify the relevant county authority. The county authority shall, within one hundred twenty days, submit a brief report to the authority recommending remedial action. The report shall be prepared in consultation with the authority and with the department's local community service offices, the local public health officer, community health clinics, health care providers, hospitals, the business community, labor representatives, and low-income advocates in the distressed area. A county authority may contract with a local nonprofit entity to develop the report. If the county authority is unwilling or unable to develop the report, it shall notify the authority within thirty days, and the authority shall develop the report for the distressed area.
(3) The authority shall review the report and use it, to the extent possible, in developing strategies to improve maternity care access in the distressed area. The authority may contract with or directly employ qualified maternity care health providers to provide maternity care services, if access to such providers in the distressed area is not possible by other means. In such cases, the authority is authorized to pay that portion of the health care providers' malpractice liability insurance that represents the percentage of maternity care provided to eligible persons by that provider through increased medical assistance payments.
[
2011 1st sp.s. c 15 s 51
;
1989 1st ex.s. c 10 s 6
.]
NOTES:
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
RCW 74.09.820
Maternity care provider's loan repayment program.
To the extent that federal matching funds are available, the authority or the department of health shall establish, in consultation with the health science programs of the state's colleges and universities, and community health clinics, a loan repayment program that will encourage maternity care providers to practice in medically underserved areas in exchange for repayment of part or all of their health education loans.
[
2011 1st sp.s. c 15 s 52
;
1989 1st ex.s. c 10 s 7
.]
NOTES:
Effective date
—
Findings
—
Intent
—
Report
—
Agency transfer
—
References to head of health care authority
—
Draft legislation
—
2011 1st sp.s. c 15:
See notes following RCW 74.09.010
.
Health professional scholarships: Chapter
28B.115
RCW.
RCW 74.09.825
Donor human milk
—
Standards
—
Federal funding.
(1) The authority shall provide coverage under this chapter for medically necessary donor human milk for inpatient use when ordered by a licensed health care provider with prescriptive authority or an international board certified lactation consultant certified by the international board of lactation consultant examiners for an infant who is medically or physically unable to receive maternal human milk or participate in chest feeding or whose parent is medically or physically unable to produce maternal human milk in sufficient quantities or caloric density or participate in chest feeding, if the infant meets at least one of the following criteria:
(a) An infant birth weight of below 2,500 grams;
(b) An infant gestational age equal to or less than 34 weeks;
(c) Infant hypoglycemia;
(d) A high risk for development of necrotizing enterocolitis, bronchopulmonary dysplasia, or retinopathy of prematurity;
(e) A congenital or acquired gastrointestinal condition with long-term feeding or malabsorption complications;
(f) Congenital heart disease requiring surgery in the first year of life;
(g) An organ or bone marrow transplant;
(h) Sepsis;
(i) Congenital hypotonias associated with feeding difficulty or malabsorption;
(j) Renal disease requiring dialysis in the first year of life;
(k) Craniofacial anomalies;
(l) An immunologic deficiency;
(m) Neonatal abstinence syndrome;
(n) Any other serious congenital or acquired condition for which the use of pasteurized donor human milk and donor human milk derived products is medically necessary and supports the treatment and recovery of the child; or
(o) Any baby still inpatient within 72 hours of birth without sufficient human milk available.
(2) Donor human milk covered under this section must be obtained from a milk bank that meets minimum standards adopted by the department of health pursuant to RCW 43.70.645
.
(3) The authority may require an enrollee to obtain expedited prior authorization to receive coverage for donor human milk as required under this section.
(4) In administering this program, the authority must seek any available federal financial participation under the medical assistance program, as codified at Title XIX of the federal social security act, the state children's health insurance program, as codified at Title XXI of the federal social security act, and any other federal funding sources that are now available or may become available.
(5) For purposes of this section:
(a) "Donor human milk" means human milk that has been contributed to a milk bank by one or more donors.
(b) "Milk bank" means an organization that engages in the procurement, processing, storage, distribution, or use of human milk contributed by donors.
[
2022 c 236 s 4
.]
RCW 74.09.830
Postpartum health care coverage.
(1) The authority shall extend health care coverage from 60 days postpartum to one year postpartum for pregnant or postpartum persons who, on or after the expiration date of the federal public health emergency declaration related to COVID-19, are receiving postpartum coverage provided under this chapter.
(2) By June 1, 2022, the authority must:
(a) Provide health care coverage to postpartum persons who reside in Washington state, have countable income equal to or below 193 percent of the federal poverty level, and are not otherwise eligible under Title XIX or Title XXI of the federal social security act; and
(b) Ensure all persons approved for pregnancy or postpartum coverage at any time are continuously eligible for postpartum coverage for 12 months after the pregnancy ends regardless of whether they experience a change in income during the period of eligibility.
(3) By November 1, 2024, the income standards for a postpartum person eligible for Washington apple health pregnancy or postpartum coverage shall have countable income equal to or below 210 percent of the federal poverty level.
(4) Health care coverage under this section must be provided during the 12-month period beginning on the last day of the pregnancy.
(5) The authority shall not provide health care coverage under this section to individuals who are eligible to receive health care coverage under Title XIX or Title XXI of the federal social security act. Health care coverage for these individuals shall be provided by a program that is funded by Title XIX or Title XXI of the federal social security act. Further, the authority shall make every effort to expedite and complete eligibility determinations for individuals who are presumptively eligible to receive health care coverage under Title XIX or Title XXI of the federal social security act to ensure the state is receiving the maximum federal match. This includes, but is not limited to, working with the managed care organizations to provide continuous outreach in various modalities until the individual's eligibility determination is completed. Beginning January 1, 2022, the authority must submit quarterly reports to the caseload forecast work group on the number of individuals who are presumptively eligible to receive health care coverage under Title XIX or Title XXI of the federal social security act but are awaiting for the authority to complete eligibility determination, the number of individuals who were presumptively eligible but are now receiving health care coverage with the maximum federal match under Title XIX or Title XXI of the federal social security act, and outreach activities including the work with managed care organizations.
(6) To ensure continuity of care and maximize the efficiency of the program, the amount and scope of health care services provided to individuals under this section must be the same as that provided to pregnant and postpartum persons under medical assistance, as defined in RCW 74.09.520
.
(7) In administering this program, the authority must seek any available federal financial participation under the medical assistance program, as codified at Title XIX of the federal social security act, the state children's health insurance program, as codified at Title XXI of the federal social security act, and any other federal funding sources that are now available or may become available. This includes, but is not limited to, ensuring the state is receiving the maximum federal match for individuals who are presumptively eligible to receive health care coverage under Title XIX or Title XXI of the federal social security act by expediting completion of the individual's eligibility determination.
(8) Working with stakeholder and community organizations and the Washington health benefit exchange, the authority must establish a comprehensive community education and outreach campaign to facilitate applications for and enrollment in the program or into a more appropriate program where the state receives maximum federal match. Subject to the availability of amounts appropriated for this specific purpose, the education and outreach campaign must provide culturally and linguistically accessible information to facilitate participation in the program, including but not limited to enrollment procedures, program services, and benefit utilization.
(9) Beginning January 1, 2022, the managed care organizations contracted with the authority to provide postpartum coverage must annually report to the legislature on their work to improve maternal health for enrollees, including but not limited to postpartum services offered to enrollees, the percentage of enrollees utilizing each postpartum service offered, outreach activities to engage enrollees in available postpartum services, and efforts to collect eligibility information for the authority to ensure the enrollee is in the most appropriate program for the state to receive the maximum federal match.
[
2024 c 213 s 4
;
2021 c 90 s 2
.]
NOTES:
Intent
—
2021 c 90:
"(1) In Washington and across the country, maternal mortality rates continue to be unacceptably high. The maternal mortality rate in the United States is higher than in most developed countries. Approximately 700 people die each year in the United States due to pregnancy-related conditions. The majority of these deaths are preventable.
(2) National and state maternal mortality data reveals significant racial and ethnic disparities. Nationally, black women are two to three times more likely to die from a pregnancy-related cause than white women. In this state, data from the maternal mortality review panel reveals that American Indian and Alaska Native women are six to seven times as likely to die from a pregnancy-related cause than white women. Significant disparities in maternal mortality rates also exist for Hispanic, Asian, and multiracial women in Washington.
(3) Over 50 percent of pregnancy-related deaths in Washington state are women enrolled in medicaid. In 2019, medicaid covered almost 37,000 births which is nearly half of the total of nonmilitary births in Washington state.
(4) The centers for disease control and prevention find pregnancy-related deaths occur up to one year postpartum, and data shows that health needs continue during that entire year. In Washington, nearly one-third of all pregnancy-related deaths and the majority of suicides and accidental overdoses occurred between 43 and 365 days postpartum.
(5) The maternal mortality review panel has identified access to health care services and gaps in continuity of care, especially during the postpartum period, as factors that contribute to preventable pregnancy-related deaths. In their October 2019 report to the legislature, the panel recommended ensuring funding and access to postpartum care and support through the first year after pregnancy. The panel also recommended addressing social determinants of health, structural racism, provider biases, and other social inequities to reduce maternal mortality in priority populations.
(6) Approximately 50,000 people also experience serious complications from childbirth each year, resulting in increased medical costs, longer hospitalization stays, and long-term health effects.
(7) Postpartum medicaid coverage currently ends 60 days after pregnancy, creating an unsafe gap in coverage. Continuity of care is critical during this vulnerable time, and uninterrupted health care coverage provides birthing parents with access to stable and consistent care. Extending health care coverage through the first year postpartum is one of the best tools for increasing access to care and improving maternal and infant health. A health impact review published by the state board of health found very strong evidence that this policy would decrease inequities by race and ethnicity, immigration status, socioeconomic status, and geography.
(8) During the public health emergency, a federal maintenance of effort requirement has extended medicaid coverage beyond 60 days postpartum. This extension is critical, with pregnancy-related deaths increasing due to COVID-19. Pregnant women are more likely to be admitted to the intensive care unit and receive invasive ventilation and are at increased risk of death compared to nonpregnant women. The pandemic has also exacerbated the behavioral health challenges normally faced in the pregnancy and postpartum period. It has also highlighted and contributed to increased housing crises. Even outside of the pandemic, research shows that pregnancy can increase a woman's risk of becoming homeless, and pregnant women face significantly greater health risks while unstably housed. The legislature is committed to continuing coverage for this population beyond the maintenance of effort requirement.
(9) Pending federal legislation, the helping moms act, would provide federal matching funds to states that provide one year of postpartum coverage under medicaid and the children's health insurance program.
(10) The legislature therefore intends to extend health care coverage from 60 days to 12 months postpartum." [
2021 c 90 s 1
.]
RCW 74.09.835
Postdelivery and transitional care program
—
Contracting
—
Funding.
(1) By no later than January 1, 2026, the authority shall create a postdelivery and transitional care program that allows for extended postdelivery hospital care for people with a substance use disorder at the time of delivery. The authority shall:
(a) Allow for up to five additional days of hospitalization stay for the birth parent;
(b) Provide the birth parent access to integrated care and medical services including, but not limited to, access to clinical health, medication management, behavioral health, addiction medicine, specialty consultations, and psychiatric providers;
(c) Provide the birth parent access to social work support which includes coordination with the department of children, youth, and families to develop a plan for safe care;
(d) Allow dedicated time for health professionals to assist in facilitating early bonding between the birth parent and infant by helping the birth parent recognize and respond to their infant's cues; and
(e) Establish provider requirements and pay only those qualified providers for the services provided through the program.
(2) In order to provide technical assistance to participating hospitals regarding the postdelivery and transitional care program, the authority shall contract with the Washington state chapter of a national organization that provides a physician-led professional community for those who prevent, treat, and promote remission and recovery from the disease of addiction and whose comprehensive set of guidelines for determining placement, continued stay, and transfer or discharge of enrollees with substance use disorders and co-occurring disorders have been incorporated into medicaid managed care contracts.
(3) In administering the program, the authority shall seek any available federal financial participation under the medical assistance program, as codified at Title XIX of the federal social security act, the state children's health insurance program, as codified at Title XXI of the federal social security act, the federal family first prevention services act, and any other federal funding sources that are now available or may become available.
[
2024 c 213 s 1
.]
RCW 74.09.837
Maternity support services program
—
Updates
—
Rule making.
(1) Subject to the amounts appropriated for this specific purpose, the authority shall update the maternity support services program to address perinatal outcomes and increase equity and healthier birth outcomes. By January 1, 2026, the authority shall:
(a) Update current screening tools to be culturally relevant, include current risk factors, ensure the tools address health equity, and include questions identifying various social determinants of health that impact a healthy birth outcome and improve health equity;
(b) Ensure care coordination, including sharing screening tools with the patient's health care providers as necessary;
(c) Develop a mechanism to collect the results of the maternity support services screenings and evaluate the outcomes of the program. At minimum, the program evaluation shall:
(i) Identify gaps, strengths, and weaknesses of the program; and
(ii) Make recommendations for how the program may improve to better align with the authority's maternal and infant health initiatives; and
(d) Increase the allowable benefit and reimbursement rates with the goal of increasing utilization of services to all eligible maternity support services clients who choose to receive the services.
(2) The authority shall adopt rules to implement this section.
[
2024 c 213 s 2
.]
RCW 74.09.839
Apple health pregnancy coverage.
By November 1, 2024, the income standards for a pregnant person eligible for Washington apple health pregnancy coverage shall have countable income equal to or below 210 percent of the federal poverty level.
[
2024 c 213 s 3
.]
RCW 74.09.840
Prior authorization.
(1) Beginning January 1, 2024, the authority shall require each managed care organization to comply with the following standards related to prior authorization for health care services and prescription drugs:
(a) The managed care organization shall meet the following time frames for prior authorization determinations and notifications to a participating provider or facility that submits the prior authorization request through an electronic prior authorization process, as designated by each managed care organization:
(i) For electronic standard prior authorization requests, the managed care organization shall make a decision and notify the provider or facility of the results of the decision within three calendar days, excluding holidays, of submission of an electronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the managed care organization to make a decision, the managed care organization shall request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization request.
(ii) For electronic expedited prior authorization requests, the managed care organization shall make a decision and notify the provider or facility of the results of the decision within one calendar day of submission of an electronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the managed care organization to make a decision, the managed care organization shall request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization request.
(b) The managed care organization shall meet the following time frames for prior authorization determinations and notifications to a participating provider or facility that submits the prior authorization request through a process other than an electronic prior authorization process described in subsection (2) of this section:
(i) For nonelectronic standard prior authorization requests, the managed care organization shall make a decision and notify the provider or facility of the results of the decision within five calendar days of submission of a nonelectronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the managed care organization to make a decision, the managed care organization shall request any additional information from the provider or facility within five calendar days of submission of the nonelectronic prior authorization request.
(ii) For nonelectronic expedited prior authorization requests, the managed care organization shall make a decision and notify the provider or facility of the results of the decision within two calendar days of submission of a nonelectronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the managed care organization to make a decision, the managed care organization shall request any additional information from the provider or facility within one calendar day of submission of the nonelectronic prior authorization request.
(c) In any instance in which a managed care organization has determined that a provider or facility has not provided sufficient information for making a determination under (a) and (b) of this subsection, a managed care organization may establish a specific reasonable time frame for submission of the additional information. This time frame must be communicated to the provider and enrollee with a managed care organization's request for additional information.
(d) The prior authorization requirements of the managed care organization must be described in detail and written in easily understandable language. The managed care organization shall make its most current prior authorization requirements and restrictions, including the written clinical review criteria, available to providers and facilities in an electronic format upon request. The prior authorization requirements must be based on peer-reviewed clinical review criteria. The clinical review criteria must be evidence-based criteria and must accommodate new and emerging information related to the appropriateness of clinical criteria with respect to black and indigenous people, other people of color, gender, and underserved populations. The clinical review criteria must be evaluated and updated, if necessary, at least annually.
(2)(a) Each managed care organization shall establish and maintain a prior authorization application programming interface that is consistent with final rules issued by the federal centers for medicare and medicaid services and published in the federal register, and that indicates that a prior authorization denial or authorization of a service less intensive than that included in the original request is an adverse benefit determination and is subject to the managed care organization's grievance and appeal process under RCW 48.43.535
.
(b) Each managed care organization shall establish and maintain an interoperable electronic process or application programming interface that automates the process for in-network providers to determine whether a prior authorization is required for a covered prescription drug. The interoperable electronic process or application programming interface must support the exchange of prior authorization requests and determinations for prescription drugs, including information on covered alternative prescription drugs, beginning January 1, 2027, and must:
(i) Allow providers to identify prior authorization information and documentation requirements;
(ii) Facilitate the exchange of prior authorization requests and determinations from its electronic health records or practice management system; and
(iii) Indicate that a prior authorization denial or authorization of a drug other than the one included in the original prior authorization request is an adverse benefit determination and is subject to the managed care organization's grievance and appeal process under RCW 48.43.535
.
(c) Regardless of whether federal rules related to standards for using an application programming interface to communicate prior authorization status to providers are revoked, delayed, suspended, or not finalized after February 8, 2024, the requirements of (a) of this subsection shall be enforced beginning January 1, 2027.
(3) Nothing in this section applies to prior authorization determinations made pursuant to RCW 71.24.618
or
74.09.490
.
(4) For the purposes of this section:
(a) "Expedited prior authorization request" means a request by a provider or facility for approval of a health care service or prescription drug where:
(i) The passage of time:
(A) Could seriously jeopardize the life or health of the enrollee;
(B) Could seriously jeopardize the enrollee's ability to regain maximum function; or
(C) In the opinion of a provider or facility with knowledge of the enrollee's medical condition, would subject the enrollee to severe pain that cannot be adequately managed without the health care service or prescription drug that is the subject of the request; or
(ii) The enrollee is undergoing a current course of treatment using a nonformulary drug.
(b) "Standard prior authorization request" means a request by a provider or facility for approval of a health care service or prescription drug where the request is made in advance of the enrollee obtaining a health care service or prescription drug that is not required to be expedited.
[
2025 c 25 s 3
;
2023 c 382 s 3
.]
RCW 74.09.850
Conflict with federal requirements.
If any part of this chapter is found to conflict with federal requirements which are a prescribed condition to the allocation of federal funds to the state, the conflicting part of this chapter is hereby declared to be inoperative solely to the extent of the conflict, and such finding or determination shall not affect the operation of the remainder of this chapter.
[
1981 2nd ex.s. c 3 s 7
.]
NOTES:
Severability
—
1981 2nd ex.s. c 3:
See note following RCW 74.09.510
.
RCW 74.09.860
Request for proposals
—
Foster children
—
Integrated managed health and behavioral health care
—
Continuation of health care benefits following reunification.
(1) The authority shall issue a request for proposals to provide integrated managed health and behavioral health care for foster children receiving care through the medical assistance program. Behavioral health services provided under chapters
71.24
and
71.34
RCW must be integrated into the managed care organization for foster children beginning January 1, 2019. The request for proposals must address the program elements described in section 110, chapter 225, Laws of 2014, including development of a service delivery system, benefit design, reimbursement mechanisms, incorporation or coordination of services currently provided by the regional support networks, and standards for contracting with health organizations. The request for proposals must be issued and completed in time for services under the integrated managed care plan to begin on October 1, 2016.
(2) The parent or guardian of a child who is no longer a dependent child pursuant to chapter
13.34
RCW may choose to continue in the transitional foster care eligibility category for up to twelve months following reunification with the child's parents or guardian if the child:
(a) Is under eighteen years of age;
(b) Was in foster care under the legal responsibility of the department of social and health services, the department of children, youth, and families, or a federally recognized Indian tribe located within the state; and
(c) Meets income and other eligibility standards for medical assistance coverage.
[
2023 c 51 s 52
;
2018 c 27 s 1
;
2015 c 283 s 1
.]
NOTES:
Effective date
—
2018 c 27:
"This act takes effect July 1, 2018." [
2018 c 27 s 2
.]
RCW 74.09.865
Postinpatient housing program for young adults.
(1) Subject to the availability of amounts appropriated for this specific purpose, the postinpatient housing program for young adults is established to provide supportive transitional housing with behavioral health support focused on securing long-term housing for young adults exiting inpatient behavioral health treatment.
(2) To be eligible for the postinpatient housing program for young adults created under this section, a person must:
(a) Be 18 through 24 years of age;
(b)(i) Be exiting inpatient behavioral health treatment; or
(ii) Have exited inpatient behavioral health treatment within the last month and be engaged in a recovery plan; and
(c) Not have secured long-term housing.
(3) Subject to the availability of amounts appropriated for this specific purpose and to fulfill the requirements of this section, the authority shall:
(a) Provide funding to a community-based organization or organizations or federally recognized tribes within Washington or tribal organizations that serve American Indians and Alaska Natives in Washington with expertise in working with young people experiencing unaccompanied homelessness, behavioral health conditions, or both, to operate a residential program or programs as described in this subsection (3)(a). The organization selected to operate a residential program or programs in this subsection (3)(a) may choose whether or not to serve individuals eligible according to the criteria established in subsection (2) of this section. The residential program or programs must be voluntary for participants and may not be a secure facility, or a facility that limits residents' ingress and egress pursuant to chapter
71.24
RCW, or a facility at which individuals may be detained pursuant to chapter
71.05
RCW. In addition, the authority shall consult with a transition support provider when soliciting and selecting a community-based organization or organizations under this subsection. The funding provided under this subsection must be used to:
(i) Establish at least two residential programs with six to 10 beds with one program on either side of the Cascade mountain range;
(ii) Establish a developmentally and culturally responsive environment that values healing and recovery;
(iii) Engage peers with behavioral health experience in the support and recovery of individuals served by the program;
(iv) Serve individuals determined eligible according to the criteria established in subsection (2) of this section for up to 90 days; and
(v) Support and strengthen the ongoing healing and learning that occurred for those served by the program during their inpatient treatment;
(b) Provide additional funding to the transition support provider for:
(i) Consultation and training services to the residential program or programs selected under (a) of this subsection;
(ii) Return-to-community planning for the individuals served by the residential programs described under (a) of this subsection; and
(iii) To the extent possible, making contact with individuals served by the residential programs described under (a) of this subsection at regular intervals after those individuals leave the residential program and reporting this information to the authority;
(c) Provide flexible funding to support individuals served by the residential programs described under (a) of this subsection. The flexible funding provided under this subsection may be provided to support the immediate needs of the individual. Uses of the flexible funding provided under this subsection may include, but are not limited to, the following:
(i) Car repair or other transportation assistance;
(ii) Rental application fees, a security deposit, or short-term rental assistance; or
(iii) Other uses that will help support the person's housing stability, education, or employment, or meet immediate basic needs; and
(d) Provide funding to contract with individuals or entities that provide behavioral health support to individuals determined eligible according to the criteria established in subsection (2) of this section, which may include, but are not limited to:
(i) On-site and community-based behavioral health supports;
(ii) Peer supports; and
(iii) Medication management.
(4) For purposes of this section, "transition support provider" means a community-based organization selected by the authority that continues to:
(a) Provide information and support services related to safe housing and support services for youth exiting inpatient behavioral health treatment; and
(b) Organize a coalition of community housing providers, federally recognized tribes within Washington or tribal organizations that serve American Indians and Alaska Natives in Washington, inpatient behavioral health discharge planners, and young people with lived experience of behavioral health conditions or unaccompanied homelessness.
[
2024 c 175 s 2
.]
NOTES:
Findings
—
2024 c 175:
"(1) The legislature has committed to and invested in ensuring that young people exiting the system of care do so with safe housing and developmentally responsive services through the enactment of Substitute Senate Bill No. 6560 (2018) and Second Substitute House Bill No. 1905 (2022).
(2) The legislature finds that young people who exit behavioral health inpatient treatment are the largest group of people who become homeless within three to 12 months of all the young people who exit any publicly funded system of care, as identified in a 2023 report produced by the research and data analysis division of the department of social and health services.
(3) The legislature has invested significant funding in the behavioral health system and finds that ensuring a person's safe return to the community postinpatient treatment is a high priority and a major opportunity to end their experience with homelessness. In addition, the legislature finds that a young person who enters treatment demonstrates the courage to engage in their personal health and creates the opportunity for family and community reunification, career development, and a full life.
(4) The legislature further finds that it often takes more time and resources than expected during a person's inpatient treatment episode to identify a return to community plan that includes long-term, safe housing and a developmentally and culturally responsive support system that includes relationships, services, and passions.
(5) For these reasons, the legislature finds that having an interim housing option that provides a safe and soft landing postinpatient treatment, located on each side of the state, that has well-trained staff and peers who have behavioral health expertise, is a sound investment in our young people and our collective goals to prevent and end homelessness." [
2024 c 175 s 1
.]
RCW 74.09.870
Regional service areas
—
Establishment.
(1) Upon receipt of guidance for the creation of common regional service areas from the adult behavioral health system task force established in section 1, chapter 338, Laws of 2013, the authority shall establish regional service areas as provided in this section.
(2) Counties, through the Washington state association of counties, must be given the opportunity to propose the composition of regional service areas. Each service area must:
(a) Include a sufficient number of medicaid lives to support full financial risk managed care contracting for services included in contracts with the department or the authority;
(b) Include full counties that are contiguous with one another; and
(c) Reflect natural medical and behavioral health service referral patterns and shared clinical, health care service, behavioral health service, and behavioral health crisis response resources.
(3) The Washington state association of counties must submit their recommendations to the department, the authority, and the task force described in section 1, chapter 225, Laws of 2014 on or before August 1, 2014.
[
2018 c 201 s 2006
;
2014 c 225 s 2
. Formerly RCW 43.20A.893
.]
NOTES:
Findings
—
Intent
—
Effective date
—
2018 c 201:
See notes following RCW 41.05.018
.