WAC 388-500-0005
Medical definitions. Unless defined in
this chapter or in other chapters of the Washington
Administrative Code, use definitions found in the Webster's
New World Dictionary. This section contains definitions of
words and phrases the department uses in rules for medical
programs. Definitions of words used for both medical and
financial programs are defined under WAC 388-22-030.
"Assignment of rights" means the client gives the state
the right to payment and support for medical care from a third
party.
"Base period" means the time period used in the limited
casualty program which corresponds with the months considered
for eligibility.
"Beneficiary" means an eligible person who receives:
*A federal cash Title XVI benefit; and/or
*State supplement under Title XVI; or
*Benefits under Title XVIII of the Social Security Act.
"Benefit period" means the time period used in
determining whether Medicare can pay for covered Part A
services. A benefit period begins the first day a beneficiary
is furnished inpatient hospital or extended care services by a
qualified provider. The benefit period ends when the
beneficiary has not been an inpatient of a hospital or other
facility primarily providing skilled nursing or rehabilitation
services for sixty consecutive days. There is no limit to the
number of benefit periods a beneficiary may receive. Benefit
period also means a "spell of illness" for Medicare payments.
"Cabulance" means a vehicle for hire designed and used to
transport a physically restricted person.
"Carrier" means:
*An organization contracting with the federal government
to process claims under Part B of Medicare; or
*A health insurance plan contracting with the department.
"Categorical assistance unit (CAU)" means one or more
family members whose eligibility for medical care is
determined separately or together based on categorical
relatedness.
"Categorically needy" means the status of a person who is
eligible for medical care under Title XIX of the Social
Security Act. See WAC 388-503-0310, chapter 388-517 WAC and
WAC 388-523-2305.
"Children's health program" means a state-funded medical
program for children under age eighteen:
*Whose family income does not exceed one hundred percent
of the federal poverty level; and
*Who are not otherwise eligible under Title XIX of the
Social Security Act.
"Coinsurance-Medicare" means the portion of reimbursable
hospital and medical expenses, after subtraction of any
deductible, which Medicare does not pay. Under Part A,
coinsurance is a per day dollar amount. Under Part B,
coinsurance is twenty percent of reasonable charges.
"Community services office (CSO)" means an office of the
department which administers social and health services at the
community level.
"Couple" means, for the purposes of an SSI-related
client, an SSI-related client living with a person of the
opposite sex and both presenting themselves to the community
as husband and wife. The department shall consider the income
and resources of such couple as if the couple were married
except when determining institutional eligibility.
"Deductible-Medicare" means an initial specified amount
that is the responsibility of the client.
*"Part A of Medicare-inpatient hospital deductible" means
an initial amount of the medical care cost in each benefit
period which Medicare does not pay.
*"Part B of Medicare-physician deductible" means an
initial amount of Medicare Part B covered expenses in each
calendar year which Medicare does not pay.
"Delayed certification" means department approval of a
person's eligibility for medicaid made after the established
application processing time limits.
"Department" means the state department of social and
health services.
"Early and periodic screening, diagnosis and treatment
(EPSDT)" also known as the "healthy kids" program, means a
program providing early and periodic screening, diagnosis and
treatment to persons under twenty-one years of age who are
eligible for Medicaid or the children's health program.
"Electronic fund transfers (EFT)" means automatic bank
deposits to a client's or provider's account.
"Emergency medical condition" means the sudden onset of a
medical condition (including labor and delivery) manifesting
itself by acute symptoms of sufficient severity (including
severe pain) such that the absence of immediate medical
attention could reasonably be expected to result in:
*Placing the patient's health in serious jeopardy;
*Serious impairment to bodily functions; or
*Serious dysfunction of any bodily organ or part.
"Emergency medical expense requirement" means a specified
amount of expenses for ambulance, emergency room or hospital
services, including physician services in a hospital, incurred
for an emergency medical condition that a client must incur
prior to certification for the medically indigent program.
"Essential spouse" see "spouse."
"Extended care patient" means a recently hospitalized
Medicare patient needing relatively short-term skilled nursing
and rehabilitative care in a skilled nursing facility.
"Garnishment" means withholding an amount from earned or
unearned income to satisfy a debt or legal obligation.
"Grandfathered client" means:
*A noninstitutionalized person who meets all current
requirements for Medicaid eligibility except the criteria for
blindness or disability; and
*Was eligible for Medicaid in December 1973 as blind or
disabled whether or not the person was receiving cash
assistance in December 1973; and
*Continues to meet the criteria for blindness or
disability and other conditions of eligibility used under the
Medicaid plan in December 1973; and
*An institutionalized person who was eligible for
Medicaid in December 1973 or any part of that month, as an
inpatient of a medical institution or resident of an
intermediate care facility that was participating in the
Medicaid program and for each consecutive month after December
1973 who:
*Continues to meet the requirements for Medicaid
eligibility that were in effect under the state's plan in
December 1973 for institutionalized persons; and
*Remains institutionalized.
"Health maintenance organization (HMO)" means an entity
licensed by the office of the insurance commissioner to
provide comprehensive medical services directly to an eligible
enrolled client in exchange for a premium paid by the
department on a prepaid capitation risk basis.
"Healthy kids," see "EPSDT."
"Home health agency" means an agency or organization
certified under Medicare to provide comprehensive health care
on a part-time or intermittent basis to a patient in the
patient's place of residence.
"Hospital" means an institution licensed as a hospital by
the department of health.
"Income for an SSI-related client," means the receipt by
an individual of any property or service which the client can
apply either directly, by sale, or conversion to meet the
client's basic needs for food, clothing, and shelter.
*"Earned income" means gross wages for services rendered
and/or net earnings from self-employment.
*"Unearned income" means all other income.
"Institution" means an establishment which furnishes
food, shelter, medically-related services, and medical care to
four or more persons unrelated to the proprietor. This
includes medical facilities, nursing facilities, and
institutions for the mentally retarded.
*"Institution-public" means an institution, including a
correctional institution that is the responsibility of a
governmental unit or over which a governmental unit exercises
administrative control.
*"Institution for mental diseases" means an institution
primarily engaged in providing diagnosis, treatment, or care
of persons with mental diseases including medical attention,
nursing care, and related services.
*"Institution for the mentally retarded or a person with
related conditions" means an institution that:
*Is primarily for the diagnosis, treatment or
rehabilitation of the mentally retarded or a person with
related conditions; and
*Provides, in a protected residential setting, on-going
care, twenty-four hour supervision, evaluation, and planning
to help each person function at the greatest ability.
*"Institution for tuberculosis" means an institution for
the diagnosis, treatment, and care of a person with
tuberculosis.
*"Medical institution" means an institution:
*Organized to provide medical care, including nursing and
convalescent care;
*With the necessary professional personnel, equipment and
facilities to manage the health needs of the patient on a
continuing basis in accordance with acceptable standards;
*Authorized under state law to provide medical care; and
*Staffed by professional personnel. Services include
adequate physician and nursing care.
"Intermediary" means an organization having an agreement
with the federal government to process Medicare claims under
Part A.
"Legal dependent" means a person for whom another person
is required by law to provide support.
"Limited casualty program (LCP)" means a medical care
program for medically needy, as defined under WAC 388-503-0320
and for medically indigent, as defined under WAC 388-503-0370.
"Medicaid" means the federal aid Title XIX program under
which medical care is provided to persons eligible for:
*Categorically needy program as defined in WAC 388-503-0310; or
*Medically needy program as defined in WAC 388-503-0320.
"Medical assistance." See "Medicaid."
"Medical assistance administration (MAA)" means the unit
within the department of social and health services authorized
to administer the Title XIX Medicaid and the state-funded
medical care programs.
"Medical assistance unit (MAU)" means one or more family
members whose eligibility for medical care is determined
separately or together based on financial responsibility.
"Medical care services" means the limited scope of care
financed by state funds and provided to general assistance
(GAU) and ADATSA clients.
"Medical consultant" means a physician employed by the
department.
"Medical facility" see "Institution."
"Medically indigent (MI)" means a state-funded medical
program for a person who has an emergency medical condition
requiring hospital-based services.
"Medically necessary" is a term for describing requested
service which is reasonably calculated to prevent, diagnose,
correct, cure, alleviate or prevent worsening of conditions in
the client that endanger life, or cause suffering or pain, or
result in an illness or infirmity, or threaten to cause or
aggravate a handicap, or cause physical deformity or
malfunction. There is no other equally effective, more
conservative or substantially less costly course of treatment
available or suitable for the client requesting the service.
For the purpose of this section, "course of treatment" may
include mere observation or, where appropriate, no treatment
at all.
"Medically needy (MN)" is the status of a person who is
eligible for a federally matched medical program under Title
XIX of the Social Security Act, who, but for income above the
categorically needy level, would be eligible as categorically
needy. Effective January 1, 1996, an AFDC-related adult is
not eligible for MN.
"Medicare" means the federal government health insurance
program for certain aged or disabled clients under Titles II
and XVIII of the Social Security Act. Medicare has two parts:
*"Part A" covers the Medicare inpatient hospital,
post-hospital skilled nursing facility care, home health
services, and hospice care.
*"Part B" is the supplementary medical insurance benefit
(SMIB) covering the Medicare doctor's services, outpatient
hospital care, outpatient physical therapy and speech
pathology services, home health care, and other health
services and supplies not covered under Part A of Medicare.
"Medicare assignment" means the method by which the
provider receives payment for services under Part B of
Medicare.
"Month of application" means the calendar month a person
files the application for medical care. When the application
is for the medically needy program, at the person's request
and if the application is filed in the last ten days of that
month, the month of application may be the following month.
"Nursing facility" means any institution or facility the
department [of health] licenses as a nursing facility, or a
nursing facility unit of a licensed hospital, that the:
*Department certifies; and
*Facility and the department agree the facility may
provide skilled nursing facility care.
"Outpatient" means a nonhospitalized patient receiving
care in a hospital outpatient or hospital emergency
department, or away from a hospital such as in a physician's
office, the patient's own home, or a nursing facility.
"Patient transportation" means client transportation to
and from covered medical services under the federal Medicaid
and state medical care programs.
"Physician" means a doctor of medicine, osteopathy, or
podiatry who is legally authorized to perform the functions of
the profession by the state in which the services are
performed.
"Professional activity study (PAS)" means a compilation
of inpatient hospital data, conducted by the commission of
professional and hospital activities, to determine the average
length of hospital stay for patients.
"Professional review organization for Washington (PRO-W)"
means the state level organization responsible for determining
whether health care activities:
*Are medically necessary;
*Meet professionally acceptable standards of health care;
and
*Are appropriately provided in an outpatient or
institutional setting for beneficiaries of Medicare and
clients of Medicaid and maternal and child health.
"Prosthetic devices" means replacement, corrective, or
supportive devices prescribed by a physician or other licensed
practitioner of the healing arts within the scope of his or
her practice as defined by state law to:
*Artificially replace a missing portion of the body;
*Prevent or correct physical deformity or malfunction; or
*Support a weak or deformed portion of the body.
"Provider" or "provider of service" means an institution,
agency, or person:
*Who has a signed agreement with the department to
furnish medical care, goods, and/or services to clients; and
*Is eligible to receive payment from the department.
"Resources for an SSI-related client," means cash or
other liquid assets or any real or personal property that an
individual or spouse, if any, owns and could convert to cash
to be used for support or maintenance.
*If an individual can reduce a liquid asset to cash, it
is a resource.
*If an individual cannot reduce an asset to cash, it is
not considered an available resource.
*Liquid means properties that are in cash or are
financial instruments which are convertible to cash such as,
but not limited to, cash, savings, checking accounts, stocks,
mutual fund shares, mortgage, or a promissory note.
*Nonliquid means all other property both real and
personal evaluated at the price the item can reasonably be
expected to sell for on the open market.
"Retroactive period" means the three calendar months
before the month of application.
"Spell of illness" see "benefit period."
"Spenddown" means the process by which a person uses
incurred medical expenses to offset income and/or resources to
meet the financial standards established by the department.
"Spouse" means:
*"Community spouse" means a person living in the
community and married to an institutionalized person or to a
person receiving services from a home and community-based
waivered program as described under chapter 388-515 WAC.
*"Eligible spouse" means an aged, blind or disabled
husband or wife of an SSI-eligible person, with whom such a
person lives.
*"Essential spouse" means, a husband or wife whose needs
were taken into account in determining old age assistance
(OAA), aid to the blind (AB), or disability assistance (DA)
client for December 1973, who continues to live in the home
and to be the spouse of such client.
*"Ineligible spouse" means the husband or wife of an
SSI-eligible person, who lives with the SSI-eligible person
and who has not applied or is not eligible to receive SSI.
*"Institutionalized spouse" means a married person in an
institution or receiving services from a home or
community-based waivered program.
*"Nonapplying spouse" means an SSI-eligible person's
husband or wife, who has not applied for assistance.
"SSI-related" means an aged, blind or disabled person not
receiving an SSI cash grant.
"Supplemental security income (SSI) program, Title XVI"
means the federal grant program for aged, blind, and disabled
established by section 301 of the Social Security amendments
of 1972, and subsequent amendments, and administered by the
Social Security Administration (SSA).
"Supplementary payment (SSP)" means the state money
payment to persons receiving benefits under Title XVI, or who
would, but for the person's income, be eligible for such
benefits, as assistance based on need in supplementation of
SSI benefits. This payment includes:
*"Mandatory state supplement" means the state money
payment to a person who, for December 1973, was a client
receiving cash assistance under the department's former
programs of old age assistance, aid to the blind and
disability assistance; and
*"Optional state supplement" means the elective state
money payment to a person eligible for SSI benefits or who,
except for the level of the person's income, would be eligible
for SSI benefits.
"Third party" means any entity that is or may be liable
to pay all or part of the medical cost of care of a medical
program client.
"Title XIX" is the portion of the federal Social Security
Act that authorizes grants to states for medical assistance
programs. Title XIX is also called Medicaid.
"Transfer" means any act or omission to act when title to
or any interest in property is assigned, set over, or
otherwise vested or allowed to vest in another person;
including delivery of personal property, bills of sale, deeds,
mortgages, pledges, or any other instrument conveying or
relinquishing an interest in property. Transfer of title to a
resource occurs by:
*An intentional act or transfer; or
*Failure to act to preserve title to the resource.
"Value-fair market for an SSI-related person" means the
current value of a resource at the price for which the
resource can reasonably be expected to sell on the open
market.
"Value of compensation received" means, for SSI-related
medical eligibility, the gross amount paid or agreed to be
paid by the purchaser of a resource.
"Value-uncompensated" means, for SSI-related medical
eligibility, the fair market value of a resource, minus the
amount of compensation received in exchange for the resource.
[Statutory Authority: RCW 34.05.353 (2)(d), 74.08.090, and
chapters 74.09, 74.04 RCW. 08-11-047, § 388-500-0005, filed
5/15/08, effective 6/15/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.04.005,
74.08.331, 74.08A.010, [74.08A.]100, [74.08A.]210,[74.08A.]230
, 74.09.510, 74.12.255, Public Law 104-193 (1997)
and the Balanced Budget Act [of] 1997. 98-15-066, §
388-500-0005, filed 7/13/98, effective 7/30/98. Statutory
Authority: RCW 74.08.090. 95-22-039 (Order 3913, #100246), §
388-500-0005, filed 10/25/95, effective 10/28/95; 94-10-065
(Order 3732), § 388-500-0005, filed 5/3/94, effective 6/3/94. Formerly parts of WAC 388-80-005, 388-82-006, 388-92-005 and 388-93-005.]
NOTES:
Reviser's note: RCW 34.05.395 requires the use of underlining and deletion marks to indicate amendments to existing rules, and deems ineffectual changes not filed by the agency in this manner. The bracketed material in the above section does not appear to conform to the statutory requirement.