WAC 388-501-0050   Healthcare general coverage.  The following rules, WAC 388-501-0050 through WAC 388-501-0065, describe the healthcare services available to a client on a fee-for-service basis or as an enrollee in a managed care organization (MCO)(defined in WAC 388-538-050). Noncovered services are described in WAC 388-501-0070.

     (1) Service categories listed in WAC 388-501-0060 do not represent a contract for services.

     (2) The client must be eligible for the covered service on the date the service is performed or provided.

     (3) The department pays only for medical or dental services, equipment, or supplies that are:

     (a) Within the scope of the client's medical program;

     (b) Covered - see subsection (5);

     (c) Medically necessary;

     (d) Ordered or prescribed by a healthcare provider meeting the requirements of chapter 388-502 WAC; and

     (e) Furnished by a provider according to the requirements of chapter 388-502 WAC.

     (4) The department's fee-for-service program pays only for services furnished by enrolled providers who meet the requirements of chapter 388-502 WAC.

     (5) The department does not pay for any service, treatment, equipment, drug, or supply requiring prior authorization from the department, if prior authorization was not obtained before the service was provided.

     (6) Covered services

     (a) Covered services are either:

     (i) "Federally mandated" - means the state of Washington is required by federal regulation (42 CFR 440.210 and 220) to cover the service for medicaid clients; or

     (ii) "State-option" - means the state of Washington is not federally mandated to cover the service but has chosen to do so at its own discretion.

     (b) The department may limit the scope, amount, duration, and/or frequency of covered services. Limitation extensions are authorized according to WAC 388-501-0169.

     (7) Noncovered services

     (a) The department does not pay for any service, equipment, or supply:

     (i) That federal or state law or regulations prohibit the department from covering;

     (ii) Listed as noncovered in WAC 388-501-0070 or in any other program rule. The department evaluates a request for a noncovered service only if an exception to rule is requested according to the provisions in WAC 388-501-0160.

     (b) When Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) applies, a noncovered service, equipment, or supply will be evaluated according to the process in WAC 388-501-0165 to determine if it is medically necessary, safe, effective, and not experimental (see WAC 388-534-0100 for EPSDT rules).



[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-501-0050, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090. 01-12-070, § 388-501-0050, filed 6/4/01, effective 7/5/01. Statutory Authority: RCW 74.04.050 and 74.08.090. 00-01-088, § 388-501-0050, filed 12/14/99, effective 1/14/00.]