Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-500 - Medical definitions › Section 182-500-0020 - Definitions-C

Current through Register Vol. 24-14, July 15, 2024
"Caretaker relative"
means a relative of a
				  dependent child by blood, adoption, or marriage with whom the child is living,
				  who assumes primary responsibility for the child's care, and who is one of the
				  following:
(a) The child's father,
				mother, grandfather, grandmother, brother, sister, stepfather, stepmother,
				stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece.
(b) The spouse of such parent or relative
				(including same sex marriage or domestic partner), even after the marriage is
				terminated by death or divorce.
(c)
				Other relatives including relatives of half-blood, first cousins once removed,
				people of earlier generations (as shown by the prefixes of great, great-great,
				or great-great-great), and natural parents whose parental rights were
				terminated by a court order.
"Carrier"
means an organization that contracts
				  with the federal government to process claims under medicare Part B.
"Categorically needy (CN) or categorically needy
				  program (CNP)"
is the state and federally funded health care program
				  established under Title XIX of the Social Security Act for people within
				  medicaid-eligible categories, whose income and/or resources are at or below set
				  standards.
"Categorically needy income level (CNIL)"
is the
				  standard used by the agency to determine eligibility under a categorically
				  needy program.
"Categorically needy (CN) scope of care"
is the
				  range of health care services included within the scope of service categories
				  described in WAC
				  182-501-0060
				  available to people eligible to receive benefits under a CN program. Some
				  state-funded health care programs provide CN scope of care.
"Center of excellence"
- A hospital, medical
				  center, or other health care provider that meets or exceeds standards set by
				  the agency for specific treatments or specialty care.
"Centers for Medicare and Medicaid Services
				  (CMS)"
- The federal agency that runs the medicare, medicaid, and
				  children's health insurance programs, and the federally facilitated
				  marketplace.
"Children's health program or children's health care
				  programs"
See "Apple health for kids."
"Client"
means a person who is an applicant for,
				  or recipient of, any Washington apple health program, including managed care
				  and long term care. See definitions for "applicant" and "recipient" in
				  RCW
				  74.09.741.
"Community spouse."
See "spouse" in WAC
				  182-500-0100.
"Continuous eligibility"
means a person continues
				  to receive their apple health coverage without interruption throughout their
				  certification period regardless of changes in income, household size,
				  immigration or citizenship status, or any other factor of eligibility other
				  than moving out-of-state or death.
"Core provider agreement"
is a written contract
				  whose terms and conditions bind each provider in the fee-for-service program to
				  applicable federal laws, state laws, and the agency's rules, provider alerts,
				  billing guides, and other subregulatory guidance. See WAC
				  182-502-0005.
				  The core provider agreement is a unilateral contract.
"Cost-sharing"
means any expenditure required by
				  or on behalf of an enrollee with respect to essential health benefits; such
				  term includes deductibles, coinsurance, copayments, or similar charges, but
				  excludes premiums, balance billing amounts for nonnetwork providers, and
				  spending for noncovered services.
"Cost-sharing reductions"
means reductions in
				  cost-sharing for an eligible person enrolled in a silver level plan in the
				  health benefit exchange or for a person who is an American Indian or Alaska
				  native enrolled in a qualified health plan (QHP) in the exchange.
"Couple."
See "spouse" in WAC
				  182-500-0100.
"Covered service"
is a health care service
				  contained within a "service category" that is included in a Washington apple
				  health (WAH) benefits package described in WAC
				  182-501-0060.
				  For conditions of payment, see WAC
				  182-501-0050(5).
				  A noncovered service is a specific health care service (for example, cosmetic
				  surgery), contained within a service category that is included in a WAH
				  benefits package, for which the agency or the agency's designee requires an
				  approved exception to rule (ETR) (see WAC
				  182-501-0160).
				  A noncovered service is not an excluded service (see WAC
				  182-501-0060).
"Creditable coverage"
means most types of public
				  and private health coverage, except Indian health services, that provide access
				  to physicians, hospitals, laboratory services, and radiology services. This
				  term applies to the coverage whether or not the coverage is equivalent to that
				  offered under premium-based programs included in Washington apple health (WAH).
				  Creditable coverage is described in
				  42
				  U.S.C.
				  300gg-3(c)(1).
11-14-075, recodified as §
											182-500-0020, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and 2011 1st sp.s. c 15. 11-14-053,
					 § 388-500-0020, filed 6/29/11, effective
					 7/30/11.