reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-554 - Enteral nutrition program › Section 182-554-200 - Enteral nutrition - Definitions

Current through Register Vol. 24-14, July 15, 2024
The following terms and definitions and those found in
				  chapter 182-500 WAC apply to this chapter:
"BMI"
see
"body mass index."
"Body mass index (BMI)"
- Means a number that
				  shows body weight relative to height, and is calculated using inches and pounds
				  or meters and kilograms.
"Dietitian"
- Means a dietitian who is
				  registered with the Academy of Nutrition and Dietetics and who is certified by
				  the Washington state department of health (DOH).
"Enteral nutrition"
- Means the use of medically
				  necessary nutritional products alone, or in combination with traditional food,
				  when a client is unable to consume enough traditional food to meet nutritional
				  requirements. Enteral nutrition may be provided orally or via feeding
				  tube.
"Enteral nutrition equipment"
- Means durable
				  medical feeding pumps and intravenous (IV) poles used in conjunction with
				  nutrition supplies to dispense formula to a client.
"Enteral nutrition product"
- Means formulas or
				  solutions that help a person meet nutritional requirements.
"Enteral nutrition supplies"
- Means the
				  supplies, such as nasogastric, gastrostomy and jejunostomy tubes, necessary to
				  allow nutritional support via the alimentary canal or any route connected to
				  the gastrointestinal system.
"Growth chart"
- Means a series of percentile
				  curves that illustrate the distribution of select body measurements (i.e.,
				  length, height, weight, and age) in children published by the World Health
				  Organization (WHO), and Centers for Disease Control and Prevention (CDC),
				  National Center for Health Statistics. CDC growth charts: United States.
http://www.cdc.gov/growthcharts/
.
"Orally administered enteral nutrition products"
- Means formulas or solutions that a person consumes orally for nutritional
				  support.
"Tube- delivered enteral nutrition products"
-
				  Means the nutritional support that a person receives through a tube into a
				  person's stomach or small intestine.
"Women, infants, and children (WIC) program"
(Also known as WIC program) - See WAC
				  246-790-001.
11-14-075, recodified as §
											182-554-200, filed 6/30/11,
					 effective 7/1/11. Statutory Authority: 2009 c 564 § 1109,
					 RCW
					 74.04.050, and
					 74.08.090. 10-01-138, §
					 388-554-200, filed 12/21/09, effective 1/21/10. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.530 and chapter 74.09 RCW.
					 05-04-059, § 388-554-200, filed 1/28/05, effective
					 3/1/05.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-554 - Enteral nutrition program › Section 182-554-300 - Enteral nutrition - Client eligibility

Current through Register Vol. 24-14, July 15, 2024
(1) To receive oral or tube-delivered enteral
				nutrition products, equipment, and related supplies, a person must be eligible
				for one of the Washington apple health programs under WAC
				182-501-0060 or be eligible for
				the alien emergency medical (AEM) program under WAC
				182-507-0110.
(2) For persons who reside in a nursing
				facility, adult family home, assisted living facility, boarding home, or any
				other residence where the provision of food is included in the daily rate, oral
				enteral nutrition products are the responsibility of the facility under
				chapters 388-76, 388-97 and 388-78A WAC.
(3) For persons who reside in a state-owned
				facility (i.e., state school, developmental disabilities facility, mental
				health facility, Western State Hospital, and Eastern State Hospital) enteral
				nutrition products, equipment, and related supplies are the responsibility of
				the state-owned facility to provide.
(4) A person who has elected to receive the
				agency's hospice benefit must arrange for enteral nutrition products, equipment
				and related supplies directly through the hospice benefit.
(5) A child who qualifies for supplemental
				nutrition from the women, infants, and children (WIC) program must receive
				supplemental nutrition directly from that program . The child may be eligible
				to receive enteral products from the agency if:
(a)The child's need for a product exceeds
				WIC's allowed amount; or
(b) The
				product is not available through the WIC program.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-554 - Enteral nutrition program › Section 182-554-400 - Enteral nutrition-Provider requirements

Current through Register Vol. 24-14, July 15, 2024
(1) The following providers are eligible to
				enroll or contract with the medicaid agency to provide orally administered and
				tube-delivered en-teral nutrition products, equipment, and related supplies:
(a) A pharmacy provider; or
(b) A durable medical equipment
				provider.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-554 - Enteral nutrition program › Section 182-554-500 - Covered orally administered enteral nutrition products, equipment and related supplies - Clients age twenty and younger only

Current through Register Vol. 24-14, July 15, 2024
(1) Subject to the prior authorization
				requirements and limitations in this section, and in the
Enteral
				Nutrition Program Billing Guide
, the agency covers orally administered
				enteral nutrition products for clients age twenty and younger.
(2) The agency's enteral nutrition program is
				not a food benefit. All clients under age five who qualify for supplemental
				nutrition from the women, infants, and children (WIC) nutrition program must
				receive products and formulas directly from that program. The agency may cover
				orally administered enteral nutrition products for a client under age five if
				the client has a WIC information form that verifies:
(a) The client is not eligible for the WIC
				program;
(b) The client is eligible
				for the WIC program, but the client's need for an oral enteral nutrition
				product or formula exceeds the amount allowed by WIC rules; or
(c) The client is eligible for the WIC
				program, but a medically necessary product or formula is not available through
				the WIC program.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-554 - Enteral nutrition program › Section 182-554-525 - Covered orally administered enteral nutrition products, equipment and related supplies - Thickeners

Current through Register Vol. 24-14, July 15, 2024
(1) The
				medicaid agency covers, with prior authorization (PA) thickeners for clients
				with dysphagia who are younger than age one. The request for PA must include:
(a) Proof the client has dysphagia as
				documented by a speech therapist or an occupational therapist that specializes
				in dysphagia;
(b) A dysphagia diet
				plan and assessment for the client from a registered dietitian; and
(c) Documented medical necessity. The report
				recommending a thickener must be in the client's chart in the prescriber's
				office.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-554 - Enteral nutrition program › Section 182-554-550 - Covered orally administered enteral nutrition products, equipment and related supplies - Clients with amino acid, fatty acid, and carbohydrate metabolic disorders, and phenylketonuria

Current through Register Vol. 24-14, July 15, 2024
(1)
				The medicaid agency covers orally administered enteral nutrition products,
				equipment and related supplies for clients who have amino acid, fatty acid, and
				carbohydrate metabolic disorders, including phenylketonuria (PKU), if the
				client requires a specialized nutrition product.
(2) Providers must use the agency's
				authorization processes as follows:
(a)
				Providers must use the expedited prior authorization (EPA) process for clients
				age twenty and younger.
(b)
				Providers may use the exception to rule process for clients age twenty-one and
				older.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-554 - Enteral nutrition program › Section 182-554-600 - Covered enteral nutrition products, equipment and related supplies - Tube-delivered

Current through Register Vol. 24-14, July 15, 2024
(1)
General.
The agency covers tube-delivered enteral nutrition
				products, equipment, and related supplies, regardless of age if the client:
(a) Has a valid prescription under WAC
				182-554-400, which must be
				submitted within three months of the date the prescriber signed the
				prescription;
(b) Can manage tube
				feedings :
(i) Independently; or
(ii) With a caregiver's assistance;
				and
(c) Has at least one
				of the following medical conditions:
(i) A
				disease or condition that impairs the client's ability to ingest sufficient
				calories and nutrients or restricts calories and nutrients from reaching the
				client's gastrointestinal tract; or
(ii) A disease or condition of the small
				bowel that impairs digestion and absorption of an oral diet, either of which
				requires tube feedings to provide sufficient nutrients to maintain weight and
				strength that is properly proportioned to the client's overall health
				status.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-554 - Enteral nutrition program › Section 182-554-700 - Enteral nutrition products, equipment and related supplies - Authorization

Current through Register Vol. 24-14, July 15, 2024
(1)
General.
(a) Providers must
				obtain authorization for all covered orally administered or tube-delivered
				enteral nutrition products, equipment and related supplies as required in this
				chapter, the agency's published billing instructions, and when the clinical
				criteria in this chapter are not met.
(b)Authorization does not guarantee
				payment.
(c) Authorization
				requirements are not a denial of service.
(d)The agency may reject an incomplete
				authorization request and return it to the provider for further action. A
				returned request is not a denial of service.
(e) If a request for authorization exceeds
				limitations in this chapter, the agency evaluates the request under WAC
				182-501-0169.
(f) If the agency determines that a service
				was wrongfully authorized or did not meet the expedited prior authorization
				(EPA) criteria, the agency may recoup payment from the provider under chapters
				182-502 and 182-502A WAC.
(g) Upon
				request, a provider must furnish documentation to the agency that shows how the
				client's condition met the criteria for prior authorization (PA) or
				EPA.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-554 - Enteral nutrition program › Section 182-554-800 - Noncovered - Enteral nutrition products, equipment, and related supplies

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency does not cover the following:
(a)
				Nonmedical equipment, supplies, and related services (for example, backpacks,
				pouches, bags, baskets, or other carrying containers); and
(b) Orally administered enteral nutrition
				products for any client age twenty-one and older.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-554 - Enteral nutrition program › Section 182-554-900 - Reimbursement - Enteral nutrition products, equipment, and related supplies

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency:
(a) Determines reimbursement for
				enteral nutrition products, equipment, and related-supplies according to a set
				fee schedule;
(b) Considers
				medicare's current fee schedule when determining maximum allowable
				fees;
(c) Considers vendor rate
				increases or decreases as directed by the legislature;
(d) Evaluates and updates the maximum
				allowable fees for enteral nutrition products, equipment, and related supplies
				at least once per year.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-555 - Medical nutrition therapy › Section 182-555-0200 - Definitions

Current through Register Vol. 24-14, July 15, 2024
The following definitions and those found in chapter 182-500
				  WAC apply to this chapter:
"Enteral nutrition"
- See WAC
				  182-554-200.
"Medical nutrition therapy"
- Means an
				  interaction between the registered dietitian (RD) and the client or client's
				  guardian for the purpose of evaluating and making recommendations regarding the
				  client's nutritional status.
"Nutrition assessment"
- Means the collection
				  and documentation of information such as food or nutrition-related history;
				  biochemical data, medical tests and procedures; anthropometric measurements,
				  nutrition-focused physical findings and client history.
"Nutrition care process"
- Means a systematic
				  approach to providing high-quality nutrition care. Provides a framework for the
				  registered dietitian to individualize care, taking into account the client's
				  needs and values and evidence available to make decisions.
"Nutrition-related diagnosis"
- Means a
				  diagnosis within the scope of practice for an RD to diagnose and treat as
				  defined by the Academy of Nutrition and Dietetics.
"Registered dietitian"
- Means a dietitian who
				  is registered with the Academy of Nutrition and Dietetics and who is certified
				  by the Washington state department of health (DOH).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-555 - Medical nutrition therapy › Section 182-555-0300 - Eligibility

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency covers medical nutrition therapy for
				  clients who are referred to a registered dietitian for medical nutrition
				  therapy by a physician, physician assistant (PA), or an advanced registered
				  nurse practitioner (ARNP).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-555 - Medical nutrition therapy › Section 182-555-0400 - Provider requirements

Current through Register Vol. 24-14, July 15, 2024
Medical nutrition therapy services must be delivered by a
				  registered dietitian (RD) who:
(1) Has
				a current core provider agreement with the medicaid agency; and
(2) Has a national provider identifier
				(NPI).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-555 - Medical nutrition therapy › Section 182-555-0500 - Covered services

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency covers medically necessary medical nutrition therapy when related to a
				nutrition-related diagnosis for eligible clients, as described under WAC
				182-555-0300.
(2) The agency covers medical nutrition
				therapy, nutrition assessment, and counseling for conditions that are within
				the scope of practice for a registered dietitian (RD) to evaluate and
				treat.
(3) Medical nutrition
				therapy services may require prior authorization or expedited prior
				authorization, as described in WAC
				182-501-0163.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-555 - Medical nutrition therapy › Section 182-555-0600 - Documentation requirements

Current through Register Vol. 24-14, July 15, 2024
In addition to the health care record requirements found in
				  WAC
				  182-502-0020,
				  the medical nutrition therapy provider must maintain the following
				  documentation in the client's file:
(1) Referral from the provider, as described
				under WAC 182-555-0300;
(2) The
				medical nutrition therapy provider assessment following the nutrition care
				process:
(a) Nutrition assessment;
(b) Nutrition diagnosis, including the
				problem, etiology, signs, and symptoms (PES) statement;
(c) Nutrition intervention;
(d) Nutrition monitoring and
				evaluation.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-556 - Medical careOther services provided › Section 182-556-0100 - Chemical dependency treatment services

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency covers chemical dependency treatment
				  services under chapter 388-877B WAC for Washington apple health clients. The
				  agency's payment is limited to services performed by providers under WAC
				  182-502-0002.
11-14-075, recodified as §
											182-556-0100, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090. 11-11-014, § 388-556-0100,
					 filed 5/9/11, effective 6/9/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.035, and
					 74.50.055. 00-18-032, §
					 388-556-0100, filed 8/29/00, effective
					 9/29/00.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-556 - Medical careOther services provided › Section 182-556-0200 - Chiropractic services for children

Current through Register Vol. 24-14, July 15, 2024
(1)
				The medicaid agency pays only for chiropractic services:
(a) For clients who are:
(i) Under age twenty-one ; and
(ii) Referred by a screening provider under
				the healthy kids/early and periodic screening, diagnosis, and treatment (EPSDT)
				program.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-556 - Medical careOther services provided › Section 182-556-0300 - Personal care services

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency pays for personal care services for a
				  Title XIX categorically needy Washington apple health client under chapter
				  388-71 WAC, Home and community services and programs.
11-14-075, recodified as §
											182-556-0300, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090. 00-17-057, § 388-556-0300,
					 filed 8/9/00, effective 9/9/00.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-556 - Medical careOther services provided › Section 182-556-0400 - Limitations on services available to categorically needy Washington apple health clients

Current through Register Vol. 24-14, July 15, 2024
(1) Organ
				transplants are limited to the cornea, heart, heart-lung, kidney,
				kidney-pancreas, liver, pancreas, single lung, and bone marrow.
(2) The medicaid agency pays for treatment,
				dialysis, equipment, and supplies for acute and chronic nonfunctioning kidneys
				for a client in a home, hospital, or kidney center as described under WAC
				182-540-005.
(3) The agency pays for detoxification and
				medical stabilization to chemical-using pregnant women in a hospital.
(4) The agency pays for detoxification of
				acute alcohol or other drug intoxication only in a certified detoxification
				center or in a general hospital that has a detoxification provider agreement
				with the agency.
(5) The agency
				pays for outpatient chemical dependency treatment in programs qualified under
				chapter 275-25 WAC and certified under chapter 275-19 WAC or its
				successor.
(6) The agency may
				require a second opinion , or consultation, or both before approving any
				elective surgical procedure.
(7)
				The agency designates diagnoses that may require surgical intervention:
(a) Performed in other than a hospital
				in-patient setting; and
(b)
				Requiring prior agency approval for a hospital admission.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-556 - Medical careOther services provided › Section 182-556-0600 - Mental health services

Current through Register Vol. 24-14, July 15, 2024
Mental health-related services are available to an eligible
				  client under chapter 388-865 WAC and WAC
				  182-531-1400.
11-14-075, recodified as §
											182-556-0600, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090. 10-02-100, § 388-556-0600,
					 filed 1/6/10, effective 2/6/10. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.530,
					 71.24.035. 00-24-053, §
					 388-556-0600, filed 11/30/00, effective
					 12/31/00.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-557 - Health homes › Section 182-557-0050 - Health home-General

Current through Register Vol. 24-14, July 15, 2024
(1) The agency's
				health home program provides patient-centered care to participants who:
(a) Have at least one chronic condition as
				defined in WAC
				182-557-0100; and
(b) Are at risk of a second chronic condition
				as evidenced by a minimum predictive risk score of 1.5.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-557 - Health homes › Section 182-557-0200 - Health home program-Eligibility

Current through Register Vol. 24-14, July 15, 2024
(1)
				To be eligible for the health home program, a client must:
(a) Be a recipient of categorically needy
				health care coverage through:
(i)
				Fee-for-service, including full dual eligible clients; or
(ii) An agency-contracted managed care
				organization.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-557 - Health homes › Section 182-557-0225 - Health home services-Methodology for calculating a person's risk score

Current through Register Vol. 24-14, July 15, 2024
The agency uses eight steps to calculate a person's risk
				  score.
(1)
Step 1. Collect paid
				claims and health plan encounter data.
The agency obtains a set of paid
				fee-for-service claims and managed care encounters for a client.
(a) For clients age 17 and younger, the
				agency uses all paid claims and encounters within the last 24 months.
(b) For clients age 18 and older, the agency
				uses all paid claims and encounters within the last 15 months.
(i) The claims and encounters include the
				international classification of diseases (ICD) diagnosis codes and national
				drug codes (NDC) submitted by health care providers. These are used in steps 2
				and 3 to create a set of risk categories.
(ii) The agency uses two algorithms developed
				by the University of San Diego:
(A) Chronic
				illness and disability payment system (CDPS) which assigns ICD diagnosis codes
				to CDPS risk categories (see Table 3 in subsection (5)(b) of this section);
				and
(B) Medical Rx (MRx) which
				assigns NDCs to MRx risk categories (see Table 2 in subsection (3)(b) of this
				section).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-557 - Health homes › Section 182-557-0300 - Health home services-Confidentiality and data sharing

Current through Register Vol. 24-14, July 15, 2024
(1) Qualified health homes must comply with
				the confidentiality and data sharing requirements that apply to participants
				eligible under medicare and Title XIX medicaid programs and as specified in the
				health home contract.
(2) The
				agency and the department of social and health services (DSHS) share health
				care data with qualified health homes under the provisions of RCW 70.02.-050
				and the Health Insurance Portability and Accountability Act of 1996
				(HIPAA).
(3) The agency requires
				qualified health homes to monitor and evaluate participant activities and
				report to the agency as required by the health home contract.
Statutory Authority:
					 RCW
					 41.05.021 and
					 2011 c
					 316 . 13-12-002, §
											182-557-0300, filed 5/22/13,
					 effective 7/1/13. 11-14-075, recodified as §
											182-557-0300, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500,
					 74.09.520, and 2007 c 259, §
					 4. 07-20-048, § 388-557-0300, filed 9/26/07, effective
					 11/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-557 - Health homes › Section 182-557-0350 - Health home-Grievance and appeals

Current through Register Vol. 24-14, July 15, 2024
(1) Qualified health homes must have a
				grievances and appeals process in place that complies with the requirements of
				this section and must maintain records of all grievances and appeals.
(a)This section contains information about
				the grievance system for fee-for-service clients, including full dual eligible
				clients, for health home services. These participants must follow the process
				in chapter 182-526 WAC for appeals.
(b) Participants who are enrolled in an
				agency-contracted managed care organization must follow the process in WAC
				182-538-110 to file a grievance
				or an appeal for health home services.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-557 - Health homes › Section 182-557-0400 - Health home-Payment

Current through Register Vol. 24-14, July 15, 2024
Only an agency-contracted qualified health home may bill and
				  be paid for providing health home services described in this chapter. Billing
				  requirements and payment methodology are described in the contract between the
				  agency and the qualified health home.
11-14-075, recodified as §
											182-557-0400, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500,
					 74.09.520, and 2007 c 259, §
					 4. 07-20-048, § 388-557-0400, filed 9/26/07, effective
					 11/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-557 - Health homes › Section 182-557-0500 - Involuntary disenrollment from a health home

Current through Register Vol. 24-14, July 15, 2024
(1)
Involuntary disenrollment for
				health and safety concerns.
If a qualified health home or care
				coordinator believes there are unresolved health or safety concerns with a
				health home client, the medicaid agency reviews the health home's written
				request for involuntary disenrollment of the client from the health home
				program.
(a) Concerns about health and safety
				include, but are not limited to:
(i)
				Inappropriate or threatening behavior, such as inappropriate sexual or physical
				behavior;
(ii) Illegal or criminal
				activity;
(iii) Harassment;
				or
(iv) Environmental hazards, such
				as methamphetamine laboratories, dangerous animals, poor sanitation, or an
				unsafe home structure.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-558 - Premium payment program › Section 182-558-0010 - Premium payment program (PPP)

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency may pay a premium assistance subsidy for
				  comprehensive health insurance premiums and other cost-sharing (defined in WAC
				  182-500-0020 ) when
				  the agency determines it would be cost-effective to maintain a client's
				  available health care coverage.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-558 - Premium payment program › Section 182-558-0020 - Definitions

Current through Register Vol. 24-14, July 15, 2024
The following definitions, and those definitions found in
				  chapter 182-500 WAC, apply to this chapter.
"Average cost per user"
means the average
				  medicaid expenditure for a person of the same age, sex, and eligibility type as
				  the applicant, per fiscal year, as calculated by the agency.
"Comprehensive"
means coverage comparable to the
				  services offered under the agency's medicaid state plan that provides at least
				  the following: Physician-related services, inpatient hospital services,
				  outpatient hospital services, prescription drugs, immunizations, and laboratory
				  and X-ray costs.
"Cost-effective"
means it would cost less for
				  the agency to pay premium assistance than not to pay premium assistance. The
				  agency determines cost-effectiveness by comparing the anticipated cost of
				  premiums, cost-sharing, and administrative costs to:
(a) The average cost per user; or
(b) The medicaid expenditures to be incurred
				if the client does not receive the premium assistance, based on the client's
				documented medical condition.
"Employer-sponsored group health insurance"
means a comprehensive group health plan provided through an employer or other
				  entity, for which the employer or entity pays some portion of the cost. Group
				  health plans must cover all applicants whose employment qualifies them for
				  coverage and cannot increase the cost for an applicant with a preexisting
				  condition.
"Flexible health spending arrangement"
means the
				  portion of an employee's wages set aside in an account to pay for qualified
				  expenses such as medical or child care costs.
"Health savings account"
means a medical savings
				  account available to employees enrolled in a high-deductible health insurance
				  plan.
"High-deductible health insurance plan"
means
				  coverage that meets the definition in Section 223 (c)(2) of the Internal
				  Revenue Code.
"Individual health insurance plan"
means any
				  plan sold on the individual market, as defined by
				  RCW
				  48.43.005.
"Overpayment"
has the same definition for
				  purposes of this chapter as that term is defined in
				  RCW
				  41.05A.010.
"Premium tax credit"
has the same definition for
				  purposes of this chapter as defined in
				  26 C.F.R.
				  1.36B-1 through
				  1.36B-5.
"Qualified employer-sponsored group health
				  insurance"
means a comprehensive group health plan provided through an
				  employer that is offered in a nondiscriminatory manner under
				  26 U.S.C. Sec.
				  105(h)(3), and for which the
				  employer subsidizes at least forty percent of the cost of the
				  premium.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-558 - Premium payment program › Section 182-558-0030 - Overview of eligibility

Current through Register Vol. 24-14, July 15, 2024
(1)
Eligibility.
To be eligible for the premium payment program (PPP):
(a) A member of the client's medical
				assistance unit, as described in chapter 182-506 WAC, must be receiving
				benefits under the medicaid agency's:
(i)
				Alternative benefits plan coverage;
(ii) Categorically needy coverage;
				or
(iii) Medically needy
				coverage.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-558 - Premium payment program › Section 182-558-0040 - PPP for a client with an individual health insurance plan

Current through Register Vol. 24-14, July 15, 2024
(1)
General
				rule.
Under section 1905(a) of the Social Security Act, the agency pays
				a premium assistance subsidy up to an eligible person's individual health
				insurance premium obligation when the agency determines it is cost
				effective.
(2)
Eligible
				persons.
An eligible person is any client who:
(a) Has a comprehensive individual health
				insurance plan; and
(b) Is
				receiving categorically needy, medically needy, or alternative benefit plan
				scope of coverage.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-558 - Premium payment program › Section 182-558-0050 - PPP for a client with an employer-sponsored group health insurance plan

Current through Register Vol. 24-14, July 15, 2024
(1)
General
				rule.
Under section 1906 of the Social Security Act, the agency pays a
				premium assistance subsidy:
(a) Up to an
				eligible person's employer-sponsored group health insurance plan premium
				obligation; and
(b) When the agency
				determines it is cost effective as defined in WAC
				182-558-0020.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-558 - Premium payment program › Section 182-558-0060 - PPP for a client with a qualified employer-sponsored group health insurance plan

Current through Register Vol. 24-14, July 15, 2024
(1)
General
				rule.
Under section 1906A of the Social Security Act, the agency pays an
				eligible person's premium assistance subsidy and other cost-sharing obligations
				when the agency determines it is cost-effective as defined in WAC
				182-558-0020.
(2)
Eligible persons.
An
				eligible person is:
(a) A client under age
				nineteen who is:
(i) Covered under a
				qualified employer-sponsored group health insurance plan as defined in WAC
				182-558-0020;
(ii) Receiving benefits under:
(A) Alternative benefits plan
				coverage;
(B) Categorically needy
				coverage; or
(C) Medically needy
				coverage.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-558 - Premium payment program › Section 182-558-0070 - Program monitoring

Current through Register Vol. 24-14, July 15, 2024
(1) The agency
				monitors payments under the premium payment program.
(2) Under
				RCW
				41.05A.110, the agency may recover any
				over-payment of a premium assistance subsidy or cost-sharing amount. Events
				that may cause an overpayment for purposes of this section include agency
				administrative error, client error, misrepresentation, or retroactive
				disenrollment from a health plan.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-558 - Premium payment program › Section 182-558-0080 - Administrative hearings

Current through Register Vol. 24-14, July 15, 2024
A client may request an administrative hearing under chapter
				  182-526 WAC if the client does not agree with an agency decision regarding
				  eligibility for the premium payment program, the amount of a premium assistance
				  subsidy, or an overpayment of a premium assistance subsidy.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-559 - Foundational community supports program › Section 182-559-100 - General

Current through Register Vol. 24-14, July 15, 2024
(1) Under the
				authority of the medicaid transformation project,
				RCW
				71.24.385, and subject to available funds,
				the medicaid agency covers targeted foundational community supports to eligible
				medicaid beneficiaries, which include the following benefits:
(a) Community support services; and
(b) Supported employment services.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-559 - Foundational community supports program › Section 182-559-150 - Definitions

Current through Register Vol. 24-14, July 15, 2024
The following definitions and those found in chapter 182-500
				  WAC apply to this chapter.
"Adverse benefit determination" means one or more of the
				  following:
(a) The denial or limited authorization of a requested
				  foundational community support services, including determinations based on the
				  type of service, requirements for medical necessity, appropriateness, setting,
				  or effectiveness of a service;
(b) The reduction, suspension, or termination of a previously
				  authorized service;
(c) The denial, in whole or in part, of payment for a
				  service;
(d) The failure to provide services in a timely manner, as
				  defined by the state; or
(e) The failure of the third-party administrator (TPA) to act
				  within the time frames provided in WAC 182-559-600 for standard resolution of
				  grievances and appeals.
"Community support services (also called supportive housing
				  services)" means active search and promotion of access to, and choice of, safe
				  and affordable housing that is appropriate to the client's age, culture and
				  needs. These services include:
(a) Providing services to eligible clients who are homeless
				  or at risk of becoming homeless through outreach, engagement and coordination
				  of services with shelter and housing;
(b) Ensuring the availability of community support services,
				  with an emphasis on supporting clients in their own home or where they live in
				  the community; and
(c) Coordinating with public housing entities, homeless
				  continuums of care and affordable housing developers.
"Individual placement and support (IPS)" refers to an
				  evidence-based approach to supported employment services based on the following
				  principles:
(a) Services are open to all eligible clients who wish to
				  work;
(b) Competitive employment is the goal;
(c) Integrated with other services provided to the
				  client;
(d) Personalized benefits planning;
(e) Job search begins soon after the client expresses
				  interest in working;
(f) Job search based on client preferences;
(g) Supports are not time-limited; and
(h) Client preferences are honored.
"Supported employment" means coordination with state and
				  local entities to provide assistance and support, such as skills assessment,
				  training, education and counseling to eligible clients who want to work.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-559 - Foundational community supports program › Section 182-559-200 - Eligible providers

Current through Register Vol. 24-14, July 15, 2024
(1) Providers of
				community support services and supported employment services under this
				authority must be:
(a) Health care
				professionals, entities, or contractors as defined by WAC
				182-502-0002;
(b) Agencies, centers, or facilities as
				defined by WAC
				182-502-0002;
(c) Health home providers as described in WAC
				182-557-0050;
(d) Behavioral health providers licensed and
				certified according to chapter 246-809 WAC; or
(e) Housing, employment, social service, or
				related agencies with demonstrated experience and ability to provide community
				support services, supported employment, or equivalent services.
(i) Community support services experience may
				be demonstrated by:
(A) Two years' experience
				in the coordination of supportive housing or in the coordination of independent
				living services in a social service setting under qualified supervision;
				or
(B) Certification in supportive
				housing services (WAC
				246-341-0722
				).
(ii) Supported
				employment experience may be demonstrated by one or more of the following:
(A) Accredited by the commission on
				accreditation of rehabilitation facilities (CARF) in employment
				services;
(B) Certified in
				employment services (WAC
				246-341-0720
				or
				246-341-0722
				); or
(C) All staff that will be
				performing supported employment services meet one of the following criteria:
(I) Be a certified employment support
				professional (CESP) by the employment support professional certification
				council (ESPCC);
(II) Be a
				certified rehabilitation counselor (CRC) by the commission of rehabilitation
				counselor certification (CRCC);
(III) Have a bachelor's degree or higher in
				human or social services from an accredited college or university and at least
				two years of demonstrated experience providing supported employment or similar
				services; or
(IV) Have four or more
				years of demonstrated experience providing supported employment or similar
				services.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-559 - Foundational community supports program › Section 182-559-300 - Eligibility for community support services

Current through Register Vol. 24-14, July 15, 2024
To be eligible for community support services, a client
				  must:
(1) Be age 16 or
				older;
(2) Be eligible for
				Washington apple health (medicaid);
(3) Meet at least one of the following health
				criteria and be expected to benefit from community support services:
(a) Clients assessed by a licensed behavioral
				health agency, under chapter 246-341 WAC, to have a behavioral health need,
				which is defined as one or both of the following criteria:
(i) Mental health needs, including a need for
				improvement, stabilization, or prevention of deterioration of functioning
				(including the ability to live independently without support) resulting from
				the presence of a mental illness; or
(ii) Substance use needs determined by an
				assessment using the American Society of Addiction Medicine (ASAM) criteria
				indicates that the client meets at least ASAM level 1.0, indicating the need
				for outpatient substance use disorder (SUD) treatment. The ASAM is a
				multidimensional assessment approach for determining a client's need for SUD
				treatment.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-559 - Foundational community supports program › Section 182-559-350 - Eligibility for supported employment services

Current through Register Vol. 24-14, July 15, 2024
To be eligible for supported employment services, a client
				  must:
(1) Be age sixteen or
				older;
(2) Be eligible for apple
				health (medicaid);
(3) Desire to
				obtain employment;
(4) Meet at
				least one of the following health criteria and is expected to benefit from
				supported employment services:
(a) Clients
				assessed by a licensed behavioral health agency, under chapter 246-341 WAC, to
				have a behavioral health need, which is defined as one or both of the following
				criteria:
(i) Mental health needs, including a
				need for improvement, stabilization, or prevention of deterioration of
				functioning (including ability to live independently without support) resulting
				from the presence of a mental illness; or
(ii) Substance use needs determined by an
				assessment using the American Society of Addiction Medicine (ASAM) criteria
				indicates that the client meets at least ASAM level 1.0, indicating the need
				for outpatient substance use disorder (SUD) treatment. The ASAM is a
				multi-dimensional assessment approach for determining a client's need for SUD
				treatment.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-559 - Foundational community supports program › Section 182-559-400 - Payment

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency pays for community support services and
				  supported employment described in WAC
				  182-559-100
				  when no other public funds are already dedicated to providing comparable
				  services to the client, unless the provider can demonstrate that the client
				  requires services that are:
(1)
				Outside the scope of services provided by the program already in place or for
				which the client is otherwise eligible; and
(2) Within the scope of the services
				identified as reimbursable in this section.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-559 - Foundational community supports program › Section 182-559-500 - Foundational community supports program - Limitation of scope of benefits

Current through Register Vol. 24-14, July 15, 2024
Nothing in this chapter shall be construed as providing a
				  legal right to any individual to any of the services referenced in this
				  chapter. The services provided under this chapter are strictly limited to the
				  authority granted to the state under the medicaid transformation project and
				  available funds, as determined solely by the authority. Nothing in this section
				  is intended to limit the right of an applicant or a beneficiary to request an
				  administrative hearing under applicable law.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-559 - Foundational community supports program › Section 182-559-600 - Grievance and appeals system

Current through Register Vol. 24-14, July 15, 2024
(1) This
				section contains information about the third-party administrator (TPA)
				grievance and appeal system and the medicaid agency's administrative hearing
				process for clients under the foundational community supports program.
(a) The TPA must have a grievance and appeal
				system and access to an agency administrative hearing to allow clients to file
				grievances and seek review of a TPA adverse benefit determination as defined in
				WAC
				182-559-150.
(b) The agency's administrative hearing rules
				in chapter 182-526 WAC apply to agency administrative hearings requested by a
				client to review the resolution of a client's appeal of a TPA adverse benefit
				determination.
(c) If a conflict
				exists between the requirements of this chapter and specific program rules, the
				requirements of this chapter prevail.
(d) The TPA's policies and procedures
				regarding the grievance system must be approved by the agency.
(e) The TPA must maintain records of
				grievances and appeals.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-560 - Achieving a Better Life Experience (ABLE) Act › Section 182-560-100 - Achieving a Better Life Experience (ABLE) Act

Current through Register Vol. 24-14, July 15, 2024
This rule describes a qualified achieving a better life
				  experience (ABLE) account and its effect on the determination of eligibility
				  for Washington apple health coverage.
(1) A qualified ABLE account:
(a) Is established and maintained by a state,
				or its designated agency or entity;
(b) Meets federal requirements under 26
				U.S.C. Sec. 529A; and
(c) Is used
				to save funds for the disability related expenses of the account's designated
				beneficiary.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-561 - Community Behavioral Health Support Services Benefit › Section 182-561-0100 - General

Current through Register Vol. 24-14, July 15, 2024
(1)
Administration.
The medicaid agency, in conjunction with the
				department of social and health services, administers the community behavioral
				health support services (CBHS) benefit.
(2)
Services.
The CBHS benefit
				tailors services designed to assist eligible clients to acquire, retain,
				restore, and improve the self-help, socialization, and adaptive skills
				necessary to reside successfully in home and community-based
				settings.
(3)
Applicability.
The rules in this chapter apply to benefits
				administered through fee-for-service delivery or a managed care
				organization.
(4)
CBHS
				benefits determined under this chapter.
(a) The agency determines eligibility for
				CBHS benefits based on the rules in this chapter.
(b) Apple health rules requiring medical
				necessity do not apply to the CBHS benefit.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-561 - Community Behavioral Health Support Services Benefit › Section 182-561-0200 - Definitions

Current through Register Vol. 24-14, July 15, 2024
The following definitions and those found in chapter 182-500
				  WAC apply to this chapter:
"Activities of daily living (ADL)" means the same as in WAC
				  388-106-0010.
"Home and community services (HCS)" means the division of the
				  department of social and health services (DSHS) that manages the state's
				  comprehensive long-term care system that provides in-home, residential, and
				  nursing home services to clients with functional
				  disabilities.