Title 182 WAC — Health Care Authority

# Title 182 WAC — Health Care Authority

## **Chapter 182-02** General definitions. {#struct-chapter-182-02}

##### **Wash. Admin. Code § 182-02-005** Definitions. {#sec-182-02-005 omnilex-key=us-wa-regs-official--title-182--182-02-005}

Chapter 182-02 WAC contains definitions of words and phrases used in rules throughout Title 182 WAC. When a term is not defined in this chapter, the definition found in another chapter of Title 182, or applicable state or applicable federal law will apply. For general terms not defined in this chapter, or in another chapter under Title 182 WAC, or state or federal law, the definitions in the Webster's New World Dictionary, Fifth Edition (2016), apply. If a definition in this chapter conflicts with a definition in another chapter of Title 182 WAC, the definition in the specific WAC prevails.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-02-030, § 182-02-005, filed 12/21/18, effective 1/21/19.*

##### **Wash. Admin. Code § 182-02-045** General definitions—H. {#sec-182-02-045 omnilex-key=us-wa-regs-official--title-182--182-02-045}

"Health care authority (HCA)" means the state agency established under chapter 41.05 RCW. In Title 182 WAC, the following terms mean the health care authority: "Agency," "authority" (unless the context clearly requires otherwise), "behavioral health administration," "HCA," "medicaid agency," "single state agency," "single state medicaid agency," and "single state behavioral health agency."

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-02-030, § 182-02-045, filed 12/21/18, effective 1/21/19.*

## **Chapter 182-04** Public records. {#struct-chapter-182-04}

##### **Wash. Admin. Code § 182-04-010** Purpose. {#sec-182-04-010 omnilex-key=us-wa-regs-official--title-182--182-04-010}

This chapter provides rules for the Washington state health care authority (agency) to comply with the provisions of chapter 42.56 RCW for access to public records.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 c 304. WSR 18-07-067, § 182-04-010, filed 3/16/18, effective 4/16/18. Statutory Authority: RCW 41.05.160, 42.56.040, and 70.02.050. WSR 10-18-051 (Order 10-01), § 182-04-010, filed 8/27/10, effective 9/27/10. Statutory Authority: RCW 41.05.160. WSR 97-21-125, § 182-04-010, filed 10/21/97, effective 11/21/97*
- *Order 01-77, § 182-04-010, filed 8/26/77.*

##### **Wash. Admin. Code § 182-04-015** Definitions. {#sec-182-04-015 omnilex-key=us-wa-regs-official--title-182--182-04-015}

The following definitions apply to this chapter:

(1) "Agency" means the Washington state health care authority.

(2) "Public record" - See RCW 42.56.010.

(3) "Writing" - See RCW 42.56.010.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 c 304. WSR 18-07-067, § 182-04-015, filed 3/16/18, effective 4/16/18. Statutory Authority: RCW 41.05.160, 42.56.040, and 70.02.050. WSR 10-18-051 (Order 10-01), § 182-04-015, filed 8/27/10, effective 9/27/10. Statutory Authority: RCW 41.05.160. WSR 97-21-125, § 182-04-015, filed 10/21/97, effective 11/21/97*
- *Order 01-77, § 182-04-015, filed 8/26/77.*

##### **Wash. Admin. Code § 182-04-020** Public records officer. {#sec-182-04-020 omnilex-key=us-wa-regs-official--title-182--182-04-020}

The agency's public records officer oversees:

(1) Responses to all requests for agency public records;

(2) The release of public records; and

(3) The coordination of agency public records staff.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 c 304. WSR 18-07-067, § 182-04-020, filed 3/16/18, effective 4/16/18. Statutory Authority: RCW 41.05.160, 42.56.040, and 70.02.050. WSR 10-18-051 (Order 10-01), § 182-04-020, filed 8/27/10, effective 9/27/10.*

##### **Wash. Admin. Code § 182-04-023** Public records—How to submit. {#sec-182-04-023 omnilex-key=us-wa-regs-official--title-182--182-04-023}

(1) Public records requests should be made in writing. The agency accepts public records requests:

(a) Made orally by telephone or in person; or

(b) Sent by email, fax, mail, hand delivery, or commercial delivery.

(2) A public records request form is available on the agency website or by contacting the agency's public records officer.

(3) If the agency's form is not used, the public records request should include:

(a) The requestor's name and contact information;

(b) The date of the request;

(c) A detailed description of an identifiable record, as described in RCW 42.56.080(1);

(d) The requestor's preferred format and delivery method for the requested records; and

(e) Any factors the requestor would like the agency to consider when deciding whether not to charge for or reduce the costs to copy and deliver the records.

(4) The agency may ask a person requesting a public record for personal identification when a law allows a record to be disclosed only to a specific person.

(5) The public records officer or designee assists requestors with identifying the public records requested, if necessary.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 c 304. WSR 18-07-067, § 182-04-023, filed 3/16/18, effective 4/16/18.*

##### **Wash. Admin. Code § 182-04-025** Response to public records requests. {#sec-182-04-025 omnilex-key=us-wa-regs-official--title-182--182-04-025}

(1) Except as provided by law, the agency makes public records available following a public records request for inspection, or copying, or both.

(2) The agency provides a written response within five business days of receiving a request for public records.

(a) A business day is 8:00 a.m. to 5:00 p.m., Monday through Friday, excluding Saturday, Sunday, and recognized holidays described in WAC 357-31-005.

(b) The agency treats a request received on a Saturday, Sunday, recognized holiday, or after 5:00 p.m. on any other day as received on the next business day.

(3) When responding to the requestor, the agency's public records officer, or designee:

(a) Provides the requested records;

(b) Acknowledges the request and gives a reasonable estimate of the time needed to provide the records. If the request is not for an identifiable record, the public records officer or designee asks for more information. (See WAC 182-04-027.) If the requestor does not respond to the agency's request for clarification, the public records officer or designee need not respond to the public records request and may consider the request closed; or

(c) Denies all or part of the public records request in writing as required by RCW 42.56.070(1), to include:

(i) The specific exemption authorizing the agency to withhold part or all of the record;

(ii) A brief explanation of how the exemption applies to the records or parts of the records withheld; and

(iii) The right to request agency review of the denial and information about how to make that request.

(4) At the public records officer's discretion, the agency may send the requested records by email, fax, or regular mail. The agency sends the requested records as hard copies or in an electronic format. The agency works with the requestor to send records in a method and format requested by the requestor that is used by the agency.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 c 304. WSR 18-07-067, § 182-04-025, filed 3/16/18, effective 4/16/18. Statutory Authority: RCW 41.05.160, 42.56.040, and 70.02.050. WSR 10-18-051 (Order 10-01), § 182-04-025, filed 8/27/10, effective 9/27/10. Statutory Authority: RCW 41.05.160. WSR 97-21-125, § 182-04-025, filed 10/21/97, effective 11/21/97*
- *Order 01-77, § 182-04-025, filed 8/26/77.*

##### **Wash. Admin. Code § 182-04-027** Additional time to respond to a public records request. {#sec-182-04-027 omnilex-key=us-wa-regs-official--title-182--182-04-027}

The agency may extend the time to respond to a public records request when necessary to:

(1) Identify and gather the records requested;

(2) Notify a person or organization affected by the request;

(3) Perform a comprehensive review to determine whether all or portions of the responsive records are exempt from disclosure; or

(4) Contact the requestor to clarify part or all of the request.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 c 304. WSR 18-07-067, § 182-04-027, filed 3/16/18, effective 4/16/18. Statutory Authority: RCW 41.05.160, 42.56.040, and 70.02.050. WSR 10-18-051 (Order 10-01), § 182-04-027, filed 8/27/10, effective 9/27/10.*

##### **Wash. Admin. Code § 182-04-029** Inspection of public records. {#sec-182-04-029 omnilex-key=us-wa-regs-official--title-182--182-04-029}

(1) All of the agency's public records are available for inspection and copying unless they are exempt from disclosure by chapter 42.56, 70.02 RCW, or other applicable law.

(2) People may inspect public records with an agency employee present at the agency's offices between 9:00 a.m. and 12:00 p.m. and between 1:00 p.m. and 4:00 p.m. during business days as defined in WAC 182-04-025 (2)(a). Records are not available for inspection if the agency is closed during a business day for reasons such as inclement weather or emergencies.

(3) During inspection, public records must:

(a) Not be removed from the agency's offices.

(b) Not be marked, torn, or otherwise damaged.

(c) Be kept as they are filed or in a chronological manner.

(d) Not be taken apart except for copying by an agency employee.

(4) The agency restricts access to file cabinets and other places where public records are kept.

(5) The agency reserves the right to restrict access to public records if the agency determines it is necessary to preserve the integrity of the public records or prevent interference with the agency's essential business functions. This does not limit the agency's duty to provide public records to the requestor. If the agency restricts access to requested public records, the agency promptly provides the requestor with:

(a) Written notice of the restriction, including the reason for restricting access; and

(b) Copies of the restricted records at no charge.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 c 304. WSR 18-07-067, § 182-04-029, filed 3/16/18, effective 4/16/18. Statutory Authority: RCW 41.05.160, 42.56.040, and 70.02.050. WSR 10-18-051 (Order 10-01), § 182-04-029, filed 8/27/10, effective 9/27/10.*

##### **Wash. Admin. Code § 182-04-041** Preserving requested records. {#sec-182-04-041 omnilex-key=us-wa-regs-official--title-182--182-04-041}

If the agency receives a public records request when the record exists but is scheduled for destruction in the near future, the public records officer or designee retains the record and does not destroy or erase the record until the request is resolved.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 c 304. WSR 18-07-067, § 182-04-041, filed 3/16/18, effective 4/16/18. Statutory Authority: RCW 41.05.160, 42.56.040, and 70.02.050. WSR 10-18-051 (Order 10-01), § 182-04-041, filed 8/27/10, effective 9/27/10. Statutory Authority: RCW 41.05.160. WSR 97-21-125, § 182-04-041, filed 10/21/97, effective 11/21/97.*

##### **Wash. Admin. Code § 182-04-045** Copying costs. {#sec-182-04-045 omnilex-key=us-wa-regs-official--title-182--182-04-045}

(1) The agency does not charge a fee to inspect public records.

(2) Under RCW 42.56.120 (2)(b), the agency does not calculate all actual costs to copy records as it would be unduly burdensome because:

(i) The agency does not have the resources to conduct a study to determine all its actual copying costs;

(ii) To conduct such a study would interfere with other essential agency functions; and

(iii) Through the 2017 legislative process, the public and requestors commented on and were informed of authorized fees and costs, including those for electronic records, described in RCW 42.56.120 (2)(b) and (c), (3) and (4).

(3) The agency charges for copies of records under the default fees in RCW 42.56.120 (2)(b) and (c).

(4) The agency charges for customized services under RCW 42.56.120(3).

(5) Under RCW 42.56.130, the agency may charge other copy fees authorized by statutes outside of chapter 42.56 RCW.

(6) The agency may enter into a contract, memorandum of understanding, or other agreement with a requestor that provides an alternative fee agreement for copying charges under RCW 42.56.120(4).

(7) Before copying any records, the agency provides the requestor with the estimated copying charge. The requestor may revise the request to limit the number of records copied and the applicable copying charges.

(8) The agency may waive the costs to copy or deliver requested records, including any charges for customized services under RCW 42.56.120(4).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 c 304. WSR 18-07-067, § 182-04-045, filed 3/16/18, effective 4/16/18. Statutory Authority: RCW 41.05.160, 42.56.040, and 70.02.050. WSR 10-18-051 (Order 10-01), § 182-04-045, filed 8/27/10, effective 9/27/10. Statutory Authority: RCW 41.05.160. WSR 97-21-125, § 182-04-045, filed 10/21/97, effective 11/21/97*
- *Order 01-77, § 182-04-045, filed 8/26/77.*

##### **Wash. Admin. Code § 182-04-055** Agency review of a denied request. {#sec-182-04-055 omnilex-key=us-wa-regs-official--title-182--182-04-055}

(1) If the agency denies all or part of a public records request, the requestor may ask, in writing, that the agency review the denial.

(2) After receiving a written request to review a decision denying all or part of a public records request, the agency considers the matter and either affirms or reverses the denial, or affirms part of the denial and reverses the remaining part of it. This decision is the agency's final action for the purposes of judicial review under RCW 42.56.520.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 c 304. WSR 18-07-067, § 182-04-055, filed 3/16/18, effective 4/16/18. Statutory Authority: RCW 41.05.160, 42.56.040, and 70.02.050. WSR 10-18-051 (Order 10-01), § 182-04-055, filed 8/27/10, effective 9/27/10. Statutory Authority: RCW 41.05.160. WSR 97-21-125, § 182-04-055, filed 10/21/97, effective 11/21/97*
- *Order 01-77, § 182-04-055, filed 8/26/77.*

## **Chapter 182-08** Procedures. {#struct-chapter-182-08}

##### **Wash. Admin. Code § 182-08-010** Declaration of purpose. {#sec-182-08-010 omnilex-key=us-wa-regs-official--title-182--182-08-010}

The general purpose of this chapter is to establish a set of rules to administer the health care authority's (HCA) public employees benefits board (PEBB) employee and retiree eligibility and PEBB benefits.

**History**
- *Statutory Authority: RCW 41.05.160. WSR 07-20-129 (Order 07-01), § 182-08-010, filed 10/3/07, effective 11/3/07. Statutory Authority: Chapter 41.05 RCW. WSR 96-08-042, § 182-08-010, filed 3/29/96, effective 4/29/96*
- *Order 7228, § 182-08-010, filed 12/8/76.*

##### **Wash. Admin. Code § 182-08-015** Definitions. {#sec-182-08-015 omnilex-key=us-wa-regs-official--title-182--182-08-015}

The following definitions apply throughout this chapter unless the context clearly indicates other meaning:

"Accidental death and dismemberment insurance" or "AD&D" means basic accidental death and dismemberment (AD&D) insurance paid for by the employing agency, as well as supplemental accidental death and dismemberment insurance offered to and paid for by employees for themselves and their dependents.

"Affordable Care Act" means the federal Patient Protection and Affordable Care Act, P.L. 111-148, as amended by the federal Health Care and Education Reconciliation Act of 2010, P.L. 111-152, or federal regulations or guidance issued under the Affordable Care Act.

"Annual open enrollment" means an annual event set aside for a period of time by the HCA when subscribers may make changes to their health plan enrollment and salary reduction elections for the following plan year. During the annual open enrollment, subscribers may transfer from one health plan to another, enroll or remove dependents from coverage, enroll in coverage, or waive enrollment (see definition of "waive" in this section). Employees eligible to participate in the salary reduction plan may enroll in or change their election under the dependent care assistance program (DCAP), the flexible spending arrangement (FSA), or limited purpose FSA. They may also enroll in or opt out of the premium payment plan.

"Authority" or "HCA" means the Washington state health care authority.

"Board" means the public employees benefits board established under provisions of RCW 41.05.055.

"Calendar days" or "days" means all days including Saturdays, Sundays, and all state legal holidays as set forth in RCW 1.16.050.

"Consolidated Omnibus Budget Reconciliation Act" or "COBRA" means continuation coverage as administered under 42 U.S.C. Secs. 300bb-1 through 300bb-8.

"Continuation coverage" means the temporary continuation of PEBB benefits available to enrollees under the Consolidated Omnibus Budget Reconciliation Act (COBRA), 42 U.S.C. Secs. 300bb-1 through 300bb-8, the Uniformed Services Employment and Reemployment Rights Act (USERRA), 38 U.S.C. Secs. 4301 through 4335, or the public employees benefits board's policies.

"Contracted vendor" means any person, persons, or entity under contract or agreement with the HCA to provide goods or services for the provision or administration of PEBB benefits. The term "contracted vendor" includes subcontractors of the HCA and subcontractors of any person, persons, or entity under contract or agreement with the HCA that provide goods or services for the provision or administration of PEBB benefits.

"Creditable coverage" means coverage that meets the definition of "creditable coverage" under RCW 48.66.020 (13)(a) and includes payment of medical and hospital benefits.

"Defer" means to postpone enrollment or interrupt enrollment in PEBB insurance coverage by a retiree, an eligible survivor, or the PEBB program.

"Dependent" means a person who meets eligibility requirements in WAC 182-12-260, except that "surviving spouses, state registered domestic partners, and dependent children" of emergency service personnel who are killed in the line of duty is defined in WAC 182-12-250.

"Dependent care assistance program" or "DCAP" means a benefit plan whereby employees may pay for certain employment related dependent care with pretax dollars as provided in the salary reduction plan under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 129 or other sections of the Internal Revenue Code.

"Director" means the director of the authority.

"Documents" means papers, letters, writings, electronic mail, electronic files, or other printed or written items.

"Employee" for the public employees benefits board program includes all employees of the state, whether or not covered by civil service; elected and appointed officials of the executive branch of government, including full-time members of boards, commissions, or committees; justices of the supreme court and judges of the court of appeals and the superior courts; and members of the state legislature. Pursuant to contractual agreement with the authority, "employee" may also include: (a) Employees of a county, municipality, or other political subdivision of the state and members of the legislative authority of any county, city, or town who are elected to office after February 20, 1970, if the legislative authority of the county, municipality, or other political subdivision of the state submits application materials to the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.04.205 and 41.05.021 (1)(g); (b) employees of employee organizations representing state civil service employees, at the option of each such employee organization; (c) through December 31, 2019, employees of a school district if the authority agrees to provide any of the school districts' insurance programs by contract with the authority as provided in RCW 28A.400.350; (d) employees of a tribal government, if the governing body of the tribal government seeks and receives the approval of the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.05.021 (1)(f) and (g); (e) employees of the Washington health benefit exchange if the governing board of the exchange established in RCW 43.71.020 seeks and receives approval of the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.05.021 (1)(g) and (n); and (f) through December 31, 2019, employees of a charter school established under chapter 28A.710 RCW. "Employee" does not include: Adult family home providers; unpaid volunteers; patients of state hospitals; inmates; students of institutions of higher education as determined by their institution; and any others not expressly defined as employees under RCW 41.05.011 or by the authority under this chapter.

"Employer" for the public employees benefits board program means the state of Washington.

"Employer-based group health plan" means group medical, group dental, and group vision related to a current employment relationship. It does not include medical, dental, or vision coverage available to retired employees, individual market medical or dental coverage, or government-sponsored programs such as medicare or medicaid.

"Employer-based group medical" means group medical related to a current employment relationship. It does not include medical coverage available to retired employees, individual market medical coverage, or government-sponsored programs such as medicare or medicaid.

"Employer contribution" means the funding amount paid to the HCA by a state agency or PEBB participating employer group for its eligible employees as described under WAC 182-12-114 and 182-12-131.

"Employer group" means:

• For the public employees benefits board as defined in RCW 41.05.011 (9)(a), those counties, municipalities, political subdivisions, the Washington health benefit exchange, tribal governments, and employee organizations representing state civil service employees, obtaining employee benefits through a contractual agreement with the authority to participate in benefit plans developed by the public employees benefits board as described in WAC 182-08-245.

• For the school employees benefits board as defined in RCW 41.05.011 (9)(b), an employee organization representing school employees and a tribal school as defined in RCW 28A.715.010, obtaining school employee benefits through a contractual agreement with the authority to participate in benefit plans developed by the school employees benefits board as described in WAC 182-30-215.

"Employer group rate surcharge" means the rate surcharge described in RCW 41.05.050(2).

"Employing agency" for the public employees benefits board program means a division, department, or separate agency of state government, including an institution of higher education; a county, municipality, or other political subdivision; and a tribal government covered by chapter 41.05 RCW.

"Enrollee" means a person who meets all eligibility requirements defined in chapter 182-12 WAC, who is enrolled in PEBB benefits, and for whom applicable premium payments have been made.

"Exchange" means the Washington health benefit exchange established in RCW 43.71.020, and any other health benefit exchange established under the Affordable Care Act.

"Exchange coverage" means coverage offered by a qualified health plan through an exchange.

"Faculty" means an academic employee of an institution of higher education whose workload is not defined by work hours but whose appointment, workload, and duties directly serve the institution's academic mission, as determined under the authority of its enabling statutes, its governing body, and any applicable collective bargaining agreement.

"Flexible spending arrangement" or "FSA" means a benefit plan whereby eligible state employees may reduce their salary before taxes to pay for medical expenses not reimbursed by insurance as provided in the salary reduction plan established under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"Forms" or "form" means both paper forms and forms completed electronically.

"Health plan" means a plan offering medical, dental, vision, or any combination of these coverages, developed by the board and provided by a contracted vendor or self-insured plans administered by the HCA.

"Insignificant shortfall" means a premium balance owed that is less than or equal to the lesser of $50 or 10 percent of the premium required by the health plan as described in Treasury Regulation 26 C.F.R. 54.4980B-8.

"Institutions of higher education" means the state public research universities, the public regional universities, The Evergreen State College, the community and technical colleges, and the state board for community and technical colleges.

"Large claim" means a claim for more than $25,000 in allowed costs for services in a quarter.

"Layoff," for purposes of this chapter, means a change in employment status due to an employer's lack of funds or an employer's organizational change.

"Life insurance" means basic life insurance paid for by the employing agency, as well as supplemental life insurance or supplemental dependent life insurance offered to and paid for by employees for themselves and their dependents. Life insurance for eligible retirees includes retiree term life insurance offered to and paid for by retirees.

"Limited purpose flexible spending arrangement" or "limited purpose FSA" means a benefit plan whereby eligible state employees may reduce their salary before taxes to pay for dental and vision expenses not reimbursed by insurance as provided in the salary reduction plan established under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"Long-term disability insurance" or "LTD insurance" means employer-paid long-term disability insurance and employee-paid long-term disability insurance offered by the PEBB program.

"Ongoing large claim" means a claim where the patient is expected to need ongoing case management into the next quarter for which the expected allowed cost is greater than $25,000 in the quarter.

"PEBB" means the public employees benefits board.

"PEBB benefits" means one or more insurance coverages or other employee benefits administered by the PEBB program within the health care authority.

"PEBB insurance coverage" means any health plan, life insurance, accidental death and dismemberment insurance, long-term disability (LTD) insurance, long-term care insurance, or property and casualty insurance administered as a PEBB benefit.

"PEBB program" means the program within the HCA that administers insurance and other benefits for eligible employees (as described in WAC 182-12-114), eligible retired employees (as described in WAC 182-12-171, 182-12-180, and 182-12-211), eligible survivors (as described in WAC 182-12-180, 182-12-250, and 182-12-265), eligible dependents (as described in WAC 182-12-250 and 182-12-260) and others as defined in RCW 41.05.011 or as described in RCW 41.05.080 (1)(a)(ii).

"Plan year" means the time period established by the authority.

"Premium payment plan" means a benefit plan whereby public employees may pay their share of group health plan premiums with pretax dollars as provided in the salary reduction plan under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"Premium surcharge" means a payment required from a subscriber, in addition to the subscriber's medical premium contribution, due to an enrollee's tobacco use or an enrolled subscriber's spouse or state registered domestic partner choosing not to enroll in their employer-based group medical when:

• The spouse's or state registered domestic partner's share of the medical premium is less than 95 percent of the additional cost an employee would be required to pay to enroll a spouse or state registered domestic partner in the public employees benefits board (PEBB) Uniform Medical Plan (UMP) Classic; and

• The benefits have an actuarial value of at least 95 percent of the actuarial value of PEBB UMP Classic benefits.

"Public employee" has the same meaning as employee.

"Qualified health plan" means a medical plan that is certified to be offered through an exchange.

"Salary reduction plan" means a benefit plan whereby public employees may agree to a reduction of salary on a pretax basis to participate in the dependent care assistance program, flexible spending arrangement, limited purpose flexible spending arrangement, or premium payment plan offered pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"School employee" means all employees of school districts and charter schools established under chapter 28A.710 RCW; represented employees of educational service districts; effective January 1, 2024, all employees of educational service districts; and effective January 1, 2024, pursuant to a contractual agreement with the authority, "school employee" may also include: (a) employees of employee organizations representing school employees, at the option of each such employee organization; and (b) employees of a tribal school as defined in RCW 28A.715.010, if the governing body of the tribal school seeks and receives the approval of the authority to provide any of its insurance programs by contracts with the authority, as provided in RCW 41.05.021 (1)(f) and (g).

"SEBB" means the school employees benefits board.

"Special open enrollment" means a period of time when subscribers may make changes to their health plan enrollment and salary reduction elections outside of the annual open enrollment period when specific life events occur. During the special open enrollment subscribers may change health plans and enroll or remove dependents from coverage. Additionally, employees may enroll in or waive enrollment (see definition of "waive" in this section). Employees eligible to participate in the salary reduction plan may enroll in or revoke their election under the DCAP, FSA, limited purpose FSA, or the premium payment plan and make a new election. For special open enrollment events related to specific PEBB benefits, see WAC 182-08-198, 182-08-199, 182-12-128, and 182-12-262.

"State agency" means an office, department, board, commission, institution, or other separate unit or division, however designated, of the state government. It includes the legislature, executive branch, and agencies or courts within the judicial branch, as well as institutions of higher education and any unit of state government established by law.

"State registered domestic partner" has the same meaning as defined in RCW 26.60.020(1) and substantially equivalent legal unions from other jurisdictions as defined in RCW 26.60.090.

"Subscriber" means the employee, retiree, continuation coverage enrollee, retired employee or retired school employee continuing health plan coverage when their employer group ceases participation with the authority, or survivor who has been determined eligible by the PEBB program, PEBB participating employer group, or state agency, is enrolled in PEBB benefits, and is the individual to whom the PEBB program and contracted vendors will issue all notices, information, requests, and premium bills on behalf of an enrollee.

"Supplemental coverage" means any life insurance or accidental death and dismemberment (AD&D) insurance coverage purchased by the employee in addition to the coverage provided by the employing agency.

"Tobacco products" means any product made with or derived from tobacco that is intended for human consumption, including any component, part, or accessory of a tobacco product. This includes, but is not limited to, cigars, cigarettes, pipe tobacco, chewing tobacco, snuff, and other tobacco products. It does not include e-cigarettes or United States Food and Drug Administration (FDA) approved quit aids.

"Tobacco use" means any use of tobacco products within the past two months. Tobacco use, however, does not include the religious or ceremonial use of tobacco.

"Tribal government" means an Indian tribal government as defined in Section 3(32) of the Employee Retirement Income Security Act of 1974 (ERISA), as amended, or an agency or instrumentality of the tribal government, that has government offices principally located in this state.

"Waive" means an eligible employee affirmatively declining enrollment in PEBB medical because the employee is enrolled in other employer-based group medical, a TRICARE plan, or medicare Part A and Part B as allowed under WAC 182-12-128. An employee on approved educational leave who obtains another employer-based group health plan may waive enrollment as allowed under WAC 182-12-136. An employee may waive enrollment in PEBB medical to enroll in SEBB medical only if they are enrolled in SEBB dental and SEBB vision. An employee who waives enrollment in PEBB medical to enroll in SEBB medical also waives enrollment in PEBB dental and PEBB vision.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 25-14-081 (Admin #2025.01.02), s 182-08-015, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], 41.05.160, 2023 c 312 § 1, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-18-077 (Admin #2024-01.02), § 182-08-015, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-08-015, filed 6/21/22, effective 1/1/23*
- *WSR 21-13-106 (Admin #2021-01.06), § 182-08-015, filed 6/18/21, effective 1/1/22*
- *WSR 20-16-062 (Admin #2020-03), § 182-08-015, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-015, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-08-015, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-08-015, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-015, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-08-015, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-08-015, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160, 2013 2nd sp.s. c 4 and PEBB policy resolutions. WSR 14-08-040, § 182-08-015, filed 3/26/14, effective 4/26/14. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-08-015, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-08-015, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-08-015, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-08-015, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-08-015, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-08-015, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-08-015, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.068. WSR 06-23-165 (Order 06-09), § 182-08-015, filed 11/22/06, effective 12/23/06. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-08-015, filed 8/26/04, effective 1/1/05*
- *WSR 03-17-031 (Order 02-07), § 182-08-015, filed 8/14/03, effective 9/14/03. Statutory Authority: Chapter 41.05 RCW. WSR 96-08-042, § 182-08-015, filed 3/29/96, effective 4/29/96.*

##### **Wash. Admin. Code § 182-08-120** Employer contribution for the public employees benefits board (PEBB) benefits. {#sec-182-08-120 omnilex-key=us-wa-regs-official--title-182--182-08-120}

The employer contribution must be used to provide public employees benefits board (PEBB) insurance coverage for the basic life insurance benefit, basic accidental death and dismemberment insurance benefit (AD&D), the employer-paid long-term disability (LTD) insurance benefit, medical insurance, dental insurance, vision insurance, and to establish a reserve for any remaining balance. There is no employer contribution available for any other insurance coverage for employees employed by state agencies.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-08-120, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-13-106 (Admin #2021-01), § 182-08-120, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-120, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-120, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-08-120, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-08-120, filed 9/25/12, effective 11/1/12*
- *WSR 09-23-102 (Order 09-02), § 182-08-120, filed 11/17/09, effective 1/1/10*
- *WSR 07-20-129 (Order 07-01), § 182-08-120, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 03-17-031 (Order 02-07), § 182-08-120, filed 8/14/03, effective 9/14/03. Statutory Authority: Chapter 41.05 RCW. WSR 96-08-042, § 182-08-120, filed 3/29/96, effective 4/29/96*
- *WSR 86-16-061 (Resolution No. 86-3), § 182-08-120, filed 8/5/86*
- *WSR 83-22-042 (Resolution No. 6-83), § 182-08-120, filed 10/28/83*
- *Order 3-77, § 182-08-120, filed 11/17/77*
- *Order 7228, § 182-08-120, filed 12/8/76.*

##### **Wash. Admin. Code § 182-08-180** Premium payments and premium refunds. {#sec-182-08-180 omnilex-key=us-wa-regs-official--title-182--182-08-180}

WAC 182-08-180

***(Effective until January 1, 2027)***

Public employees benefits board (PEBB) insurance coverage premiums and applicable premium surcharges for all subscribers are due as described in this section, except when an employing agency is correcting its enrollment error as described in WAC 182-08-187 (4) or (5).

(1) Premium payments. PEBB insurance coverage premiums and applicable premium surcharges for all subscribers become due the first of the month in which PEBB insurance coverage is effective.

Premiums and applicable premium surcharges are due from the subscriber for the entire month of PEBB insurance coverage and will not be prorated during any month, except as described in (e) of this subsection.

(a) For subscribers not eligible for the employer contribution that are electing to enroll in PEBB retiree insurance coverage as described in WAC 182-12-171 (1)(a), 182-12-180 (3)(a), 182-12-200 (3)(a) or (b), 182-12-205 (6) or (7), 182-12-211, and 182-12-265 (1), (2)(d), and (3); or electing to enroll in continuation coverage as described in WAC 182-12-133, 182-12-141, 182-12-142, 182-12-146, 182-12-148, and 182-12-270; or a retired employee, a retired school employee, or a survivor electing to enroll in PEBB health plan coverage when their employer group ceases participation as described in WAC 182-12-232, the first premium payment and applicable premium surcharges are due to the health care authority (HCA) or the contracted vendor no later than 45 days after the election period ends as described within the Washington Administrative Code applicable to the subscriber. Premiums and applicable premium surcharges associated with continuing PEBB medical must be made to the HCA as well as premiums associated with continuing PEBB dental, PEBB vision, or long-term disability (LTD) insurance coverage. Any medicare part D late enrollment penalty associated with the medicare advantage-prescription drug plan or Uniform Medical Plan Classic medicare plan must be made to the contracted vendor. Premiums associated with life insurance and accidental death and dismemberment (AD&D) insurance coverage must be made to the contracted vendor. Following the first premium payment, premiums and applicable premium surcharges must be paid as premiums become due.

| Exceptions: | (1) A subscriber electing to enroll in PEBB retiree insurance coverage who elects to pay premiums by deducting from their Washington state department of retirement systems pension retirement benefit is not required to make the first premium payment and applicable premium surcharges to begin enrollment. If there is a delay in the deduction from the pension when the subscriber first enrolls, HCA will send an invoice to the subscriber for the first premium payment and applicable premium surcharges. (2) A subscriber enrolled in continuation coverage as defined in WAC 182-08-015 or 182-30-020 who is electing to enroll in PEBB retiree insurance coverage, or a subscriber enrolled in continuation coverage as defined in WAC 182-08-015 who is electing to enroll in another type of continuation coverage is not required to make the first premium payment and applicable premium surcharges to begin the new enrollment. |
| --- | --- |

(b) For employees who are eligible for the employer contribution, premiums and applicable premium surcharges are due to the employing agency or contracted vendor. If an employee elects supplemental coverage or employee-paid LTD insurance, or is enrolled in employee-paid LTD insurance as described in WAC 182-08-197 (1)(a) or (3)(a), or is enrolled in employee-paid LTD insurance as described in WAC 182-08-197 (1)(b), the employee is responsible for payment of premiums from the month that the supplemental coverage or employee-paid LTD insurance begins.

| Exception: | An employee who is on a leave of absence and maintains eligibility for the employer contribution, will have their premiums waived for their employee-paid LTD insurance for the first 90 days. For this purpose, "leave of absence" is defined as a paid or unpaid temporary or indefinite administrative leave, involuntary leave, sick leave, or insurance continued under the federal Family and Medical Leave Act, or paid family and medical leave program as described in WAC 182-12-138. |
| --- | --- |

(c) Unpaid or underpaid premiums or applicable premium surcharges for all subscribers must be paid, and are due from the employing agency, subscriber, or a subscriber's legal representative to the HCA or contacted vendor. For subscribers not eligible for the employer contribution, monthly premiums or applicable premium surcharges that remain unpaid for 30 days will be considered delinquent. A subscriber is allowed a grace period of 30 days from the date the monthly premiums or applicable premium surcharges become delinquent to pay the unpaid premium balance or applicable premium surcharges. If a subscriber's monthly premiums or applicable premium surcharges remain unpaid for 60 days from the original due date, the subscriber's PEBB insurance coverage will be terminated retroactive to the last day of the month for which the monthly premiums and any applicable premium surcharges were paid. If it is determined by the HCA that payment of the unpaid balance in a lump sum would be considered a hardship, the HCA may develop a reasonable payment plan of up to 12 months in duration with the subscriber or the subscriber's legal representative upon request.

| Exception: | For a subscriber enrolled in a medicare advantage plan, a medicare advantage-prescription drug plan, or the Uniform Medical Plan Classic medicare plan a notice will be sent to them notifying them that they are delinquent on their monthly premiums and that the enrollment will be terminated prospectively to the end of the month after the notice is sent. |
| --- | --- |

(d) Monthly premiums or applicable premium surcharges due from a subscriber who is not eligible for the employer contribution will be considered unpaid if one of the following occurs:

(i) No payment of premiums or applicable premium surcharges are received by the HCA or contracted vendor and the monthly premiums or applicable premium surcharges remain unpaid for 30 days; or

(ii) Premium payments or applicable premium surcharges received by the HCA or contracted vendor are underpaid by an amount greater than an insignificant shortfall and the monthly premiums or applicable premium surcharges remain underpaid for 30 days past the date the monthly premiums or applicable premium surcharges were due.

(e) When an enrolled retiree dies on or after June 6, 2024, the premium payments for PEBB medical, PEBB dental, PEBB vision, and any applicable premium surcharges for the retiree will be waived by HCA for the month in which the death occurred. Subscribers enrolled as described in WAC 182-12-265 (2)(c) will be responsible for their continued payment of premiums and applicable premium surcharges as described in this section.

(2) Premium refunds. PEBB insurance coverage premiums and applicable premium surcharges will be refunded using the following methods:

(a) When a subscriber submits an enrollment change affecting subscriber or dependent eligibility, HCA may allow up to three months of accounting adjustments. HCA will refund to the individual or the employing agency any excess premiums and applicable premium surcharges paid during the 60-day adjustment period, except as indicated in WAC 182-12-148(5).

(b) When premiums and applicable premium surcharges are waived for a retiree who dies as described in subsection (1)(e) of this section, HCA will refund any excess premiums and applicable premium surcharges paid to the retiree's estate, to the department of retirement systems, or apply any excess premiums to the surviving dependent's account.

(c) If a PEBB subscriber, dependent, or beneficiary submits a written appeal as described in WAC 182-16-2010, and provides clear and convincing evidence of extraordinary circumstances, such that the subscriber could not timely submit the necessary information to accomplish an allowable enrollment change within 60 days after the event that created a change of premiums, the PEBB director, the PEBB director's designee, or the PEBB appeals unit may:

(i) Approve a refund of premiums and applicable premium surcharges which does not exceed 12 months of premiums; and

(ii) Approve the enrollment change that was originally requested and which forms the basis for the refund.

(d) If a federal government entity determines that an enrollee is retroactively enrolled in coverage (for example, medicare) the subscriber or beneficiary may be eligible for a refund of premiums and applicable premium surcharges paid during the time they were enrolled under the federal program if approved by the PEBB director or the PEBB director's designee.

(e) HCA errors will be corrected by returning all excess premiums and applicable premium surcharges paid by the employing agency, subscriber, or beneficiary.

(f) Employing agency errors will be corrected by returning all excess premiums and applicable premium surcharges paid by the employee or beneficiary as described in WAC 182-08-187 (4) and (5).

***(Effective January 1, 2027)***

PDF WAC 182-08-180

Premium payments and premium refunds.

Public employees benefits board (PEBB) insurance coverage premiums and applicable premium surcharges for all subscribers are due as described in this section, except when an employing agency is correcting its enrollment error as described in WAC 182-08-187 (4) or (5).

(1) Premium payments. PEBB insurance coverage premiums and applicable premium surcharges for all subscribers become due the first of the month in which PEBB insurance coverage is effective.

Premiums and applicable premium surcharges are due from the subscriber for the entire month of PEBB insurance coverage and will not be prorated during any month, except as described in (e) of this subsection.

(a) For subscribers not eligible for the employer contribution that are electing to enroll in PEBB retiree insurance coverage as described in WAC 182-12-171 (1)(a), 182-12-180 (3)(a), 182-12-200 (3)(a) or (b), 182-12-205 (6) or (7), 182-12-211, and 182-12-265 (1), (2)(d), and (3); or electing to enroll in continuation coverage as described in WAC 182-12-133, 182-12-141, 182-12-142, 182-12-146, 182-12-148, and 182-12-270; or a retired employee, a retired school employee, or a survivor electing to enroll in PEBB health plan coverage when their employer group ceases participation as described in WAC 182-12-232, the first premium payment and applicable premium surcharges are due to the health care authority (HCA) or the contracted vendor no later than 45 days after the election period ends as described within the Washington Administrative Code applicable to the subscriber. Premiums and applicable premium surcharges associated with continuing PEBB medical must be made to the HCA as well as premiums associated with continuing PEBB dental, PEBB vision, or long-term disability (LTD) insurance coverage. Any medicare Part D late enrollment penalty associated with the medicare advantage-prescription drug (MA-PD) plan or Uniform Medical Plan (UMP) Classic medicare plan must be made to the contracted vendor. Premiums associated with life insurance and accidental death and dismemberment (AD&D) insurance coverage must be made to the contracted vendor. Following the first premium payment, premiums and applicable premium surcharges must be paid as premiums become due.

| Exceptions: | (1) A subscriber electing to enroll in PEBB retiree insurance coverage who elects to pay premiums by deducting from their Washington state department of retirement systems pension retirement benefit is not required to make the first premium payment and applicable premium surcharges to begin enrollment. If there is a delay in the deduction from the pension when the subscriber first enrolls, HCA will send an invoice to the subscriber for the first premium payment and applicable premium surcharges. |
| --- | --- |
| | (2) A subscriber enrolled in continuation coverage as defined in WAC 182-08-015 or 182-30-020 who is electing to enroll in PEBB retiree insurance coverage, or a subscriber enrolled in continuation coverage as defined in WAC 182-08-015 who is electing to enroll in another type of continuation coverage is not required to make the first premium payment and applicable premium surcharges to begin the new enrollment. |

(b) For employees who are eligible for the employer contribution, premiums and applicable premium surcharges are due to the employing agency or contracted vendor. If an employee elects supplemental coverage or employee-paid LTD insurance, or is enrolled in employee-paid LTD insurance as described in WAC 182-08-197 (1)(a) or (3)(a), or is enrolled in employee-paid LTD insurance as described in WAC 182-08-197 (1)(b), the employee is responsible for payment of premiums from the month that the supplemental coverage or employee-paid LTD insurance begins.

| Exception: | An employee who is on a leave of absence and maintains eligibility for the employer contribution, will have their premiums waived for their employee-paid LTD insurance for the first 90 days. For this purpose, "leave of absence" is defined as a paid or unpaid temporary or indefinite administrative leave, involuntary leave, sick leave, or insurance continued under the federal Family and Medical Leave Act, or paid family and medical leave program as described in WAC 182-12-138. |
| --- | --- |

(c) Unpaid or underpaid premiums or applicable premium surcharges for all subscribers must be paid, and are due from the employing agency, subscriber, or a subscriber's legal representative to the HCA or contacted vendor. For subscribers not eligible for the employer contribution, monthly premiums or applicable premium surcharges that remain unpaid for 30 days will be considered delinquent. A subscriber is allowed a grace period of 30 days from the date the monthly premiums or applicable premium surcharges become delinquent to pay the unpaid premium balance or applicable premium surcharges. If a subscriber's monthly premiums or applicable premium surcharges remain unpaid for 60 days from the original due date, the subscriber's PEBB insurance coverage will be terminated retroactive to the last day of the month for which the monthly premiums and any applicable premium surcharges were paid. If it is determined by the HCA that payment of the unpaid balance in a lump sum would be considered a hardship, the HCA may develop a reasonable payment plan of up to 12 months in duration with the subscriber or the subscriber's legal representative upon request.

| Exception: | For a subscriber enrolled in a medicare advantage plan, a MA-PD plan, or the UMP Classic medicare plan a notice will be sent to them notifying them that they are delinquent on their monthly premiums and that the enrollment will be terminated prospectively to the end of the month after the notice is sent. |
| --- | --- |

(d) Monthly premiums or applicable premium surcharges due from a subscriber who is not eligible for the employer contribution will be considered unpaid if one of the following occurs:

(i) No payment of premiums or applicable premium surcharges are received by the HCA or contracted vendor and the monthly premiums or applicable premium surcharges remain unpaid for 30 days; or

(ii) Premium payments or applicable premium surcharges received by the HCA or contracted vendor are underpaid by an amount greater than an insignificant shortfall and the monthly premiums or applicable premium surcharges remain underpaid for 30 days past the date the monthly premiums or applicable premium surcharges were due.

(e) When an enrolled retiree dies on or after June 6, 2024, the premium payments for PEBB medical, PEBB dental, PEBB vision, and any applicable premium surcharges for the retiree will be waived by HCA for the month in which the death occurred. Subscribers enrolled as described in WAC 182-12-265 (2)(c) will be responsible for their continued payment of premiums and applicable premium surcharges as described in this section.

(2) Premium refunds. PEBB insurance coverage premiums and applicable premium surcharges will be refunded using the following methods:

(a) When a subscriber submits an enrollment change affecting subscriber or dependent eligibility, HCA may allow up to three months of accounting adjustments. HCA will refund to the individual or the employing agency any excess premiums and applicable premium surcharges paid during the 60-day adjustment period, except as indicated in WAC 182-12-148(5).

(b) When premiums and applicable premium surcharges are waived for a retiree who dies as described in subsection (1)(e) of this section, HCA will refund any excess premiums and applicable premium surcharges paid to the retiree's estate, to the department of retirement systems, or apply any excess premiums to the surviving dependent's account.

(c) If a PEBB subscriber, dependent, or beneficiary submits a written appeal as described in WAC 182-16-2010, and provides clear and convincing evidence of extraordinary circumstances, such that the subscriber could not timely submit the necessary information to accomplish an allowable enrollment change within 60 days after the event that created a change of premiums, the PEBB director, the PEBB director's designee, or the PEBB appeals unit may:

(i) Approve a refund of premiums and applicable premium surcharges which does not exceed 12 months of premiums; and

(ii) Approve the enrollment change that was originally requested and which forms the basis for the refund.

(d) If a federal government entity determines that an enrollee is retroactively enrolled in coverage (for example, medicare) the subscriber or beneficiary may be eligible for a refund of premiums and applicable premium surcharges paid during the time they were enrolled under the federal program if approved by the PEBB director or the PEBB director's designee.

(e) If the Centers for Medicare and Medicaid Services determines that an enrollee is retroactively disenrolled from coverage (for example, a PEBB program MA-PD plan or a PEBB program medicare Part D plan), the subscriber or beneficiary may be eligible for a refund of premiums and applicable premium surcharges paid during the time they were disenrolled from the plan if approved by the PEBB director or the PEBB director's designee.

(f) HCA errors will be corrected by returning all excess premiums and applicable premium surcharges paid by the employing agency, subscriber, or beneficiary.

(g) Employing agency errors will be corrected by returning all excess premiums and applicable premium surcharges paid by the employee or beneficiary as described in WAC 182-08-187 (4) and (5).

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], 41.05.160, 2023 c 312 § 1, and 2024 c 185 § 1. WSR 24-18-078 (Admin #2024-01.03), § 182-08-180, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-08-180, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions PEBB 2021-11 and 2021-12. WSR 21-13-103 (Admin #2021-01.03), § 182-08-180, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-08-180, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-180, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-08-180, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-08-180, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-180, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-08-180, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-08-180, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-08-180, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-08-180, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-08-180, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-08-180, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-08-180, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-08-180, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-08-180, filed 8/26/04, effective 1/1/05*
- *WSR 03-17-031 (Order 02-07), § 182-08-180, filed 8/14/03, effective 9/14/03. Statutory Authority: Chapter 41.05 RCW. WSR 96-08-042, § 182-08-180, filed 3/29/96, effective 4/29/96*
- *Order 01-77, § 182-08-180, filed 8/26/77.](Effective January 1, 2027) PDF WAC 182-08-180 Premium payments and premium refunds. Public employees benefits board (PEBB) insurance coverage premiums and applicable premium surcharges for all subscribers are due as described in this section, except when an employing agency is correcting its enrollment error as described in WAC 182-08-187 (4) or (5).(1) Premium payments. PEBB insurance coverage premiums and applicable premium surcharges for all subscribers become due the first of the month in which PEBB insurance coverage is effective.Premiums and applicable premium surcharges are due from the subscriber for the entire month of PEBB insurance coverage and will not be prorated during any month, except as described in (e) of this subsection.(a) For subscribers not eligible for the employer contribution that are electing to enroll in PEBB retiree insurance coverage as described in WAC 182-12-171 (1)(a), 182-12-180 (3)(a), 182-12-200 (3)(a) or (b), 182-12-205 (6) or (7), 182-12-211, and 182-12-265 (1), (2)(d), and (3)*
- *or electing to enroll in continuation coverage as described in WAC 182-12-133, 182-12-141, 182-12-142, 182-12-146, 182-12-148, and 182-12-270*
- *or a retired employee, a retired school employee, or a survivor electing to enroll in PEBB health plan coverage when their employer group ceases participation as described in WAC 182-12-232, the first premium payment and applicable premium surcharges are due to the health care authority (HCA) or the contracted vendor no later than 45 days after the election period ends as described within the Washington Administrative Code applicable to the subscriber. Premiums and applicable premium surcharges associated with continuing PEBB medical must be made to the HCA as well as premiums associated with continuing PEBB dental, PEBB vision, or long-term disability (LTD) insurance coverage. Any medicare Part D late enrollment penalty associated with the medicare advantage-prescription drug (MA-PD) plan or Uniform Medical Plan (UMP) Classic medicare plan must be made to the contracted vendor. Premiums associated with life insurance and accidental death and dismemberment (AD&D) insurance coverage must be made to the contracted vendor. Following the first premium payment, premiums and applicable premium surcharges must be paid as premiums become due.Exceptions:(1) A subscriber electing to enroll in PEBB retiree insurance coverage who elects to pay premiums by deducting from their Washington state department of retirement systems pension retirement benefit is not required to make the first premium payment and applicable premium surcharges to begin enrollment. If there is a delay in the deduction from the pension when the subscriber first enrolls, HCA will send an invoice to the subscriber for the first premium payment and applicable premium surcharges. (2) A subscriber enrolled in continuation coverage as defined in WAC 182-08-015 or 182-30-020 who is electing to enroll in PEBB retiree insurance coverage, or a subscriber enrolled in continuation coverage as defined in WAC 182-08-015 who is electing to enroll in another type of continuation coverage is not required to make the first premium payment and applicable premium surcharges to begin the new enrollment.(b) For employees who are eligible for the employer contribution, premiums and applicable premium surcharges are due to the employing agency or contracted vendor. If an employee elects supplemental coverage or employee-paid LTD insurance, or is enrolled in employee-paid LTD insurance as described in WAC 182-08-197 (1)(a) or (3)(a), or is enrolled in employee-paid LTD insurance as described in WAC 182-08-197 (1)(b), the employee is responsible for payment of premiums from the month that the supplemental coverage or employee-paid LTD insurance begins.Exception:An employee who is on a leave of absence and maintains eligibility for the employer contribution, will have their premiums waived for their employee-paid LTD insurance for the first 90 days. For this purpose, "leave of absence" is defined as a paid or unpaid temporary or indefinite administrative leave, involuntary leave, sick leave, or insurance continued under the federal Family and Medical Leave Act, or paid family and medical leave program as described in WAC 182-12-138.(c) Unpaid or underpaid premiums or applicable premium surcharges for all subscribers must be paid, and are due from the employing agency, subscriber, or a subscriber's legal representative to the HCA or contacted vendor. For subscribers not eligible for the employer contribution, monthly premiums or applicable premium surcharges that remain unpaid for 30 days will be considered delinquent. A subscriber is allowed a grace period of 30 days from the date the monthly premiums or applicable premium surcharges become delinquent to pay the unpaid premium balance or applicable premium surcharges. If a subscriber's monthly premiums or applicable premium surcharges remain unpaid for 60 days from the original due date, the subscriber's PEBB insurance coverage will be terminated retroactive to the last day of the month for which the monthly premiums and any applicable premium surcharges were paid. If it is determined by the HCA that payment of the unpaid balance in a lump sum would be considered a hardship, the HCA may develop a reasonable payment plan of up to 12 months in duration with the subscriber or the subscriber's legal representative upon request.Exception:For a subscriber enrolled in a medicare advantage plan, a MA-PD plan, or the UMP Classic medicare plan a notice will be sent to them notifying them that they are delinquent on their monthly premiums and that the enrollment will be terminated prospectively to the end of the month after the notice is sent.(d) Monthly premiums or applicable premium surcharges due from a subscriber who is not eligible for the employer contribution will be considered unpaid if one of the following occurs:(i) No payment of premiums or applicable premium surcharges are received by the HCA or contracted vendor and the monthly premiums or applicable premium surcharges remain unpaid for 30 days*
- *or(ii) Premium payments or applicable premium surcharges received by the HCA or contracted vendor are underpaid by an amount greater than an insignificant shortfall and the monthly premiums or applicable premium surcharges remain underpaid for 30 days past the date the monthly premiums or applicable premium surcharges were due.(e) When an enrolled retiree dies on or after June 6, 2024, the premium payments for PEBB medical, PEBB dental, PEBB vision, and any applicable premium surcharges for the retiree will be waived by HCA for the month in which the death occurred. Subscribers enrolled as described in WAC 182-12-265 (2)(c) will be responsible for their continued payment of premiums and applicable premium surcharges as described in this section.(2) Premium refunds. PEBB insurance coverage premiums and applicable premium surcharges will be refunded using the following methods:(a) When a subscriber submits an enrollment change affecting subscriber or dependent eligibility, HCA may allow up to three months of accounting adjustments. HCA will refund to the individual or the employing agency any excess premiums and applicable premium surcharges paid during the 60-day adjustment period, except as indicated in WAC 182-12-148(5).(b) When premiums and applicable premium surcharges are waived for a retiree who dies as described in subsection (1)(e) of this section, HCA will refund any excess premiums and applicable premium surcharges paid to the retiree's estate, to the department of retirement systems, or apply any excess premiums to the surviving dependent's account.(c) If a PEBB subscriber, dependent, or beneficiary submits a written appeal as described in WAC 182-16-2010, and provides clear and convincing evidence of extraordinary circumstances, such that the subscriber could not timely submit the necessary information to accomplish an allowable enrollment change within 60 days after the event that created a change of premiums, the PEBB director, the PEBB director's designee, or the PEBB appeals unit may:(i) Approve a refund of premiums and applicable premium surcharges which does not exceed 12 months of premiums*
- *and(ii) Approve the enrollment change that was originally requested and which forms the basis for the refund.(d) If a federal government entity determines that an enrollee is retroactively enrolled in coverage (for example, medicare) the subscriber or beneficiary may be eligible for a refund of premiums and applicable premium surcharges paid during the time they were enrolled under the federal program if approved by the PEBB director or the PEBB director's designee.(e) If the Centers for Medicare and Medicaid Services determines that an enrollee is retroactively disenrolled from coverage (for example, a PEBB program MA-PD plan or a PEBB program medicare Part D plan), the subscriber or beneficiary may be eligible for a refund of premiums and applicable premium surcharges paid during the time they were disenrolled from the plan if approved by the PEBB director or the PEBB director's designee.(f) HCA errors will be corrected by returning all excess premiums and applicable premium surcharges paid by the employing agency, subscriber, or beneficiary.(g) Employing agency errors will be corrected by returning all excess premiums and applicable premium surcharges paid by the employee or beneficiary as described in WAC 182-08-187 (4) and (5).[Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 26-14-080 (Admin #2026.01), s 182-08-180, filed 6/29/26, effective 1/1/27. Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], 41.05.160, 2023 c 312 § 1, and 2024 c 185 § 1. WSR 24-18-078 (Admin #2024-01.03), § 182-08-180, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-08-180, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions PEBB 2021-11 and 2021-12. WSR 21-13-103 (Admin #2021-01.03), § 182-08-180, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-08-180, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-180, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-08-180, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-08-180, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-180, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-08-180, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-08-180, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-08-180, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-08-180, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-08-180, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-08-180, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-08-180, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-08-180, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-08-180, filed 8/26/04, effective 1/1/05*
- *WSR 03-17-031 (Order 02-07), § 182-08-180, filed 8/14/03, effective 9/14/03. Statutory Authority: Chapter 41.05 RCW. WSR 96-08-042, § 182-08-180, filed 3/29/96, effective 4/29/96*
- *Order 01-77, § 182-08-180, filed 8/26/77.*

##### **Wash. Admin. Code § 182-08-185** What are the requirements regarding premium surcharges? {#sec-182-08-185 omnilex-key=us-wa-regs-official--title-182--182-08-185}

WAC 182-08-185

***(Effective until January 1, 2027)***

(1) A subscriber's account will incur a premium surcharge in addition to the subscriber's monthly medical premium, when any enrollee, 13 years and older, engages in tobacco use.

(a) A subscriber must attest to whether any enrollee, 13 years and older, enrolled in their public employees benefits board (PEBB) medical engages in tobacco use. The subscriber must attest as described in (a)(i) through (vii) of this subsection:

(i) An employee who is newly eligible or regains eligibility for the employer contribution toward PEBB benefits must complete the required form to enroll in PEBB medical as described in WAC 182-08-197 (1) or (3). The employee must include their attestation on that form. The employee must submit the form to their employing agency. If the employee's attestation results in a premium surcharge, it will take effect the same date as PEBB medical begins.

(ii) If there is a change in the tobacco use status of any enrollee, 13 years and older on the subscriber's PEBB medical, the subscriber must update their attestation on the required form. An employee must submit the form to their employing agency. Any other subscriber must submit their form to the PEBB program. The attestation change will apply as follows:

• A change that results in a premium surcharge will begin the first day of the month following the status change. If that day is the first of the month, the change to the surcharge begins on that day.

• A change that results in removing the premium surcharge will begin the first day of the month following receipt of the attestation. If that day is the first of the month, the change to the surcharge begins on that day.

(iii) If a subscriber submits the required form to enroll a dependent, 13 years and older, in PEBB medical as described in WAC 182-12-262, the subscriber must attest for their dependent on the required form. An employee must submit the form to their employing agency. Any other subscriber must submit their form to the PEBB program. A change that results in a premium surcharge will take effect the same date as PEBB medical begins.

(iv) An enrollee, 13 years and older, who elects to continue medical coverage as described in WAC 182-12-133, 182-12-141, 182-12-142, 182-12-146, 182-12-148, 182-12-270, or 182-12-232 must provide an attestation on the required form if they have not previously attested as described in (a) of this subsection. The enrollee must submit their form to the PEBB program. An attestation that results in a premium surcharge will take effect the same date as PEBB medical begins.

(v) An employee or retiree who enrolls in PEBB medical as described in WAC 182-12-171 (1)(a), 182-12-180 (3)(a), 182-12-200 (3)(a) or (b), 182-12-205 (6) or (7), or 182-12-211, must provide an attestation on the required form if they have not previously attested as described in (a) of this subsection. The employee or retiree must submit their form to the PEBB program. An attestation that results in a premium surcharge will take effect the same date as PEBB medical begins.

(vi) A surviving spouse, state registered domestic partner, or dependent child, 13 years and older, who enrolls in PEBB medical as described in WAC 182-12-180 (3)(a), 182-12-250(5) or 182-12-265, must provide an attestation on the required form to the PEBB program if they have not previously attested as described in (a) of this subsection. An attestation that results in a premium surcharge will take effect the same date as PEBB medical begins.

(vii) An employee who previously waived PEBB medical must complete the required form to enroll in PEBB medical as described in WAC 182-12-128(3). The employee must include their attestation on that form. An employee must submit the form to their employing agency. An attestation that results in a premium surcharge will take effect the same date as PEBB medical begins.

| Exceptions: | (1) A subscriber enrolled in both medicare Parts A and B and in the medicare risk pool as described in RCW 41.05.080(3) is not required to provide an attestation and no premium surcharge will be imposed on the subscriber's account. |
| --- | --- |
| | (2) An employee who waives PEBB medical as described in WAC 182-12-128 is not required to provide an attestation and no premium surcharge will be applied to their account as long as the employee remains in waived status. |

(b) A subscriber's account will incur a premium surcharge when a subscriber fails to attest to the tobacco use status of all enrollees as described in (a) of this subsection.

(c) The PEBB program will provide a reasonable alternative for enrollees who use tobacco products. A subscriber can avoid the tobacco use premium surcharge if the subscriber attests on the required form that all enrollees who use tobacco products enrolled in or accessed one of the applicable reasonable alternatives offered below:

(i) An enrollee who is 18 years and older and uses tobacco products is currently enrolled in the free tobacco cessation program through their PEBB medical.

(ii) An enrollee who is 13 through 17 years old and uses tobacco products accessed the information and resources aimed at teens on the Washington state department of health's website at https://teen.smokefree.gov.

(iii) A subscriber may contact the PEBB program to accommodate a physician's recommendation that addresses an enrollee's use of tobacco products or for information on how to avoid the tobacco use premium surcharge.

(2) A subscriber will incur a premium surcharge in addition to the subscriber's monthly medical premium, if an enrolled spouse or state registered domestic partner has chosen not to enroll in another employer-based group medical where the spouse's or state registered domestic partner's share of the medical premium is less than 95 percent of the additional cost an employee would be required to pay to enroll a spouse or state registered domestic partner in the PEBB Uniform Medical Plan (UMP) Classic and the benefits have an actuarial value of at least 95 percent of the actuarial value of the PEBB UMP Classic's benefits.

(a) A subscriber who enrolled a spouse or state registered domestic partner under their PEBB medical may only attest during the following times:

(i) When a subscriber becomes eligible to enroll a spouse or state registered domestic partner in PEBB medical as described in WAC 182-12-262. The subscriber must complete the required form to enroll their spouse or state registered domestic partner, and include their attestation on that form. The employee must submit the form to their employing agency. Any other subscriber must submit the form to the PEBB program. If the subscriber's attestation results in a premium surcharge it will take effect the same date as PEBB medical begins;

(ii) During the annual open enrollment. A subscriber must attest if during the month prior to the annual open enrollment the subscriber was:

• Incurring the surcharge;

• Not incurring the surcharge because the spouse's or state registered domestic partner's share of the medical premium through their employer-based group medical was more than 95 percent of the additional cost an employee would be required to pay to enroll a spouse or state registered domestic partner in the PEBB UMP Classic; or

• Not incurring the surcharge because the actuarial value of benefits provided through the spouse's or state registered domestic partner's employer-based group medical was less than 95 percent of the actuarial value of the PEBB UMP Classic's benefits.

A subscriber must update their attestation on the required form. An employee must submit the form to their employing agency. Any other subscriber must submit the form to the PEBB program. The subscriber's attestation or any correction to a subscriber's attestation must be received no later than December 31st of the year in which the annual open enrollment occurs. If the subscriber's attestation results in a premium surcharge, being added or removed, the change to the surcharge will take effect January 1st of the following year; and

(iii) When there is a change in the spouse's or state registered domestic partner's employer-based group medical. A subscriber must provide evidence of the event and update their attestation on the required form. An employee must submit the form to their employing agency no later than 60 days after the spouse's or state registered domestic partner's employer-based group medical status changes. Any other subscriber must submit the form to the PEBB program no later than 60 days after the spouse's or state registered domestic partner's employer-based group medical status changes.

• A change that results in a premium surcharge will begin the first day of the month following the status change. If that day is the first day of the month, the change to the premium surcharge begins on that day.

• A change that results in removing the premium surcharge will begin the first day of the month following receipt of the attestation. If that day is the first day of the month, the change to the premium surcharge begins on that day.

| Exceptions: | (1) A subscriber enrolled in both medicare Parts A and B and in the medicare risk pool as described in RCW 41.05.080(3) is not required to provide an attestation and no premium surcharge will be imposed on the subscriber's account. |
| --- | --- |
| | (2) An employee who waives PEBB medical as described in WAC 182-12-128 is not required to provide an attestation and no premium surcharge will be applied to their account as long as the employee remains in waived status. |
| | (3) An employee who covers their spouse or state registered domestic partner who has waived their own PEBB medical must attest as described in this subsection, but will not incur a premium surcharge if the employee provides an attestation that their spouse or state registered domestic partner is eligible for PEBB medical. |
| | (4) A subscriber who covers their spouse or state registered domestic partner who elected not to enroll in a TRICARE plan must attest as described in this subsection, but will not incur a premium surcharge if the subscriber provides an attestation that their spouse or state registered domestic partner is eligible for a TRICARE plan. |

(b) A premium surcharge will be applied to a subscriber who does not attest as described in (a) of this subsection.

***(Effective January 1, 2027)***

PDF WAC 182-08-185

What are the requirements regarding premium surcharges?

(1) A subscriber's account will incur a premium surcharge in addition to the subscriber's monthly medical premium, when any enrollee, 13 years and older, engages in tobacco use.

(a) A subscriber must attest to whether any enrollee, 13 years and older, enrolled in their public employees benefits board (PEBB) medical engages in tobacco use. The subscriber must attest as described in (a)(i) through (vii) of this subsection:

(i) An employee who is newly eligible or regains eligibility for the employer contribution toward PEBB benefits must complete the required form to enroll in PEBB medical as described in WAC 182-08-197 (1) or (3). The employee must include their attestation on that form. The employee must submit the form to their employing agency. If the employee's attestation results in a premium surcharge, it will take effect the same date as PEBB medical begins.

(ii) If there is a change in the tobacco use status of any enrollee, 13 years and older on the subscriber's PEBB medical, the subscriber must update their attestation on the required form. An employee must submit the form to their employing agency. Any other subscriber must submit their form to the PEBB program. The attestation change will apply as follows:

• A change that results in a premium surcharge will begin the first day of the month following the status change. If that day is the first of the month, the change to the surcharge begins on that day.

• A change that results in removing the premium surcharge will begin the first day of the month following receipt of the attestation. If that day is the first of the month, the change to the surcharge begins on that day.

(iii) If a subscriber submits the required form to enroll a dependent, 13 years and older, in PEBB medical as described in WAC 182-12-262, the subscriber must attest for their dependent on the required form. An employee must submit the form to their employing agency. Any other subscriber must submit their form to the PEBB program. A change that results in a premium surcharge will take effect the same date as PEBB medical begins.

(iv) An enrollee, 13 years and older, who elects to continue medical coverage as described in WAC 182-12-133, 182-12-141, 182-12-142, 182-12-146, 182-12-148, 182-12-270, or 182-12-232 must provide an attestation on the required form if they have not previously attested as described in (a) of this subsection. The enrollee must submit their form to the PEBB program. An attestation that results in a premium surcharge will take effect the same date as PEBB medical begins.

(v) An employee or retiree who enrolls in PEBB medical as described in WAC 182-12-171 (1)(a), 182-12-180 (3)(a), 182-12-200 (3)(a) or (b), 182-12-205 (6) or (7), or 182-12-211, must provide an attestation on the required form if they have not previously attested as described in (a) of this subsection. The employee or retiree must submit their form to the PEBB program. An attestation that results in a premium surcharge will take effect the same date as PEBB medical begins.

(vi) A surviving spouse, state registered domestic partner, or dependent child, 13 years and older, who enrolls in PEBB medical as described in WAC 182-12-180 (3)(a), 182-12-250(5) or 182-12-265, must provide an attestation on the required form to the PEBB program if they have not previously attested as described in (a) of this subsection. An attestation that results in a premium surcharge will take effect the same date as PEBB medical begins.

(vii) An employee who previously waived PEBB medical must complete the required form to enroll in PEBB medical as described in WAC 182-12-128(3). The employee must include their attestation on that form. An employee must submit the form to their employing agency. An attestation that results in a premium surcharge will take effect the same date as PEBB medical begins.

| Exceptions: | (1) A subscriber enrolled in both medicare Parts A and B and in the medicare risk pool as described in RCW 41.05.080(3) is not required to provide an attestation and no premium surcharge will be imposed on the subscriber's account. |
| --- | --- |
| | (2) An employee who waives PEBB medical as described in WAC 182-12-128 is not required to provide an attestation and no premium surcharge will be applied to their account as long as the employee remains in waived status. |

(b) A subscriber's account will incur a premium surcharge when a subscriber fails to attest to the tobacco use status of all enrollees as described in (a) of this subsection.

(c) The PEBB program will provide a reasonable alternative for enrollees who use tobacco products. A subscriber can avoid the tobacco use premium surcharge if the subscriber attests on the required form that all enrollees who use tobacco products enrolled in or accessed one of the applicable reasonable alternatives offered below:

(i) An enrollee who is 18 years and older and uses tobacco products is currently enrolled in the free tobacco cessation program through their PEBB medical.

(ii) An enrollee who is 13 through 17 years old and uses tobacco products accessed the information and resources aimed at teens on the Washington state department of health's website at https://teen.smokefree.gov.

(iii) A subscriber may contact the PEBB program to accommodate a physician's recommendation that addresses an enrollee's use of tobacco products or for information on how to avoid the tobacco use premium surcharge.

(2) A subscriber will incur a premium surcharge in addition to the subscriber's monthly medical premium, if an enrolled spouse or state registered domestic partner has chosen not to enroll in another employer-based group medical where the spouse's or state registered domestic partner's share of the medical premium is less than 95 percent of the additional cost an employee would be required to pay to enroll a spouse or state registered domestic partner in the PEBB Uniform Medical Plan (UMP) Classic and the benefits have an actuarial value of at least 95 percent of the actuarial value of the PEBB UMP Classic's benefits.

(a) A subscriber who enrolled a spouse or state registered domestic partner under their PEBB medical may only attest during the following times:

(i) When a subscriber becomes eligible to enroll a spouse or state registered domestic partner in PEBB medical as described in WAC 182-12-262. The subscriber must complete the required form to enroll their spouse or state registered domestic partner, and include their attestation on that form. The employee must submit the form to their employing agency. Any other subscriber must submit the form to the PEBB program. If the subscriber's attestation results in a premium surcharge it will take effect the same date as PEBB medical begins;

(ii) During the annual open enrollment. A subscriber must attest if during the month prior to the annual open enrollment the subscriber was:

• Incurring the surcharge;

• Not incurring the surcharge because the spouse's or state registered domestic partner's share of the medical premium through their employer-based group medical was more than 95 percent of the additional cost an employee would be required to pay to enroll a spouse or state registered domestic partner in the PEBB UMP Classic; or

• Not incurring the surcharge because the actuarial value of benefits provided through the spouse's or state registered domestic partner's employer-based group medical was less than 95 percent of the actuarial value of the PEBB UMP Classic's benefits.

A subscriber must update their attestation on the required form. An employee must submit the form to their employing agency. Any other subscriber must submit the form to the PEBB program. The subscriber's attestation or any correction to a subscriber's attestation must be received no later than December 31st of the year in which the annual open enrollment occurs. If the subscriber's attestation results in a premium surcharge, being added or removed, the change to the surcharge will take effect January 1st of the following year; and

(iii) When there is a change in the spouse's or state registered domestic partner's employer-based group medical. A subscriber must provide evidence of the event and update their attestation on the required form. An employee must submit the form to their employing agency no later than 60 days after the spouse's or state registered domestic partner's employer-based group medical status changes. Any other subscriber must submit the form to the PEBB program no later than 60 days after the spouse's or state registered domestic partner's employer-based group medical status changes.

• A change that results in a premium surcharge will begin the first day of the month following the status change. If that day is the first day of the month, the change to the premium surcharge begins on that day.

• A change that results in removing the premium surcharge will begin the first day of the month following receipt of the attestation. If that day is the first day of the month, the change to the premium surcharge begins on that day.

| Exceptions: | (1) A subscriber enrolled in both medicare Parts A and B and in the medicare risk pool as described in RCW 41.05.080(3) is not required to provide an attestation and no premium surcharge will be imposed on the subscriber's account. |
| --- | --- |
| | (2) An employee who waives PEBB medical as described in WAC 182-12-128 is not required to provide an attestation and no premium surcharge will be applied to their account as long as the employee remains in waived status. |
| | (3) An employee who covers their spouse or state registered domestic partner who has waived their own PEBB or school employees benefits board (SEBB) medical must attest as described in this subsection, but will not incur a premium surcharge if the employee provides an attestation that their spouse or state registered domestic partner is eligible for PEBB or SEBB medical. |
| | (4) A subscriber who covers their spouse or state registered domestic partner who elected not to enroll in a TRICARE plan must attest as described in this subsection, but will not incur a premium surcharge if the subscriber provides an attestation that their spouse or state registered domestic partner is eligible for a TRICARE plan. |

(b) A premium surcharge will be applied to a subscriber who does not attest as described in (a) of this subsection.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-08-185, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-13-106 (Admin #2021-01.01), § 182-08-185, filed 6/18/21, effective 1/1/22*
- *WSR 20-16-062 (Admin #2020-03), § 182-08-185, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-185, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-08-185, filed 10/3/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-185, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-08-185, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-08-185, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160, 2013 2nd sp.s. c 4 and PEBB policy resolutions. WSR 14-08-040, § 182-08-185, filed 3/26/14, effective 4/26/14.](Effective January 1, 2027) PDF WAC 182-08-185 What are the requirements regarding premium surcharges? (1) A subscriber's account will incur a premium surcharge in addition to the subscriber's monthly medical premium, when any enrollee, 13 years and older, engages in tobacco use.(a) A subscriber must attest to whether any enrollee, 13 years and older, enrolled in their public employees benefits board (PEBB) medical engages in tobacco use. The subscriber must attest as described in (a)(i) through (vii) of this subsection:(i) An employee who is newly eligible or regains eligibility for the employer contribution toward PEBB benefits must complete the required form to enroll in PEBB medical as described in WAC 182-08-197 (1) or (3). The employee must include their attestation on that form. The employee must submit the form to their employing agency. If the employee's attestation results in a premium surcharge, it will take effect the same date as PEBB medical begins.(ii) If there is a change in the tobacco use status of any enrollee, 13 years and older on the subscriber's PEBB medical, the subscriber must update their attestation on the required form. An employee must submit the form to their employing agency. Any other subscriber must submit their form to the PEBB program. The attestation change will apply as follows:• A change that results in a premium surcharge will begin the first day of the month following the status change. If that day is the first of the month, the change to the surcharge begins on that day.• A change that results in removing the premium surcharge will begin the first day of the month following receipt of the attestation. If that day is the first of the month, the change to the surcharge begins on that day.(iii) If a subscriber submits the required form to enroll a dependent, 13 years and older, in PEBB medical as described in WAC 182-12-262, the subscriber must attest for their dependent on the required form. An employee must submit the form to their employing agency. Any other subscriber must submit their form to the PEBB program. A change that results in a premium surcharge will take effect the same date as PEBB medical begins.(iv) An enrollee, 13 years and older, who elects to continue medical coverage as described in WAC 182-12-133, 182-12-141, 182-12-142, 182-12-146, 182-12-148, 182-12-270, or 182-12-232 must provide an attestation on the required form if they have not previously attested as described in (a) of this subsection. The enrollee must submit their form to the PEBB program. An attestation that results in a premium surcharge will take effect the same date as PEBB medical begins.(v) An employee or retiree who enrolls in PEBB medical as described in WAC 182-12-171 (1)(a), 182-12-180 (3)(a), 182-12-200 (3)(a) or (b), 182-12-205 (6) or (7), or 182-12-211, must provide an attestation on the required form if they have not previously attested as described in (a) of this subsection. The employee or retiree must submit their form to the PEBB program. An attestation that results in a premium surcharge will take effect the same date as PEBB medical begins.(vi) A surviving spouse, state registered domestic partner, or dependent child, 13 years and older, who enrolls in PEBB medical as described in WAC 182-12-180 (3)(a), 182-12-250(5) or 182-12-265, must provide an attestation on the required form to the PEBB program if they have not previously attested as described in (a) of this subsection. An attestation that results in a premium surcharge will take effect the same date as PEBB medical begins.(vii) An employee who previously waived PEBB medical must complete the required form to enroll in PEBB medical as described in WAC 182-12-128(3). The employee must include their attestation on that form. An employee must submit the form to their employing agency. An attestation that results in a premium surcharge will take effect the same date as PEBB medical begins.Exceptions:(1) A subscriber enrolled in both medicare Parts A and B and in the medicare risk pool as described in RCW 41.05.080(3) is not required to provide an attestation and no premium surcharge will be imposed on the subscriber's account. (2) An employee who waives PEBB medical as described in WAC 182-12-128 is not required to provide an attestation and no premium surcharge will be applied to their account as long as the employee remains in waived status.(b) A subscriber's account will incur a premium surcharge when a subscriber fails to attest to the tobacco use status of all enrollees as described in (a) of this subsection.(c) The PEBB program will provide a reasonable alternative for enrollees who use tobacco products. A subscriber can avoid the tobacco use premium surcharge if the subscriber attests on the required form that all enrollees who use tobacco products enrolled in or accessed one of the applicable reasonable alternatives offered below:(i) An enrollee who is 18 years and older and uses tobacco products is currently enrolled in the free tobacco cessation program through their PEBB medical.(ii) An enrollee who is 13 through 17 years old and uses tobacco products accessed the information and resources aimed at teens on the Washington state department of health's website at https://teen.smokefree.gov.(iii) A subscriber may contact the PEBB program to accommodate a physician's recommendation that addresses an enrollee's use of tobacco products or for information on how to avoid the tobacco use premium surcharge.(2) A subscriber will incur a premium surcharge in addition to the subscriber's monthly medical premium, if an enrolled spouse or state registered domestic partner has chosen not to enroll in another employer-based group medical where the spouse's or state registered domestic partner's share of the medical premium is less than 95 percent of the additional cost an employee would be required to pay to enroll a spouse or state registered domestic partner in the PEBB Uniform Medical Plan (UMP) Classic and the benefits have an actuarial value of at least 95 percent of the actuarial value of the PEBB UMP Classic's benefits.(a) A subscriber who enrolled a spouse or state registered domestic partner under their PEBB medical may only attest during the following times:(i) When a subscriber becomes eligible to enroll a spouse or state registered domestic partner in PEBB medical as described in WAC 182-12-262. The subscriber must complete the required form to enroll their spouse or state registered domestic partner, and include their attestation on that form. The employee must submit the form to their employing agency. Any other subscriber must submit the form to the PEBB program. If the subscriber's attestation results in a premium surcharge it will take effect the same date as PEBB medical begins*
- *(ii) During the annual open enrollment. A subscriber must attest if during the month prior to the annual open enrollment the subscriber was:• Incurring the surcharge*
- *• Not incurring the surcharge because the spouse's or state registered domestic partner's share of the medical premium through their employer-based group medical was more than 95 percent of the additional cost an employee would be required to pay to enroll a spouse or state registered domestic partner in the PEBB UMP Classic*
- *or• Not incurring the surcharge because the actuarial value of benefits provided through the spouse's or state registered domestic partner's employer-based group medical was less than 95 percent of the actuarial value of the PEBB UMP Classic's benefits.A subscriber must update their attestation on the required form. An employee must submit the form to their employing agency. Any other subscriber must submit the form to the PEBB program. The subscriber's attestation or any correction to a subscriber's attestation must be received no later than December 31st of the year in which the annual open enrollment occurs. If the subscriber's attestation results in a premium surcharge, being added or removed, the change to the surcharge will take effect January 1st of the following year*
- *and(iii) When there is a change in the spouse's or state registered domestic partner's employer-based group medical. A subscriber must provide evidence of the event and update their attestation on the required form. An employee must submit the form to their employing agency no later than 60 days after the spouse's or state registered domestic partner's employer-based group medical status changes. Any other subscriber must submit the form to the PEBB program no later than 60 days after the spouse's or state registered domestic partner's employer-based group medical status changes.• A change that results in a premium surcharge will begin the first day of the month following the status change. If that day is the first day of the month, the change to the premium surcharge begins on that day.• A change that results in removing the premium surcharge will begin the first day of the month following receipt of the attestation. If that day is the first day of the month, the change to the premium surcharge begins on that day.Exceptions:(1) A subscriber enrolled in both medicare Parts A and B and in the medicare risk pool as described in RCW 41.05.080(3) is not required to provide an attestation and no premium surcharge will be imposed on the subscriber's account. (2) An employee who waives PEBB medical as described in WAC 182-12-128 is not required to provide an attestation and no premium surcharge will be applied to their account as long as the employee remains in waived status. (3) An employee who covers their spouse or state registered domestic partner who has waived their own PEBB or school employees benefits board (SEBB) medical must attest as described in this subsection, but will not incur a premium surcharge if the employee provides an attestation that their spouse or state registered domestic partner is eligible for PEBB or SEBB medical. (4) A subscriber who covers their spouse or state registered domestic partner who elected not to enroll in a TRICARE plan must attest as described in this subsection, but will not incur a premium surcharge if the subscriber provides an attestation that their spouse or state registered domestic partner is eligible for a TRICARE plan.(b) A premium surcharge will be applied to a subscriber who does not attest as described in (a) of this subsection.[Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 26-14-080 (Admin #2026.01), s 182-08-185, filed 6/29/26, effective 1/1/27. Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-08-185, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-13-106 (Admin #2021-01.01), § 182-08-185, filed 6/18/21, effective 1/1/22*
- *WSR 20-16-062 (Admin #2020-03), § 182-08-185, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-185, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-08-185, filed 10/3/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-185, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-08-185, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-08-185, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160, 2013 2nd sp.s. c 4 and PEBB policy resolutions. WSR 14-08-040, § 182-08-185, filed 3/26/14, effective 4/26/14.*

##### **Wash. Admin. Code § 182-08-187** How do employing agencies and contracted vendors correct enrollment errors and is there a limit on retroactive enrollment? {#sec-182-08-187 omnilex-key=us-wa-regs-official--title-182--182-08-187}

WAC 182-08-187

***(Effective until January 1, 2027)***

(1) An employing agency or contracted vendor that makes one or more of the following enrollment errors must correct the error as described in subsections (2) through (5) of this section.

(a) Failure to timely notify an employee of their eligibility for public employee benefits board (PEBB) benefits and the employer contribution as described in WAC 182-12-113(2);

(b) Failure to enroll the employee and their dependents in PEBB benefits as elected by the employee, if the elections were timely;

(c) Failure to enroll an employee and their dependents in PEBB benefits as described in WAC 182-08-197 (1)(b) or (3)(c);

(d) Failure to accurately reflect an employee's premium surcharge attestation on the employee's account;

(e) Enrolling an employee or their dependent in PEBB insurance coverage when they are not eligible as described in WAC 182-12-114 or 182-12-260 and it is clear there was no fraud or intentional misrepresentation by the employee involved; or

(f) Providing incorrect information regarding PEBB benefits to the employee that they relied upon.

(2) The employing agency or the applicable contracted vendor must enroll the employee and the employee's dependents, as elected, or terminate enrollment in PEBB benefits as described in subsection (3) of this section, reconcile premium payments and applicable premium surcharges as described in subsection (4) of this section, and provide recourse as described in subsection (5) of this section.

(3) Enrollment or termination.

(a) PEBB medical, dental, and vision enrollment is effective the first day of the month following the date the enrollment error is identified, unless the authority determines additional recourse is warranted, as described in subsection (5) of this section. If the enrollment error is identified on the first day of the month, the enrollment correction is effective that day;

| Exception: | When an employee who is called to active duty in the uniformed services under Uniformed Services Employment and Reemployment Rights Act (USERRA) loses eligibility for the employer contribution toward PEBB benefits, they regain eligibility for the employer contribution toward PEBB benefits the day they return from active duty. Employer-paid PEBB benefits will begin the first day of the month in which they return from active duty. |
| --- | --- |

(b) Basic life, supplemental life insurance, basic accidental death and dismemberment (AD&D), supplemental AD&D, employer-paid long-term disability (LTD) insurance, and employee-paid LTD insurance will begin for a newly eligible employee as described in WAC 182-12-114 and for an employee regaining eligibility as described in WAC 182-08-197(3). An employee who regains eligibility may need to submit evidence of insurability for supplemental life insurance or employee-paid LTD insurance as required in WAC 182-08-197(3).

(c) If the employee is eligible and elects (or elected) to enroll in the flexible spending arrangement (FSA), limited purpose FSA, or dependent care assistance program (DCAP), enrollment is limited to 60 days prior to the date enrollment is processed, but not earlier than the current plan year. If an employee was not enrolled in a FSA, limited purpose FSA, or DCAP as elected, the employee may either participate at the amount originally elected with a corresponding increase in contributions for the balance of the plan year, or participate at a reduced amount for the plan year by maintaining the per-pay period contribution in effect;

(d) If the employee or their dependent was not eligible but still enrolled as described in subsection (1)(e) of this section, the employee's or their dependent's PEBB benefits will be terminated prospectively effective as of the last day of the month.

(4) Premium payments.

(a) The employing agency must remit to the authority the employer contribution and the employee contribution for health plan premiums, applicable premium surcharges, basic life, basic AD&D, and employer-paid LTD starting the date PEBB benefits begins as described in subsections (3) and (5)(a)(i) of this section. If a state agency failed to notify a newly eligible employee of their eligibility for PEBB benefits, the state agency may only collect the employee contribution for health plan premiums and applicable premium surcharges for coverage for the months after the employee was notified.

(b) When an employing agency fails to correctly enroll the amount of employee-paid LTD insurance elected by the employee, premiums will be corrected as follows:

(i) When additional premiums are due to the authority, the employee is responsible for premiums for the most recent 24 months of coverage. The employing agency is responsible for additional months of premiums.

(ii) When a premium refund is due to the employee, the LTD insurance contracted vendor is responsible for premium refunds for the most recent 24 months of coverage. The employing agency is responsible for additional months of premium refund.

(c) When an employing agency mistakenly enrolls an employee or their dependent as described in subsection (1)(e) of this section, premiums and any applicable premium surcharges will be refunded by the employing agency to the employee without rescinding the insurance coverage.

(5) Recourse.

(a) An employee who establishes eligibility will have benefits begin as described in WAC 182-12-114. An employee who regains eligibility for the employer contribution toward PEBB benefits will have benefits begin as described in WAC 182-08-197(3). Dependent eligibility is described in WAC 182-12-260, and dependent enrollment is described in WAC 182-12-262. When retroactive correction of an enrollment error is limited as described in subsection (3)(a), (b), and (c) of this section, the employing agency must work with the employee, and receive approval from the authority, to implement retroactive PEBB benefits within the following parameters:

(i) Retroactive enrollment in a PEBB insurance coverage;

(ii) Reimbursement of claims paid;

(iii) Reimbursement of amounts paid by the employee or dependent for medical, dental, and vision premiums;

(iv) Reimbursement of amounts paid by the employee for the premium surcharges;

(v) Other legal remedy received or offered; or

(vi) Other recourse, upon approval by the authority.

(b) Recourse must not contradict a specific provision of federal law or statute and does not apply to requests for noncovered services or in the case of an individual who is not eligible for PEBB benefits.

***(Effective January 1, 2027)***

PDF WAC 182-08-187

How do employing agencies and contracted vendors correct enrollment errors and is there a limit on retroactive enrollment?

(1) An employing agency or contracted vendor that makes one or more of the following enrollment errors must correct the error as described in subsections (2) through (5) of this section.

(a) Failure to timely notify an employee of their eligibility for public employee benefits board (PEBB) benefits and the employer contribution as described in WAC 182-12-113(2);

(b) Failure to enroll the employee and their dependents in PEBB benefits as elected by the employee, if the elections were timely;

(c) Failure to enroll an employee and their dependents in PEBB benefits as described in WAC 182-08-197 (1)(b) or (3)(c);

(d) Failure to accurately reflect an employee's premium surcharge attestation on the employee's account;

(e) Enrolling an employee or their dependent in PEBB insurance coverage when they are not eligible as described in WAC 182-12-114 or 182-12-260 and it is clear there was no fraud or intentional misrepresentation by the employee involved; or

(f) Providing incorrect information regarding PEBB benefits to the employee that they relied upon.

(2) The employing agency or the applicable contracted vendor must enroll the employee and the employee's dependents, as elected, or terminate enrollment in PEBB benefits as described in subsection (3) of this section, reconcile premium payments and applicable premium surcharges as described in subsection (4) of this section, and provide recourse as described in subsection (5) of this section.

(3) Enrollment or termination.

(a) PEBB medical, dental, and vision enrollment is effective the first day of the month following the date the enrollment error is identified, unless the authority determines additional recourse is warranted, as described in subsection (5) of this section. If the enrollment error is identified on the first day of the month, the enrollment correction is effective that day;

| Exception: | When an employee who is called to active duty in the uniformed services under Uniformed Services Employment and Reemployment Rights Act (USERRA) loses eligibility for the employer contribution toward PEBB benefits, they regain eligibility for the employer contribution toward PEBB benefits the day they return from active duty. Employer-paid PEBB benefits will begin the first day of the month in which they return from active duty. |
| --- | --- |

(b) Basic life, supplemental life insurance, basic accidental death and dismemberment (AD&D), supplemental AD&D, employer-paid long-term disability (LTD) insurance, and employee-paid LTD insurance will begin for a newly eligible employee as described in WAC 182-12-114 and for an employee regaining eligibility as described in WAC 182-08-197(3). An employee who regains eligibility may need to submit evidence of insurability for supplemental life insurance or employee-paid LTD insurance as required in WAC 182-08-197(3).

| Exception: | When an employing agency fails to timely notify an employee that they are eligible for PEBB benefits, the employee may elect to prospectively enroll, without requiring evidence of insurability, in supplemental life insurance, supplemental AD&D insurance, and employee-paid LTD insurance effective the first day of the month following the date the enrollment error is identified, unless the authority determines additional recourse is warranted, as described in subsection (5) of this section. If the enrollment error is identified on the first day of the month, the enrollment correction is effective that day. |
| --- | --- |

(c) If the employee is eligible and elects (or elected) to enroll in the flexible spending arrangement (FSA), limited purpose FSA, or dependent care assistance program (DCAP), enrollment is limited to 60 days prior to the date enrollment is processed, but not earlier than the current plan year. If an employee was not enrolled in a FSA, limited purpose FSA, or DCAP as elected, the employee may either participate at the amount originally elected with a corresponding increase in contributions for the balance of the plan year, or participate at a reduced amount for the plan year by maintaining the per-pay period contribution in effect;

(d) If the employee or their dependent was not eligible but still enrolled as described in subsection (1)(e) of this section, the employee's or their dependent's PEBB benefits will be terminated prospectively effective as of the last day of the month.

(4) Premium payments.

(a) The employing agency must remit to the authority the employer contribution and the employee contribution for health plan premiums, applicable premium surcharges, basic life, basic AD&D, and employer-paid LTD starting the date PEBB benefits begins as described in subsections (3) and (5)(a)(i) of this section. If a state agency failed to notify a newly eligible employee of their eligibility for PEBB benefits, the state agency may only collect the employee contribution for health plan premiums and applicable premium surcharges for coverage for the months after the employee was notified.

(b) When an employing agency fails to correctly enroll the amount of employee-paid LTD insurance elected by the employee, premiums will be corrected as follows:

(i) When additional premiums are due to the authority, the employee is responsible for premiums for the most recent 24 months of coverage. The employing agency is responsible for additional months of premiums.

(ii) When a premium refund is due to the employee, the LTD insurance contracted vendor is responsible for premium refunds for the most recent 24 months of coverage. The employing agency is responsible for additional months of premium refund.

(c) When an employing agency mistakenly enrolls an employee or their dependent as described in subsection (1)(e) of this section, premiums and any applicable premium surcharges will be refunded by the employing agency to the employee without rescinding the insurance coverage.

(5) Recourse.

(a) An employee who establishes eligibility will have benefits begin as described in WAC 182-12-114. An employee who regains eligibility for the employer contribution toward PEBB benefits will have benefits begin as described in WAC 182-08-197(3). Dependent eligibility is described in WAC 182-12-260, and dependent enrollment is described in WAC 182-12-262. When retroactive correction of an enrollment error is limited as described in subsection (3)(a), (b), and (c) of this section, the employing agency must work with the employee, and receive approval from the authority, to implement retroactive PEBB benefits within the following parameters:

(i) Retroactive enrollment in a PEBB insurance coverage;

(ii) Reimbursement of claims paid;

(iii) Reimbursement of amounts paid by the employee or dependent for medical, dental, and vision premiums;

(iv) Reimbursement of amounts paid by the employee for the premium surcharges;

(v) Other legal remedy received or offered; or

(vi) Other recourse, upon approval by the authority.

(b) Recourse must not contradict a specific provision of federal law or statute and does not apply to requests for noncovered services or in the case of an individual who is not eligible for PEBB benefits.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 25-14-081 (Admin #2025.01.02), s 182-08-187, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-083 (Admin #2024-02), § 182-08-187, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolution PEBB 2022-01. WSR 23-14-017 (Admin #2023-02.02), § 182-08-187, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-08-187, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions PEBB 2021-11 and 2021-12. WSR 21-13-103 (Admin #2021-01.03), § 182-08-187, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-08-187, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-187, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-08-187, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-08-187, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-187, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-08-187, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-08-187, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-08-187, filed 10/28/13, effective 1/1/14.](Effective January 1, 2027) PDF WAC 182-08-187 How do employing agencies and contracted vendors correct enrollment errors and is there a limit on retroactive enrollment? (1) An employing agency or contracted vendor that makes one or more of the following enrollment errors must correct the error as described in subsections (2) through (5) of this section.(a) Failure to timely notify an employee of their eligibility for public employee benefits board (PEBB) benefits and the employer contribution as described in WAC 182-12-113(2)*
- *(b) Failure to enroll the employee and their dependents in PEBB benefits as elected by the employee, if the elections were timely*
- *(c) Failure to enroll an employee and their dependents in PEBB benefits as described in WAC 182-08-197 (1)(b) or (3)(c)*
- *(d) Failure to accurately reflect an employee's premium surcharge attestation on the employee's account*
- *(e) Enrolling an employee or their dependent in PEBB insurance coverage when they are not eligible as described in WAC 182-12-114 or 182-12-260 and it is clear there was no fraud or intentional misrepresentation by the employee involved*
- *or(f) Providing incorrect information regarding PEBB benefits to the employee that they relied upon.(2) The employing agency or the applicable contracted vendor must enroll the employee and the employee's dependents, as elected, or terminate enrollment in PEBB benefits as described in subsection (3) of this section, reconcile premium payments and applicable premium surcharges as described in subsection (4) of this section, and provide recourse as described in subsection (5) of this section.(3) Enrollment or termination.(a) PEBB medical, dental, and vision enrollment is effective the first day of the month following the date the enrollment error is identified, unless the authority determines additional recourse is warranted, as described in subsection (5) of this section. If the enrollment error is identified on the first day of the month, the enrollment correction is effective that day*
- *Exception:When an employee who is called to active duty in the uniformed services under Uniformed Services Employment and Reemployment Rights Act (USERRA) loses eligibility for the employer contribution toward PEBB benefits, they regain eligibility for the employer contribution toward PEBB benefits the day they return from active duty. Employer-paid PEBB benefits will begin the first day of the month in which they return from active duty.(b) Basic life, supplemental life insurance, basic accidental death and dismemberment (AD&D), supplemental AD&D, employer-paid long-term disability (LTD) insurance, and employee-paid LTD insurance will begin for a newly eligible employee as described in WAC 182-12-114 and for an employee regaining eligibility as described in WAC 182-08-197(3). An employee who regains eligibility may need to submit evidence of insurability for supplemental life insurance or employee-paid LTD insurance as required in WAC 182-08-197(3).Exception:When an employing agency fails to timely notify an employee that they are eligible for PEBB benefits, the employee may elect to prospectively enroll, without requiring evidence of insurability, in supplemental life insurance, supplemental AD&D insurance, and employee-paid LTD insurance effective the first day of the month following the date the enrollment error is identified, unless the authority determines additional recourse is warranted, as described in subsection (5) of this section. If the enrollment error is identified on the first day of the month, the enrollment correction is effective that day. (c) If the employee is eligible and elects (or elected) to enroll in the flexible spending arrangement (FSA), limited purpose FSA, or dependent care assistance program (DCAP), enrollment is limited to 60 days prior to the date enrollment is processed, but not earlier than the current plan year. If an employee was not enrolled in a FSA, limited purpose FSA, or DCAP as elected, the employee may either participate at the amount originally elected with a corresponding increase in contributions for the balance of the plan year, or participate at a reduced amount for the plan year by maintaining the per-pay period contribution in effect*
- *(d) If the employee or their dependent was not eligible but still enrolled as described in subsection (1)(e) of this section, the employee's or their dependent's PEBB benefits will be terminated prospectively effective as of the last day of the month.(4) Premium payments.(a) The employing agency must remit to the authority the employer contribution and the employee contribution for health plan premiums, applicable premium surcharges, basic life, basic AD&D, and employer-paid LTD starting the date PEBB benefits begins as described in subsections (3) and (5)(a)(i) of this section. If a state agency failed to notify a newly eligible employee of their eligibility for PEBB benefits, the state agency may only collect the employee contribution for health plan premiums and applicable premium surcharges for coverage for the months after the employee was notified.(b) When an employing agency fails to correctly enroll the amount of employee-paid LTD insurance elected by the employee, premiums will be corrected as follows:(i) When additional premiums are due to the authority, the employee is responsible for premiums for the most recent 24 months of coverage. The employing agency is responsible for additional months of premiums.(ii) When a premium refund is due to the employee, the LTD insurance contracted vendor is responsible for premium refunds for the most recent 24 months of coverage. The employing agency is responsible for additional months of premium refund.(c) When an employing agency mistakenly enrolls an employee or their dependent as described in subsection (1)(e) of this section, premiums and any applicable premium surcharges will be refunded by the employing agency to the employee without rescinding the insurance coverage.(5) Recourse.(a) An employee who establishes eligibility will have benefits begin as described in WAC 182-12-114. An employee who regains eligibility for the employer contribution toward PEBB benefits will have benefits begin as described in WAC 182-08-197(3). Dependent eligibility is described in WAC 182-12-260, and dependent enrollment is described in WAC 182-12-262. When retroactive correction of an enrollment error is limited as described in subsection (3)(a), (b), and (c) of this section, the employing agency must work with the employee, and receive approval from the authority, to implement retroactive PEBB benefits within the following parameters:(i) Retroactive enrollment in a PEBB insurance coverage*
- *(ii) Reimbursement of claims paid*
- *(iii) Reimbursement of amounts paid by the employee or dependent for medical, dental, and vision premiums*
- *(iv) Reimbursement of amounts paid by the employee for the premium surcharges*
- *(v) Other legal remedy received or offered*
- *or(vi) Other recourse, upon approval by the authority.(b) Recourse must not contradict a specific provision of federal law or statute and does not apply to requests for noncovered services or in the case of an individual who is not eligible for PEBB benefits.[Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 26-14-080 (Admin #2026.01), s 182-08-187, filed 6/29/26, effective 1/1/27*
- *WSR 25-14-081 (Admin #2025.01.02), s 182-08-187, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-083 (Admin #2024-02), § 182-08-187, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolution PEBB 2022-01. WSR 23-14-017 (Admin #2023-02.02), § 182-08-187, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-08-187, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions PEBB 2021-11 and 2021-12. WSR 21-13-103 (Admin #2021-01.03), § 182-08-187, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-08-187, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-187, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-08-187, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-08-187, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-187, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-08-187, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-08-187, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-08-187, filed 10/28/13, effective 1/1/14.*

##### **Wash. Admin. Code § 182-08-190** The employer contribution is set by the health care authority (HCA) and paid to the HCA for all eligible employees. {#sec-182-08-190 omnilex-key=us-wa-regs-official--title-182--182-08-190}

WAC 182-08-190

***(Effective until January 1, 2027)***

State agencies and employer groups that participate in the public employees benefits board (PEBB) program under contract with the health care authority (HCA) must pay the employer contributions to the HCA for PEBB for all eligible employees and their enrolled dependents.

(1) Employer contributions for state agencies are set by the HCA, and are subject to the approval of the governor for availability of funds as specifically appropriated by the legislature for that purpose. Insurance and health care contributions for ferry employees shall be governed by RCW 47.64.270.

(2) Employer contributions must include an amount determined by the HCA to pay administrative costs to administer PEBB benefits for employees of these groups.

(3) Each employee of a state agency eligible under WAC 182-12-131 or each eligible employee of a state agency on leave under the federal Family and Medical Leave Act (FMLA) or the paid family and medical leave program is eligible for the employer contribution as described in WAC 182-12-138.

(4) Employees of employer groups eligible under criteria stipulated under contract with the HCA are eligible for the employer contribution.

(5) The entire employer contribution is due and payable to the HCA even if enrollment is waived as described in WAC 182-12-128.

(6) Washington state patrol officers disabled while performing their duties as determined by the chief of the Washington state patrol are eligible for the employer contribution for PEBB medical as authorized in RCW 43.43.040. No other retiree or disabled employee is eligible for the employer contribution for PEBB benefits unless they are an eligible employee as described in WAC 182-12-114 or 182-12-131.

(7) The terms of payment to HCA for employer groups shall be stipulated under contract with the HCA.

***(Effective January 1, 2027)***

PDF WAC 182-08-190

The employer contribution is set by the health care authority (HCA) and paid to the HCA for all eligible employees.

State agencies and employer groups that participate in the public employees benefits board (PEBB) program under contract with the health care authority (HCA) must pay the employer contributions to the HCA for PEBB benefits for all eligible employees and their enrolled dependents.

(1) Employer contributions for state agencies are set by the HCA, and are subject to the approval of the governor for availability of funds as specifically appropriated by the legislature for that purpose. Insurance and health care contributions for ferry employees shall be governed by RCW 47.64.270.

(2) Employer contributions must include an amount determined by the HCA to pay administrative costs to administer PEBB benefits for employees of these groups.

(3) Each employee of a state agency eligible under WAC 182-12-131 or each eligible employee of a state agency on leave under the federal Family and Medical Leave Act (FMLA) or the paid family and medical leave program is eligible for the employer contribution as described in WAC 182-12-138.

(4) Employees of employer groups eligible under criteria stipulated under contract with the HCA are eligible for the employer contribution.

(5) The entire employer contribution is due and payable to the HCA from the date the employee is eligible for PEBB benefits to begin, even if enrollment is waived as described in WAC 182-12-128.

(6) Washington state patrol officers disabled while performing their duties as determined by the chief of the Washington state patrol are eligible for the employer contribution for PEBB medical as authorized in RCW 43.43.040. No other retiree or disabled employee is eligible for the employer contribution for PEBB benefits unless they are an eligible employee as described in WAC 182-12-114 or 182-12-131.

(7) The terms of payment to HCA for employer groups shall be stipulated under contract with the HCA.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions PEBB 2021-11 and 2021-12. WSR 21-13-103 (Admin #2021-01.03), § 182-08-190, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-08-190, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-190, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-190, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-08-190, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-08-190, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-08-190, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 09-23-102 (Order 09-02), § 182-08-190, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-08-190, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-08-190, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-08-190, filed 8/26/04, effective 1/1/05*
- *WSR 03-17-031 (Order 02-07), § 182-08-190, filed 8/14/03, effective 9/14/03. Statutory Authority: RCW 41.05.160. WSR 02-18-088 (Order 02-03), § 182-08-190, filed 9/3/02, effective 10/4/02. Statutory Authority: Chapter 41.05 RCW. WSR 96-08-042, § 182-08-190, filed 3/29/96, effective 4/29/96*
- *WSR 93-23-065, § 182-08-190, filed 11/16/93, effective 12/17/93*
- *WSR 78-02-015 (Order 2-78), § 182-08-190, filed 1/10/78*
- *Order 3-77, § 182-08-190, filed 11/17/77.](Effective January 1, 2027) PDF WAC 182-08-190 The employer contribution is set by the health care authority (HCA) and paid to the HCA for all eligible employees. State agencies and employer groups that participate in the public employees benefits board (PEBB) program under contract with the health care authority (HCA) must pay the employer contributions to the HCA for PEBB benefits for all eligible employees and their enrolled dependents.(1) Employer contributions for state agencies are set by the HCA, and are subject to the approval of the governor for availability of funds as specifically appropriated by the legislature for that purpose. Insurance and health care contributions for ferry employees shall be governed by RCW 47.64.270.(2) Employer contributions must include an amount determined by the HCA to pay administrative costs to administer PEBB benefits for employees of these groups.(3) Each employee of a state agency eligible under WAC 182-12-131 or each eligible employee of a state agency on leave under the federal Family and Medical Leave Act (FMLA) or the paid family and medical leave program is eligible for the employer contribution as described in WAC 182-12-138.(4) Employees of employer groups eligible under criteria stipulated under contract with the HCA are eligible for the employer contribution.(5) The entire employer contribution is due and payable to the HCA from the date the employee is eligible for PEBB benefits to begin, even if enrollment is waived as described in WAC 182-12-128.(6) Washington state patrol officers disabled while performing their duties as determined by the chief of the Washington state patrol are eligible for the employer contribution for PEBB medical as authorized in RCW 43.43.040. No other retiree or disabled employee is eligible for the employer contribution for PEBB benefits unless they are an eligible employee as described in WAC 182-12-114 or 182-12-131.(7) The terms of payment to HCA for employer groups shall be stipulated under contract with the HCA.[Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 26-14-080 (Admin #2026.01), s 182-08-190, filed 6/29/26, effective 1/1/27. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions PEBB 2021-11 and 2021-12. WSR 21-13-103 (Admin #2021-01.03), § 182-08-190, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-08-190, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-190, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-190, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-08-190, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-08-190, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-08-190, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 09-23-102 (Order 09-02), § 182-08-190, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-08-190, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-08-190, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-08-190, filed 8/26/04, effective 1/1/05*
- *WSR 03-17-031 (Order 02-07), § 182-08-190, filed 8/14/03, effective 9/14/03. Statutory Authority: RCW 41.05.160. WSR 02-18-088 (Order 02-03), § 182-08-190, filed 9/3/02, effective 10/4/02. Statutory Authority: Chapter 41.05 RCW. WSR 96-08-042, § 182-08-190, filed 3/29/96, effective 4/29/96*
- *WSR 93-23-065, § 182-08-190, filed 11/16/93, effective 12/17/93*
- *WSR 78-02-015 (Order 2-78), § 182-08-190, filed 1/10/78*
- *Order 3-77, § 182-08-190, filed 11/17/77.*

##### **Wash. Admin. Code § 182-08-191** Subscriber address requirements. {#sec-182-08-191 omnilex-key=us-wa-regs-official--title-182--182-08-191}

WAC 182-08-191

***(Effective until January 1, 2027)***

(1) All employees must provide their employing agency with their correct address and update their address if it changes. All other subscribers must provide the PEBB program with their correct address and updates to their address if it changes.

(2) In the event of an appeal, appellants must update their address as required in WAC 182-16-055.

***(Effective January 1, 2027)***

PDF WAC 182-08-191

Subscriber address requirements.

(1) All employees must provide their employing agency with their correct address and update their address if it changes. All other subscribers must provide the public employees benefits board (PEBB) program with their correct address and updates to their address if it changes.

(2) All subscribers enrolling in a medicare supplement plan, a medicare advantage plan, a medicare advantage-prescription drug plan, or the Uniform Medical Plan Classic medicare plan, must provide their permanent residence address to the PEBB program to determine that they reside in the health plan service area.

(3) In the event of an appeal, appellants must update their address as required in WAC 182-16-055.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-08-191, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-08-191, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-191, filed 8/20/19, effective 1/1/20.](Effective January 1, 2027) PDF WAC 182-08-191 Subscriber address requirements. (1) All employees must provide their employing agency with their correct address and update their address if it changes. All other subscribers must provide the public employees benefits board (PEBB) program with their correct address and updates to their address if it changes.(2) All subscribers enrolling in a medicare supplement plan, a medicare advantage plan, a medicare advantage-prescription drug plan, or the Uniform Medical Plan Classic medicare plan, must provide their permanent residence address to the PEBB program to determine that they reside in the health plan service area.(3) In the event of an appeal, appellants must update their address as required in WAC 182-16-055.[Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 26-14-080 (Admin #2026.01), s 182-08-191, filed 6/29/26, effective 1/1/27. Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-08-191, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-08-191, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-191, filed 8/20/19, effective 1/1/20.*

##### **Wash. Admin. Code § 182-08-196** What happens if my health plan becomes unavailable? {#sec-182-08-196 omnilex-key=us-wa-regs-official--title-182--182-08-196}

WAC 182-08-196

***(Effective until January 1, 2027)***

(1) A subscriber must elect a new health plan when their previously selected health plan becomes unavailable due to a change in contracting service area as described below:

(a) When a health plan becomes unavailable during the plan year, a subscriber must elect a new health plan no later than 60 days after the date their previously selected health plan becomes unavailable.

(i) An employee must submit the required forms to their employing agency electing their new health plan.

(ii) Any other subscriber must submit the required forms to the PEBB program electing their new health plan.

(iii) The effective date of the change in health plan will be the first day of the month following the later of the date the health plan becomes unavailable or the date the form is received. If that day is the first of the month, the change in health plan begins on that day.

(b) When a health plan becomes unavailable at the beginning of the next plan year, a subscriber must elect a new health plan no later than the last day of the public employees benefits board (PEBB) annual open enrollment.

(i) An employee must submit the required forms to their employing agency electing their new health plan.

(ii) Any other subscriber must submit the required forms to the PEBB program electing their new health plan.

(iii) The effective date of the change in health plan will be January 1st of the following year.

(c) A subscriber who fails to elect a new health plan within the required time period as required in (a) or (b) of this subsection will be enrolled in a health plan designated by the director or designee.

(2) A subscriber must elect a new health plan when their previously selected health plan becomes unavailable due to the subscriber or subscriber's dependent ceasing to be eligible for their current health plan because of enrollment in medicare as described below:

(a) The required forms electing a new health plan must be received no later than 60 days after the date their previously selected health plan becomes unavailable.

| Exception: | The required forms electing a new medicare advantage (MA) plan, medicare advantage-prescription drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan must be received no later than two months after the date their previously selected health plan becomes unavailable. |
| --- | --- |

(i) An employee must submit the required forms to their employing agency electing their new health plan.

(ii) Any other subscriber must submit the required forms to the PEBB program electing their new health plan.

(iii) The effective date of the change in health plan will be the first day of the month following the later of the date the health plan becomes unavailable or the date the form is received. If that day is the first of the month, the change in health plan begins on that day except for a MA plan, MA-PD plan, or the UMP Classic medicare plan which will begin the first day of the month following the date the form is received.

(b) A subscriber who is enrolled in a consumer directed health plan (CDHP) with a health savings account (HSA), and fails to elect a new health plan within the required time period as required in this subsection, will not be eligible to receive contributions to the HSA. A subscriber will be liable for any tax penalties resulting from contributions made when they are no longer eligible.

(3) A subscriber must elect a new medical plan when their previously selected medical plan becomes unavailable due to a change in their residence as described below.

(a) When a subscriber's medical plan becomes unavailable during the plan year, a subscriber must elect a new medical plan no later than 60 days after the date their previously selected medical plan becomes unavailable as described in WAC 182-08-198 (2)(e).

(i) An employee must submit the required forms to their employing agency electing their new medical plan.

(ii) Any other subscriber must submit the required forms to the PEBB program electing their new medical plan.

(iii) The effective date of the change in medical plan will be the first day of the month following the later of the date the medical plan becomes unavailable or the date the form is received. If that day is the first of the month, the change in medical plan begins on that day except for a MA plan, a MA-PD plan, or the UMP Classic medicare plan which will begin the first day of the month following the date the form is received.

(b) A subscriber who fails to elect a new medical plan within the required time period as required in (a) of this subsection will be enrolled in a public employees benefits board medical plan designated by the director or designee.

(4) When a subscriber or their dependent must be disenrolled by a MA plan, MA-PD plan, or a medicare Part D plan as required by federal law, the subscriber and their enrolled dependents will be enrolled in a PEBB medical plan as designated by the director or designee. The new medical plan coverage will begin the first day of the month following the date the MA plan, the MA-PD plan, or the UMP Classic medicare plan is terminated.

(5) When a subscriber or their dependent must be disenrolled by a MA plan, MA-PD plan, or a medicare Part D plan as required by federal law, due to permanently living in a location outside of the United States, PEBB medical plan enrollment will terminate on the last day of the month as required by federal law. A retiree or a survivor may defer enrollment in PEBB retiree insurance coverage as described in WAC 182-12-205 (3)(f).

(6) A subscriber enrolled in a health plan as described in subsection (1)(c), (2)(b), (3)(b), or (4) of this section may not change health plans except as allowed in WAC 182-08-198.

***(Effective January 1, 2027)***

PDF WAC 182-08-196

What happens if my health plan becomes unavailable?

(1) A subscriber must elect a new health plan when their previously selected health plan becomes unavailable due to a change in contracting service area as described below:

(a) When a health plan becomes unavailable during the plan year, a subscriber must elect a new health plan no later than 60 days after the date their previously selected health plan becomes unavailable.

(i) An employee must submit the required forms to their employing agency electing their new health plan.

(ii) Any other subscriber must submit the required forms to the public employees benefits board (PEBB) program electing their new health plan.

(iii) The effective date of the change in health plan will be the first day of the month following the later of the date the health plan becomes unavailable or the date the form is received. If that day is the first of the month, the change in health plan begins on that day.

(b) When a health plan becomes unavailable at the beginning of the next plan year, a subscriber must elect a new health plan no later than the last day of the PEBB annual open enrollment.

(i) An employee must submit the required forms to their employing agency electing their new health plan.

(ii) Any other subscriber must submit the required forms to the PEBB program electing their new health plan.

(iii) The effective date of the change in health plan will be January 1st of the following year.

(c) A subscriber who fails to elect a new health plan within the required time period as required in (a) or (b) of this subsection will be enrolled in a health plan designated by the director or designee.

(2) A subscriber must elect a new health plan when their previously selected health plan becomes unavailable due to the subscriber or subscriber's dependent ceasing to be eligible for their current health plan because of enrollment in medicare as described below:

(a) The required forms electing a new health plan must be received no later than 60 days after the date their previously selected health plan becomes unavailable.

| Exception: | The required forms electing a new medicare advantage (MA) plan, medicare advantage-prescription drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan must be received no later than two months after the date their previously selected health plan becomes unavailable. |
| --- | --- |

(i) An employee must submit the required forms to their employing agency electing their new health plan.

(ii) Any other subscriber must submit the required forms to the PEBB program electing their new health plan.

(iii) The effective date of the change in health plan will be the first day of the month following the later of the date the health plan becomes unavailable or the date the form is received. If that day is the first of the month, the change in health plan begins on that day except for a MA plan, MA-PD plan, or the UMP Classic medicare plan which will begin the first day of the month following the date the form is received.

(b) A subscriber who is enrolled in a consumer directed health plan (CDHP) with a health savings account (HSA), and fails to elect a new health plan within the required time period as required in this subsection, will not be eligible to receive contributions to the HSA. A subscriber will be liable for any tax penalties resulting from contributions made when they are no longer eligible.

(3) Except as described in subsection (5) of this section, a subscriber must elect a new medical plan when their previously selected medical plan becomes unavailable due to a change in their residence as described below:

(a) When a subscriber's medical plan becomes unavailable during the plan year, a subscriber must elect a new medical plan no later than 60 days after the date their previously selected medical plan becomes unavailable as described in WAC 182-08-198 (2)(e).

(i) An employee must submit the required forms to their employing agency electing their new medical plan.

(ii) Any other subscriber must submit the required forms to the PEBB program electing their new medical plan.

(iii) The effective date of the change in medical plan will be the first day of the month following the later of the date the medical plan becomes unavailable or the date the form is received. If that day is the first of the month, the change in medical plan begins on that day except for a MA plan, a MA-PD plan, or the UMP Classic medicare plan which will begin the first day of the month following the date the form is received.

(b) A subscriber who fails to elect a new medical plan within the required time period as required in (a) of this subsection will be enrolled in a PEBB medical plan designated by the director or designee.

(4) Except as described in subsection (5) of this section, when a subscriber or their dependent must be disenrolled by a MA plan, MA-PD plan, or a medicare Part D plan as required by federal law, the subscriber and their enrolled dependents will be enrolled in a PEBB medical plan as designated by the director or designee. The new medical plan coverage will begin the first day of the month following the date the MA plan, the MA-PD plan, or the UMP Classic medicare plan is terminated.

(5) When a subscriber or their dependent must be disenrolled by a MA plan, MA-PD plan, or a medicare Part D plan as required by federal law as described below, PEBB medical plan enrollment will terminate on the last day of the month as required by federal law. A retiree's or a survivor's enrollment in PEBB retiree insurance coverage will be automatically deferred as described in WAC 182-12-205 (11)(c).

(a) A subscriber or their dependent permanently resides outside of the United States; or

(b) A subscriber or their dependent has a temporary absence from the United States that exceeds the permitted time allowed under the federal regulations and guidance of the Centers for Medicare and Medicaid Services.

(6) A subscriber enrolled in a health plan as described in subsection (1)(c), (2)(b), (3)(b), or (4) of this section may not change health plans except as allowed in WAC 182-08-198.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.065, 41.05.160, and Policy Resolution PEBB 2024-26. WSR 25-14-067 (Admin #2025.02), s 182-08-196, filed 6/27/25, effective 8/1/25. Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-083 (Admin #2024-02), § 182-08-196, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, Policy Resolutions PEBB 2023-01 and 2023-02. WSR 23-14-016 (Admin #2023-02.01), § 182-08-196, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-08-196, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-196, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-08-196, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-08-196, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-196, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-08-196, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-08-196, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-08-196, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-08-196, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-08-196, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. WSR 05-16-046 (Order 05-01), § 182-08-196, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-08-196, filed 8/26/04, effective 1/1/05*
- *WSR 03-17-031 (Order 02-07), § 182-08-196, filed 8/14/03, effective 9/14/03.](Effective January 1, 2027) PDF WAC 182-08-196 What happens if my health plan becomes unavailable? (1) A subscriber must elect a new health plan when their previously selected health plan becomes unavailable due to a change in contracting service area as described below:(a) When a health plan becomes unavailable during the plan year, a subscriber must elect a new health plan no later than 60 days after the date their previously selected health plan becomes unavailable.(i) An employee must submit the required forms to their employing agency electing their new health plan.(ii) Any other subscriber must submit the required forms to the public employees benefits board (PEBB) program electing their new health plan.(iii) The effective date of the change in health plan will be the first day of the month following the later of the date the health plan becomes unavailable or the date the form is received. If that day is the first of the month, the change in health plan begins on that day.(b) When a health plan becomes unavailable at the beginning of the next plan year, a subscriber must elect a new health plan no later than the last day of the PEBB annual open enrollment.(i) An employee must submit the required forms to their employing agency electing their new health plan.(ii) Any other subscriber must submit the required forms to the PEBB program electing their new health plan.(iii) The effective date of the change in health plan will be January 1st of the following year.(c) A subscriber who fails to elect a new health plan within the required time period as required in (a) or (b) of this subsection will be enrolled in a health plan designated by the director or designee.(2) A subscriber must elect a new health plan when their previously selected health plan becomes unavailable due to the subscriber or subscriber's dependent ceasing to be eligible for their current health plan because of enrollment in medicare as described below:(a) The required forms electing a new health plan must be received no later than 60 days after the date their previously selected health plan becomes unavailable.Exception:The required forms electing a new medicare advantage (MA) plan, medicare advantage-prescription drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan must be received no later than two months after the date their previously selected health plan becomes unavailable.(i) An employee must submit the required forms to their employing agency electing their new health plan.(ii) Any other subscriber must submit the required forms to the PEBB program electing their new health plan.(iii) The effective date of the change in health plan will be the first day of the month following the later of the date the health plan becomes unavailable or the date the form is received. If that day is the first of the month, the change in health plan begins on that day except for a MA plan, MA-PD plan, or the UMP Classic medicare plan which will begin the first day of the month following the date the form is received.(b) A subscriber who is enrolled in a consumer directed health plan (CDHP) with a health savings account (HSA), and fails to elect a new health plan within the required time period as required in this subsection, will not be eligible to receive contributions to the HSA. A subscriber will be liable for any tax penalties resulting from contributions made when they are no longer eligible.(3) Except as described in subsection (5) of this section, a subscriber must elect a new medical plan when their previously selected medical plan becomes unavailable due to a change in their residence as described below:(a) When a subscriber's medical plan becomes unavailable during the plan year, a subscriber must elect a new medical plan no later than 60 days after the date their previously selected medical plan becomes unavailable as described in WAC 182-08-198 (2)(e).(i) An employee must submit the required forms to their employing agency electing their new medical plan.(ii) Any other subscriber must submit the required forms to the PEBB program electing their new medical plan.(iii) The effective date of the change in medical plan will be the first day of the month following the later of the date the medical plan becomes unavailable or the date the form is received. If that day is the first of the month, the change in medical plan begins on that day except for a MA plan, a MA-PD plan, or the UMP Classic medicare plan which will begin the first day of the month following the date the form is received.(b) A subscriber who fails to elect a new medical plan within the required time period as required in (a) of this subsection will be enrolled in a PEBB medical plan designated by the director or designee.(4) Except as described in subsection (5) of this section, when a subscriber or their dependent must be disenrolled by a MA plan, MA-PD plan, or a medicare Part D plan as required by federal law, the subscriber and their enrolled dependents will be enrolled in a PEBB medical plan as designated by the director or designee. The new medical plan coverage will begin the first day of the month following the date the MA plan, the MA-PD plan, or the UMP Classic medicare plan is terminated.(5) When a subscriber or their dependent must be disenrolled by a MA plan, MA-PD plan, or a medicare Part D plan as required by federal law as described below, PEBB medical plan enrollment will terminate on the last day of the month as required by federal law. A retiree's or a survivor's enrollment in PEBB retiree insurance coverage will be automatically deferred as described in WAC 182-12-205 (11)(c).(a) A subscriber or their dependent permanently resides outside of the United States*
- *or(b) A subscriber or their dependent has a temporary absence from the United States that exceeds the permitted time allowed under the federal regulations and guidance of the Centers for Medicare and Medicaid Services.(6) A subscriber enrolled in a health plan as described in subsection (1)(c), (2)(b), (3)(b), or (4) of this section may not change health plans except as allowed in WAC 182-08-198.[Statutory Authority: RCW 41.05.021, 41.05.065, 41.05.160, and PEBB policy resolutions. WSR 26-14-081 (Admin #2026.02), s 182-08-196, filed 6/29/26, effective 1/1/27. Statutory Authority: RCW 41.05.021, 41.05.065, 41.05.160, and Policy Resolution PEBB 2024-26. WSR 25-14-067 (Admin #2025.02), s 182-08-196, filed 6/27/25, effective 8/1/25. Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-083 (Admin #2024-02), § 182-08-196, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, Policy Resolutions PEBB 2023-01 and 2023-02. WSR 23-14-016 (Admin #2023-02.01), § 182-08-196, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-08-196, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-196, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-08-196, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-08-196, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-196, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-08-196, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-08-196, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-08-196, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-08-196, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-08-196, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. WSR 05-16-046 (Order 05-01), § 182-08-196, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-08-196, filed 8/26/04, effective 1/1/05*
- *WSR 03-17-031 (Order 02-07), § 182-08-196, filed 8/14/03, effective 9/14/03.*

##### **Wash. Admin. Code § 182-08-197** When must a newly eligible employee, or an employee who regains eligibility for the employer contribution, elect public employees benefits board (PEBB) benefits and complete required forms? {#sec-182-08-197 omnilex-key=us-wa-regs-official--title-182--182-08-197}

An employee who is newly eligible or who regains eligibility for the employer contribution toward public employees benefits board (PEBB) benefits enrolls as described in this section.

(1) When an employee is newly eligible for PEBB benefits:

(a) An employee must complete the required forms indicating their enrollment elections, including an election to waive enrollment provided the employee is eligible to waive as described in WAC 182-12-128. The required forms must be returned to the employee's employing agency or contracted vendor. Their employing agency or contracted vendor must receive the forms no later than 31 days after the employee becomes eligible for PEBB benefits under WAC 182-12-114.

(i) An employee may enroll in supplemental life insurance up to the guaranteed issue coverage amount without evidence of insurability if the required forms are returned to the employee's employing agency or contracted vendor as required. An employee may apply for enrollment in supplemental life insurance over the guaranteed issue coverage amount at any time during the calendar year by submitting the required form to the contracted vendor for approval. For an employee who requests a change in their supplemental life insurance after the election period described in this subsection, the change begins the first day of the month following the date the contracted vendor approves the request. An employee may enroll in supplemental accidental death and dismemberment (AD&D) insurance at any time during the calendar year without evidence of insurability by submitting the required form to the contracted vendor.

(ii) Employees are enrolled in employee-paid long-term disability (LTD) insurance automatically. An employee may elect to reduce their employee-paid LTD insurance or decline their employee-paid LTD insurance by returning the form to their employing agency. An employee may apply for a change in their employee-paid LTD insurance at any time during the calendar year by submitting the required form to their employing agency or the contracted vendor. For an employee who requests a change in their employee-paid LTD insurance after the election period described in this subsection, the change begins the first day of the month following the date the employing agency receives the required form requesting to reduce or decline the employee-paid LTD insurance, or the day of the month the contracted vendor approves the required form to increase the employee-paid LTD insurance.

(iii) If an employee is eligible to participate in the salary reduction plan (see WAC 182-12-116), the employee will automatically enroll in the premium payment plan upon enrollment in PEBB medical allowing medical premiums to be taken on a pretax basis. To opt out of the premium payment plan, a new employee must complete the required form and return it to their state agency. The form must be received by their state agency no later than 31 days after the employee becomes eligible for PEBB benefits.

(iv) If an employee is eligible to participate in the salary reduction plan (see WAC 182-12-116), the employee may enroll in the state's flexible spending arrangement (FSA), limited purpose FSA, dependent care assistance program (DCAP), or both an FSA and DCAP, except as limited by subsection (4) of this section. To enroll in these PEBB benefits, the employee must return the required form to their state agency. The form must be received by the state agency no later than 31 days after the employee becomes eligible for PEBB benefits.

(b) If a newly eligible employee's employing agency, or the authority's contracted vendor in the case of life insurance and AD&D insurance, does not receive the employee's required forms indicating medical, dental, vision, life insurance, AD&D insurance, and LTD insurance elections, and the employee's tobacco use status attestation within 31 days of the employee becoming eligible, their enrollment will be as follows for those elections not received within 31 days:

(i) A medical plan determined by the health care authority (HCA);

(ii) A dental plan determined by the HCA;

(iii) A vision plan determined by the HCA;

(iv) Basic life insurance;

(v) Basic AD&D insurance;

(vi) Employer-paid LTD insurance and employee-paid LTD insurance;

(vii) Dependents will not be enrolled; and

(viii) A tobacco use premium surcharge will be incurred as described in WAC 182-08-185 (1)(b).

(2) The employer contribution toward PEBB benefits ends according to WAC 182-12-131. When an employee's employment ends, participation in the salary reduction plan ends.

(3) When an employee regains eligibility for the employer contribution toward PEBB benefits, including following a period of leave described in WAC 182-12-133(1), or after being between periods of leave as described in WAC 182-12-142 (1) and (2), or 182-12-131 (3)(e), PEBB medical, dental, and vision begin on the first day of the month the employee is in pay status eight or more hours, or the first day of the month in which the quarter or semester begins for faculty who regains eligibility as described in WAC 182-12-131 (3)(e).

| Note: | When an employee who is called to active duty in the uniformed services under Uniformed Services Employment and Reemployment Rights Act (USERRA) loses eligibility for the employer contribution toward PEBB benefits, they regain eligibility for the employer contribution toward PEBB benefits the day they return from active duty. Employer-paid PEBB benefits will begin the first day of the month in which they return from active duty. |
| --- | --- |

(a) An employee must complete the required forms indicating their enrollment elections, including an election to waive enrollment if the employee chooses to waive enrollment as described in WAC 182-12-128. The required forms must be returned to the employee's employing agency except as described in (d) of this subsection. Forms must be received by the employing agency, life insurance contracted vendor, or AD&D contracted vendor, if required, no later than 31 days after the employee regains eligibility, except as described in (a)(i) and (b) of this subsection:

(i) An employee who self-paid for supplemental life insurance or supplemental AD&D coverage after losing eligibility will maintain that level of coverage upon return;

(ii) An employee who was eligible to continue supplemental life insurance but discontinued that supplemental coverage must submit evidence of insurability to the contracted vendor if they choose to reenroll when they regain eligibility for the employer contribution;

(iii) An employee who was eligible to continue employee-paid LTD insurance but discontinued that coverage must submit evidence of insurability for employee-paid LTD insurance to the contracted vendor when they regain eligibility for the employer contribution.

(b) An employee or faculty in any of the following circumstances does not have to return a form indicating employee-paid LTD insurance elections. Their employee-paid LTD insurance will be automatically reinstated effective the first day of the month they are in pay status eight or more hours or the first day of the month in which the quarter or semester begins for faculty who regains eligibility as described in WAC 182-12-131 (3)(e):

(i) The employee continued to self-pay for their employee-paid LTD insurance after losing eligibility for the employer contribution;

(ii) The employee was not eligible to continue employee-paid LTD insurance after losing eligibility for the employer contribution.

(c) If an employee's employing agency, or contracted vendor accepting forms directly, does not receive the required forms within 31 days of the employee regaining eligibility, the employee's enrollment for those elections not received will be as described in subsection (1)(b)(i) through (viii) of this section, except as described in (a)(i) and (b) of this subsection.

(d) If an employee is eligible to participate in the salary reduction plan (see WAC 182-12-116) the employee may enroll in the FSA, limited purpose FSA, DCAP, or both an FSA and DCAP, except as limited by subsection (4) of this section. To enroll in these PEBB benefits, the employee must return the required form to the contracted vendor or their state agency. The contracted vendor or employee's state agency must receive the form no later than 31 days after the employee becomes eligible for PEBB benefits.

(4) If an employee who is eligible to participate in the salary reduction plan (see WAC 182-12-116) is hired into a new position that is eligible for PEBB benefits in the same year, the employee may not resume participation in a DCAP, a FSA, or a limited purpose FSA until the beginning of the next plan year, unless the time between employments is 30 days or less and within the current plan year. The employee must notify their new state agency of the transfer by providing the new state agency's personnel, payroll, or benefits office the required form no later than 31 days after the employee's first day of work with the new state agency.

(5) An employee's PEBB benefits elections remain the same when an employee transfers from one employing agency to another employing agency without a break in PEBB benefits for one month or more. This includes movement of an employee between any entities described in WAC 182-12-111 and participating in PEBB benefits. PEBB benefits elections also remain the same when an employee has a break in employment that does not interrupt their employer contribution toward PEBB benefits.

(6) When a retiree or a survivor becomes eligible for the employer contribution toward PEBB benefits, PEBB retiree insurance coverage will be automatically deferred. The subscriber will be exempt from the deferral form requirement.

| Note: | When the subscriber is no longer eligible for the employer contribution toward PEBB benefits, they may enroll in PEBB retiree insurance coverage as described in WAC 182-12-171, 182-12-180, or 182-12-205 (6)(a)(ii), or continue in a deferred status if they meet the requirements described in WAC 182-12-200 or 182-12-205. |
| --- | --- |

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 25-14-081 (Admin #2025.01.02), s 182-08-197, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-083 (Admin #2024-02), § 182-08-197, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-08-197, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolutions PEBB 2022-01 and 2022-04. WSR 22-13-163 (Admin #2022-02.01), § 182-08-197, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions PEBB 2021-11 and 2021-12. WSR 21-13-103 (Admin #2021-01.03), § 182-08-197, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and PEBB policy resolution 2020-04. WSR 20-16-059 (Admin #2020-01), § 182-08-197, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-197, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-08-197, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-08-197, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-197, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-08-197, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-08-197, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-08-197, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-08-197, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-08-197, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-08-197, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-08-197, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-08-197, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-08-197, filed 10/3/07, effective 11/3/07*
- *WSR 06-11-156 (Order 06-02), § 182-08-197, filed 5/24/06, effective 6/24/06. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. WSR 05-16-046 (Order 05-01), § 182-08-197, filed 7/27/05, effective 8/27/05.*

##### **Wash. Admin. Code § 182-08-198** When may a subscriber change health plans? {#sec-182-08-198 omnilex-key=us-wa-regs-official--title-182--182-08-198}

WAC 182-08-198

***(Effective until January 1, 2027)***

A subscriber may change health plans at the following times:

(1) During the annual open enrollment: A subscriber may change health plans during the public employees benefits board (PEBB) annual open enrollment period. A subscriber must submit the required enrollment forms to change their health plan. An employee submits the enrollment forms to their employing agency. Any other subscriber submits the enrollment forms to the PEBB program. The required enrollment forms must be received no later than the last day of the annual open enrollment. Enrollment in the new health plan will begin January 1st of the following year.

(2) During a special open enrollment: A subscriber may revoke their health plan election and make a new election outside of the annual open enrollment if a special open enrollment event occurs. A special open enrollment event must be an event other than an employee gaining initial eligibility for PEBB benefits as described in WAC 182-12-114 or regaining eligibility for PEBB benefits as described in WAC 182-08-197. The change in enrollment must be allowable under Internal Revenue Code and Treasury regulations, and correspond to and be consistent with the event that creates the special open enrollment for the subscriber, the subscriber's dependent, or both.

A subscriber may not change their health plan during a special open enrollment if their state registered domestic partner or state registered domestic partner's child is not a tax dependent. A subscriber may change their health plan as described in subsection (1) of this section.

To disenroll from a medicare advantage (MA) plan, medicare advantage-prescription drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan, the change in enrollment must be allowable under 42 C.F.R. Secs. 422.62(b) and 423.38(c). To make a health plan change, a subscriber must submit the required enrollment forms (and a completed disenrollment form, if required). The forms must be received no later than 60 days after the event occurs, except as described in (i) and (j) of this subsection. An employee submits the enrollment forms to their employing agency. Any other subscriber submits the enrollment forms to the PEBB program. In addition to the required forms, a subscriber must provide evidence of the event that created the special open enrollment. New health plan coverage will begin the first day of the month following the later of the event date or the date the form is received. If that day is the first of the month, the change in enrollment begins on that day except for a MA plan, a MA-PD plan, or the UMP Classic medicare plan which will begin the first day of the month following the date the form is received.

| Exception: | When a subscriber or their dependent is enrolled in a MA plan, a MA-PD plan, or the UMP Classic medicare plan, they may disenroll during a special enrollment period as allowed under 42 C.F.R. Secs. 422.62(b) and 423.38(c). The new medical plan coverage will begin the first day of the month following the date the plan disenrollment form is received. |
| --- | --- |

If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, health plan coverage will begin the month in which the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption occurs. If the special open enrollment is due to the enrollment of an extended dependent or a dependent with a disability, the change in health plan coverage will begin the first day of the month following the later of the event date or eligibility certification. Any one of the following events may create a special open enrollment:

(a) Subscriber acquires a new dependent due to:

(i) Marriage or registering a state registered domestic partnership;

(ii) Birth, adoption, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption; or

(iii) A child becoming eligible as an extended dependent through legal custody or legal guardianship;

(b) Subscriber or a subscriber's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA);

(c) Subscriber has a change in employment status that affects the subscriber's eligibility for their employer contribution toward their employer-based group health plan;

(d) The subscriber's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution under their employer-based group health plan;

| Note: | As used in (d) of this subsection, "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 26 C.F.R. 54.9801-6. |
| --- | --- |

(e) Subscriber or a subscriber's dependent has a change in residence that affects health plan availability;

(i) If the subscriber has a change in residence and the subscriber's current medical plan is no longer available, the subscriber must select a new medical plan as described in WAC 182-08-196(3);

(ii) If the subscriber or the subscriber's dependent has a change in residence and the subscriber's current dental plan does not have available providers within 50 miles of the subscriber or the subscriber's dependent's new residence, the subscriber may select a new dental plan;

(f) A court order requires the subscriber or any other individual to provide insurance coverage for an eligible dependent of the subscriber (a former spouse or former state registered domestic partner is not an eligible dependent);

(g) Subscriber or a subscriber's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the subscriber or a subscriber's dependent loses eligibility for coverage under medicaid or CHIP;

(h) Subscriber or a subscriber's dependent becomes eligible for state premium assistance subsidy for PEBB health plan coverage from medicaid or CHIP;

(i) Subscriber or a subscriber's dependent enrolls in coverage under medicare, or the subscriber or a subscriber's dependent loses eligibility for coverage under medicare, or enrolls in or terminates enrollment in a MA-PD or a Part D plan. If the subscriber's current medical plan becomes unavailable due to the subscriber's or a subscriber's dependent's enrollment in medicare, the subscriber must select a new medical plan as described in WAC 182-08-196(2);

(i) A subscriber enrolled in PEBB retiree insurance coverage, a retired employee, a retired school employee, or a survivor enrolled in PEBB health plan coverage after their employer group ceased participation, or an eligible subscriber enrolled in Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage has six months from the date of their or their dependent's enrollment in medicare Part B to enroll in a PEBB medicare supplement plan for which they or their dependent is eligible. The forms must be received by the PEBB program no later than six months after the enrollment in medicare Part B for either the subscriber or the subscriber's dependent;

(ii) A subscriber enrolled in PEBB retiree insurance coverage, a retired employee, a retired school employee, or a survivor enrolled in PEBB health plan coverage after their employer group ceased participation, or an eligible subscriber enrolled in COBRA coverage has seven months to enroll in a MA plan, MA-PD plan, or the UMP Classic medicare plan that begins three months before they or their dependent first enrolled in both medicare Part A and Part B and ends three months after the month of medicare eligibility. A subscriber may also enroll themselves or their dependent in a MA plan, MA-PD plan, or the UMP Classic medicare plan before their last day of the medicare Part B initial enrollment period. The forms must be received by the PEBB program no later than the last day of the month prior to the month the subscriber or the subscriber's dependent enrolls in the MA plan, MA-PD plan, or the UMP Classic medicare plan;

(j) Subscriber or a subscriber's dependent gains, loses, or has a change in low-income subsidy (LIS) eligibility as described in 42 C.F.R. § 423.38 (c)(9). They may enroll in a MA plan, MA-PD plan, medicare supplement plan, or the UMP Classic medicare plan if eligible, within three months after a gain, loss, or change to LIS eligibility, or notification of such a change, whichever is later. The forms must be received by the PEBB program no later than three months after they gain, lose, or have a change in LIS eligibility, or notification of such a change, whichever is later;

(k) Subscriber or a subscriber's dependent's current medical plan becomes unavailable because the subscriber or enrolled dependent is no longer eligible for a health savings account (HSA). The authority may require evidence that the subscriber or subscriber's dependent is no longer eligible for an HSA;

(l) Subscriber or a subscriber's dependent experiences a disruption of care for active and ongoing treatment, that could function as a reduction in benefits for the subscriber or the subscriber's dependent. A subscriber may not change their health plan election if the subscriber's or dependent's physician stops participation with the subscriber's health plan unless the PEBB program determines that a continuity of care issue exists. The PEBB program will consider but not limit its consideration to the following:

(i) Active cancer treatment such as chemotherapy or radiation therapy;

(ii) Treatment following a recent organ transplant;

(iii) A scheduled surgery;

(iv) Recent major surgery still within the postoperative period; or

(v) Treatment for a high-risk pregnancy;

(m) The PEBB program determines that there has been a substantial decrease in the providers available under a PEBB medical plan.

(3) If the employee is having premiums taken from payroll on a pretax basis, a medical plan change will not be approved if it would conflict with provisions of the salary reduction plan authorized under RCW 41.05.300.

***(Effective January 1, 2027)***

PDF WAC 182-08-198

When may a subscriber change health plans?

A subscriber may change health plans at the following times:

(1) During the annual open enrollment: A subscriber may change health plans during the public employees benefits board (PEBB) annual open enrollment period. A subscriber must submit the required enrollment forms to change their health plan. An employee submits the enrollment forms to their employing agency. Any other subscriber submits the enrollment forms to the PEBB program. The required enrollment forms must be received no later than the last day of the annual open enrollment. Enrollment in the new health plan will begin January 1st of the following year.

(2) During a special open enrollment: A subscriber may revoke their health plan election and make a new election outside of the annual open enrollment if a special open enrollment event occurs. A special open enrollment event must be an event other than an employee gaining initial eligibility for PEBB benefits as described in WAC 182-12-114 or regaining eligibility for PEBB benefits as described in WAC 182-08-197. The change in enrollment must be allowable under Internal Revenue Code and Treasury regulations, and correspond to and be consistent with the event that creates the special open enrollment for the subscriber, the subscriber's dependent, or both.

A subscriber may not change their health plan during a special open enrollment if their state registered domestic partner or state registered domestic partner's child is not a tax dependent. A subscriber may change their health plan as described in subsection (1) of this section.

To disenroll from a medicare advantage (MA) plan, medicare advantage-prescription drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan, the change in enrollment must be allowable under 42 C.F.R. Secs. 422.62(b) and 423.38(c). To make a health plan change, a subscriber must submit the required enrollment forms (and a completed disenrollment form, if required). The forms must be received no later than 60 days after the event occurs, except as described in (i) and (j) of this subsection. An employee submits the enrollment forms to their employing agency. Any other subscriber submits the enrollment forms to the PEBB program. In addition to the required forms, a subscriber must provide evidence of the event that created the special open enrollment. New health plan coverage will begin the first day of the month following the later of the event date or the date the form is received. If that day is the first of the month, the change in enrollment begins on that day except for a MA plan, a MA-PD plan, or the UMP Classic medicare plan which will begin the first day of the month following the date the form is received.

| Exception: | When a subscriber or their dependent is enrolled in a MA plan, a MA-PD plan, or the UMP Classic medicare plan, they may disenroll during a special enrollment period as allowed under 42 C.F.R. Secs. 422.62(b) and 423.38(c). The new medical plan coverage will begin the first day of the month following the date the plan disenrollment form is received. |
| --- | --- |

If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, health plan coverage will begin the month in which the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption occurs. If the special open enrollment is due to the enrollment of an extended dependent or a dependent with a disability, the change in health plan coverage will begin the first day of the month following the later of the event date or eligibility certification. Any one of the following events may create a special open enrollment:

(a) Subscriber acquires a new dependent due to:

(i) Marriage or registering a state registered domestic partnership;

(ii) Birth, adoption, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption; or

(iii) A child becoming eligible as an extended dependent through legal custody or legal guardianship;

(b) Subscriber or a subscriber's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA);

(c) Subscriber has a change in employment status that affects the subscriber's eligibility for their employer contribution toward their employer-based group health plan;

(d) The subscriber's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution under their employer-based group health plan;

| Note: | As used in (d) of this subsection, "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 26 C.F.R. 54.9801-6. |
| --- | --- |

(e) Subscriber or a subscriber's dependent has a change in residence that affects health plan availability;

(i) If the subscriber has a change in residence and the subscriber's current medical plan is no longer available, the subscriber must select a new medical plan as described in WAC 182-08-196(3);

(ii) If the subscriber or the subscriber's dependent has a change in residence and the subscriber's current dental plan does not have available providers within 50 miles of the subscriber or the subscriber's dependent's new residence, the subscriber may select a new dental plan;

(f) A court order requires the subscriber or any other individual to provide insurance coverage for an eligible dependent of the subscriber (a former spouse or former state registered domestic partner is not an eligible dependent);

(g) Subscriber or a subscriber's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the subscriber or a subscriber's dependent loses eligibility for coverage under medicaid or CHIP;

(h) Subscriber or a subscriber's dependent becomes eligible for state premium assistance subsidy for PEBB health plan coverage from medicaid or CHIP;

(i) Subscriber or a subscriber's dependent enrolls in coverage under medicare, or the subscriber or a subscriber's dependent loses eligibility for coverage under medicare, or enrolls in or terminates enrollment in a MA-PD or a Part D plan. If the subscriber's current medical plan becomes unavailable due to the subscriber's or a subscriber's dependent's enrollment in medicare, the subscriber must select a new medical plan as described in WAC 182-08-196(2);

(i) A subscriber enrolled in PEBB retiree insurance coverage, a retired employee, a retired school employee, or a survivor enrolled in PEBB health plan coverage after their employer group ceased participation, or an eligible subscriber enrolled in Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage has six months from the date of their or their dependent's enrollment in medicare Part B to enroll in a PEBB medicare supplement plan for which they or their dependent is eligible. The forms must be received by the PEBB program no later than six months after the enrollment in medicare Part B for either the subscriber or the subscriber's dependent;

(ii) A subscriber enrolled in PEBB retiree insurance coverage, a retired employee, a retired school employee, or a survivor enrolled in PEBB health plan coverage after their employer group ceased participation, or an eligible subscriber enrolled in COBRA coverage has seven months to enroll in a MA plan, MA-PD plan, or the UMP Classic medicare plan that begins three months before they or their dependent first enrolled in both medicare Part A and Part B and ends three months after the month of medicare eligibility. A subscriber may also enroll themselves or their dependent in a MA plan, MA-PD plan, or the UMP Classic medicare plan before their last day of the medicare Part B initial enrollment period. The forms must be received by the PEBB program no later than the last day of the month prior to the month the subscriber or the subscriber's dependent enrolls in the MA plan, MA-PD plan, or the UMP Classic medicare plan;

(j) Subscriber or a subscriber's dependent gains, loses, or has a change in low-income subsidy (LIS) eligibility as described in 42 C.F.R. § 423.38 (c)(9). They may enroll in a MA plan, MA-PD plan, medicare supplement plan, or the UMP Classic medicare plan if eligible, within three months after a gain, loss, or change to LIS eligibility, or notification of such a change, whichever is later. The forms must be received by the PEBB program no later than three months after they gain, lose, or have a change in LIS eligibility, or notification of such a change, whichever is later;

(k) Subscriber or a subscriber's dependent's current medical plan becomes unavailable because the subscriber or enrolled dependent is no longer eligible for a health savings account (HSA). The authority may require evidence that the subscriber or subscriber's dependent is no longer eligible for an HSA;

(l) Subscriber or a subscriber's dependent experiences a disruption of care for active and ongoing treatment, that could function as a reduction in benefits for the subscriber or the subscriber's dependent. A subscriber may not change their health plan election if the subscriber's or dependent's physician stops participation with the subscriber's health plan unless the PEBB program determines that a continuity of care issue exists. The PEBB program will consider but not limit its consideration to the following:

(i) Active cancer treatment such as chemotherapy or radiation therapy;

(ii) Treatment following a recent organ transplant;

(iii) A scheduled surgery;

(iv) Recent major surgery still within the postoperative period; or

(v) Treatment for a high-risk pregnancy;

(m) Subscriber or a subscriber's dependent becomes eligible and enrolls in a TRICARE plan or loses eligibility for a TRICARE plan;

(n) The PEBB program determines that there has been a substantial decrease in the providers available under a PEBB medical plan;

(o) The PEBB program determines that there has been a substantial increase in the employee's premiums when the employee transfers from one employing agency to another employing agency.

(3) If the employee is having premiums taken from payroll on a pretax basis, a medical plan change will not be approved if it would conflict with provisions of the salary reduction plan authorized under RCW 41.05.300.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 25-14-081 (Admin #2025.01.02), s 182-08-198, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.05.065, 41.05.160, 2023 c 164 § 1, 2023 c 312 § 1, 2023 c 13 § 5, Policy Resolutions PEBB 2024-14, 2024-19, 2024-20, and 2024-21. WSR 24-18-081 (Admin #2024-01.05), § 182-08-198, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, Policy Resolutions PEBB 2023-01 and 2023-02. WSR 23-14-016 (Admin #2023-02.01), § 182-08-198, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-08-198, filed 6/21/22, effective 1/1/23*
- *WSR 21-13-106 (Admin #2021-01.06), § 182-08-198, filed 6/18/21, effective 1/1/22*
- *WSR 20-16-062 (Admin #2020-03), § 182-08-198, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-198, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-08-198, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-08-198, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-198, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-08-198, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160, 2013 2nd sp.s. c 4 and PEBB policy resolutions. WSR 14-08-040, § 182-08-198, filed 3/26/14, effective 4/26/14. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-08-198, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-08-198, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-08-198, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-08-198, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-08-198, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-08-198, filed 10/1/08, effective 1/1/09*
- *WSR 08-09-027 (Order 08-01), § 182-08-198, filed 4/8/08, effective 4/9/08*
- *WSR 07-20-129 (Order 07-01), § 182-08-198, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.068. WSR 06-23-165 (Order 06-09), § 182-08-198, filed 11/22/06, effective 12/23/06. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. WSR 05-16-046 (Order 05-01), § 182-08-198, filed 7/27/05, effective 8/27/05.](Effective January 1, 2027) PDF WAC 182-08-198 When may a subscriber change health plans? A subscriber may change health plans at the following times:(1) During the annual open enrollment: A subscriber may change health plans during the public employees benefits board (PEBB) annual open enrollment period. A subscriber must submit the required enrollment forms to change their health plan. An employee submits the enrollment forms to their employing agency. Any other subscriber submits the enrollment forms to the PEBB program. The required enrollment forms must be received no later than the last day of the annual open enrollment. Enrollment in the new health plan will begin January 1st of the following year.(2) During a special open enrollment: A subscriber may revoke their health plan election and make a new election outside of the annual open enrollment if a special open enrollment event occurs. A special open enrollment event must be an event other than an employee gaining initial eligibility for PEBB benefits as described in WAC 182-12-114 or regaining eligibility for PEBB benefits as described in WAC 182-08-197. The change in enrollment must be allowable under Internal Revenue Code and Treasury regulations, and correspond to and be consistent with the event that creates the special open enrollment for the subscriber, the subscriber's dependent, or both.A subscriber may not change their health plan during a special open enrollment if their state registered domestic partner or state registered domestic partner's child is not a tax dependent. A subscriber may change their health plan as described in subsection (1) of this section.To disenroll from a medicare advantage (MA) plan, medicare advantage-prescription drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan, the change in enrollment must be allowable under 42 C.F.R. Secs. 422.62(b) and 423.38(c). To make a health plan change, a subscriber must submit the required enrollment forms (and a completed disenrollment form, if required). The forms must be received no later than 60 days after the event occurs, except as described in (i) and (j) of this subsection. An employee submits the enrollment forms to their employing agency. Any other subscriber submits the enrollment forms to the PEBB program. In addition to the required forms, a subscriber must provide evidence of the event that created the special open enrollment. New health plan coverage will begin the first day of the month following the later of the event date or the date the form is received. If that day is the first of the month, the change in enrollment begins on that day except for a MA plan, a MA-PD plan, or the UMP Classic medicare plan which will begin the first day of the month following the date the form is received.Exception:When a subscriber or their dependent is enrolled in a MA plan, a MA-PD plan, or the UMP Classic medicare plan, they may disenroll during a special enrollment period as allowed under 42 C.F.R. Secs. 422.62(b) and 423.38(c). The new medical plan coverage will begin the first day of the month following the date the plan disenrollment form is received.If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, health plan coverage will begin the month in which the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption occurs. If the special open enrollment is due to the enrollment of an extended dependent or a dependent with a disability, the change in health plan coverage will begin the first day of the month following the later of the event date or eligibility certification. Any one of the following events may create a special open enrollment:(a) Subscriber acquires a new dependent due to:(i) Marriage or registering a state registered domestic partnership*
- *(ii) Birth, adoption, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption*
- *or(iii) A child becoming eligible as an extended dependent through legal custody or legal guardianship*
- *(b) Subscriber or a subscriber's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA)*
- *(c) Subscriber has a change in employment status that affects the subscriber's eligibility for their employer contribution toward their employer-based group health plan*
- *(d) The subscriber's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution under their employer-based group health plan*
- *Note:As used in (d) of this subsection, "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 26 C.F.R. 54.9801-6.(e) Subscriber or a subscriber's dependent has a change in residence that affects health plan availability*
- *(i) If the subscriber has a change in residence and the subscriber's current medical plan is no longer available, the subscriber must select a new medical plan as described in WAC 182-08-196(3)*
- *(ii) If the subscriber or the subscriber's dependent has a change in residence and the subscriber's current dental plan does not have available providers within 50 miles of the subscriber or the subscriber's dependent's new residence, the subscriber may select a new dental plan*
- *(f) A court order requires the subscriber or any other individual to provide insurance coverage for an eligible dependent of the subscriber (a former spouse or former state registered domestic partner is not an eligible dependent)*
- *(g) Subscriber or a subscriber's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the subscriber or a subscriber's dependent loses eligibility for coverage under medicaid or CHIP*
- *(h) Subscriber or a subscriber's dependent becomes eligible for state premium assistance subsidy for PEBB health plan coverage from medicaid or CHIP*
- *(i) Subscriber or a subscriber's dependent enrolls in coverage under medicare, or the subscriber or a subscriber's dependent loses eligibility for coverage under medicare, or enrolls in or terminates enrollment in a MA-PD or a Part D plan. If the subscriber's current medical plan becomes unavailable due to the subscriber's or a subscriber's dependent's enrollment in medicare, the subscriber must select a new medical plan as described in WAC 182-08-196(2)*
- *(i) A subscriber enrolled in PEBB retiree insurance coverage, a retired employee, a retired school employee, or a survivor enrolled in PEBB health plan coverage after their employer group ceased participation, or an eligible subscriber enrolled in Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage has six months from the date of their or their dependent's enrollment in medicare Part B to enroll in a PEBB medicare supplement plan for which they or their dependent is eligible. The forms must be received by the PEBB program no later than six months after the enrollment in medicare Part B for either the subscriber or the subscriber's dependent*
- *(ii) A subscriber enrolled in PEBB retiree insurance coverage, a retired employee, a retired school employee, or a survivor enrolled in PEBB health plan coverage after their employer group ceased participation, or an eligible subscriber enrolled in COBRA coverage has seven months to enroll in a MA plan, MA-PD plan, or the UMP Classic medicare plan that begins three months before they or their dependent first enrolled in both medicare Part A and Part B and ends three months after the month of medicare eligibility. A subscriber may also enroll themselves or their dependent in a MA plan, MA-PD plan, or the UMP Classic medicare plan before their last day of the medicare Part B initial enrollment period. The forms must be received by the PEBB program no later than the last day of the month prior to the month the subscriber or the subscriber's dependent enrolls in the MA plan, MA-PD plan, or the UMP Classic medicare plan*
- *(j) Subscriber or a subscriber's dependent gains, loses, or has a change in low-income subsidy (LIS) eligibility as described in 42 C.F.R. § 423.38 (c)(9). They may enroll in a MA plan, MA-PD plan, medicare supplement plan, or the UMP Classic medicare plan if eligible, within three months after a gain, loss, or change to LIS eligibility, or notification of such a change, whichever is later. The forms must be received by the PEBB program no later than three months after they gain, lose, or have a change in LIS eligibility, or notification of such a change, whichever is later*
- *(k) Subscriber or a subscriber's dependent's current medical plan becomes unavailable because the subscriber or enrolled dependent is no longer eligible for a health savings account (HSA). The authority may require evidence that the subscriber or subscriber's dependent is no longer eligible for an HSA*
- *(l) Subscriber or a subscriber's dependent experiences a disruption of care for active and ongoing treatment, that could function as a reduction in benefits for the subscriber or the subscriber's dependent. A subscriber may not change their health plan election if the subscriber's or dependent's physician stops participation with the subscriber's health plan unless the PEBB program determines that a continuity of care issue exists. The PEBB program will consider but not limit its consideration to the following:(i) Active cancer treatment such as chemotherapy or radiation therapy*
- *(ii) Treatment following a recent organ transplant*
- *(iii) A scheduled surgery*
- *(iv) Recent major surgery still within the postoperative period*
- *or(v) Treatment for a high-risk pregnancy*
- *(m) Subscriber or a subscriber's dependent becomes eligible and enrolls in a TRICARE plan or loses eligibility for a TRICARE plan*
- *(n) The PEBB program determines that there has been a substantial decrease in the providers available under a PEBB medical plan*
- *(o) The PEBB program determines that there has been a substantial increase in the employee's premiums when the employee transfers from one employing agency to another employing agency.(3) If the employee is having premiums taken from payroll on a pretax basis, a medical plan change will not be approved if it would conflict with provisions of the salary reduction plan authorized under RCW 41.05.300.[Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 26-14-080 (Admin #2026.01), s 182-08-198, filed 6/29/26, effective 1/1/27*
- *WSR 25-14-081 (Admin #2025.01.02), s 182-08-198, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.05.065, 41.05.160, 2023 c 164 § 1, 2023 c 312 § 1, 2023 c 13 § 5, Policy Resolutions PEBB 2024-14, 2024-19, 2024-20, and 2024-21. WSR 24-18-081 (Admin #2024-01.05), § 182-08-198, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, Policy Resolutions PEBB 2023-01 and 2023-02. WSR 23-14-016 (Admin #2023-02.01), § 182-08-198, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-08-198, filed 6/21/22, effective 1/1/23*
- *WSR 21-13-106 (Admin #2021-01.06), § 182-08-198, filed 6/18/21, effective 1/1/22*
- *WSR 20-16-062 (Admin #2020-03), § 182-08-198, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-198, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-08-198, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-08-198, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-198, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-08-198, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160, 2013 2nd sp.s. c 4 and PEBB policy resolutions. WSR 14-08-040, § 182-08-198, filed 3/26/14, effective 4/26/14. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-08-198, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-08-198, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-08-198, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-08-198, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-08-198, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-08-198, filed 10/1/08, effective 1/1/09*
- *WSR 08-09-027 (Order 08-01), § 182-08-198, filed 4/8/08, effective 4/9/08*
- *WSR 07-20-129 (Order 07-01), § 182-08-198, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.068. WSR 06-23-165 (Order 06-09), § 182-08-198, filed 11/22/06, effective 12/23/06. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. WSR 05-16-046 (Order 05-01), § 182-08-198, filed 7/27/05, effective 8/27/05.*

##### **Wash. Admin. Code § 182-08-199** When may an employee enroll, or revoke an election and make a new election under the premium payment plan, flexible spending arrangement (FSA), limited purpose FSA, or dependent care assistance program (DCAP)? {#sec-182-08-199 omnilex-key=us-wa-regs-official--title-182--182-08-199}

WAC 182-08-199

***(Effective until January 1, 2027)***

An employee who is eligible to participate in the salary reduction plan as described in WAC 182-12-116 may enroll, or revoke their election and make a new election under the premium payment plan, flexible spending arrangement (FSA), limited purpose FSA, or dependent care assistance program (DCAP) at the following times:

(1) When newly eligible under WAC 182-12-114 and enrolling as described in WAC 182-08-197(1).

(2) During annual open enrollment: An eligible employee may elect to enroll in or opt out of participation under the premium payment plan during the annual open enrollment by submitting the required form to their employing agency. An eligible employee may elect to enroll or reenroll in the FSA, limited purpose FSA, DCAP, or both an FSA and DCAP during the annual open enrollment by submitting the required forms to their employing agency or applicable contracted vendor as instructed. All required forms must be received no later than the last day of the annual open enrollment. The enrollment or new election becomes effective January 1st of the following year.

(a) Employees cannot enroll in a FSA and a limited purpose FSA in the same year.

(b) Employees enrolled in a consumer directed health plan (CDHP) with a health savings account (HSA) cannot also enroll in a FSA in the same plan year. Employees who elect enrollment in the CDHP with a HSA and a FSA will only be enrolled in a CDHP with a HSA.

(c) Employees who enroll in a CDHP with a HSA during the annual open enrollment and have a carryover amount from a FSA, will be enrolled in a limited purpose FSA and the carryover amount will be deposited into the limited purpose FSA.

(d) Employees who are not enrolled in a CDHP with a HSA and elect both a FSA and a limited purpose FSA will be enrolled in the FSA.

(3) During a special open enrollment: An employee who is eligible to participate in the salary reduction plan may enroll or revoke their election and make a new election under the premium payment plan, FSA, limited purpose FSA, or DCAP outside of the annual open enrollment if a special open enrollment event occurs. The enrollment or change in election must be allowable under Internal Revenue Code (IRC) and Treasury regulations, and correspond to and be consistent with the event that creates the special open enrollment. To make a change or enroll, the employee must submit the required form to their employing agency. The employing agency must receive the required form and evidence of the event that created the special open enrollment no later than 60 days after the event occurs.

For purposes of this section, an eligible dependent includes any person who qualifies as a dependent of the employee for tax purposes under IRC 26 U.S.C. Sec. 152 without regard to the income limitations of that section. It does not include a state registered domestic partner unless the state registered domestic partner otherwise qualifies as a dependent for tax purposes under IRC 26 U.S.C. Sec. 152.

(a) Premium payment plan. An employee may enroll or revoke their election and elect to opt out of the premium payment plan when any of the following special open enrollment events occur, if the requested change corresponds to and is consistent with the event. The enrollment or election to opt out will be effective the first day of the month following the later of the event date or the date the required form is received. If that day is the first of the month, the enrollment or change in election begins on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, the enrollment or change in election will begin the first of the month in which the event occurs.

(i) Employee acquires a new dependent due to:

• Marriage;

• Registering a state registered domestic partnership when the dependent is a tax dependent of the employee;

• Birth, adoption, or when the employee has assumed a legal obligation for total or partial support in anticipation of adoption; or

• A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(ii) Employee's dependent no longer meets public employee benefits board (PEBB) eligibility criteria because:

• Employee has a change in marital status;

• Employee's domestic partnership with a state registered domestic partner who is a tax dependent is dissolved or terminated;

• An eligible dependent child turns age 26 or otherwise does not meet dependent child eligibility criteria;

• An eligible dependent ceases to be eligible as an extended dependent or as a dependent with a disability; or

• An eligible dependent dies.

(iii) Employee or an employee's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA);

(iv) Employee has a change in employment status that affects the employee's eligibility for their employer contribution toward their employer-based group health plan;

(v) The employee's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution under their employer-based group health plan;

| Note: | As used in (a)(v) of this subsection, "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 26 C.F.R. 54.9801-6. |
| --- | --- |

(vi) Employee or an employee's dependent has a change in enrollment under an employer-based group health plan during its annual open enrollment that does not align with the PEBB annual open enrollment;

(vii) Employee or an employee's dependent has a change in residence that affects health plan availability. If the employee has a change in residence and the employee's current medical plan is no longer available, the employee must select a new medical plan as described in WAC 182-08-196(3);

(viii) Employee's dependent has a change in residence from outside of the United States to within the United States, or from within the United States to outside of the United States and that change in residence resulted in the dependent losing their health insurance;

(ix) A court order requires the employee or any other individual to provide insurance coverage for an eligible dependent of the subscriber (a former spouse or former state registered domestic partner is not an eligible dependent);

(x) Employee or an employee's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the subscriber or a subscriber's dependent loses eligibility for coverage under medicaid or CHIP;

(xi) Employee or an employee's dependent becomes eligible for state premium assistance subsidy for PEBB medical plan coverage from medicaid or CHIP;

(xii) Employee or an employee's dependent enrolls in coverage under medicare or the employee or an employee's dependent loses eligibility for coverage under medicare;

(xiii) Employee or an employee's dependent's current medical plan becomes unavailable because the employee or enrolled dependent is no longer eligible for a health savings account (HSA). The health care authority (HCA) requires evidence that the employee or employee's dependent is no longer eligible for an HSA;

(xiv) Employee or an employee's dependent experiences a disruption of care for active and ongoing treatment, that could function as a reduction in benefits for the employee or the employee's dependent. The employee may not change their health plan election if the employee's or dependent's physician stops participation with the employee's health plan unless the PEBB program determines that a continuity of care issue exists. The PEBB program will consider but not limit its consideration to the following:

• Active cancer treatment such as chemotherapy or radiation therapy;

• Treatment following a recent organ transplant;

• A scheduled surgery;

• Recent major surgery still within the postoperative period; or

• Treatment for a high-risk pregnancy.

(xv) Employee or employee's dependent becomes eligible and enrolls in a TRICARE plan, or loses eligibility for a TRICARE plan;

(xvi) The PEBB program determines that there has been a substantial decrease in the providers available under a PEBB medical plan.

If the employee is having premiums taken from payroll on a pretax basis, a medical plan change will not be approved if it would conflict with provisions of the salary reduction plan authorized under RCW 41.05.300.

(b) FSA and limited purpose FSA. An employee may enroll or revoke their election and make a new election under the FSA or limited purpose FSA when any one of the following special open enrollment events occur, if the requested change corresponds to and is consistent with the event. The enrollment or new election will be effective the first day of the month following the later of the event date or the date the required form and evidence of the event that created the special open enrollment is received by the employing agency. If that day is the first of the month, the enrollment or change in election begins on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, the enrollment or change in election will begin the first of the month in which the event occurs.

(i) Employee acquires a new dependent due to:

• Marriage;

• Registering a state registered domestic partnership if the domestic partner qualifies as a tax dependent of the employee;

• Birth, adoption, or when the employee has assumed a legal obligation for total or partial support in anticipation of adoption; or

• A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(ii) Employee's dependent no longer meets PEBB eligibility criteria because:

• Employee has a change in marital status;

• Employee's domestic partnership with a state registered domestic partner who qualifies as a tax dependent is dissolved or terminated;

• An eligible dependent child turns age 26 or otherwise does not meet dependent child eligibility criteria;

• An eligible dependent ceases to be eligible as an extended dependent or as a dependent with a disability; or

• An eligible dependent dies.

(iii) Employee or an employee's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the HIPAA;

(iv) Employee or an employee's dependent has a change in employment status that affects the employee's or a dependent's eligibility for the FSA or limited purpose FSA;

(v) A court order requires the employee or any other individual to provide insurance coverage for an eligible dependent of the subscriber (a former spouse or former state registered domestic partner is not an eligible dependent);

(vi) Employee or an employee's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the employee or an employee's dependent loses eligibility for coverage under medicaid or CHIP;

(vii) Employee or an employee's dependent enrolls in coverage under medicare.

(c) DCAP. An employee may enroll or revoke their election and make a new election under the DCAP when any one of the following special open enrollment events occur, if the requested change corresponds to and is consistent with the event. The enrollment or new election will be effective the first day of the month following the later of the event date or the date the required form and evidence of the event that created the special open enrollment is received by the employing agency. If that day is the first of the month, the enrollment or change in election begins on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, the enrollment or change in election will begin the first of the month in which the event occurs.

(i) Employee acquires a new dependent due to:

• Marriage;

• Registering a state registered domestic partnership if the domestic partner qualifies as a tax dependent of the employee;

• Birth, adoption, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption; or

• A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(ii) Employee or an employee's dependent has a change in employment status that affects the employee's or a dependent's eligibility for DCAP;

(iii) Employee or an employee's dependent has a change in enrollment under an employer-based DCAP during its annual open enrollment that does not align with the PEBB annual open enrollment;

(iv) Employee changes dependent care provider; the change to the DCAP election amount can reflect the cost of the new provider;

(v) Employee or the employee's spouse experiences a change in the number of qualifying individuals as defined in IRC 26 U.S.C. Sec. 21 (b)(1);

(vi) Employee's dependent care provider imposes a change in the cost of dependent care; employee may make a change in the DCAP election amount to reflect the new cost if the dependent care provider is not a qualifying relative of the employee as defined in IRC 26 U.S.C. Sec. 152.

***(Effective January 1, 2027)***

PDF WAC 182-08-199

When may an employee enroll, or revoke an election and make a new election under the premium payment plan, flexible spending arrangement (FSA), limited purpose FSA, or dependent care assistance program (DCAP)?

An employee who is eligible to participate in the salary reduction plan as described in WAC 182-12-116 may enroll, or revoke their election and make a new election under the premium payment plan, flexible spending arrangement (FSA), limited purpose FSA, or dependent care assistance program (DCAP) at the following times:

(1) When newly eligible under WAC 182-12-114 and enrolling as described in WAC 182-08-197(1).

(2) During annual open enrollment: An eligible employee may elect to enroll in or opt out of participation under the premium payment plan during the annual open enrollment by submitting the required form to their employing agency. An eligible employee may elect to enroll or reenroll in the FSA, limited purpose FSA, DCAP, or both an FSA and DCAP during the annual open enrollment by submitting the required forms to their employing agency or applicable contracted vendor as instructed. All required forms must be received no later than the last day of the annual open enrollment. The enrollment or new election becomes effective January 1st of the following year.

(a) Employees cannot enroll in a FSA and a limited purpose FSA in the same year.

(b) Employees enrolled in a consumer directed health plan (CDHP) with a health savings account (HSA) cannot also enroll in a FSA in the same plan year. Employees who elect enrollment in the CDHP with a HSA and a FSA will only be enrolled in a CDHP with a HSA.

(c) Employees who enroll in a CDHP with a HSA during the annual open enrollment and have a carryover amount from a FSA, will be enrolled in a limited purpose FSA and the carryover amount will be deposited into the limited purpose FSA.

(d) Employees who are not enrolled in a CDHP with a HSA and elect both a FSA and a limited purpose FSA will be enrolled in the FSA.

(3) During a special open enrollment: An employee who is eligible to participate in the salary reduction plan may enroll or revoke their election and make a new election under the premium payment plan, FSA, limited purpose FSA, or DCAP outside of the annual open enrollment if a special open enrollment event occurs. The enrollment or change in election must be allowable under Internal Revenue Code (IRC) and Treasury regulations, and correspond to and be consistent with the event that creates the special open enrollment. To make a change or enroll, the employee must submit the required form to their employing agency. The employing agency must receive the required form and evidence of the event that created the special open enrollment no later than 60 days after the event occurs.

For purposes of this section, an eligible dependent includes any person who qualifies as a dependent of the employee for tax purposes under IRC 26 U.S.C. Sec. 152 without regard to the income limitations of that section. It does not include a state registered domestic partner unless the state registered domestic partner otherwise qualifies as a dependent for tax purposes under IRC 26 U.S.C. Sec. 152.

(a) Premium payment plan. An employee may enroll or revoke their election and elect to opt out of the premium payment plan when any of the following special open enrollment events occur, if the requested change corresponds to and is consistent with the event. The enrollment or election to opt out will be effective the first day of the month following the later of the event date or the date the required form is received. If that day is the first of the month, the enrollment or change in election begins on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, the enrollment or change in election will begin the first of the month in which the event occurs.

(i) Employee acquires a new dependent due to:

• Marriage;

• Registering a state registered domestic partnership when the dependent is a tax dependent of the employee;

• Birth, adoption, or when the employee has assumed a legal obligation for total or partial support in anticipation of adoption; or

• A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(ii) Employee's dependent no longer meets public employee benefits board (PEBB) eligibility criteria because:

• Employee has a change in marital status;

• Employee's domestic partnership with a state registered domestic partner who is a tax dependent is dissolved or terminated;

• An eligible dependent child turns age 26 or otherwise does not meet dependent child eligibility criteria;

• An eligible dependent ceases to be eligible as an extended dependent or as a dependent with a disability; or

• An eligible dependent dies.

(iii) Employee or an employee's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA);

(iv) Employee has a change in employment status that affects the employee's eligibility for their employer contribution toward their employer-based group health plan;

(v) The employee's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution under their employer-based group health plan;

| Note: | As used in (a)(v) of this subsection, "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 26 C.F.R. 54.9801-6. |
| --- | --- |

(vi) Employee or an employee's dependent has a change in enrollment under an employer-based group health plan during its annual open enrollment that does not align with the PEBB annual open enrollment;

(vii) Employee or an employee's dependent has a change in residence that affects health plan availability. If the employee has a change in residence and the employee's current medical plan is no longer available, the employee must select a new medical plan as described in WAC 182-08-196(3);

(viii) Employee's dependent has a change in residence from outside of the United States to within the United States, or from within the United States to outside of the United States and that change in residence resulted in the dependent losing their health insurance;

(ix) A court order requires the employee or any other individual to provide insurance coverage for an eligible dependent of the subscriber (a former spouse or former state registered domestic partner is not an eligible dependent);

(x) Employee or an employee's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the subscriber or a subscriber's dependent loses eligibility for coverage under medicaid or CHIP;

(xi) Employee or an employee's dependent becomes eligible for state premium assistance subsidy for PEBB medical plan coverage from medicaid or CHIP;

(xii) Employee or an employee's dependent enrolls in coverage under medicare or the employee or an employee's dependent loses eligibility for coverage under medicare;

(xiii) Employee or an employee's dependent's current medical plan becomes unavailable because the employee or enrolled dependent is no longer eligible for a health savings account (HSA). The health care authority (HCA) requires evidence that the employee or employee's dependent is no longer eligible for an HSA;

(xiv) Employee or an employee's dependent experiences a disruption of care for active and ongoing treatment, that could function as a reduction in benefits for the employee or the employee's dependent. The employee may not change their health plan election if the employee's or dependent's physician stops participation with the employee's health plan unless the PEBB program determines that a continuity of care issue exists. The PEBB program will consider but not limit its consideration to the following:

• Active cancer treatment such as chemotherapy or radiation therapy;

• Treatment following a recent organ transplant;

• A scheduled surgery;

• Recent major surgery still within the postoperative period; or

• Treatment for a high-risk pregnancy.

(xv) Employee or employee's dependent becomes eligible and enrolls in a TRICARE plan, or loses eligibility for a TRICARE plan;

(xvi) The PEBB program determines that there has been a substantial decrease in the providers available under a PEBB medical plan;

(xvii) The PEBB program determines that there has been a substantial increase in the employee's premiums when the employee transfers from one employing agency to another employing agency.

If the employee is having premiums taken from payroll on a pretax basis, a medical plan change will not be approved if it would conflict with provisions of the salary reduction plan authorized under RCW 41.05.300.

(b) FSA and limited purpose FSA. An employee may enroll or revoke their election and make a new election under the FSA or limited purpose FSA when any one of the following special open enrollment events occur, if the requested change corresponds to and is consistent with the event. The enrollment or new election will be effective the first day of the month following the later of the event date or the date the required form and evidence of the event that created the special open enrollment is received by the employing agency. If that day is the first of the month, the enrollment or change in election begins on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, the enrollment or change in election will begin the first of the month in which the event occurs.

(i) Employee acquires a new dependent due to:

• Marriage;

• Registering a state registered domestic partnership if the domestic partner qualifies as a tax dependent of the employee;

• Birth, adoption, or when the employee has assumed a legal obligation for total or partial support in anticipation of adoption; or

• A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(ii) Employee's dependent no longer meets PEBB eligibility criteria because:

• Employee has a change in marital status;

• Employee's domestic partnership with a state registered domestic partner who qualifies as a tax dependent is dissolved or terminated;

• An eligible dependent child turns age 26 or otherwise does not meet dependent child eligibility criteria;

• An eligible dependent ceases to be eligible as an extended dependent or as a dependent with a disability; or

• An eligible dependent dies.

(iii) Employee or an employee's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the HIPAA;

(iv) Employee or an employee's dependent has a change in employment status that affects the employee's or a dependent's eligibility for the FSA or limited purpose FSA;

(v) A court order requires the employee or any other individual to provide insurance coverage for an eligible dependent of the subscriber (a former spouse or former state registered domestic partner is not an eligible dependent);

(vi) Employee or an employee's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the employee or an employee's dependent loses eligibility for coverage under medicaid or CHIP;

(vii) Employee or an employee's dependent enrolls in coverage under medicare.

(c) DCAP. An employee may enroll or revoke their election and make a new election under the DCAP when any one of the following special open enrollment events occur, if the requested change corresponds to and is consistent with the event. The enrollment or new election will be effective the first day of the month following the later of the event date or the date the required form and evidence of the event that created the special open enrollment is received by the employing agency. If that day is the first of the month, the enrollment or change in election begins on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, the enrollment or change in election will begin the first of the month in which the event occurs.

(i) Employee acquires a new dependent due to:

• Marriage;

• Registering a state registered domestic partnership if the domestic partner qualifies as a tax dependent of the employee;

• Birth, adoption, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption; or

• A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(ii) Employee or an employee's dependent has a change in employment status that affects the employee's or a dependent's eligibility for DCAP;

(iii) Employee or an employee's dependent has a change in enrollment under an employer-based DCAP during its annual open enrollment that does not align with the PEBB annual open enrollment;

(iv) Employee changes dependent care provider; the change to the DCAP election amount can reflect the cost of the new provider;

(v) Employee or the employee's spouse experiences a change in the number of qualifying individuals as defined in IRC 26 U.S.C. Sec. 21 (b)(1);

(vi) Employee's dependent care provider imposes a change in the cost of dependent care; employee may make a change in the DCAP election amount to reflect the new cost if the dependent care provider is not a qualifying relative of the employee as defined in IRC 26 U.S.C. Sec. 152.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-083 (Admin #2024-02), § 182-08-199, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-08-199, filed 6/23/23, effective 1/1/24*
- *WSR 22-13-158 (Admin #2022-01), § 182-08-199, filed 6/21/22, effective 1/1/23*
- *WSR 20-16-062 (Admin #2020-03), § 182-08-199, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-199, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-08-199, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-08-199, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-199, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-08-199, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-08-199, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160, 2013 2nd sp.s. c 4 and PEBB policy resolutions. WSR 14-08-040, § 182-08-199, filed 3/26/14, effective 4/26/14. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-08-199, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-08-199, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-08-199, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-08-199, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-08-199, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-08-199, filed 10/1/08, effective 1/1/09.](Effective January 1, 2027) PDF WAC 182-08-199 When may an employee enroll, or revoke an election and make a new election under the premium payment plan, flexible spending arrangement (FSA), limited purpose FSA, or dependent care assistance program (DCAP)? An employee who is eligible to participate in the salary reduction plan as described in WAC 182-12-116 may enroll, or revoke their election and make a new election under the premium payment plan, flexible spending arrangement (FSA), limited purpose FSA, or dependent care assistance program (DCAP) at the following times:(1) When newly eligible under WAC 182-12-114 and enrolling as described in WAC 182-08-197(1).(2) During annual open enrollment: An eligible employee may elect to enroll in or opt out of participation under the premium payment plan during the annual open enrollment by submitting the required form to their employing agency. An eligible employee may elect to enroll or reenroll in the FSA, limited purpose FSA, DCAP, or both an FSA and DCAP during the annual open enrollment by submitting the required forms to their employing agency or applicable contracted vendor as instructed. All required forms must be received no later than the last day of the annual open enrollment. The enrollment or new election becomes effective January 1st of the following year.(a) Employees cannot enroll in a FSA and a limited purpose FSA in the same year.(b) Employees enrolled in a consumer directed health plan (CDHP) with a health savings account (HSA) cannot also enroll in a FSA in the same plan year. Employees who elect enrollment in the CDHP with a HSA and a FSA will only be enrolled in a CDHP with a HSA.(c) Employees who enroll in a CDHP with a HSA during the annual open enrollment and have a carryover amount from a FSA, will be enrolled in a limited purpose FSA and the carryover amount will be deposited into the limited purpose FSA.(d) Employees who are not enrolled in a CDHP with a HSA and elect both a FSA and a limited purpose FSA will be enrolled in the FSA.(3) During a special open enrollment: An employee who is eligible to participate in the salary reduction plan may enroll or revoke their election and make a new election under the premium payment plan, FSA, limited purpose FSA, or DCAP outside of the annual open enrollment if a special open enrollment event occurs. The enrollment or change in election must be allowable under Internal Revenue Code (IRC) and Treasury regulations, and correspond to and be consistent with the event that creates the special open enrollment. To make a change or enroll, the employee must submit the required form to their employing agency. The employing agency must receive the required form and evidence of the event that created the special open enrollment no later than 60 days after the event occurs.For purposes of this section, an eligible dependent includes any person who qualifies as a dependent of the employee for tax purposes under IRC 26 U.S.C. Sec. 152 without regard to the income limitations of that section. It does not include a state registered domestic partner unless the state registered domestic partner otherwise qualifies as a dependent for tax purposes under IRC 26 U.S.C. Sec. 152.(a) Premium payment plan. An employee may enroll or revoke their election and elect to opt out of the premium payment plan when any of the following special open enrollment events occur, if the requested change corresponds to and is consistent with the event. The enrollment or election to opt out will be effective the first day of the month following the later of the event date or the date the required form is received. If that day is the first of the month, the enrollment or change in election begins on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, the enrollment or change in election will begin the first of the month in which the event occurs.(i) Employee acquires a new dependent due to:• Marriage*
- *• Registering a state registered domestic partnership when the dependent is a tax dependent of the employee*
- *• Birth, adoption, or when the employee has assumed a legal obligation for total or partial support in anticipation of adoption*
- *or• A child becoming eligible as an extended dependent through legal custody or legal guardianship.(ii) Employee's dependent no longer meets public employee benefits board (PEBB) eligibility criteria because:• Employee has a change in marital status*
- *• Employee's domestic partnership with a state registered domestic partner who is a tax dependent is dissolved or terminated*
- *• An eligible dependent child turns age 26 or otherwise does not meet dependent child eligibility criteria*
- *• An eligible dependent ceases to be eligible as an extended dependent or as a dependent with a disability*
- *or• An eligible dependent dies.(iii) Employee or an employee's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA)*
- *(iv) Employee has a change in employment status that affects the employee's eligibility for their employer contribution toward their employer-based group health plan*
- *(v) The employee's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution under their employer-based group health plan*
- *Note:As used in (a)(v) of this subsection, "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 26 C.F.R. 54.9801-6.(vi) Employee or an employee's dependent has a change in enrollment under an employer-based group health plan during its annual open enrollment that does not align with the PEBB annual open enrollment*
- *(vii) Employee or an employee's dependent has a change in residence that affects health plan availability. If the employee has a change in residence and the employee's current medical plan is no longer available, the employee must select a new medical plan as described in WAC 182-08-196(3)*
- *(viii) Employee's dependent has a change in residence from outside of the United States to within the United States, or from within the United States to outside of the United States and that change in residence resulted in the dependent losing their health insurance*
- *(ix) A court order requires the employee or any other individual to provide insurance coverage for an eligible dependent of the subscriber (a former spouse or former state registered domestic partner is not an eligible dependent)*
- *(x) Employee or an employee's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the subscriber or a subscriber's dependent loses eligibility for coverage under medicaid or CHIP*
- *(xi) Employee or an employee's dependent becomes eligible for state premium assistance subsidy for PEBB medical plan coverage from medicaid or CHIP*
- *(xii) Employee or an employee's dependent enrolls in coverage under medicare or the employee or an employee's dependent loses eligibility for coverage under medicare*
- *(xiii) Employee or an employee's dependent's current medical plan becomes unavailable because the employee or enrolled dependent is no longer eligible for a health savings account (HSA). The health care authority (HCA) requires evidence that the employee or employee's dependent is no longer eligible for an HSA*
- *(xiv) Employee or an employee's dependent experiences a disruption of care for active and ongoing treatment, that could function as a reduction in benefits for the employee or the employee's dependent. The employee may not change their health plan election if the employee's or dependent's physician stops participation with the employee's health plan unless the PEBB program determines that a continuity of care issue exists. The PEBB program will consider but not limit its consideration to the following:• Active cancer treatment such as chemotherapy or radiation therapy*
- *• Treatment following a recent organ transplant*
- *• A scheduled surgery*
- *• Recent major surgery still within the postoperative period*
- *or• Treatment for a high-risk pregnancy.(xv) Employee or employee's dependent becomes eligible and enrolls in a TRICARE plan, or loses eligibility for a TRICARE plan*
- *(xvi) The PEBB program determines that there has been a substantial decrease in the providers available under a PEBB medical plan*
- *(xvii) The PEBB program determines that there has been a substantial increase in the employee's premiums when the employee transfers from one employing agency to another employing agency.If the employee is having premiums taken from payroll on a pretax basis, a medical plan change will not be approved if it would conflict with provisions of the salary reduction plan authorized under RCW 41.05.300.(b) FSA and limited purpose FSA. An employee may enroll or revoke their election and make a new election under the FSA or limited purpose FSA when any one of the following special open enrollment events occur, if the requested change corresponds to and is consistent with the event. The enrollment or new election will be effective the first day of the month following the later of the event date or the date the required form and evidence of the event that created the special open enrollment is received by the employing agency. If that day is the first of the month, the enrollment or change in election begins on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, the enrollment or change in election will begin the first of the month in which the event occurs.(i) Employee acquires a new dependent due to:• Marriage*
- *• Registering a state registered domestic partnership if the domestic partner qualifies as a tax dependent of the employee*
- *• Birth, adoption, or when the employee has assumed a legal obligation for total or partial support in anticipation of adoption*
- *or• A child becoming eligible as an extended dependent through legal custody or legal guardianship.(ii) Employee's dependent no longer meets PEBB eligibility criteria because:• Employee has a change in marital status*
- *• Employee's domestic partnership with a state registered domestic partner who qualifies as a tax dependent is dissolved or terminated*
- *• An eligible dependent child turns age 26 or otherwise does not meet dependent child eligibility criteria*
- *• An eligible dependent ceases to be eligible as an extended dependent or as a dependent with a disability*
- *or• An eligible dependent dies.(iii) Employee or an employee's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the HIPAA*
- *(iv) Employee or an employee's dependent has a change in employment status that affects the employee's or a dependent's eligibility for the FSA or limited purpose FSA*
- *(v) A court order requires the employee or any other individual to provide insurance coverage for an eligible dependent of the subscriber (a former spouse or former state registered domestic partner is not an eligible dependent)*
- *(vi) Employee or an employee's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the employee or an employee's dependent loses eligibility for coverage under medicaid or CHIP*
- *(vii) Employee or an employee's dependent enrolls in coverage under medicare.(c) DCAP. An employee may enroll or revoke their election and make a new election under the DCAP when any one of the following special open enrollment events occur, if the requested change corresponds to and is consistent with the event. The enrollment or new election will be effective the first day of the month following the later of the event date or the date the required form and evidence of the event that created the special open enrollment is received by the employing agency. If that day is the first of the month, the enrollment or change in election begins on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, the enrollment or change in election will begin the first of the month in which the event occurs.(i) Employee acquires a new dependent due to:• Marriage*
- *• Registering a state registered domestic partnership if the domestic partner qualifies as a tax dependent of the employee*
- *• Birth, adoption, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption*
- *or• A child becoming eligible as an extended dependent through legal custody or legal guardianship.(ii) Employee or an employee's dependent has a change in employment status that affects the employee's or a dependent's eligibility for DCAP*
- *(iii) Employee or an employee's dependent has a change in enrollment under an employer-based DCAP during its annual open enrollment that does not align with the PEBB annual open enrollment*
- *(iv) Employee changes dependent care provider*
- *the change to the DCAP election amount can reflect the cost of the new provider*
- *(v) Employee or the employee's spouse experiences a change in the number of qualifying individuals as defined in IRC 26 U.S.C. Sec. 21 (b)(1)*
- *(vi) Employee's dependent care provider imposes a change in the cost of dependent care*
- *employee may make a change in the DCAP election amount to reflect the new cost if the dependent care provider is not a qualifying relative of the employee as defined in IRC 26 U.S.C. Sec. 152.[Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 26-14-080 (Admin #2026.01), s 182-08-199, filed 6/29/26, effective 1/1/27. Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-083 (Admin #2024-02), § 182-08-199, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-08-199, filed 6/23/23, effective 1/1/24*
- *WSR 22-13-158 (Admin #2022-01), § 182-08-199, filed 6/21/22, effective 1/1/23*
- *WSR 20-16-062 (Admin #2020-03), § 182-08-199, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-199, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-08-199, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-08-199, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-199, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-08-199, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-08-199, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160, 2013 2nd sp.s. c 4 and PEBB policy resolutions. WSR 14-08-040, § 182-08-199, filed 3/26/14, effective 4/26/14. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-08-199, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-08-199, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-08-199, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-08-199, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-08-199, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-08-199, filed 10/1/08, effective 1/1/09.*

##### **Wash. Admin. Code § 182-08-200** Which employing agency is responsible to pay the employer contribution for eligible employees changing agency employment or for faculty employed by more than one institution of higher education? {#sec-182-08-200 omnilex-key=us-wa-regs-official--title-182--182-08-200}

Employing agencies responsible for paying the employer contribution:

(1) For eligible employees changing agencies: When an eligible employee's employment relationship terminates with an employing agency at any time during the month for which a premium contribution is due and that employee transfers to another agency, the agency losing the employee is responsible for the payment of the employer contribution for the employee for that month. The receiving agency is liable for any employer contribution for the eligible employee beginning the first day of the month following the transfer.

(2) For eligible faculty employed by more than one institution of higher education:

(a) When a faculty is eligible for the employer contribution during an anticipated work period (quarter, semester or instructional year), under WAC 182-12-131(3), one institution will pay the entire cost of the employer contribution if the employee is eligible by virtue of employment at that single institution. Otherwise:

(i) Each institution contributes based on its percentage of the employee's total work at all institutions during the anticipated work period.

(ii) The institution with the greatest percentage coordinates with the other institutions and is responsible for sending the total premium payment to the health care authority (HCA).

(b) When a faculty is eligible for the employer contribution during the summer or off-quarter/semester, under WAC 182-12-131 (3)(c), one institution will pay the entire cost of the employer contribution if the employee is eligible by virtue of employment at that single institution. Otherwise:

(i) Each institution contributes based on its percentage of the employee's total work at all institutions throughout the instructional year or equivalent nine-month period.

(ii) The institution with the greatest percentage coordinates with the other institutions and is responsible for sending the total premium payment to HCA.

(c) When a faculty is eligible through two-year averaging under WAC 182-12-131 (3)(d) for the employer contribution, one institution will pay the entire cost of the employer contribution if the employee is eligible by virtue of employment at that single institution. Otherwise:

(i) Each institution contributes to coverage based on its percentage of the employee's total work at all institutions throughout the preceding two academic years. This division of the employer contribution begins the summer quarter or semester following the second academic year and continues through that academic year or until eligibility under two-year averaging ceases.

| Note: | "Academic year" means summer, fall, winter, and spring quarters or summer, fall, and spring semesters, in that order. |
| --- | --- |

(ii) The institution with the greatest percentage coordinates with the other institutions and is responsible for sending the total premium payment to HCA.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-200, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-08-200, filed 10/3/18, effective 1/1/19. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-08-200, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160. WSR 09-23-102 (Order 09-02), § 182-08-200, filed 11/17/09, effective 1/1/10*
- *WSR 07-20-129 (Order 07-01), § 182-08-200, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-08-200, filed 8/26/04, effective 1/1/05. Statutory Authority: Chapter 41.05 RCW. WSR 96-08-042, § 182-08-200, filed 3/29/96, effective 4/29/96*
- *Order 3-77, § 182-08-200, filed 11/17/77.*

##### **Wash. Admin. Code § 182-08-220** Advertising or promotion of public employees benefits board (PEBB) benefit plans. {#sec-182-08-220 omnilex-key=us-wa-regs-official--title-182--182-08-220}

(1) In order to assure equal and unbiased representation of public employees benefits board (PEBB) benefits, contracted vendors must comply with all of the following:

(a) All materials describing PEBB benefits must be prepared by or approved by the health care authority (HCA) before use.

(b) Distribution or mailing of all benefit descriptions must be performed by or under the direction of the HCA.

(c) All media announcements or advertising by a contracted vendor which includes any mention of the "public employees benefits board," "PEBB," "health care authority," "HCA," any reference to benefits for "state employees," or "retirees," or any group of enrollees covered by PEBB benefits, must receive the advance written approval of the HCA.

(2) Failure to comply with any or all of these requirements by a PEBB contracted vendor or subcontractor may result in contract termination by the HCA, refusal to continue or renew a contract with the noncomplying party, or both.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-220, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-08-220, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160. WSR 07-20-129 (Order 07-01), § 182-08-220, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 03-17-031 (Order 02-07), § 182-08-220, filed 8/14/03, effective 9/14/03. Statutory Authority: Chapter 41.05 RCW. WSR 96-08-042, § 182-08-220, filed 3/29/96, effective 4/29/96*
- *WSR 91-20-163, § 182-08-220, filed 10/2/91, effective 11/2/91*
- *WSR 86-16-061 (Resolution No. 86-3), § 182-08-220, filed 8/5/86.*

##### **Wash. Admin. Code § 182-08-235** Employer group application process. {#sec-182-08-235 omnilex-key=us-wa-regs-official--title-182--182-08-235}

This section applies to employer groups for the public employees benefits board (PEBB) program as defined in WAC 182-08-015. An employer group may apply to obtain PEBB insurance coverage through a contract with the health care authority (HCA).

(1) Employer groups with less than 500 employees must apply at least 60 days before the requested coverage effective date. Employer groups with 500 or more employees but with less than 5,000 employees must apply at least 90 days before the requested effective date.

Employer groups with 5,000 or more employees must apply at least 120 days before the requested coverage effective date.

To apply, employer groups must submit the documents and information described in subsection (2) of this section to the PEBB program as follows:

(a) Counties, municipalities, political subdivisions, and tribal governments with fewer than 5,000 employees are required to provide the documents and information described in subsection (2)(a) through (f) of this section;

(b) Counties, municipalities, political subdivisions, and tribal governments with 5,000 or more employees will have their application approved or denied through the evaluation criteria described in WAC 182-08-240 and are required to provide the documents and information described in subsection (2)(a) through (d), (f), and (g) of this section; and

(c) All employee organizations representing state civil services employees and the Washington health benefit exchange, regardless of the number of employees, will have their application approved or denied through the evaluation criteria described in WAC 182-08-240 and are required to provide the documents and information described in subsection (2)(a) through (d), (f), and (g) of this section.

(2) Documents and information required with application:

(a) A letter of application that includes the information described in (a)(i) through (iv) of this subsection:

(i) A reference to the group's authorizing statute;

(ii) A description of the organizational structure of the group and a description of the employee bargaining unit or group of nonrepresented employees for which the group is applying;

(iii) Tax identification number; and

(iv) A statement of whether the group is applying to obtain only medical or all available PEBB insurance coverages.

(b) A resolution from the group's governing body authorizing the purchase of PEBB insurance coverage.

(c) A signed governmental function attestation document that attests to the fact that employees for whom the group is applying are governmental employees whose services are substantially all in the performance of essential governmental functions.

(d) A member level census file for all of the employees for whom the group is applying. The file must be provided in the format required by the authority and contain the following demographic data, by member, with each member classified as employee, spouse or state registered domestic partner, or child:

(i) Employee ID (any identifier which uniquely identifies the employee; for dependents the employee's unique identifier must be used);

(ii) Age;

(iii) Birth sex;

(iv) First three digits of the member's zip code based on residence;

(v) Indicator of whether the employee is active or retired, if the group is requesting to include retirees; and

(vi) Indicator of whether the member is enrolled in coverage.

(e) Historical claims and cost information that include the following:

(i) Large claims history for 24 months by quarter that excludes the most recent three months;

(ii) Ongoing large claims management report for the most recent quarter provided in the large claims history;

(iii) Summary of historical plan costs; and

(iv) The director or the director's designee may make an exception to the claims and cost information requirements based on the size of the group, except that the current health plan does not have a case management program, then the primary diagnosis code designated by the authority must be reported for each large claimant. If the code indicates a condition which is expected to continue into the next quarter, the claim is counted as an ongoing large claim. If historical claims and cost information as described in (e)(i) through (iii) of this subsection are unavailable, the director or the director's designee may make an exception to allow all of the following alternative requirements:

• A letter from their carrier indicating they will not or cannot provide claims data.

• Provide information about the health plan most employees are enrolled in by completing the actuarial calculator authorized by the PEBB program.

• Current premiums for the health plan.

(f) If the application is for a subset of the group's employees (e.g., bargaining unit), the group must provide a member level census file of all employees eligible under their current health plan who are not included on the member level census file in (d) of this subsection. This includes retired employees participating under the group's current health plan. The file must include the same demographic data by member.

(g) Employer groups described in subsection (1)(b) and (c) of this section must submit to an actuarial evaluation of the group provided by an actuary designated by the PEBB program. The group must pay for the cost of the evaluation. This cost is nonrefundable. A group that is approved will not have to pay for an additional actuarial evaluation if it applies to add another bargaining unit within two years of the evaluation. Employer groups of this size must provide the following:

(i) Large claims history for 24 months, by quarter that excludes the most recent three months;

(ii) Ongoing large claims management report for the most recent quarter provided in the large claims history;

(iii) Executive summary of benefits;

(iv) Summary of benefits and certificate of coverage; and

(v) Summary of historical plan costs.

| Exception: | If the current health plan does not have a case management program then the primary diagnosis code designated by the authority must be reported for each large claimant. If the code indicates a condition which is expected to continue into the next quarter, the claim is counted as an ongoing large claim. |
| --- | --- |

(3) The authority may automatically deny a group application if the group fails to provide the required information and documents described in this section.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-08-235, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-08-235, filed 6/23/23, effective 1/1/24*
- *WSR 22-13-158 (Admin #2022-01), § 182-08-235, filed 6/21/22, effective 1/1/23*
- *WSR 20-16-062 (Admin #2020-03), § 182-08-235, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-235, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-08-235, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-08-235, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-235, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-08-235, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-08-235, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-08-235, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-08-235, filed 9/25/12, effective 11/1/12.*

##### **Wash. Admin. Code § 182-08-237** May a local government entity or tribal government entity applying for participation in public employees benefits board (PEBB) insurance coverage include their retirees? {#sec-182-08-237 omnilex-key=us-wa-regs-official--title-182--182-08-237}

A local government or tribal government that applies for participation in public employees benefits board (PEBB) insurance coverage under WAC 182-08-235 will have a one-time opportunity to request inclusion of retired employees who are covered under its retiree health plan at the time of application.

(1) The authority will use the following criteria to approve or deny a request to include retirees:

(a) The local government or tribal government retiree health plan must have existed at least three years before the date of the employer group application;

(b) Eligibility for coverage under the local government's or tribal government's retiree health plan must have required immediate enrollment in retiree health plan coverage upon termination of employee coverage; and

(c) The retirees must have maintained continuous enrollment in the local government or tribal government retiree health plan.

(2) If the local government's or tribal government's application is for a subset of their employees (e.g., bargaining unit) only retirees previously within the bargaining unit may be included in the transfer.

(3) Retirees and dependents included in the transfer unit are subject to the enrollment and eligibility rules outlined in chapters 182-08, 182-12 and 182-16 WAC.

(4) Employees eligible for retirement subsequent to the local government or tribal government transferring to PEBB health plan coverage must meet retiree eligibility as outlined in chapter 182-12 WAC.

(5) To protect the integrity of the risk pool, if total local government or tribal government retiree enrollment exceeds ten percent of the total PEBB retiree population, the PEBB program may:

(a) Stop approving inclusion of retirees with local government or tribal government unit transfers; or

(b) Adopt a new rating methodology reflective of the cost of covering local government or tribal government retirees.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-237, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-08-237, filed 9/25/12, effective 11/1/12.*

##### **Wash. Admin. Code § 182-08-240** How will the health care authority (HCA) decide to approve or deny a group application? {#sec-182-08-240 omnilex-key=us-wa-regs-official--title-182--182-08-240}

This section applies to counties, municipalities, political subdivisions, and tribal governments with five thousand or more employees. This section also applies to employee organizations representing state civil service employees and the Washington health benefit exchange, regardless of the number of employees. Group applications for participation in public employees benefits board (PEBB) insurance coverage provided through the PEBB program are approved or denied by the health care authority (HCA) based upon the information and documents submitted by the group and the employer group evaluation (EGE) criteria described in this rule.

(1) Groups are evaluated as a single unit. To support this requirement the group must provide a census file, as described in WAC 182-08-235 (2)(d), and additional information as described in WAC 182-08-235 (2)(g) for all employees eligible to participate under the group's current health plan. If the group's application is for both employees and retirees, the census file data and additional information for retired employees participating under the group's current health plan must also be included.

(a) If the group's application is only for participation of its employees, the PEBB enrollment data used to evaluate the group will be state agency employee data.

(b) If a group's application is for participation of both its employees and retirees, the PEBB enrollment data used to evaluate the group will include data from the PEBB nonmedicare risk pool limited to state retiree enrollment data and state agency employee data.

(2) A group must pass the EGE criteria or the actuarial evaluation required in subsection (3) of this section as a single unit before the application can be approved. For purposes of this section a single unit includes all employees eligible under the group's current health plan. If the application is only for a bargaining unit, then the bargaining unit must be evaluated using the EGE criteria in addition to all eligible employees of the group as a single unit. If the group passes the EGE criteria as a single unit, but an individual bargaining unit does not, the group may only participate if all eligible employees of the entity participate.

(3) The authority will use the following criteria to evaluate the group.

(a) The member level census file demographic data must indicate a relative underwriting factor that is equal to or better than the relative underwriting factor as determined by the authority for the like population within the nonmedicare PEBB risk pool as described in subsection (1) of this section;

(b) One of the following two conditions must be met:

(i) The frequency of large claims must be less than or equal to the PEBB historical benchmark frequency for the PEBB like population within the nonmedicare population as described in subsection (1) of this section;

(ii) The ongoing large claims management report must demonstrate that the frequency of ongoing large claims is less than or equal to the recurring benchmark frequency for the PEBB like population within the nonmedicare population as described in subsection (1) of this section.

(c) Provide an executive summary of benefits;

(d) Provide a summary of benefits and certificate of coverage;

(e) Provide a summary of historical plan costs; and

(f) The evaluation of criteria in (c), (d), and (e) of this subsection must indicate that the historical cost of benefits for the group is equal to or less than the historical cost of the PEBB like population within the nonmedicare population as described in subsection (1) of this section for a comparable plan design.

(4) An approved group application is valid for three hundred sixty-five calendar days after the date the application is approved by the authority. If a group applies to add additional bargaining units after the three hundred sixty-five calendar day period has ended, the group must be reevaluated.

(5) An entity whose group application is denied may appeal the authority's decision to the PEBB appeals unit through the process described in WAC 182-16-2060.

(6) An entity whose group application is approved may purchase insurance for its employees under the participation requirements described in WAC 182-08-245.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and PEBB policy resolutions. WSR 18-20-117 (Admin #2018-02), § 182-08-240, filed 10/3/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-240, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-08-240, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-08-240, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-08-240, filed 9/25/12, effective 11/1/12.*

##### **Wash. Admin. Code § 182-08-245** Employer group participation requirements. {#sec-182-08-245 omnilex-key=us-wa-regs-official--title-182--182-08-245}

This section applies to an employer group for the public employees benefits board (PEBB) program as defined in WAC 182-08-015 that is approved to purchase insurance for its employees through a contract with the health care authority (HCA).

(1) Prior to enrollment of employees in PEBB insurance coverage, the employer group must:

(a) Remit to the authority the required start-up fee in the amount publicized by the PEBB program;

(b) Sign a contract with the authority;

(c) Determine employee and dependent eligibility and terms of enrollment for PEBB insurance coverage by the criteria outlined in this chapter and chapter 182-12 WAC unless otherwise approved by the authority in the employer group's contract with the authority;

(d) Determine eligibility in order to ensure the PEBB program's continued status as a governmental plan under Section 3(32) of the Employee Retirement Income Security Act of 1974 (ERISA) as amended. This means the employer group may only consider employees whose services are substantially all in the performance of essential governmental functions, but not in the performance of commercial activities, whether or not those activities qualify as essential governmental functions to be eligible; and

(e) Ensure PEBB insurance coverage is the only employer-sponsored coverage available to groups of employees eligible for PEBB insurance coverage under the contract.

(2) Pay premiums under its contract with the authority. The premium rate structure for employer groups will be a tiered rate based on health plan election and family enrollment. Employer groups must collect an amount equal to the premium surcharges applied to an employee's account by the authority from their employees and include the funds in their payment to the authority.

| Exception: | The authority will allow employer groups that enrolled prior to January 1, 1996, to continue to participate based on a composite rate structure. The authority may require the employer group to change to a tiered rate structure with 90 days advance written notice. |
| --- | --- |

(3) Counties, municipalities, political subdivisions, and tribal governments must pay the monthly employer group rate surcharge in the amount invoiced by the authority.

(4) If an employer group wants to make subsequent changes to the contract, the changes must be submitted to the authority for approval.

(5) The employer group must maintain participation in PEBB insurance coverage for at least one full year. An employer group may only end participation at the end of a plan year unless the authority approves a mid-year termination. To end participation, an employer group must provide written notice to the PEBB program at least 60 days before the requested termination date. If an employer group terminates participation in PEBB insurance coverage, they must:

(a) Notify all their employees, dependents, or retirees who are enrolled in PEBB insurance coverage 45 days prior to the employer group's date of termination; and

(b) Provide assistance to retirees as described in RCW 41.04.208(12).

(6) Upon approval to purchase insurance through a contract with the authority, the employer group must provide a list of employees and dependents that are enrolled in Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage and the remaining number of months available to them based on their qualifying event. These employees and dependents may enroll in a PEBB health plan as COBRA subscribers for the remainder of the months available to them based on their qualifying event.

(7) Enrollees in PEBB insurance coverage under one of the continuation of coverage provisions allowed under chapter 182-12 WAC or retirees included in the transfer unit as allowed under WAC 182-08-237 cease to be eligible as of the last day of the contract and may not continue enrollment beyond the end of the month in which the contract is terminated.

| Exception: | If an employer group ends participation, retired and disabled employees who began participation before September 15, 1991, are eligible to continue enrollment in PEBB retiree insurance coverage if they continue to meet the procedural and eligibility requirements of WAC 182-12-171. Employees who enrolled after September 15, 1991, who are enrolled in PEBB retiree insurance coverage cease to be eligible under WAC 182-12-171, but may continue health plan enrollment as described in WAC 182-12-232. |
| --- | --- |

(8) Employer groups that enter into a contractual agreement with the authority on or after May 4, 2023, and whose contractual agreement is subsequently terminated, shall make a one-time payment to the authority for each of the employer group's retired or disabled employees who continue their participation in insurance plans and contracts under WAC 182-12-232.

(a) For each of the employer group's retired or disabled employees who will be continuing their participation, the authority shall determine the one-time payment by:

(i) Calculating the difference in cost between the rate charged to retired or disabled employees as described in RCW 41.05.080(2); and

(ii) The actuarially determined value of the medical benefits for retired and disabled employees who are not eligible for parts A and B of medicare; and

(iii) Multiplying that difference by the number of months until the retired or disabled employee would become eligible for medicare.

(b) Employer groups shall not be entitled to any refund of the amount paid to the authority as described in this subsection.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.065, 41.05.160, 2023 c 164 § 1, 2023 c 312 § 1, 2023 c 13 § 5, Policy Resolutions PEBB 2024-14, 2024-19, 2024-20, and 2024-21. WSR 24-18-081 (Admin #2024-01.05), § 182-08-245, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01) § 182-08-245, filed 6/23/23, effective 1/1/24*
- *WSR 21-13-106 (Admin #2021-01.06), § 182-08-245, filed 6/18/21, effective 1/1/22*
- *WSR 20-16-062 (Admin #2020-03), § 182-08-245, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-245, filed 8/20/19, effective 1/1/20*
- *WSR 17-19-077 (Order 2017-01), § 182-08-245, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-245, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-08-245, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-08-245, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160, 2013 2nd sp.s. c 4 and PEBB policy resolutions. WSR 14-08-040, § 182-08-245, filed 3/26/14, effective 4/26/14. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-08-245, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-08-245, filed 9/25/12, effective 11/1/12.*

## **Chapter 182-12** Eligible and noneligible employees. {#struct-chapter-182-12}

##### **Wash. Admin. Code § 182-12-108** Purpose. {#sec-182-12-108 omnilex-key=us-wa-regs-official--title-182--182-12-108}

The purpose of this chapter is to establish eligibility criteria for and effective date of enrollment in the public employees benefits board (PEBB) approved benefits.

**History**
- *Statutory Authority: RCW 41.05.160. WSR 07-20-129 (Order 07-01), § 182-12-108, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-108, filed 8/26/04, effective 1/1/05.*

##### **Wash. Admin. Code § 182-12-109** Definitions. {#sec-182-12-109 omnilex-key=us-wa-regs-official--title-182--182-12-109}

The following definitions apply throughout this chapter unless the context clearly indicates another meaning:

"Accidental death and dismemberment insurance" or "AD&D" means basic accidental death and dismemberment (AD&D) insurance paid for by the employing agency, as well as supplemental accidental death and dismemberment insurance offered to and paid for by employees for themselves and their dependents.

"Affordable Care Act" means the federal Patient Protection and Affordable Care Act, P.L. 111-148, as amended by the federal Health Care and Education Reconciliation Act of 2010, P.L. 111-152, or federal regulations or guidance issued under the Affordable Care Act.

"Annual open enrollment" means an annual event set aside for a period of time by the HCA when subscribers may make changes to their health plan enrollment and salary reduction elections for the following plan year. During the annual open enrollment, subscribers may transfer from one health plan to another, enroll or remove dependents from coverage, enroll in coverage, or waive enrollment (see definition of "waive" in this section). Employees eligible to participate in the salary reduction plan may enroll in or change their election under the dependent care assistance program (DCAP), the flexible spending arrangement (FSA), or limited purpose FSA. They may also enroll in or opt out of the premium payment plan.

"Authority" or "HCA" means the Washington state health care authority.

"Benefits-eligible position" means any position held by an employee who is eligible for benefits under WAC 182-12-114, with the exception of employees who establish eligibility under WAC 182-12-114 (2) or (3)(a)(ii).

"Blind vendor" means a "licensee" as defined in RCW 74.18.200.

"Board" means the public employees benefits board established under provisions of RCW 41.05.055.

"Calendar days" or "days" means all days including Saturdays, Sundays, and all state legal holidays as set forth in RCW 1.16.050.

"Consolidated Omnibus Budget Reconciliation Act" or "COBRA" means continuation coverage as administered under 42 U.S.C. Secs. 300bb-1 through 300bb-8.

"Continuation coverage" means the temporary continuation of PEBB benefits available to enrollees under the Consolidated Omnibus Budget Reconciliation Act (COBRA), 42 U.S.C. Secs. 300bb-1 through 300bb-8, the Uniformed Services Employment and Reemployment Rights Act (USERRA), 38 U.S.C. Secs. 4301 through 4335, or the public employees benefits board's policies.

"Contracted vendor" means any person, persons, or entity under contract or agreement with the HCA to provide goods or services for the provision or administration of PEBB benefits. The term "contracted vendor" includes subcontractors of the HCA and subcontractors of any person, persons, or entity under contract or agreement with the HCA that provide goods or services for the provision or administration of PEBB benefits.

"Creditable coverage" means coverage that meets the definition of "creditable coverage" under RCW 48.66.020 (13)(a) and includes payment of medical and hospital benefits.

"Defer" means to postpone enrollment or interrupt enrollment in PEBB insurance coverage by a retiree, an eligible survivor, or the PEBB program.

"Dependent" means a person who meets eligibility requirements in WAC 182-12-260, except that "surviving spouses, state registered domestic partners, and dependent children" of emergency service personnel who are killed in the line of duty is defined in WAC 182-12-250.

"Dependent care assistance program" or "DCAP" means a benefit plan whereby employees may pay for certain employment related dependent care with pretax dollars as provided in the salary reduction plan under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 129 or other sections of the Internal Revenue Code.

"Director" means the director of the authority.

"Documents" means papers, letters, writings, electronic mail, electronic files, or other printed or written items.

"Effective date of enrollment" means the first date when an enrollee is entitled to receive covered benefits.

"Employee" for the public employees benefits board program includes all employees of the state, whether or not covered by civil service; elected and appointed officials of the executive branch of government, including full-time members of boards, commissions, or committees; justices of the supreme court and judges of the court of appeals and the superior courts; and members of the state legislature. Pursuant to contractual agreement with the authority, "employee" may also include: (a) Employees of a county, municipality, or other political subdivision of the state and members of the legislative authority of any county, city, or town who are elected to office after February 20, 1970, if the legislative authority of the county, municipality, or other political subdivision of the state submits application materials to the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.04.205 and 41.05.021 (1)(g); (b) employees of employee organizations representing state civil service employees, at the option of each such employee organization; (c) through December 31, 2019, employees of a school district if the authority agrees to provide any of the school districts' insurance programs by contract with the authority as provided in RCW 28A.400.350; (d) employees of a tribal government, if the governing body of the tribal government seeks and receives the approval of the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.05.021 (1)(f) and (g); (e) employees of the Washington health benefit exchange if the governing board of the exchange established in RCW 43.71.020 seeks and receives approval of the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.05.021 (1)(g) and (n); and (f) through December 31, 2019, employees of a charter school established under chapter 28A.710 RCW. "Employee" does not include: Adult family home providers; unpaid volunteers; patients of state hospitals; inmates; students of institutions of higher education as determined by their institution; and any others not expressly defined as employees under RCW 41.05.011 or by the authority under this chapter.

"Employer" for the public employees benefits board program means the state of Washington.

"Employer-based group dental" means group dental related to a current employment relationship. It does not include dental coverage available to retired employees, individual market dental coverage, or government-sponsored programs such as medicaid.

"Employer-based group health plan" means group medical, group dental, and group vision related to a current employment relationship. It does not include medical, dental, or vision coverage available to retired employees, individual market medical or dental coverage, or government-sponsored programs such as medicare or medicaid.

"Employer-based group medical" means group medical related to a current employment relationship. It does not include medical coverage available to retired employees, individual market medical coverage, or government-sponsored programs such as medicare or medicaid.

"Employer contribution" means the funding amount paid to the HCA by a state agency or PEBB participating employer group for its eligible employees as described under WAC 182-12-114 and 182-12-131.

"Employer group" means:

• For the public employees benefits board as defined in RCW 41.05.011 (9)(a), those counties, municipalities, political subdivisions, the Washington health benefit exchange, tribal governments, and employee organizations representing state civil service employees obtaining employee benefits through a contractual agreement with the authority to participate in benefit plans developed by the public employees benefits board as described in WAC 182-08-245.

• For the school employees benefits board as defined in RCW 41.05.011 (9)(b), an employee organization representing school employees and a tribal school as defined in RCW 28A.715.010, obtaining school employee benefits through a contractual agreement with the authority to participate in benefit plans developed by the school employees benefits board as described in WAC 182-30-215.

"Employer-paid coverage" means PEBB insurance coverage for which an employer contribution is made by a state agency or a PEBB participating employer group for employees eligible in WAC 182-12-114 and 182-12-131. It also means SEBB insurance coverage for which an employer contribution is made by a SEBB organization or a SEBB participating employer group, or basic benefits described in RCW 28A.400.270(1) for which an employer contribution is made by an educational service district.

"Employing agency" for the public employees benefits board means a division, department, or separate agency of state government, including an institution of higher education; a county, municipality, or other political subdivision; and a tribal government covered by chapter 41.05 RCW.

"Enrollee" means a person who meets all eligibility requirements defined in chapter 182-12 WAC, who is enrolled in PEBB benefits, and for whom applicable premium payments have been made.

"Exchange" means the Washington health benefit exchange established in RCW 43.71.020, and any other health benefit exchange established under the Affordable Care Act.

"Exchange coverage" means coverage offered by a qualified health plan through an exchange.

"Faculty" means an academic employee of an institution of higher education whose workload is not defined by work hours but whose appointment, workload, and duties directly serve the institution's academic mission, as determined under the authority of its enabling statutes, its governing body, and any applicable collective bargaining agreement.

"Federal retiree medical plan" means the Federal Employees Health Benefits program (FEHB) or TRICARE plans which are not employer-based group medical.

"Flexible spending arrangement" or "FSA" means a benefit plan whereby eligible state employees may reduce their salary before taxes to pay for medical expenses not reimbursed by insurance as provided in the salary reduction plan established under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"Forms" or "form" means both paper forms and forms completed electronically.

"Health plan" means a plan offering medical, dental, vision, or any combination of these coverages, developed by the board and provided by a contracted vendor or self-insured plans administered by the HCA.

"Institutions of higher education" means the state public research universities, the public regional universities, The Evergreen State College, the community and technical colleges, and the state board for community and technical colleges.

"Layoff," for purposes of this chapter, means a change in employment status due to an employer's lack of funds or an employer's organizational change.

"Life insurance" means basic life insurance paid for by the employing agency, as well as supplemental life insurance or supplemental dependent life insurance offered to and paid for by employees for themselves and their dependents. Life insurance for eligible retirees includes retiree term life insurance offered to and paid for by retirees.

"Limited purpose flexible spending arrangement" or "limited purpose FSA" means a benefit plan whereby eligible state employees may reduce their salary before taxes to pay for dental and vision expenses not reimbursed by insurance as provided in the salary reduction plan established under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"Long-term disability insurance" or "LTD insurance" means employer-paid long-term disability insurance and employee-paid long-term disability insurance offered by the PEBB program.

"Pay status" means all hours for which an employee receives pay.

"PEBB" means the public employees benefits board.

"PEBB benefits" means one or more insurance coverages or other employee benefits administered by the PEBB program within the health care authority.

"PEBB insurance coverage" means any health plan, life insurance, accidental death and dismemberment insurance, long-term disability (LTD) insurance, long-term care insurance, or property and casualty insurance administered as a PEBB benefit.

"PEBB program" means the program within the HCA that administers insurance and other benefits for eligible employees (as described in WAC 182-12-114), eligible retired employees (as described in WAC 182-12-171, 182-12-180, and 182-12-211), eligible survivors (as described in WAC 182-12-180, 182-12-250, and 182-12-265), eligible dependents (as described in WAC 182-12-250 and 182-12-260) and others as defined in RCW 41.05.011 or as described in RCW 41.05.080 (1)(a)(ii).

"Plan year" means the time period established by the authority.

"Premium payment plan" means a benefit plan whereby public employees may pay their share of group health plan premiums with pretax dollars as provided in the salary reduction plan under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"Premium surcharge" means a payment required from a subscriber, in addition to the subscriber's medical premium contribution, due to an enrollee's tobacco use or an enrolled subscriber's spouse or state registered domestic partner choosing not to enroll in their employer-based group medical when:

• The spouse's or state registered domestic partner's share of the medical premium is less than 95 percent of the additional cost an employee would be required to pay to enroll a spouse or state registered domestic partner in the public employees benefits board (PEBB) Uniform Medical Plan (UMP) Classic; and

• The benefits have an actuarial value of at least 95 percent of the actuarial value of PEBB UMP Classic benefits.

"Public employee" has the same meaning as employee.

"Qualified health plan" means a medical plan that is certified to be offered through an exchange.

"Salary reduction plan" means a benefit plan whereby public employees may agree to a reduction of salary on a pretax basis to participate in the dependent care assistance program, flexible spending arrangement, limited purpose flexible spending arrangement, or premium payment plan offered pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"School employee" means all employees of school districts and charter schools established under chapter 28A.710 RCW; represented employees of educational service districts; effective January 1, 2024, all employees of educational service districts; and effective January 1, 2024, pursuant to a contractual agreement with the authority, "school employee" may also include: (a) Employees of employee organizations representing school employees, at the option of each such employee organization; and (b) employees of a tribal school as defined in RCW 28A.715.010, if the governing body of the tribal school seeks and receives the approval of the authority to provide any of its insurance programs by contracts with the authority, as provided in RCW 41.05.021 (1)(f) and (g).

"SEBB" means the school employees benefits board.

"SEBB insurance coverage" means any medical, dental, vision, life insurance, accidental death and dismemberment insurance, or long-term disability insurance administered as a SEBB benefit.

"SEBB organization" means a public school district or educational service district or charter school established under chapter 28A.710 RCW that is required to participate in benefit plans provided by the school employees benefits board.

"Season" means any recurring annual period of work at a specific time of year that lasts three to 11 consecutive months.

"Seasonal employee" means a state employee hired to work during a recurring, annual season with a duration of three months or more, and anticipated to return each season to perform similar work.

"Special open enrollment" means a period of time when subscribers may make changes to their health plan enrollment and salary reduction elections outside of the annual open enrollment period when specific life events occur. During the special open enrollment subscribers may change health plans and enroll or remove dependents from coverage. Additionally, employees may enroll in or waive enrollment (see definition of "waive" in this section). Employees eligible to participate in the salary reduction plan may enroll in or revoke their election under the DCAP, FSA, limited purpose FSA, or the premium payment plan and make a new election. For special open enrollment events related to specific PEBB benefits, see WAC 182-08-198, 182-08-199, 182-12-128, and 182-12-262.

"State agency" means an office, department, board, commission, institution, or other separate unit or division, however designated, of the state government. It includes the legislature, executive branch, and agencies or courts within the judicial branch, as well as institutions of higher education and any unit of state government established by law.

"State registered domestic partner" has the same meaning as defined in RCW 26.60.020(1) and substantially equivalent legal unions from other jurisdictions as defined in RCW 26.60.090.

"Subscriber" means the employee, retiree, continuation coverage enrollee, retired employee or retired school employee continuing health plan coverage when their employer group ceases participation with the authority, or survivor who has been determined eligible by the PEBB program, PEBB participating employer group, or state agency, is enrolled in PEBB benefits, and is the individual to whom the PEBB program and contracted vendors will issue all notices, information, requests, and premium bills on behalf of an enrollee.

"Supplemental coverage" means any life insurance or accidental death and dismemberment (AD&D) insurance coverage purchased by the employee in addition to the coverage provided by the employing agency.

"Tobacco products" means any product made with or derived from tobacco that is intended for human consumption, including any component, part, or accessory of a tobacco product. This includes, but is not limited to, cigars, cigarettes, pipe tobacco, chewing tobacco, snuff, and other tobacco products. It does not include e-cigarettes or United States Food and Drug Administration (FDA) approved quit aids.

"Tobacco use" means any use of tobacco products within the past two months. Tobacco use, however, does not include the religious or ceremonial use of tobacco.

"Tribal government" means an Indian tribal government as defined in Section 3(32) of the Employee Retirement Income Security Act of 1974 (ERISA), as amended, or an agency or instrumentality of the tribal government, that has government offices principally located in this state.

"Waive" means an eligible employee affirmatively declining enrollment in PEBB medical because the employee is enrolled in other employer-based group medical, a TRICARE plan, or medicare Part A and Part B as allowed under WAC 182-12-128. An employee on approved educational leave who obtains another employer-based group health plan may waive enrollment as allowed under WAC 182-12-136. An employee may waive enrollment in PEBB medical to enroll in SEBB medical only if they are enrolled in SEBB dental and SEBB vision. An employee who waives enrollment in PEBB medical to enroll in SEBB medical also waives enrollment in PEBB dental and PEBB vision.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 25-14-081 (Admin #2025.01.02), s 182-12-109, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], 41.05.160, 2023 c 312 § 1, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-18-077 (Admin #2024-01.02), § 182-12-109, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-12-109, filed 6/23/23, effective 1/1/24*
- *WSR 22-13-158 (Admin #2022-01), § 182-12-109, filed 6/21/22, effective 1/1/23*
- *WSR 21-13-106 (Admin #2021-01.06), § 182-12-109, filed 6/18/21, effective 1/1/22*
- *WSR 20-16-062 (Admin #2020-03), § 182-12-109, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-109, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-109, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-109, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-109, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-109, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-109, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160, 2013 2nd sp.s. c 4 and PEBB policy resolutions. WSR 14-08-040, § 182-12-109, filed 3/26/14, effective 4/26/14. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-109, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-109, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-12-109, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-12-109, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-12-109, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-12-109, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-12-109, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.068. WSR 06-23-165 (Order 06-09), § 182-12-109, filed 11/22/06, effective 12/23/06. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-109, filed 8/26/04, effective 1/1/05.*

##### **Wash. Admin. Code § 182-12-111** Which entities and individuals are eligible for public employees benefits board (PEBB) benefits? {#sec-182-12-111 omnilex-key=us-wa-regs-official--title-182--182-12-111}

The following entities and individuals shall be eligible for public employees benefits board (PEBB) benefits subject to the terms and conditions set forth below:

(1) State agencies. State agencies, as defined in WAC 182-12-109, are required to participate in all PEBB benefits. Insurance and health care contributions for ferry employees shall be governed by RCW 47.64.270.

(2) Employer groups. Employer groups as defined in WAC 182-12-109 for the PEBB program may apply to participate in PEBB insurance coverage for groups of employees described in (a)(i) of this subsection and for members of the group's governing authority as described in (a)(i), (ii), and (iii) of this subsection at the option of each employer group:

(a) All eligible employees of the entity must transfer as a unit with the following exceptions:

(i) Bargaining units may elect to participate separately from the whole group;

(ii) Nonrepresented employees may elect to participate separately from the whole group provided all nonrepresented employees join as a group; and

(iii) Members of the employer group's governing authority may participate as described in the employer group's governing statutes and RCW 41.04.205.

(b) Employer groups must apply through the process described in WAC 182-08-235. Applications from employees of employee organizations representing state civil service employees, the Washington health benefit exchange, and employer groups with 5,000 or more employees are subject to review and approval by the health care authority (HCA) based on the employer group evaluation criteria described in WAC 182-08-240.

(c) Employer groups participate through a contract with the authority as described in WAC 182-08-245.

(3) The Washington health benefit exchange. In addition to subsection (2) of this section, the following provisions apply:

(a) The Washington health benefit exchange is subject to the same rules as an employing agency in chapters 182-08, 182-12, and 182-16 WAC.

(b) Employees of the Washington health benefit exchange are subject to the same rules as employees of an employing agency in chapters 182-08, 182-12 and 182-16 WAC.

(4) Eligible nonemployees.

(a) Blind vendors actively operating a business enterprise program facility in the state of Washington and deemed eligible by the department of services for the blind (DSB) may voluntarily participate in PEBB medical. Dependents of blind vendors are eligible as described in WAC 182-12-260.

(i) Eligible blind vendors and their dependents may enroll during the following times:

• When newly eligible: The DSB will notify eligible blind vendors of their eligibility in advance of the date they are eligible for enrollment in PEBB medical.

To enroll, blind vendors must submit the required forms to the DSB. The forms must be received by the DSB no later than 31 days after the blind vendor becomes eligible for PEBB medical;

• During the annual open enrollment: Blind vendors may enroll during the annual open enrollment. The required form must be received by the DSB before the end of the annual open enrollment. Enrollment will begin January 1st of the following year; or

• Following loss of other medical insurance coverage: Blind vendors may enroll following loss of other medical insurance coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA). To enroll, blind vendors must submit the required forms to the DSB. The forms must be received by the DSB no later than 60 days after the loss of other medical insurance coverage. In addition to the required forms, the DSB will require blind vendors to provide evidence of loss of other medical insurance coverage.

(ii) Blind vendors who cease to actively operate a facility become ineligible to participate in PEBB medical as described in (a) of this subsection. Enrollees who lose eligibility for coverage may continue enrollment in PEBB medical on a self-pay basis under Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage as described in WAC 182-12-146 (6).

(iii) Blind vendors are not eligible for PEBB retiree insurance coverage.

(b) Dislocated forest products workers enrolled in the employment and career orientation program pursuant to chapter 50.70 RCW shall be eligible for PEBB medical, dental, and vision while enrolled in that program.

(5) Individuals and entities not eligible as employees include:

(a) Adult family home providers as defined in RCW 70.128.010;

(b) Unpaid volunteers;

(c) Patients of state hospitals;

(d) Inmates in work programs offered by the Washington state department of corrections as described in RCW 72.09.100 or an equivalent program administered by a local government;

(e) Students of institutions of higher education as determined by their institutions; and

(f) Any others not expressly defined as an employee.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-12-111, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-12-111, filed 6/23/23, effective 1/1/24*
- *WSR 20-16-062 (Admin #2020-03), § 182-12-111, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-111, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-111, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-111, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-111, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-111, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-111, filed 9/25/12, effective 11/1/12*
- *WSR 10-20-147 (Order 10-02), § 182-12-111, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-12-111, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-12-111, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-12-111, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-111, filed 8/26/04, effective 1/1/05*
- *WSR 03-17-031 (Order 02-07), § 182-12-111, filed 8/14/03, effective 9/14/03. Statutory Authority: RCW 41.05.160. WSR 02-18-087 (Order 02-02), § 182-12-111, filed 9/3/02, effective 10/4/02*
- *WSR 99-19-028 (Order 99-04), § 182-12-111, filed 9/8/99, effective 10/9/99*
- *WSR 97-21-127, § 182-12-111, filed 10/21/97, effective 11/21/97. Statutory Authority: Chapter 41.05 RCW. WSR 96-08-043, § 182-12-111, filed 3/29/96, effective 4/29/96. Statutory Authority: RCW 41.04.205, 41.05.065, 41.05.011, 41.05.080 and chapter 41.05 RCW. WSR 92-03-040, § 182-12-111, filed 1/10/92, effective 1/10/92. Statutory Authority: Chapter 41.05 RCW. WSR 78-02-015 (Order 2-78), § 182-12-111, filed 1/10/78.*

##### **Wash. Admin. Code § 182-12-113** What are the obligations of a state agency in the application of employee eligibility? {#sec-182-12-113 omnilex-key=us-wa-regs-official--title-182--182-12-113}

(1) All state agencies must carry out all actions, policies, and guidance issued by the public employees benefits board (PEBB) program necessary for the operation of benefit plans, education of employees, claims administration, and appeals process including those described in chapters 182-08, 182-12, and 182-16 WAC. State agencies must:

(a) Use the methods provided by the PEBB program to determine eligibility and enrollment in benefits, unless otherwise approved in writing;

(b) Provide eligibility determination reports with content and in a format designed and communicated by the PEBB program or otherwise as approved in writing by the PEBB program; and

(c) Carry out corrective action and pay any penalties imposed by the authority and established by the board when the state agency's eligibility determinations fail to comply with the criteria under these rules.

(2) All state agencies must determine employee eligibility for PEBB benefits and the employer contribution according to the criteria in WAC 182-12-114 and 182-12-131. State agencies must:

(a) Notify newly hired employees of PEBB program rules and guidance for eligibility and appeal rights;

(b) Provide written notice to faculty who are potentially eligible for benefits and employer contribution of their potential eligibility as described in WAC 182-12-114(3) and 182-12-131;

(c) Inform an employee in writing whether or not they are eligible for PEBB benefits upon employment. The written notice must include a description of any hours that are excluded in determining eligibility and information about the employee's right to appeal eligibility and enrollment decisions. An employee eligible for PEBB benefits must have no less than 10 calendar days after the date of notice to elect coverage;

(d) Routinely monitor all employees' eligible work hours to establish eligibility and maintain the employer contribution toward PEBB benefits;

(e) Make eligibility determinations based on the criteria of the eligibility category that most closely describes the employee's work circumstances per the PEBB program's direction;

(f) Identify when a previously ineligible employee becomes eligible or a previously eligible employee loses eligibility; and

(g) Inform an employee in writing whether or not they are eligible for PEBB benefits and the employer contribution whenever there is a change in work pattern such that the employee's eligibility status changes. Whenever this occurs, state agencies must inform the employee of the right to appeal eligibility and enrollment decisions. An employee eligible for PEBB benefits must have no less than 10 calendar days after the date of notice to elect coverage.

(3) State agencies must determine employee's dependents eligibility for PEBB health plan coverage according to the criteria in WAC 182-12-260.

(4) State agencies must assist an employee in determining whether or not the employee or their dependent has experienced an event that creates a special open enrollment as described in WAC 182-08-198, 182-08-199, 182-12-128, or 182-12-262, and inform the employee of the changes they can make consistent with that event.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-12-113, filed 6/23/23, effective 1/1/24*
- *WSR 20-16-062 (Admin #2020-03), § 182-12-113, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-113, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-113, filed 10/3/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-113, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-113, filed 9/25/12, effective 11/1/12*
- *WSR 09-23-102 (Order 09-02), § 182-12-113, filed 11/17/09, effective 1/1/10.*

##### **Wash. Admin. Code § 182-12-114** How do employees establish eligibility for public employees benefits board (PEBB) benefits? {#sec-182-12-114 omnilex-key=us-wa-regs-official--title-182--182-12-114}

Eligibility for an employee whose work circumstances are described by more than one of the eligibility categories in subsections (1) through (5) of this section shall be determined solely by the criteria of the category that most closely describes the employee's work circumstances.

Hours that are excluded in determining eligibility include standby hours and any temporary increases in work hours, of six months or less, caused by training or emergencies (except governor-declared emergencies) that have not been or are not anticipated to be part of the employee's regular work schedule or pattern. Any hours worked in direct response to a governor-declared emergency are not excludable and must be included in determining eligibility. In order to include excluded hours in determining eligibility, employing agencies must request and receive the public employees benefits board (PEBB) program's approval.

For how the employer contribution toward PEBB benefits is maintained after eligibility is established under this section, see WAC 182-12-131.

(1) Employees are eligible for PEBB benefits as follows, except as described in subsections (2) through (5) of this section:

(a) Eligibility. An employee is eligible if they are anticipated to work an average of at least 80 hours per month and are anticipated to work for at least eight hours in each month for more than six consecutive months.

(b) Determining eligibility.

(i) Upon employment: An employee is eligible from the date of employment if the employing agency anticipates the employee will work according to the criteria in (a) of this subsection.

(ii) Upon revision of anticipated work pattern: If an employing agency revises an employee's anticipated work hours or anticipated duration of employment such that the employee meets the eligibility criteria in (a) of this subsection, the employee becomes eligible when the revision is made.

(iii) Based on work pattern: An employee who is determined to be ineligible, but later meets the eligibility criteria in (a) of this subsection, becomes eligible the first of the month following the six-month averaging period.

(c) Stacking of hours. As long as the work is within one state agency, employees may "stack" or combine hours worked in more than one position or job to establish eligibility and maintain the employer contribution toward PEBB benefits. Employees become eligible through stacking when they meet the requirements described in (a) of this subsection. They must notify their employing agency if they believe they are eligible through stacking. Stacking includes work situations in which:

(i) The employee works two or more positions or jobs at the same time (concurrent stacking);

(ii) The employee moves from one position or job to another (consecutive stacking); or

(iii) The employee combines hours from a seasonal position with hours from a nonseasonal position or job. An employee who establishes eligibility by stacking hours from a seasonal position or job with hours from a nonseasonal position or job shall maintain the employer contribution toward PEBB benefits as described in WAC 182-12-131(1).

(d) When PEBB benefits begin. Medical, dental, vision, basic life insurance, basic accidental death and dismemberment (AD&D) insurance, employer-paid long-term disability (LTD) insurance, employee-paid LTD insurance (unless the employee declines the employee-paid LTD insurance as described in WAC 182-08-197(1)), and if eligible, benefits under the salary reduction plan begin on the first day of the month following the date an employee becomes eligible. If the employee becomes eligible on the first working day of a month, then coverage begins on that date. Supplemental life insurance and supplemental AD&D insurance begin on the first day of the month following the date the contracted vendor receives the required form or approves the enrollment.

(2) Seasonal employees, as defined in WAC 182-12-109, are eligible as follows:

(a) Eligibility. A seasonal employee is eligible if they are anticipated to work an average of at least 80 hours per month and are anticipated to work for at least eight hours in each month of at least three consecutive months of the season.

(b) Determining eligibility.

(i) Upon employment: A seasonal employee is eligible from the date of employment if the employing agency anticipates that they will work according to the criteria in (a) of this subsection.

(ii) Upon revision of anticipated work pattern. If an employing agency revises an employee's anticipated work hours or anticipated duration of employment such that the employee meets the eligibility criteria in (a) of this subsection, the employee becomes eligible when the revision is made.

(iii) Based on work pattern. An employee who is determined to be ineligible for benefits, but later works an average of at least 80 hours per month and works for at least eight hours in each month and works for more than six consecutive months, becomes eligible the first of the month following a six-month averaging period.

(c) Stacking of hours. As long as the work is within one state agency, employees may "stack" or combine hours worked in more than one position or job to establish eligibility and maintain the employer contribution toward PEBB benefits. Employees become eligible through stacking when they meet the requirements described in (a) of this subsection. They must notify their employing agency if they believe they are eligible through stacking. Stacking includes work situations in which:

(i) The employee works two or more positions or jobs at the same time (concurrent stacking);

(ii) The employee moves from one position or job to another (consecutive stacking); or

(iii) The employee combines hours from a seasonal position or job with hours from a nonseasonal position or job. An employee who establishes eligibility by stacking hours from a seasonal position or job with hours from a nonseasonal position or job shall maintain the employer contribution toward PEBB benefits as described in WAC 182-12-131(1).

(d) When PEBB benefits begin. Medical, dental, vision, basic life insurance, basic AD&D insurance, employer-paid LTD insurance, employee-paid LTD insurance (unless the employee declines the employee-paid LTD insurance as described in WAC 182-08-197(1)), and if eligible, benefits under the salary reduction plan begin on the first day of the month following the day the employee becomes eligible. If the employee becomes eligible on the first working day of a month, then coverage begins on that date. Supplemental life insurance and supplemental AD&D insurance begin on the first day of the month following the date the contracted vendor receives the required form or approves the enrollment.

| Exception: | Seasonal employees who work a recurring, annual season with a duration of less than nine months are not eligible for the employee-paid LTD insurance benefit. |
| --- | --- |

(3) Faculty are eligible as follows:

(a) Determining eligibility. "Half-time" means one-half of the full-time academic workload as determined by each institution, except that half-time for community and technical college faculty employees is governed by RCW 28B.50.489.

(i) Upon employment: Faculty who the employing agency anticipates will work half-time or more for the entire instructional year, or equivalent nine-month period, are eligible from the date of employment.

(ii) For faculty hired on quarter/semester to quarter/semester basis: Faculty who the employing agency anticipates will not work for the entire instructional year, or equivalent nine-month period, are eligible at the beginning of the second consecutive quarter or semester of employment in which they are anticipated to work, or has actually worked, half-time or more. Spring and fall are considered consecutive quarters/semesters when first establishing eligibility for faculty that work less than half-time during the summer quarter/semester.

(iii) Upon revision of anticipated work pattern: Faculty who receive additional workload after the beginning of the anticipated work period (quarter, semester, or instructional year), such that their workload meets the eligibility criteria as described in (a)(i) or (ii) of this subsection become eligible when the revision is made.

(b) Stacking. Faculty may establish eligibility and maintain the employer contribution toward PEBB benefits by working as faculty for more than one institution of higher education. Faculty workloads may only be stacked with other faculty workloads to establish eligibility under this section or maintain eligibility as described in WAC 182-12-131(3). A faculty becomes eligible through stacking when they meet the requirements as described in (a) of this subsection. When a faculty works for more than one institution of higher education, the faculty must notify their employing agencies that they work at more than one institution and may be eligible through stacking.

(c) When PEBB benefits begin.

(i) Medical, dental, vision, basic life insurance, basic AD&D insurance, employer-paid LTD insurance, employee-paid LTD insurance (unless the faculty declines the employee-paid LTD insurance as described in WAC 182-08-197(1)), and if eligible, benefits under the salary reduction plan begin on the first day of the month following the day the faculty becomes eligible. If the faculty becomes eligible on the first working day of a month, then coverage begins on that date. Supplemental life insurance and supplemental AD&D insurance begin on the first day of the month following the date the contracted vendor receives the required form or approves the enrollment.

(ii) For faculty hired on a quarter/semester to quarter/semester basis under (a)(ii) of this subsection, medical, dental, vision, basic life insurance, basic AD&D insurance, employer-paid LTD insurance, employee-paid LTD insurance (unless the faculty declines the employee-paid LTD insurance as described in WAC 182-08-197(1)), and if eligible, benefits under the salary reduction plan begin the first day of the month following the beginning of the second consecutive quarter/semester of half-time or more employment. If the first day of the second consecutive quarter/semester is the first working day of the month, then coverage begins at the beginning of the second consecutive quarter/semester. Supplemental life insurance and supplemental AD&D insurance begin on the first day of the month following the date the contracted vendor receives the required form or approves the enrollment.

(4) Elected and full-time appointed officials of the legislative and executive branches of state government are eligible as follows:

(a) Eligibility. A legislator is eligible for PEBB benefits on the date their term begins. All other elected and full-time appointed officials of the legislative and executive branches of state government are eligible on the date their terms begin or the date they take the oath of office, whichever occurs first.

(b) When PEBB benefits begin. Medical, dental, vision, basic life insurance, basic AD&D insurance, employer-paid LTD insurance, employee-paid LTD insurance (unless the employee declines the employee-paid LTD insurance as described in WAC 182-08-197(1)), and if eligible, benefits under the salary reduction plan begin on the first day of the month following the day the employee becomes eligible. If the employee becomes eligible on the first working day of a month, then coverage begins on that date. Supplemental life insurance and supplemental AD&D insurance begin on the first day of the month following the date the contracted vendor receives the required form or approves the enrollment.

(5) Justices and judges are eligible as follows:

(a) Eligibility. A justice of the supreme court and judges of the court of appeals and the superior courts become eligible for PEBB benefits on the date they take the oath of office.

(b) When PEBB benefits begin. Medical, dental, vision, basic life insurance, basic AD&D insurance, employer-paid LTD insurance, employee-paid LTD insurance (unless the employee declines the employee-paid LTD insurance as described in WAC 182-08-197(1)), and if eligible, benefits under the salary reduction plan begin on the first day of the month following the day the employee becomes eligible. If the employee becomes eligible on the first working day of a month, then coverage begins on that date. Supplemental life insurance and supplemental AD&D insurance begin on the first day of the month following the date the contracted vendor receives the required form or approves the enrollment.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-12-114, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-12-114, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions PEBB 2021-11 and 2021-12. WSR 21-13-103 (Admin #2021-01.03), § 182-12-114, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-12-114, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-114, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-114, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-114, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-114, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-114, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-12-114, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-12-114, filed 11/17/09, effective 1/1/10.*

##### **Wash. Admin. Code § 182-12-116** Who is eligible to participate in the salary reduction plan? {#sec-182-12-116 omnilex-key=us-wa-regs-official--title-182--182-12-116}

(1) Employees of state agencies are eligible to participate in the state's salary reduction plan provided they are eligible for public employees benefits board (PEBB) benefits as described in WAC 182-12-114 and they elect to participate within the time frames described in WAC 182-08-197, 182-08-187, or 182-08-199.

(2) Employees of PEBB participating employer groups, as defined in WAC 182-12-109, are not eligible to participate in the state's salary reduction plan.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-12-116, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160 and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-116, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-116, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-116, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 09-23-102 (Order 09-02), § 182-12-116, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-12-116, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-12-116, filed 10/3/07, effective 11/3/07*
- *WSR 06-11-156 (Order 06-02), § 182-12-116, filed 5/24/06, effective 6/24/06. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. WSR 05-16-046 (Order 05-01), § 182-12-116, filed 7/27/05, effective 8/27/05.*

##### **Wash. Admin. Code § 182-12-123** Is dual enrollment in public employees benefits board (PEBB) and school employees benefits board (SEBB) prohibited? {#sec-182-12-123 omnilex-key=us-wa-regs-official--title-182--182-12-123}

WAC 182-12-123

***(Effective until January 1, 2027)***

Public employees benefits board (PEBB) medical, dental, and vision coverage is limited to a single enrollment per individual as described in subsections (1) through (5) of this section. Effective January 1, 2022, individuals are limited to a single enrollment in medical, dental, and vision plans in either the PEBB program or school employees benefits board (SEBB) program as described in subsection (6) of this section.

(1) An individual who has more than one source of eligibility for enrollment in PEBB medical, PEBB dental, and PEBB vision coverage (called "dual eligibility") is limited to one enrollment.

(2) An eligible employee may waive PEBB medical and enroll as a dependent under the PEBB medical plan of their spouse, state registered domestic partner, or parent as described in WAC 182-12-128.

(3) A dependent enrolled in PEBB medical, PEBB dental, or PEBB vision who becomes eligible for PEBB benefits as an employee must elect to enroll in PEBB benefits as described in WAC 182-08-197 (1) or (3). This includes making an election to enroll in or waive enrollment in PEBB medical as described in WAC 182-12-128.

(a) If the employee does not waive enrollment in PEBB medical, the employee is not eligible to remain enrolled in their spouse's, state registered domestic partner's, or parent's PEBB medical as a dependent. If the employee's spouse, state registered domestic partner, or parent does not take action to remove the employee (who is enrolled as a dependent) from their subscriber account, the PEBB program will automatically disenroll the employee's enrollment as a dependent the last day of the month before the employee's enrollment in PEBB benefits begins as described in WAC 182-12-114.

| Exception: | An enrolled dependent who becomes newly eligible for PEBB benefits as an employee may be dual-enrolled in PEBB medical, dental, and vision for one month. This exception is only allowed for the first month the dependent is enrolled as an employee, and only if the dependent becomes enrolled as an employee on the first working day of a month that is not the first day of the month. |
| --- | --- |

(b) If the employee elects to waive their enrollment in PEBB medical, the employee will remain enrolled in PEBB medical under their spouse's, state registered domestic partner's, or parent's PEBB medical as a dependent.

(4) A child who is eligible for PEBB medical, PEBB dental, and PEBB vision under two subscribers may be enrolled under both subscribers but is limited to a single enrollment in PEBB medical, a single enrollment in PEBB dental, and a single enrollment in PEBB vision.

(5) When an employee is eligible for the employer contribution toward PEBB benefits due to employment in more than one PEBB-participating employing agency the following provisions apply:

(a) The employee must choose to enroll under only one employing agency.

| Exception: | Faculty who stack to establish or maintain eligibility as described in WAC 182-12-114(3) with two or more state institutions of higher education will be enrolled under the employing agency responsible to pay the employer contribution according to WAC 182-08-200(2). |
| --- | --- |

(b) If the employee loses eligibility under the employing agency, they must notify their other employing agency no later than 60 days from the date PEBB benefits end through the employing agency described in (a) of this subsection to transfer coverage.

(c) The employee's elections remain the same when an employee transfers their enrollment under one employing agency to another employing agency without a break in PEBB benefits for one month or more, as described in (b) of this subsection.

(6) An individual who has more than one source of eligibility for enrollment in the PEBB and SEBB programs is limited to a single enrollment in medical, dental, and vision plans in either the PEBB or SEBB program. An employee must elect to enroll in PEBB benefits as described in WAC 182-08-197, waive enrollment as described in WAC 182-12-128, or remove eligible dependents as described in WAC 182-12-262. If the employee takes no action to resolve the dual enrollment, the PEBB program or the SEBB program will automatically enroll or automatically disenroll the individual as described in (c) through (g) of this subsection.

(a) An eligible employee may waive enrollment in PEBB medical to enroll in SEBB medical only if they are enrolled in SEBB dental and SEBB vision as described in WAC 182-12-128. An employee who waives enrollment in PEBB medical to enroll in SEBB medical also waives enrollment in PEBB dental and PEBB vision.

(b) A school employee in the SEBB program who waives SEBB medical, SEBB dental, and SEBB vision for PEBB medical must be enrolled in PEBB dental and PEBB vision. If the school employee is not already enrolled in PEBB dental and PEBB vision the PEBB program will automatically enroll the school employee in the associated subscriber's PEBB dental and PEBB vision.

(c) If the employee is enrolled only in PEBB dental and PEBB vision, and is also enrolled in SEBB medical, and no action is taken to resolve their dual enrollment, the employee will remain in SEBB medical. The PEBB program will automatically disenroll the employee from PEBB dental and PEBB vision in which they are enrolled. If the employee is not already enrolled in SEBB dental or SEBB vision, the SEBB program will automatically enroll them in both as described in WAC 182-31-070 (6)(g). The employee's enrollment in PEBB program life insurance, accidental death and dismemberment (AD&D) insurance, and long-term disability (LTD) insurance will remain.

(d) If the employee is enrolled in PEBB medical and is also a school employee in the SEBB program and enrolled in SEBB medical, and the employee has been enrolled in SEBB medical longer than they have been enrolled in PEBB medical, and no action is taken by the employee to resolve their dual enrollment, they will remain in SEBB medical. The PEBB program will automatically disenroll the employee from PEBB medical, PEBB dental, and PEBB vision. The employee's enrollment in PEBB program life insurance, AD&D insurance, and LTD insurance will remain. If the employee is not enrolled in any medical under either the PEBB or SEBB program but is enrolled in PEBB dental, PEBB vision, SEBB dental, and SEBB vision, the employee will remain in SEBB benefits. The PEBB program will automatically disenroll the employee from PEBB dental and PEBB vision.

(e) If the employee's dependent is enrolled in any PEBB medical, PEBB dental, or PEBB vision plan, and the dependent is also a school employee in the SEBB program and enrolled in SEBB medical, and no action is taken by either the employee or the dependent to resolve the dependent's dual enrollment, the employee's dependent will remain in SEBB medical. The PEBB program will automatically disenroll the employee's dependent from PEBB medical, PEBB dental, and PEBB vision in which they are enrolled.

(f) If the employee's dependent is enrolled in both PEBB medical and SEBB medical as a dependent and has been enrolled in SEBB medical longer than they have been enrolled in PEBB medical, and no action is taken to resolve the dual enrollment, the employee's dependent will remain in SEBB medical. The PEBB program will automatically disenroll the employee's dependent from PEBB medical, PEBB dental, and PEBB vision if they are enrolled. If the employee's dependent who is eligible as a dependent in both the PEBB and SEBB programs is not enrolled in any medical but is enrolled in both a PEBB and SEBB dental plan, PEBB and SEBB vision plan, or any combination of these coverages as a dependent, the dependent will remain in SEBB benefits. The PEBB program will automatically disenroll the employee's dependent from PEBB benefits.

| Exception: | If there is a National Medical Support Notice (NMSN) or a court order in place, enrollment will be in accordance with the NMSN or order. |
| --- | --- |

(g) If the employee's dependent, who is also a school employee in the SEBB program who the SEBB program automatically disenrolled from SEBB dental and SEBB vision, the PEBB program will automatically enroll the employee's dependent in PEBB dental and PEBB vision, if they are not already enrolled.

(h) If the employee who is eligible for the employer contribution toward PEBB benefits was enrolled as a dependent in SEBB medical, SEBB dental, and SEBB vision and is removed by the SEBB subscriber, the employee will be required to return from waived enrollment as described in WAC 182-12-128 (3)(b).

(i) If the PEBB program automatically disenrolls an individual from PEBB medical, PEBB dental, or PEBB vision to resolve their dual enrollment as described in (d), (e), or (f) of this subsection, but later determines that the employee did take action to resolve their dual enrollment within the required timelines, the PEBB program will reinstate coverage retroactive to the first of the month in which the individual was disenrolled.

(7) A retiree who defers enrollment in PEBB retiree insurance coverage as described in WAC 182-12-200 by enrolling as an eligible dependent in a health plan sponsored by PEBB or SEBB and who loses the employer contribution for such coverage must enroll in PEBB retiree insurance coverage as described in WAC 182-12-200 or defer enrollment as described in WAC 182-12-205.

***(Effective January 1, 2027)***

PDF WAC 182-12-123

Is dual enrollment in public employees benefits board (PEBB) and school employees benefits board (SEBB) prohibited?

Public employees benefits board (PEBB) medical, dental, and vision coverage is limited to a single enrollment per individual as described in subsections (1) through (5) of this section. Effective January 1, 2022, individuals are limited to a single enrollment in medical, dental, and vision plans in either the PEBB program or school employees benefits board (SEBB) program as described in subsection (6) of this section.

(1) An individual who has more than one source of eligibility for enrollment in PEBB medical, PEBB dental, and PEBB vision coverage (called "dual eligibility") is limited to one enrollment.

(2) An eligible employee may waive PEBB medical and enroll as a dependent under the PEBB medical plan of their spouse, state registered domestic partner, or parent as described in WAC 182-12-128.

(3) A dependent enrolled in PEBB medical, PEBB dental, or PEBB vision who becomes eligible for PEBB benefits as an employee must elect to enroll in PEBB benefits as described in WAC 182-08-197 (1) or (3). This includes making an election to enroll in or waive enrollment in PEBB medical as described in WAC 182-12-128.

(a) If the employee does not waive enrollment in PEBB medical, the employee is not eligible to remain enrolled in their spouse's, state registered domestic partner's, or parent's PEBB medical as a dependent. If the employee's spouse, state registered domestic partner, or parent does not take action to remove the employee (who is enrolled as a dependent) from their subscriber account, the PEBB program will automatically disenroll the employee's enrollment as a dependent the last day of the month before the employee's enrollment in PEBB benefits begins as described in WAC 182-12-114.

| Exception: | An enrolled dependent who becomes newly eligible for PEBB benefits as an employee may be dual-enrolled in PEBB medical, dental, and vision for one month. This exception is only allowed for the first month the dependent is enrolled as an employee, and only if the dependent becomes enrolled as an employee on the first working day of a month that is not the first day of the month. |
| --- | --- |

(b) If the employee elects to waive their enrollment in PEBB medical, the employee will remain enrolled in PEBB medical under their spouse's, state registered domestic partner's, or parent's PEBB medical as a dependent.

(4) A child who is eligible for PEBB medical, PEBB dental, and PEBB vision under two subscribers may be enrolled under both subscribers but is limited to a single enrollment in PEBB medical, a single enrollment in PEBB dental, and a single enrollment in PEBB vision.

(5) When an employee is eligible for the employer contribution toward PEBB benefits due to employment in more than one PEBB-participating employing agency the following provisions apply:

(a) The employee must choose to enroll under only one employing agency.

| Exception: | Faculty who stack to establish or maintain eligibility as described in WAC 182-12-114(3) with two or more state institutions of higher education will be enrolled under the employing agency responsible to pay the employer contribution according to WAC 182-08-200(2). |
| --- | --- |

(b) If the employee loses eligibility under the employing agency, they must notify their other employing agency no later than 60 days from the date PEBB benefits end through the employing agency described in (a) of this subsection to transfer coverage.

(c) The employee's elections remain the same when an employee transfers their enrollment under one employing agency to another employing agency without a break in PEBB benefits for one month or more, as described in (b) of this subsection.

(6) An individual who has more than one source of eligibility for enrollment in the PEBB and SEBB programs is limited to a single enrollment in medical, dental, and vision plans in either the PEBB or SEBB program. An employee must elect to enroll in PEBB benefits as described in WAC 182-08-197, waive enrollment as described in WAC 182-12-128, or remove eligible dependents as described in WAC 182-12-262. An employee may not waive PEBB medical, PEBB dental, and PEBB vision to enroll in SEBB medical with a SEBB participating employer group that offers only medical coverage. If the employee takes no action to resolve the dual enrollment, the PEBB program or the SEBB program will automatically enroll or automatically disenroll the individual as described in (c) through (g) of this subsection.

(a) An eligible employee may waive enrollment in PEBB medical to enroll in SEBB medical only if they are enrolled in SEBB dental and SEBB vision as described in WAC 182-12-128. An employee who waives enrollment in PEBB medical to enroll in SEBB medical also waives enrollment in PEBB dental and PEBB vision.

(b) A school employee in the SEBB program who waives SEBB medical, SEBB dental, and SEBB vision for PEBB medical must be enrolled in PEBB dental and PEBB vision. If the school employee is not already enrolled in PEBB dental and PEBB vision the PEBB program will automatically enroll the school employee in the associated subscriber's PEBB dental and PEBB vision.

(c) If the employee is enrolled only in PEBB dental and PEBB vision, and is also enrolled in SEBB medical, and no action is taken to resolve their dual enrollment, the employee will remain in SEBB medical. The PEBB program will automatically disenroll the employee from PEBB dental and PEBB vision in which they are enrolled. If the employee is not already enrolled in SEBB dental or SEBB vision, the SEBB program will automatically enroll them in both as described in WAC 182-31-070 (6)(g). The employee's enrollment in PEBB program life insurance, accidental death and dismemberment (AD&D) insurance, and long-term disability (LTD) insurance will remain.

(d) If the employee is enrolled in PEBB medical and is also a school employee in the SEBB program and enrolled in SEBB medical, and the employee has been enrolled in SEBB medical longer than they have been enrolled in PEBB medical, and no action is taken by the employee to resolve their dual enrollment, they will remain in SEBB medical. The PEBB program will automatically disenroll the employee from PEBB medical, PEBB dental, and PEBB vision. The employee's enrollment in PEBB program life insurance, AD&D insurance, and LTD insurance will remain. If the employee is not enrolled in any medical under either the PEBB or SEBB program but is enrolled in PEBB dental, PEBB vision, SEBB dental, and SEBB vision, the employee will remain in SEBB benefits. The PEBB program will automatically disenroll the employee from PEBB dental and PEBB vision.

(e) If the employee's dependent is enrolled in any PEBB medical, PEBB dental, or PEBB vision plan, and the dependent is also a school employee in the SEBB program and enrolled in SEBB medical, and no action is taken by either the employee or the dependent to resolve the dependent's dual enrollment, the employee's dependent will remain in SEBB medical. The PEBB program will automatically disenroll the employee's dependent from PEBB medical, PEBB dental, and PEBB vision in which they are enrolled.

(f) If the employee's dependent is enrolled in both PEBB medical and SEBB medical as a dependent and has been enrolled in SEBB medical longer than they have been enrolled in PEBB medical, and no action is taken to resolve the dual enrollment, the employee's dependent will remain in SEBB medical. The PEBB program will automatically disenroll the employee's dependent from PEBB medical, PEBB dental, and PEBB vision if they are enrolled. If the employee's dependent who is eligible as a dependent in both the PEBB and SEBB programs is not enrolled in any medical but is enrolled in both a PEBB and SEBB dental plan, PEBB and SEBB vision plan, or any combination of these coverages as a dependent, the dependent will remain in SEBB benefits. The PEBB program will automatically disenroll the employee's dependent from PEBB benefits.

| Exception: | If there is a National Medical Support Notice (NMSN) or a court order in place, enrollment will be in accordance with the NMSN or order. |
| --- | --- |

(g) If the employee's dependent, who is also a school employee in the SEBB program who the SEBB program automatically disenrolled from SEBB dental and SEBB vision, the PEBB program will automatically enroll the employee's dependent in PEBB dental and PEBB vision, if they are not already enrolled.

(h) If the employee who is eligible for the employer contribution toward PEBB benefits was enrolled as a dependent in SEBB medical, SEBB dental, and SEBB vision and is removed by the SEBB subscriber, the employee will be required to return from waived enrollment as described in WAC 182-12-128 (3)(b).

(i) If the PEBB program automatically disenrolls an individual from PEBB medical, PEBB dental, or PEBB vision to resolve their dual enrollment as described in (d), (e), or (f) of this subsection, but later determines that the employee did take action to resolve their dual enrollment within the required timelines, the PEBB program will reinstate coverage retroactive to the first of the month in which the individual was disenrolled.

(7) A retiree who defers enrollment in PEBB retiree insurance coverage as described in WAC 182-12-200 by enrolling as an eligible dependent in a medical plan sponsored by PEBB or SEBB and who loses the employer contribution for such coverage must enroll in PEBB retiree insurance coverage as described in WAC 182-12-200 or defer enrollment as described in WAC 182-12-205.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-083 (Admin #2024-02), § 182-12-123, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-12-123, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolution PEBB 2022-02. WSR 22-13-164 (Admin #2022-02.02), § 182-12-123, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions PEBB 2021-02, 2021-03, 2021-04, 2021-05, 2021-06, 2021-07, 2021-08, 2021-09. WSR 21-13-102 (Admin #2021-01.02), § 182-12-123, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-12-123, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-123, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-123, filed 10/3/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-123, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-123, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-123, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-123, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-123, filed 9/25/12, effective 11/1/12*
- *WSR 10-20-147 (Order 10-02), § 182-12-123, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-12-123, filed 11/17/09, effective 1/1/10*
- *WSR 07-20-129 (Order 07-01), § 182-12-123, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-123, filed 8/26/04, effective 1/1/05.](Effective January 1, 2027) PDF WAC 182-12-123 Is dual enrollment in public employees benefits board (PEBB) and school employees benefits board (SEBB) prohibited? Public employees benefits board (PEBB) medical, dental, and vision coverage is limited to a single enrollment per individual as described in subsections (1) through (5) of this section. Effective January 1, 2022, individuals are limited to a single enrollment in medical, dental, and vision plans in either the PEBB program or school employees benefits board (SEBB) program as described in subsection (6) of this section.(1) An individual who has more than one source of eligibility for enrollment in PEBB medical, PEBB dental, and PEBB vision coverage (called "dual eligibility") is limited to one enrollment.(2) An eligible employee may waive PEBB medical and enroll as a dependent under the PEBB medical plan of their spouse, state registered domestic partner, or parent as described in WAC 182-12-128.(3) A dependent enrolled in PEBB medical, PEBB dental, or PEBB vision who becomes eligible for PEBB benefits as an employee must elect to enroll in PEBB benefits as described in WAC 182-08-197 (1) or (3). This includes making an election to enroll in or waive enrollment in PEBB medical as described in WAC 182-12-128.(a) If the employee does not waive enrollment in PEBB medical, the employee is not eligible to remain enrolled in their spouse's, state registered domestic partner's, or parent's PEBB medical as a dependent. If the employee's spouse, state registered domestic partner, or parent does not take action to remove the employee (who is enrolled as a dependent) from their subscriber account, the PEBB program will automatically disenroll the employee's enrollment as a dependent the last day of the month before the employee's enrollment in PEBB benefits begins as described in WAC 182-12-114.Exception:An enrolled dependent who becomes newly eligible for PEBB benefits as an employee may be dual-enrolled in PEBB medical, dental, and vision for one month. This exception is only allowed for the first month the dependent is enrolled as an employee, and only if the dependent becomes enrolled as an employee on the first working day of a month that is not the first day of the month.(b) If the employee elects to waive their enrollment in PEBB medical, the employee will remain enrolled in PEBB medical under their spouse's, state registered domestic partner's, or parent's PEBB medical as a dependent.(4) A child who is eligible for PEBB medical, PEBB dental, and PEBB vision under two subscribers may be enrolled under both subscribers but is limited to a single enrollment in PEBB medical, a single enrollment in PEBB dental, and a single enrollment in PEBB vision.(5) When an employee is eligible for the employer contribution toward PEBB benefits due to employment in more than one PEBB-participating employing agency the following provisions apply:(a) The employee must choose to enroll under only one employing agency.Exception:Faculty who stack to establish or maintain eligibility as described in WAC 182-12-114(3) with two or more state institutions of higher education will be enrolled under the employing agency responsible to pay the employer contribution according to WAC 182-08-200(2).(b) If the employee loses eligibility under the employing agency, they must notify their other employing agency no later than 60 days from the date PEBB benefits end through the employing agency described in (a) of this subsection to transfer coverage.(c) The employee's elections remain the same when an employee transfers their enrollment under one employing agency to another employing agency without a break in PEBB benefits for one month or more, as described in (b) of this subsection.(6) An individual who has more than one source of eligibility for enrollment in the PEBB and SEBB programs is limited to a single enrollment in medical, dental, and vision plans in either the PEBB or SEBB program. An employee must elect to enroll in PEBB benefits as described in WAC 182-08-197, waive enrollment as described in WAC 182-12-128, or remove eligible dependents as described in WAC 182-12-262. An employee may not waive PEBB medical, PEBB dental, and PEBB vision to enroll in SEBB medical with a SEBB participating employer group that offers only medical coverage. If the employee takes no action to resolve the dual enrollment, the PEBB program or the SEBB program will automatically enroll or automatically disenroll the individual as described in (c) through (g) of this subsection.(a) An eligible employee may waive enrollment in PEBB medical to enroll in SEBB medical only if they are enrolled in SEBB dental and SEBB vision as described in WAC 182-12-128. An employee who waives enrollment in PEBB medical to enroll in SEBB medical also waives enrollment in PEBB dental and PEBB vision.(b) A school employee in the SEBB program who waives SEBB medical, SEBB dental, and SEBB vision for PEBB medical must be enrolled in PEBB dental and PEBB vision. If the school employee is not already enrolled in PEBB dental and PEBB vision the PEBB program will automatically enroll the school employee in the associated subscriber's PEBB dental and PEBB vision.(c) If the employee is enrolled only in PEBB dental and PEBB vision, and is also enrolled in SEBB medical, and no action is taken to resolve their dual enrollment, the employee will remain in SEBB medical. The PEBB program will automatically disenroll the employee from PEBB dental and PEBB vision in which they are enrolled. If the employee is not already enrolled in SEBB dental or SEBB vision, the SEBB program will automatically enroll them in both as described in WAC 182-31-070 (6)(g). The employee's enrollment in PEBB program life insurance, accidental death and dismemberment (AD&D) insurance, and long-term disability (LTD) insurance will remain.(d) If the employee is enrolled in PEBB medical and is also a school employee in the SEBB program and enrolled in SEBB medical, and the employee has been enrolled in SEBB medical longer than they have been enrolled in PEBB medical, and no action is taken by the employee to resolve their dual enrollment, they will remain in SEBB medical. The PEBB program will automatically disenroll the employee from PEBB medical, PEBB dental, and PEBB vision. The employee's enrollment in PEBB program life insurance, AD&D insurance, and LTD insurance will remain. If the employee is not enrolled in any medical under either the PEBB or SEBB program but is enrolled in PEBB dental, PEBB vision, SEBB dental, and SEBB vision, the employee will remain in SEBB benefits. The PEBB program will automatically disenroll the employee from PEBB dental and PEBB vision.(e) If the employee's dependent is enrolled in any PEBB medical, PEBB dental, or PEBB vision plan, and the dependent is also a school employee in the SEBB program and enrolled in SEBB medical, and no action is taken by either the employee or the dependent to resolve the dependent's dual enrollment, the employee's dependent will remain in SEBB medical. The PEBB program will automatically disenroll the employee's dependent from PEBB medical, PEBB dental, and PEBB vision in which they are enrolled.(f) If the employee's dependent is enrolled in both PEBB medical and SEBB medical as a dependent and has been enrolled in SEBB medical longer than they have been enrolled in PEBB medical, and no action is taken to resolve the dual enrollment, the employee's dependent will remain in SEBB medical. The PEBB program will automatically disenroll the employee's dependent from PEBB medical, PEBB dental, and PEBB vision if they are enrolled. If the employee's dependent who is eligible as a dependent in both the PEBB and SEBB programs is not enrolled in any medical but is enrolled in both a PEBB and SEBB dental plan, PEBB and SEBB vision plan, or any combination of these coverages as a dependent, the dependent will remain in SEBB benefits. The PEBB program will automatically disenroll the employee's dependent from PEBB benefits.Exception:If there is a National Medical Support Notice (NMSN) or a court order in place, enrollment will be in accordance with the NMSN or order.(g) If the employee's dependent, who is also a school employee in the SEBB program who the SEBB program automatically disenrolled from SEBB dental and SEBB vision, the PEBB program will automatically enroll the employee's dependent in PEBB dental and PEBB vision, if they are not already enrolled.(h) If the employee who is eligible for the employer contribution toward PEBB benefits was enrolled as a dependent in SEBB medical, SEBB dental, and SEBB vision and is removed by the SEBB subscriber, the employee will be required to return from waived enrollment as described in WAC 182-12-128 (3)(b).(i) If the PEBB program automatically disenrolls an individual from PEBB medical, PEBB dental, or PEBB vision to resolve their dual enrollment as described in (d), (e), or (f) of this subsection, but later determines that the employee did take action to resolve their dual enrollment within the required timelines, the PEBB program will reinstate coverage retroactive to the first of the month in which the individual was disenrolled.(7) A retiree who defers enrollment in PEBB retiree insurance coverage as described in WAC 182-12-200 by enrolling as an eligible dependent in a medical plan sponsored by PEBB or SEBB and who loses the employer contribution for such coverage must enroll in PEBB retiree insurance coverage as described in WAC 182-12-200 or defer enrollment as described in WAC 182-12-205.[Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 26-14-080 (Admin #2026.01), s 182-12-123, filed 6/29/26, effective 1/1/27. Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-083 (Admin #2024-02), § 182-12-123, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-12-123, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolution PEBB 2022-02. WSR 22-13-164 (Admin #2022-02.02), § 182-12-123, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions PEBB 2021-02, 2021-03, 2021-04, 2021-05, 2021-06, 2021-07, 2021-08, 2021-09. WSR 21-13-102 (Admin #2021-01.02), § 182-12-123, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-12-123, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-123, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-123, filed 10/3/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-123, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-123, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-123, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-123, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-123, filed 9/25/12, effective 11/1/12*
- *WSR 10-20-147 (Order 10-02), § 182-12-123, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-12-123, filed 11/17/09, effective 1/1/10*
- *WSR 07-20-129 (Order 07-01), § 182-12-123, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-123, filed 8/26/04, effective 1/1/05.*

##### **Wash. Admin. Code § 182-12-128** When may an employee waive enrollment in public employees benefits board (PEBB) medical and when may they enroll in PEBB medical after having waived enrollment? {#sec-182-12-128 omnilex-key=us-wa-regs-official--title-182--182-12-128}

WAC 182-12-128

***(Effective until January 1, 2027)***

An employee may waive enrollment in public employees benefits board (PEBB) medical if they are enrolled in other employer-based group medical, a TRICARE plan, or medicare Part A and Part B as described in subsection (1)(a) through (c) of this section. They may not waive enrollment in PEBB medical if they are enrolled in PEBB retiree insurance coverage, and their PEBB retiree insurance coverage will be automatically deferred as described in WAC 182-12-205 (11)(a) or will be auto disenrolled as described in WAC 182-12-262 (2)(d). An employee who waives enrollment in PEBB medical must enroll in PEBB dental, PEBB vision, basic life insurance, basic accidental death and dismemberment insurance, and employer-paid long-term disability (LTD) insurance (unless the employing agency does not participate in these PEBB insurance coverages). For an employing agency that participates in LTD insurance, an employee will also be enrolled in employee-paid LTD insurance automatically unless the employee declines their employee-paid LTD insurance as described in WAC 182-08-197.

| Exception: | An employee may waive their enrollment in PEBB medical to enroll in school employees benefits board (SEBB) medical only if they are enrolled in SEBB dental and SEBB vision. An employee who waives enrollment in PEBB medical to enroll in SEBB medical also waives enrollment in PEBB dental and PEBB vision. |
| --- | --- |

(1) To waive enrollment in PEBB medical, the employee must submit the required form to their employing agency at one of the following times:

(a) When the employee becomes eligible: An employee may waive PEBB medical when they become eligible for PEBB benefits. The employee must indicate their election to waive enrollment in PEBB medical on the required form and submit the form to their employing agency. The employing agency must receive the form no later than 31 days after the date the employee becomes eligible for PEBB benefits (see WAC 182-08-197). PEBB medical will be waived as of the date the employee becomes eligible for PEBB benefits.

(b) During the annual open enrollment: An employee may waive PEBB medical during the annual open enrollment. The required form must be received by the employee's employing agency before the end of the annual open enrollment. PEBB medical will be waived beginning January 1st of the following year.

(c) During a special open enrollment: An employee may waive PEBB medical during a special open enrollment only if they are enrolled in other employer-based group medical, a TRICARE plan, or medicare Part A and Part B as described in subsection (4) of this section. A special open enrollment event must be an event other than an employee gaining initial eligibility or regaining eligibility for PEBB benefits.

The employee must submit the required form to their employing agency. The employing agency must receive the form no later than 60 days after the event that creates the special open enrollment. In addition to the required form, the employee must provide evidence of the event that creates the special open enrollment to the employing agency.

PEBB medical will be waived the last day of the month following the later of the event date or the date the required form is received. If that day is the first of the month, PEBB medical will be waived the last day of the previous month. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, PEBB medical will be waived the last day of the previous month.

(2) If an employee waives PEBB medical, the employee may not enroll dependents in PEBB medical.

(3) Once PEBB medical is waived, the employee is only allowed to enroll in PEBB medical at the following times:

(a) During the annual open enrollment. The required form must be received by the employee's employing agency before the end of the annual open enrollment. PEBB medical will begin January 1st of the following year.

(b) During a special open enrollment. A special open enrollment allows an employee to revoke their election and make a new election outside of the annual open enrollment. A special open enrollment may be created when one of the events described in subsection (4) of this section occurs.

The employee must submit the required form to their employing agency. The employing agency must receive the form no later than 60 days after the event that creates the special open enrollment. In addition to the required form, the employee must provide evidence of the event that creates the special open enrollment to the employing agency.

PEBB medical will begin the first day of the month following the later of the event date or the date the required form is received. If that day is the first of the month, coverage is effective on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, PEBB medical for the employee will begin on the first day of the month in which the event occurs. PEBB medical for the newly born child, newly adopted child, spouse, or state registered domestic partner will begin as described in WAC 182-12-262 (3)(a)(iv).

If an employee who is eligible for the employer contribution toward PEBB benefits was enrolled as a dependent in SEBB medical, SEBB dental, and SEBB vision and is removed by the SEBB subscriber, the health care authority will notify the employee of their removal from the SEBB subscriber's account and that they have experienced a special enrollment event. The employee will be required to return from waived enrollment and elect PEBB medical, PEBB dental, and PEBB vision. If the employee's employing agency does not receive the employee's required forms indicating their medical, dental, and vision elections within 60 days of the employee losing SEBB medical, SEBB dental, and SEBB vision, they will be defaulted into employee-only PEBB medical, PEBB dental, and PEBB vision as described in WAC 182-08-197 (1)(b)(i) through (iii).

(4) Special open enrollment: Any one of the events in (a) through (k) of this subsection may create a special open enrollment that allows the employee to enroll in PEBB medical after having waived enrollment. The change in enrollment must be allowable under the Internal Revenue Code (IRC) and Treasury regulations, and correspond to and be consistent with the event that creates the special open enrollment for the employee, the employee's dependent, or both.

(a) Employee acquires a new dependent due to:

(i) Marriage or registering a state registered domestic partnership;

(ii) Birth, adoption, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption; or

(iii) A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(b) Employee or an employee's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA);

(c) Employee has a change in employment status that affects the employee's eligibility for their employer contribution toward their employer-based group medical;

(d) The employee's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution under their employer-based group medical;

| Note: | As used in (d) of this subsection, "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 26 C.F.R. 54.9801-6. |
| --- | --- |

(e) Employee or an employee's dependent has a change in enrollment under an employer-based group medical plan during its annual open enrollment that does not align with the PEBB program's annual open enrollment;

(f) Employee's dependent has a change in residence from outside of the United States to within the United States, or from within the United States to outside of the United States and that change in residence resulted in the dependent losing their health insurance;

(g) A court order requires the employee or any other individual to provide a health plan for an eligible dependent of the employee (a former spouse or former state registered domestic partner is not an eligible dependent);

(h) Employee or an employee's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the employee or an employee's dependent loses eligibility for coverage under medicaid or CHIP;

| Note: | An employee may only return from having waived PEBB medical for the events described in (h) of this subsection. An employee may not waive their PEBB medical for the events described in (h) of this subsection. |
| --- | --- |

(i) Employee or an employee's dependent becomes eligible for state premium assistance subsidy for PEBB health plan coverage from medicaid or CHIP;

(j) Employee or employee's dependent becomes eligible and enrolls in a TRICARE plan, or loses eligibility for a TRICARE plan;

(k) Employee becomes eligible and enrolls in medicare, or loses eligibility for medicare.

***(Effective January 1, 2027)***

PDF WAC 182-12-128

When may an employee waive enrollment in public employees benefits board (PEBB) medical and when may they enroll in PEBB medical after having waived enrollment?

An employee may waive enrollment in public employees benefits board (PEBB) medical if they are enrolled in other employer-based group medical, a TRICARE plan, or medicare Part A and Part B as described in subsection (1)(a) through (c) of this section. They may not waive enrollment in PEBB medical if they are enrolled in PEBB retiree insurance coverage, and their PEBB retiree insurance coverage will be automatically deferred as described in WAC 182-12-205 (11)(a) or will be auto disenrolled as described in WAC 182-12-262 (2)(d). An employee who waives enrollment in PEBB medical must enroll in PEBB dental, PEBB vision, basic life insurance, basic accidental death and dismemberment insurance, and employer-paid long-term disability (LTD) insurance (unless the employing agency does not participate in these PEBB insurance coverages). For an employing agency that participates in LTD insurance, an employee will also be enrolled in employee-paid LTD insurance automatically unless the employee declines their employee-paid LTD insurance as described in WAC 182-08-197.

| Exception: | An employee may waive their enrollment in PEBB medical to enroll in school employees benefits board (SEBB) medical only if they are enrolled in SEBB dental and SEBB vision. An employee who waives enrollment in PEBB medical to enroll in SEBB medical also waives enrollment in PEBB dental and PEBB vision. An employee may not waive PEBB medical, PEBB dental, and PEBB vision to enroll in SEBB medical with a SEBB participating employer group that offers only medical coverage. |
| --- | --- |

(1) To waive enrollment in PEBB medical, the employee must submit the required form to their employing agency at one of the following times:

(a) When the employee becomes eligible: An employee may waive PEBB medical when they become eligible for PEBB benefits. The employee must indicate their election to waive enrollment in PEBB medical on the required form and submit the form to their employing agency. The employing agency must receive the form no later than 31 days after the date the employee becomes eligible for PEBB benefits (see WAC 182-08-197). PEBB medical will be waived as of the date the employee becomes eligible for PEBB benefits.

(b) During the annual open enrollment: An employee may waive PEBB medical during the annual open enrollment. The required form must be received by the employee's employing agency before the end of the annual open enrollment. PEBB medical will be waived beginning January 1st of the following year.

(c) During a special open enrollment: An employee may waive PEBB medical during a special open enrollment only if they are enrolled in other employer-based group medical, a TRICARE plan, or medicare Part A and Part B as described in subsection (4) of this section. A special open enrollment event must be an event other than an employee gaining initial eligibility or regaining eligibility for PEBB benefits.

The employee must submit the required form to their employing agency. The employing agency must receive the form no later than 60 days after the event that creates the special open enrollment. In addition to the required form, the employee must provide evidence of the event that creates the special open enrollment to the employing agency.

PEBB medical will be waived the last day of the month following the later of the event date or the date the required form is received. If that day is the first of the month, PEBB medical will be waived the last day of the previous month. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, PEBB medical will be waived the last day of the month prior to the month in which the birth, adoption, or assuming legal obligation occurred.

(2) If an employee waives PEBB medical, the employee may not enroll dependents in PEBB medical.

(3) Once PEBB medical is waived, the employee is only allowed to enroll in PEBB medical at the following times:

(a) During the annual open enrollment. The required form must be received by the employee's employing agency before the end of the annual open enrollment. PEBB medical will begin January 1st of the following year.

(b) During a special open enrollment. A special open enrollment allows an employee to revoke their election and make a new election outside of the annual open enrollment. A special open enrollment may be created when one of the events described in subsection (4) of this section occurs.

The employee must submit the required form to their employing agency. The employing agency must receive the form no later than 60 days after the event that creates the special open enrollment. In addition to the required form, the employee must provide evidence of the event that creates the special open enrollment to the employing agency.

PEBB medical will begin the first day of the month following the later of the event date or the date the required form is received. If that day is the first of the month, coverage is effective on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, PEBB medical for the employee will begin on the first day of the month in which the event occurs. PEBB medical for the newly born child, newly adopted child, spouse, or state registered domestic partner will begin as described in WAC 182-12-262 (3)(a)(iv).

If an employee who is eligible for the employer contribution toward PEBB benefits was enrolled as a dependent in SEBB medical, SEBB dental, and SEBB vision and is removed by the SEBB subscriber, the health care authority will notify the employee of their removal from the SEBB subscriber's account and that they have experienced a special enrollment event. The employee will be required to return from waived enrollment and elect PEBB medical, PEBB dental, and PEBB vision. If the employee's employing agency does not receive the employee's required forms indicating their medical, dental, and vision elections within 60 days of the employee losing SEBB medical, SEBB dental, and SEBB vision, they will be defaulted into employee-only PEBB medical, PEBB dental, and PEBB vision as described in WAC 182-08-197 (1)(b)(i) through (iii).

(4) Special open enrollment: Any one of the events in (a) through (k) of this subsection may create a special open enrollment that allows the employee to enroll in PEBB medical after having waived enrollment. The change in enrollment must be allowable under the Internal Revenue Code (IRC) and Treasury regulations, and correspond to and be consistent with the event that creates the special open enrollment for the employee, the employee's dependent, or both.

(a) Employee acquires a new dependent due to:

(i) Marriage or registering a state registered domestic partnership;

(ii) Birth, adoption, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption; or

(iii) A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(b) Employee or an employee's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA);

(c) Employee has a change in employment status that affects the employee's eligibility for their employer contribution toward their employer-based group medical;

(d) The employee's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution under their employer-based group medical;

| Note: | As used in (d) of this subsection, "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 26 C.F.R. 54.9801-6. |
| --- | --- |

(e) Employee or an employee's dependent has a change in enrollment under an employer-based group medical plan during its annual open enrollment that does not align with the PEBB program's annual open enrollment;

(f) Employee's dependent has a change in residence from outside of the United States to within the United States, or from within the United States to outside of the United States and that change in residence resulted in the dependent losing their health insurance;

(g) A court order requires the employee or any other individual to provide a health plan for an eligible dependent of the employee (a former spouse or former state registered domestic partner is not an eligible dependent);

(h) Employee or an employee's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the employee or an employee's dependent loses eligibility for coverage under medicaid or CHIP;

| Note: | An employee may only return from having waived PEBB medical for the events described in (h) of this subsection. An employee may not waive their PEBB medical for the events described in (h) of this subsection. |
| --- | --- |

(i) Employee or an employee's dependent becomes eligible for state premium assistance subsidy for PEBB health plan coverage from medicaid or CHIP;

(j) Employee or employee's dependent becomes eligible and enrolls in a TRICARE plan, or loses eligibility for a TRICARE plan;

(k) Employee becomes eligible and enrolls in medicare, or loses eligibility for medicare.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 25-14-084 (Admin #2025-02), s 182-12-128, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-083 (Admin #2024-02), § 182-12-128, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-12-128, filed 6/23/23, effective 1/1/24*
- *WSR 22-13-158 (Admin #2022-01), § 182-12-128, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions PEBB 2021-02, 2021-03, 2021-04, 2021-05, 2021-06, 2021-07, 2021-08, 2021-09. WSR 21-13-102 (Admin #2021-01.02), § 182-12-128, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-12-128, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-128, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-128, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-128, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-128, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-128, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-128, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160, 2013 2nd sp.s. c 4 and PEBB policy resolutions. WSR 14-08-040, § 182-12-128, filed 3/26/14, effective 4/26/14. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-128, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-128, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-12-128, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-12-128, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-12-128, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-12-128, filed 10/1/08, effective 1/1/09*
- *WSR 08-09-027 (Order 08-01), § 182-12-128, filed 4/8/08, effective 4/9/08*
- *WSR 07-20-129 (Order 07-01), § 182-12-128, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-128, filed 8/26/04, effective 1/1/05.](Effective January 1, 2027) PDF WAC 182-12-128 When may an employee waive enrollment in public employees benefits board (PEBB) medical and when may they enroll in PEBB medical after having waived enrollment? An employee may waive enrollment in public employees benefits board (PEBB) medical if they are enrolled in other employer-based group medical, a TRICARE plan, or medicare Part A and Part B as described in subsection (1)(a) through (c) of this section. They may not waive enrollment in PEBB medical if they are enrolled in PEBB retiree insurance coverage, and their PEBB retiree insurance coverage will be automatically deferred as described in WAC 182-12-205 (11)(a) or will be auto disenrolled as described in WAC 182-12-262 (2)(d). An employee who waives enrollment in PEBB medical must enroll in PEBB dental, PEBB vision, basic life insurance, basic accidental death and dismemberment insurance, and employer-paid long-term disability (LTD) insurance (unless the employing agency does not participate in these PEBB insurance coverages). For an employing agency that participates in LTD insurance, an employee will also be enrolled in employee-paid LTD insurance automatically unless the employee declines their employee-paid LTD insurance as described in WAC 182-08-197.Exception:An employee may waive their enrollment in PEBB medical to enroll in school employees benefits board (SEBB) medical only if they are enrolled in SEBB dental and SEBB vision. An employee who waives enrollment in PEBB medical to enroll in SEBB medical also waives enrollment in PEBB dental and PEBB vision. An employee may not waive PEBB medical, PEBB dental, and PEBB vision to enroll in SEBB medical with a SEBB participating employer group that offers only medical coverage.(1) To waive enrollment in PEBB medical, the employee must submit the required form to their employing agency at one of the following times:(a) When the employee becomes eligible: An employee may waive PEBB medical when they become eligible for PEBB benefits. The employee must indicate their election to waive enrollment in PEBB medical on the required form and submit the form to their employing agency. The employing agency must receive the form no later than 31 days after the date the employee becomes eligible for PEBB benefits (see WAC 182-08-197). PEBB medical will be waived as of the date the employee becomes eligible for PEBB benefits.(b) During the annual open enrollment: An employee may waive PEBB medical during the annual open enrollment. The required form must be received by the employee's employing agency before the end of the annual open enrollment. PEBB medical will be waived beginning January 1st of the following year.(c) During a special open enrollment: An employee may waive PEBB medical during a special open enrollment only if they are enrolled in other employer-based group medical, a TRICARE plan, or medicare Part A and Part B as described in subsection (4) of this section. A special open enrollment event must be an event other than an employee gaining initial eligibility or regaining eligibility for PEBB benefits.The employee must submit the required form to their employing agency. The employing agency must receive the form no later than 60 days after the event that creates the special open enrollment. In addition to the required form, the employee must provide evidence of the event that creates the special open enrollment to the employing agency.PEBB medical will be waived the last day of the month following the later of the event date or the date the required form is received. If that day is the first of the month, PEBB medical will be waived the last day of the previous month. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, PEBB medical will be waived the last day of the month prior to the month in which the birth, adoption, or assuming legal obligation occurred.(2) If an employee waives PEBB medical, the employee may not enroll dependents in PEBB medical.(3) Once PEBB medical is waived, the employee is only allowed to enroll in PEBB medical at the following times:(a) During the annual open enrollment. The required form must be received by the employee's employing agency before the end of the annual open enrollment. PEBB medical will begin January 1st of the following year.(b) During a special open enrollment. A special open enrollment allows an employee to revoke their election and make a new election outside of the annual open enrollment. A special open enrollment may be created when one of the events described in subsection (4) of this section occurs.The employee must submit the required form to their employing agency. The employing agency must receive the form no later than 60 days after the event that creates the special open enrollment. In addition to the required form, the employee must provide evidence of the event that creates the special open enrollment to the employing agency.PEBB medical will begin the first day of the month following the later of the event date or the date the required form is received. If that day is the first of the month, coverage is effective on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, PEBB medical for the employee will begin on the first day of the month in which the event occurs. PEBB medical for the newly born child, newly adopted child, spouse, or state registered domestic partner will begin as described in WAC 182-12-262 (3)(a)(iv).If an employee who is eligible for the employer contribution toward PEBB benefits was enrolled as a dependent in SEBB medical, SEBB dental, and SEBB vision and is removed by the SEBB subscriber, the health care authority will notify the employee of their removal from the SEBB subscriber's account and that they have experienced a special enrollment event. The employee will be required to return from waived enrollment and elect PEBB medical, PEBB dental, and PEBB vision. If the employee's employing agency does not receive the employee's required forms indicating their medical, dental, and vision elections within 60 days of the employee losing SEBB medical, SEBB dental, and SEBB vision, they will be defaulted into employee-only PEBB medical, PEBB dental, and PEBB vision as described in WAC 182-08-197 (1)(b)(i) through (iii).(4) Special open enrollment: Any one of the events in (a) through (k) of this subsection may create a special open enrollment that allows the employee to enroll in PEBB medical after having waived enrollment. The change in enrollment must be allowable under the Internal Revenue Code (IRC) and Treasury regulations, and correspond to and be consistent with the event that creates the special open enrollment for the employee, the employee's dependent, or both.(a) Employee acquires a new dependent due to:(i) Marriage or registering a state registered domestic partnership*
- *(ii) Birth, adoption, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption*
- *or(iii) A child becoming eligible as an extended dependent through legal custody or legal guardianship.(b) Employee or an employee's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA)*
- *(c) Employee has a change in employment status that affects the employee's eligibility for their employer contribution toward their employer-based group medical*
- *(d) The employee's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution under their employer-based group medical*
- *Note:As used in (d) of this subsection, "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 26 C.F.R. 54.9801-6.(e) Employee or an employee's dependent has a change in enrollment under an employer-based group medical plan during its annual open enrollment that does not align with the PEBB program's annual open enrollment*
- *(f) Employee's dependent has a change in residence from outside of the United States to within the United States, or from within the United States to outside of the United States and that change in residence resulted in the dependent losing their health insurance*
- *(g) A court order requires the employee or any other individual to provide a health plan for an eligible dependent of the employee (a former spouse or former state registered domestic partner is not an eligible dependent)*
- *(h) Employee or an employee's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the employee or an employee's dependent loses eligibility for coverage under medicaid or CHIP*
- *Note:An employee may only return from having waived PEBB medical for the events described in (h) of this subsection. An employee may not waive their PEBB medical for the events described in (h) of this subsection.(i) Employee or an employee's dependent becomes eligible for state premium assistance subsidy for PEBB health plan coverage from medicaid or CHIP*
- *(j) Employee or employee's dependent becomes eligible and enrolls in a TRICARE plan, or loses eligibility for a TRICARE plan*
- *(k) Employee becomes eligible and enrolls in medicare, or loses eligibility for medicare.[Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 26-14-080 (Admin #2026.01), s 182-12-128, filed 6/29/26, effective 1/1/27*
- *WSR 25-14-084 (Admin #2025-02), s 182-12-128, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-083 (Admin #2024-02), § 182-12-128, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-12-128, filed 6/23/23, effective 1/1/24*
- *WSR 22-13-158 (Admin #2022-01), § 182-12-128, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions PEBB 2021-02, 2021-03, 2021-04, 2021-05, 2021-06, 2021-07, 2021-08, 2021-09. WSR 21-13-102 (Admin #2021-01.02), § 182-12-128, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-12-128, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-128, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-128, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-128, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-128, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-128, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-128, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160, 2013 2nd sp.s. c 4 and PEBB policy resolutions. WSR 14-08-040, § 182-12-128, filed 3/26/14, effective 4/26/14. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-128, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-128, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-12-128, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-12-128, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-12-128, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-12-128, filed 10/1/08, effective 1/1/09*
- *WSR 08-09-027 (Order 08-01), § 182-12-128, filed 4/8/08, effective 4/9/08*
- *WSR 07-20-129 (Order 07-01), § 182-12-128, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-128, filed 8/26/04, effective 1/1/05.*

##### **Wash. Admin. Code § 182-12-129** What happens when an employee moves from an eligible to an otherwise ineligible position or job due to a layoff? {#sec-182-12-129 omnilex-key=us-wa-regs-official--title-182--182-12-129}

This section applies to employees employed by state agencies (as defined in this chapter), including benefits-eligible seasonal employees, and is intended to address situations where an employee moves from one position or job to another due to a layoff, as described in WAC 182-12-109. This section does not apply to employees with an anticipated end date.

If an employee moves from an eligible to an otherwise ineligible position due to layoff, the employee may retain their eligibility for the employer contribution toward public employees benefits board (PEBB) benefits for each month that the employee is in pay status for at least eight hours. To maintain eligibility using this section the employee must:

• Be hired into a position with a state agency within 24 months of the original eligible position ending; and

• Upon hire, notify the employing state agency that they are potentially eligible to use this section.

This section ceases to apply when the employee is employed in a position eligible for PEBB benefits under WAC 182-12-114 or at the end of the 24th month after the original eligible position ended, whichever occurs first.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-12-129, filed 6/23/23, effective 1/1/24*
- *WSR 20-16-062 (Admin #2020-03), § 182-12-129, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160 and PEBB policy resolutions. WSR 18-20-117 (Admin #2018-02), § 182-12-129, filed 10/3/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-129, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-129, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 09-23-102 (Order 09-02), § 182-12-129, filed 11/17/09, effective 1/1/10.*

##### **Wash. Admin. Code § 182-12-131** How do eligible employees maintain the employer contribution toward public employees benefits board (PEBB) benefits? {#sec-182-12-131 omnilex-key=us-wa-regs-official--title-182--182-12-131}

The employer contribution toward public employees benefits board (PEBB) benefits begins as described in WAC 182-12-114. This section describes under what circumstances employees maintain eligibility for the employer contribution toward PEBB benefits.

(1) Maintaining the employer contribution. Except as described in subsections (2), (3), and (4) of this section, employees who have established eligibility for benefits as described in WAC 182-12-114 are eligible for the employer contribution each month in which they are in pay status eight or more hours per month.

(2) Maintaining the employer contribution - Benefits-eligible seasonal employees.

(a) Benefits-eligible seasonal employees (eligible as described in WAC 182-12-114(2)) who work a season of less than nine months are eligible for the employer contribution in any month of the season in which they are in pay status eight or more hours during that month. The employer contribution toward PEBB benefits for seasonal employees returning after their off season begins on the first day of the first month of the season in which they are in pay status eight hours or more.

(b) Benefits-eligible seasonal employees (eligible as described in WAC 182-12-114(2)) who work a season of nine months or more are eligible for the employer contribution:

(i) In any month of the season in which they are in pay status eight or more hours during that month; and

(ii) Through the off season following each season worked, but the eligibility may not exceed a total of 12 consecutive calendar months for the combined season and off season.

(3) Maintaining the employer contribution - Eligible faculty.

(a) Benefits-eligible faculty anticipated to work half time or more the entire instructional year or equivalent nine-month period (eligible as described in WAC 182-12-114 (3)(a)(i)) are eligible for the employer contribution each month of the instructional year, except as described in subsection (7) of this section.

(b) Benefits-eligible faculty who are hired on a quarter/semester to quarter/semester basis (eligible as described in WAC 182-12-114 (3)(a)(ii)) are eligible for the employer contribution each quarter or semester in which employees work half-time or more.

(c) Summer or off-quarter/semester coverage: All benefits-eligible faculty (eligible as described in WAC 182-12-114 (3)(a) and (b)) who work an average of half-time or more throughout the entire instructional year or equivalent nine-month period and work each quarter/semester of the instructional year or equivalent nine-month period are eligible for the employer contribution toward summer or off-quarter/semester PEBB benefits.

| Exception: | Eligibility for the employer contribution toward summer or off-quarter/semester PEBB benefits ends on the end date specified in an employing agency's termination notice or an employee's resignation letter, whichever is earlier, if the employing agency has no anticipation that the employee will be returning as faculty at any institution of higher education where the employee has employment. If the employing agency deducted the employee's premium for PEBB insurance coverage after the employee was no longer eligible for the employer contribution, PEBB benefits end the last day of the month for which employee premiums were deducted. |
| --- | --- |

(d) Two-year averaging: All benefits-eligible faculty (eligible as described in WAC 182-12-114 (3)(a) and (b)) who worked an average of half-time or more in each of the two preceding academic years are potentially eligible to receive uninterrupted employer contribution toward PEBB benefits. "Academic year" means summer, fall, winter, and spring quarters or summer, fall, and spring semesters and begins with summer quarter/semester. In order to be eligible for the employer contribution through two-year averaging, the faculty must provide written notification of their potential eligibility to their employing agency or agencies within the deadlines established by the employing agency or agencies. Faculty continue to receive uninterrupted employer contribution for each academic year in which they:

(i) Are employed on a quarter/semester to quarter/semester basis and work at least two quarters or two semesters; and

(ii) Have an average workload of half-time or more for three quarters or two semesters.

Eligibility for the employer contribution under two-year averaging ceases immediately if the eligibility criteria is not met or if the eligibility criteria becomes impossible to meet.

(e) Faculty who lose eligibility for the employer contribution: All benefits-eligible faculty (eligible as described in WAC 182-12-114 (3)(a) and (b)) who lose eligibility for the employer contribution will regain it if they return to a faculty position where it is anticipated that they will work half-time or more for the quarter/semester no later than the twelfth month after the month in which they lost eligibility for the employer contribution. The employer contribution begins on the first day of the month in which the quarter/semester begins.

(4) Maintaining the employer contribution - Employees on leave and under the special circumstances listed below.

(a) Employees who are on approved leave under the federal Family and Medical Leave Act (FMLA) or the paid family and medical leave program continue to receive the employer contribution as long as they are approved under the act.

(b) Unless otherwise indicated in this section, employees in the following circumstances receive the employer contribution only for the months they are in pay status eight hours or more:

(i) Employees on authorized leave without pay;

(ii) Employees on approved educational leave;

(iii) Employees receiving time-loss benefits under workers' compensation;

(iv) Employees called to active duty in the uniformed services as defined under the Uniformed Services Employment and Reemployment Rights Act (USERRA); or

(v) Employees applying for disability retirement.

(5) Maintaining the employer contribution - Employees who move from an eligible to an otherwise ineligible position due to a layoff maintain the employer contribution toward PEBB benefits as described in WAC 182-12-129.

(6) Employees who are in pay status less than eight hours in a month. Unless otherwise indicated in this section, when there is a month in which employees are not in pay status for at least eight hours, employees:

(a) Lose eligibility for the employer contribution for that month; and

(b) Must reestablish eligibility for PEBB benefits as described in WAC 182-12-114 in order to be eligible for the employer contribution again.

(7) The employer contribution toward PEBB benefits ends in any one of these circumstances for all employees:

(a) When employees fail to maintain eligibility for the employer contribution as indicated in the criteria in subsections (1) through (6) of this section.

(b) When the employment relationship is terminated. As long as the employing agency has no anticipation that the employee will be rehired, the employment relationship is terminated:

(i) On the date specified in an employee's letter of resignation; or

(ii) On the date specified in any contract or hire letter or on the effective date of an employer-initiated termination notice.

(c) When employees move to a position that is not anticipated to be eligible for PEBB benefits as described in WAC 182-12-114, not including changes in position due to a layoff.

(d) The employer contribution toward PEBB benefits cease for employees and their enrolled dependents the last day of the month in which employees are eligible for the employer contribution under this section.

| Exception: | If the employing agency deducted the employee's premium for PEBB insurance coverage after the employee was no longer eligible for the employer contribution, PEBB benefits end the last day of the month for which employee premiums were deducted. |
| --- | --- |

(8) Options for continuation coverage by self-paying. During temporary or permanent loss of the employer contribution toward PEBB benefits, employees have options for providing continuation coverage for themselves and their dependents by self-paying the premium and applicable premium surcharges set by the health care authority (HCA). These options are available as described in WAC 182-12-133, 182-12-141, 182-12-142, 182-12-146, 182-12-148, and 182-12-270.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-12-131, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-12-131, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-131, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-131, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-131, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-131, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-131, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-131, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-131, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-131, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-12-131, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-12-131, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-12-131, filed 11/17/09, effective 1/1/10*
- *WSR 07-20-129 (Order 07-01), § 182-12-131, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-131, filed 8/26/04, effective 1/1/05.*

##### **Wash. Admin. Code § 182-12-133** What options for continuation coverage are available to employees and their dependents during certain types of leave or when employment ends due to a layoff? {#sec-182-12-133 omnilex-key=us-wa-regs-official--title-182--182-12-133}

Employees who have established eligibility for public employees benefits board (PEBB) benefits as described in WAC 182-12-114 may continue coverage for themselves and their dependents during certain types of leave or when their employment ends due to a layoff.

(1) Employees who are no longer eligible for the employer contribution toward PEBB benefits due to an event described in (b)(i) through (vi) of this subsection may continue coverage by self-paying the premium and applicable premium surcharges set by the health care authority (HCA) from the date eligibility for the employer contribution is lost:

(a) Employees may continue any combination of medical, dental, or vision and may also continue life insurance and accidental death and dismemberment (AD&D) insurance. If life insurance or AD&D insurance is elected, both basic life and basic AD&D insurance must be continued. Employees who continue basic life insurance and basic AD&D insurance may also continue supplemental life and AD&D insurance. Employees on approved educational leave or called in to active duty in the uniformed services as defined under the Uniformed Services Employment and Reemployment Rights Act (USERRA) may continue either employer-paid long-term disability (LTD) insurance or both employer-paid and employee-paid LTD insurance.

(b) Employees in the following circumstances who lose their eligibility for the employer contribution toward PEBB benefits qualify to continue coverage under this subsection:

(i) Employees who are on authorized leave without pay;

(ii) Employees who are on approved educational leave;

(iii) Employees who are receiving time-loss benefits under workers' compensation;

(iv) Employees who are called to active duty in the uniformed services as defined under USERRA;

(v) Employees whose employment ends due to a layoff as defined in WAC 182-12-109; and

(vi) Employees who are applying for disability retirement.

(c) The employee's election must be received by the PEBB program no later than 60 days from the date the employee's PEBB health plan coverage ended or from the postmark date on the election notice sent by the PEBB program, whichever is later;

(d) Employees may self-pay for a maximum of 29 months. The employee's first premium payment and applicable premium surcharges are due no later than 45 days after the election period ends as described in (c) of this subsection, except as described in WAC 182-08-180 (1)(a).

Premiums and applicable premium surcharges associated with continuing PEBB medical, must be made to the HCA as well as premiums associated with continuing PEBB dental, PEBB vision, or LTD insurance coverage. Premiums associated with continuing life insurance and AD&D insurance coverage must be made to the contracted vendor. Following the employee's first premium payment, the employee must pay the premium amounts for PEBB insurance coverage and applicable premium surcharges as premiums become due; and

(e) If the employee's monthly premium or applicable premium surcharges remain unpaid for 60 days from the original due date, the employee's PEBB insurance coverage will be terminated retroactive to the last day of the month for which the monthly premium and applicable premium surcharges were paid as described in WAC 182-08-180 (1)(c).

(2) The number of months that employees self-pay the premium while eligible as described in subsection (1) of this section will count toward the total months of continuation coverage allowed under the federal Consolidated Omnibus Budget Reconciliation Act (COBRA). Employees who are no longer eligible for continuation coverage as described in subsection (1) of this section but who have not used the maximum number of months allowed under COBRA coverage may continue medical, dental, vision, or any combination of these benefits for the remaining difference in months by self-paying the premium and applicable premium surcharges as described in WAC 182-12-146.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-12-133, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions PEBB 2021-11 and 2021-12. WSR 21-13-103 (Admin #2021-01.03), § 182-12-133, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-12-133, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-133, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-133, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-133, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-133, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-133, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-133, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-133, filed 9/25/12, effective 11/1/12*
- *WSR 10-20-147 (Order 10-02), § 182-12-133, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-12-133, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-12-133, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-12-133, filed 10/3/07, effective 11/3/07*
- *WSR 06-11-156 (Order 06-02), § 182-12-133, filed 5/24/06, effective 6/24/06. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-133, filed 8/26/04, effective 1/1/05.*

##### **Wash. Admin. Code § 182-12-136** May employees on approved educational leave waive continuation coverage? {#sec-182-12-136 omnilex-key=us-wa-regs-official--title-182--182-12-136}

In order to avoid duplication of group health plan coverage, the following shall apply to employees during any period of approved educational leave. Employees eligible for continuation coverage provided in WAC 182-12-133 who obtain other employer-based group medical, dental, vision, or any combination of these benefits, may waive continuation of such coverage for each full calendar month in which they maintain coverage under the other employer-based medical, dental, or vision. These employees have the right to reenroll in a public employees benefits board (PEBB) health plan effective the first day of the month after the date the other employer-based group medical, dental, or vision ends, provided evidence of such other coverage is provided to the PEBB program upon application for reenrollment.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-12-136, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-136, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-136, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160. WSR 09-23-102 (Order 09-02), § 182-12-136, filed 11/17/09, effective 1/1/10*
- *WSR 07-20-129 (Order 07-01), § 182-12-136, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-136, filed 8/26/04, effective 1/1/05.*

##### **Wash. Admin. Code § 182-12-138** What options are available if an employee is approved for the federal Family and Medical Leave Act (FMLA) or the paid family and medical leave program? {#sec-182-12-138 omnilex-key=us-wa-regs-official--title-182--182-12-138}

(1) An employee on approved leave under the federal Family and Medical Leave Act (FMLA) may continue to receive the employer contribution toward public employees benefits board (PEBB) benefits in accordance with the federal FMLA. The employee may also continue current supplemental life, supplemental accidental death and dismemberment (AD&D), and employee-paid long-term disability (LTD) insurance. The employee's employing agency is responsible for determining if the employee is eligible for leave under FMLA and the duration of such leave.

(2) An employee on approved leave under the paid family and medical leave program under chapter 50A.05 RCW may continue to receive the employer contribution toward PEBB benefits in accordance with RCW 50A.35.020. The employee may also continue current supplemental life, supplemental AD&D, and employee-paid LTD insurance. The employment security department is responsible for determining if the employee is eligible for the paid family and medical leave program.

(3) If an employee exhausts the period of leave approved under FMLA or paid family and medical leave, PEBB insurance coverage may be continued by self-paying the premium and applicable premium surcharges set by the HCA, with no contribution from the employing agency as described in WAC 182-12-133(1).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions PEBB 2021-11 and 2021-12. WSR 21-13-103 (Admin #2021-01.03), § 182-12-138, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-12-138, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-138, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-138, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-138, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-138, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-138, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-138, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-12-138, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 09-23-102 (Order 09-02), § 182-12-138, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-12-138, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-12-138, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-138, filed 8/26/04, effective 1/1/05.*

##### **Wash. Admin. Code § 182-12-141** If an employee reverts from an eligible position, what happens to their public employees benefits board (PEBB) insurance coverage? {#sec-182-12-141 omnilex-key=us-wa-regs-official--title-182--182-12-141}

(1) If an employee reverts for reasons other than a layoff and is not eligible for the employer contribution toward public employees benefits board (PEBB) benefits under this chapter, they may continue PEBB insurance coverage by self-paying the premium and applicable premium surcharge set by the health care authority (HCA) for up to 18 months under the same terms as an employee who is granted leave without pay under WAC 182-12-133(1):

(a) The employee's election must be received by the PEBB program no later than 60 days from the date the employee's PEBB health plan coverage ended or from the postmark date on the election notice sent by the PEBB program, whichever is later;

(b) The employee's first premium payment and applicable premium surcharges are due to the HCA no later than 45 days after the election period ends as described in (a) of this subsection, except as described in WAC 182-08-180 (1)(a). Premiums and applicable premium surcharges associated with continuing PEBB medical must be made to the HCA as well as premiums associated with continuing PEBB dental and PEBB vision. Premiums associated with continuing life insurance and accidental death and dismemberment insurance coverage must be made to the contracted vendor;

(c) Following the employee's first premium payment, the employee must pay the premium amounts associated with PEBB insurance coverage and applicable premium surcharges as premiums become due; and

(d) If the employee's monthly premium or applicable premium surcharges remain unpaid for 60 days from the original due date, the employee's PEBB insurance coverage will be terminated retroactive to the last day of the month for which the monthly premium and applicable premium surcharges were paid as described in WAC 182-08-180 (1)(c).

(2) If an employee is reverted due to a layoff, the employee may be eligible for the employer contribution toward PEBB benefits under the criteria of WAC 182-12-129. If determined not to be eligible under WAC 182-12-129, the employee may continue PEBB insurance coverage by self-paying the premium and applicable premium surcharges set by the HCA under WAC 182-12-133.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-12-141, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-12-141, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-141, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-141, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-141, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-141, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-12-141, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-12-141, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-12-141, filed 11/17/09, effective 1/1/10*
- *WSR 07-20-129 (Order 07-01), § 182-12-141, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-141, filed 8/26/04, effective 1/1/05.*

##### **Wash. Admin. Code § 182-12-142** What options for continuation coverage are available to faculty and seasonal employees who are between periods of eligibility? {#sec-182-12-142 omnilex-key=us-wa-regs-official--title-182--182-12-142}

(1) Faculty may continue any combination of medical, dental, or vision, and may also continue life insurance and accidental death and dismemberment (AD&D) insurance by self-paying the premium and applicable premium surcharges set by the health care authority (HCA), with no contribution from the employer, for a maximum of 12 months between periods of eligibility. If life insurance or AD&D insurance is elected, both basic life and basic AD&D insurance must be continued. Employees who continue basic life insurance and basic AD&D insurance may also continue supplemental life and AD&D insurance:

(a) The employee's election must be received by the public employees benefits board (PEBB) program no later than 60 days from the date the employee's PEBB health plan coverage ended or from the postmark date on the election notice sent by the PEBB program, whichever is later;

(b) The employee's first premium payment and applicable premium surcharges are due to the HCA no later than 45 days after the election period ends as described in (a) of this subsection, except as described in WAC 182-08-180 (1)(a). Premiums and applicable premium surcharges associated with continuing PEBB medical must be made to the HCA as well as premiums associated with continuing PEBB dental and PEBB vision. Premiums associated with continuing life insurance and AD&D insurance coverage must be made to the contracted vendor;

(c) Following the employee's first premium payment, the employee must pay the premium amounts associated with PEBB insurance coverage and applicable premium surcharges as premiums become due; and

(d) If the employee's monthly premium or applicable premium surcharges remain unpaid for 60 days from the original due date, the employee's PEBB insurance coverage will be terminated retroactive to the last day of the month for which the monthly premium and applicable premium surcharges were paid as described in WAC 182-08-180 (1)(c).

(2) Benefits-eligible seasonal employees may continue any combination of medical, dental, or vision, and may also continue life insurance and AD&D insurance by self-paying the premium and applicable premium surcharges set by the HCA, with no contribution from the employer, for a maximum of 12 months between periods of eligibility. If life insurance or AD&D insurance is elected, both basic life and basic AD&D insurance must be continued. Employees who continue basic life insurance and basic AD&D insurance may also continue supplemental life and AD&D insurance:

(a) The employee's election must be received by the PEBB program no later than 60 days from the date the employee's PEBB health plan coverage ended or from the postmark date on the election notice sent by the PEBB program, whichever is later;

(b) The employee's first premium payment and applicable premium surcharges are due to the HCA no later than 45 days after the election period ends as described in (a) of this subsection, except as described in WAC 182-08-180 (1)(a). Premiums and applicable premium surcharges associated with continuing PEBB medical must be made to the HCA as well as premiums associated with continuing PEBB dental and PEBB vision. Premiums associated with continuing life insurance and AD&D insurance coverage must be made to the contracted vendor;

(c) Following the employee's first premium payment, the employee must pay the premium amounts associated with PEBB insurance coverage and applicable premium surcharges as premiums become due; and

(d) If the employee's monthly premium or applicable premium surcharges remain unpaid for 60 days from the original due date, the employee's PEBB insurance coverage will be terminated retroactive to the last day of the month for which the monthly premium and applicable premium surcharges were paid as described in WAC 182-08-180 (1)(c).

(3) COBRA. An employee who is no longer eligible for continuation coverage as described in subsections (1) and (2) of this section, but who has not used the maximum number of months allowed under the federal Consolidated Omnibus Budget Reconciliation Act (COBRA), may continue medical, dental, vision, or any combination of these benefits for the remaining difference in months by self-paying the premium and applicable premium surcharges set by the HCA under COBRA as described in WAC 182-12-146. The number of months that a faculty or seasonal employee self-pays premiums under the criteria in subsection (1) or (2) of this section will count toward the total months of continuation coverage allowed under COBRA.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-12-142, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-12-142, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-142, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-142, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-142, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-142, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-12-142, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-12-142, filed 11/17/09, effective 1/1/10.*

##### **Wash. Admin. Code § 182-12-146** When is an enrollee eligible to continue public employees benefits board (PEBB) benefits under Consolidated Omnibus Budget Reconciliation Act (COBRA)? {#sec-182-12-146 omnilex-key=us-wa-regs-official--title-182--182-12-146}

(1) An employee or an employee's dependent who loses eligibility for the employer contribution toward public employees benefits board (PEBB) benefits and who qualifies for continuation coverage under the federal Consolidated Omnibus Budget Reconciliation Act (COBRA) may continue coverage for all or any combination of PEBB medical, dental, or vision for the maximum number of months allowed under COBRA.

(2) An employee or an employee's dependent who loses eligibility for continuation coverage described in WAC 182-12-133, 182-12-141, 182-12-142, or 182-12-148 but who has not used the maximum number of months allowed under COBRA may continue any combination of PEBB medical, dental, or vision for the remaining difference in months.

(3) A retired employee, a retired school employee, or survivor who loses eligibility for PEBB retiree insurance coverage because their employer group ceases participation with the authority may continue PEBB medical, dental, or vision as described in WAC 182-12-232.

(4) A dependent of a subscriber enrolled as described in WAC 182-12-232 who is no longer eligible as described in WAC 182-12-260 may continue any combination of PEBB medical, dental, or vision for the maximum number of months allowed under COBRA.

(5) A retiree or a dependent of a retiree, who is no longer eligible as described in WAC 182-12-171, 182-12-180, or 182-12-260 may continue any combination of PEBB medical, dental, or vision for the maximum number of months allowed under COBRA.

(6) A blind vendor who ceases to actively operate a facility as described in WAC 182-12-111 (4)(a) may continue enrollment in PEBB medical for the maximum number of months allowed under COBRA as described in this section.

(7) An enrollee may continue any combination of PEBB medical, dental, or vision under COBRA by self-paying the premium and applicable premium surcharges set by the health care authority (HCA):

(a) The election must be received by the PEBB program no later than 60 days from the date the enrollee's PEBB health plan coverage ended or from the postmark date on the election notice sent by the PEBB program, whichever is later;

(b) The first premium payment under COBRA coverage and applicable premium surcharges are due to the HCA no later than 45 days after the election period ends as described in (a) of this subsection, except as described in WAC 182-08-180 (1)(a). Following the enrollee's first premium payment, premiums and applicable premium surcharges must be paid as described in WAC 182-08-180 (1)(c);

(c) COBRA continuation coverage enrollees who voluntarily terminate their COBRA coverage will not be eligible to reenroll in COBRA coverage unless they regain eligibility as described in WAC 182-12-114. Those who request to terminate their COBRA coverage must do so in writing. COBRA coverage will end on the last day of the month in which the PEBB program receives the termination request or on the last day of the month specified in the COBRA enrollee's termination request, whichever is later. If the termination request is received on the first day of the month, COBRA coverage will end on the last day of the previous month;

| Exception: | When a subscriber or their dependent is enrolled in a medicare advantage plan, a medicare advantage-prescription drug plan, or the Uniform Medical Plan Classic medicare plan, the enrollment will terminate on the last day of the month when the plan disenrollment form is received. |
| --- | --- |

(d) An employee enrolled in a flexible spending arrangement (FSA) or limited purpose FSA and the employee's dependents will have an opportunity to continue making contributions to their FSA or limited purpose FSA by electing COBRA if on the date of the qualifying event, as described under 42 U.S.C. Sec. 300bb-3, the employee's FSA or limited purpose FSA has a greater amount in remaining benefits than remaining contribution payments for the current year. The election must be received by the contracted vendor no later than 60 days from the date the PEBB health plan coverage ended or from the postmark date on the election notice sent by the contracted vendor, whichever is later. The first premium payment under COBRA coverage is due to the contracted vendor no later than 45 days after the election period ends as described above.

(8) A subscriber's state registered domestic partner and the state registered domestic partner's children may continue any combination of PEBB medical, dental, or vision on the same terms and conditions as spouses and other eligible dependents under COBRA as described under RCW 26.60.015.

(9) Medical, dental, and vision coverage under COBRA begin on the first day of the month following the day the COBRA enrollee loses eligibility for PEBB health plan coverage as described in WAC 182-12-131, 182-12-133, 182-12-141, 182-12-142, 182-12-148, 182-12-171, 182-12-180, 182-12-250, 182-12-260, or 182-12-265.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 25-14-081 (Admin #2025.01.02), s 182-12-146, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.05.065, 41.05.160, 2023 c 164 § 1, 2023 c 312 § 1, 2023 c 13 § 5, Policy Resolutions PEBB 2024-14, 2024-19, 2024-20, and 2024-21. WSR 24-18-081 (Admin #2024-01.05), § 182-12-146, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-12-146, filed 6/23/23, effective 1/1/24*
- *WSR 22-13-158 (Admin #2022-01), § 182-12-146, filed 6/21/22, effective 1/1/23*
- *WSR 20-16-062 (Admin #2020-03), § 182-12-146, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-146, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-146, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-146, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-146, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-146, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin 2013-01), § 182-12-146, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-146, filed 9/25/12, effective 11/1/12*
- *WSR 09-23-102 (Order 09-02), § 182-12-146, filed 11/17/09, effective 1/1/10*
- *WSR 07-20-129 (Order 07-01), § 182-12-146, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-146, filed 8/26/04, effective 1/1/05.*

##### **Wash. Admin. Code § 182-12-148** What options for continuation coverage are available to employees during their appeal of dismissal? {#sec-182-12-148 omnilex-key=us-wa-regs-official--title-182--182-12-148}

(1) Employees awaiting the hearing outcome of a dismissal action before any of the following may continue their public employees benefits board (PEBB) insurance coverage by self-paying the premium and applicable premium surcharges set by the health care authority (HCA), with no contribution from the employer, on the same terms as an employee who is granted leave as described in WAC 182-12-133:

(a) The personnel resources board;

(b) An arbitrator;

(c) A grievance or appeals committee established under a collective bargaining agreement for union represented employees; or

(d) A court.

(2) The employee must pay premium amounts and applicable premium surcharges associated with PEBB insurance coverage as premiums and applicable premium surcharges become due. If the monthly premium or applicable premium surcharges remain unpaid for 60 days from the original due date, PEBB insurance coverage will be terminated retroactive to the last day of the month for which the monthly premium and applicable premium surcharges were paid as described in WAC 182-08-180 (1)(c).

(3) If the dismissal is upheld, all PEBB insurance coverage will terminate at the end of the month in which the decision is entered, or the date to which premiums have been paid, whichever is later, with the exception described in subsection (4) of this section.

(4) If the dismissal is upheld and the employee is eligible under the federal Consolidated Omnibus Budget Reconciliation Act (COBRA), the employee may continue any combination of PEBB medical, dental, or vision for the remaining months available under COBRA. See WAC 182-12-146 for information on COBRA. The number of months the employee self-paid premiums during the appeal will count toward the total number of months allowed under COBRA.

(5) If the board, arbitrator, committee, or court sustains the employee in the appeal and directs reinstatement of employer paid PEBB insurance coverage retroactively, the employing agency must forward to HCA the full employer contribution for the period directed by the board, arbitrator, committee, or court and collect from the employee the employee's share of premiums due, if any.

(a) When the employer contribution is reinstated, the HCA will refund to the employee any premiums and applicable premium surcharges the employee paid. In the alternative, at the request of the employee, HCA may deduct the employee's contribution amount for PEBB benefits from the refund of premiums and applicable premium surcharges self-paid by the employee during the appeal period.

(b) All supplemental life, supplemental accidental death and dismemberment, and employee-paid LTD insurance which was in force at the time of dismissal shall be reinstated retroactively only if the employee makes retroactive payment of premium for any such supplemental coverage and employee-paid LTD insurance which was not continued by self-payment during the appeal process. If the employee chooses not to pay the retroactive premium, evidence of insurability will be required to enroll in such supplemental coverage and employee-paid LTD insurance.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-12-148, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions PEBB 2021-11 and 2021-12. WSR 21-13-103 (Admin #2021-01.03), § 182-12-148, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-12-148, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-148, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-148, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-148, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-148, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-148, filed 9/25/12, effective 11/1/12*
- *WSR 09-23-102 (Order 09-02), § 182-12-148, filed 11/17/09, effective 1/1/10*
- *WSR 07-20-129 (Order 07-01), § 182-12-148, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. WSR 05-16-046 (Order 05-01), § 182-12-148, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-148, filed 8/26/04, effective 1/1/05.*

##### **Wash. Admin. Code § 182-12-171** When is a retiring employee or a retiring school employee eligible to enroll in public employees benefits board (PEBB) retiree insurance coverage? {#sec-182-12-171 omnilex-key=us-wa-regs-official--title-182--182-12-171}

A retiring employee or a retiring school employee is eligible to continue enrollment or defer enrollment in public employees benefits board (PEBB) insurance coverage as a retiree if they meet procedural and substantive eligibility requirements as described in subsections (1), (2), and (3) of this section. An elected and full-time appointed official of the legislative and executive branch of state government is eligible as described in WAC 182-12-180.

(1) Procedural requirements. A retiring employee or a retiring school employee must enroll or defer enrollment in PEBB retiree insurance coverage as described in (a) through (e) of this subsection:

(a) To enroll in PEBB retiree insurance coverage, the required form must be received by the PEBB program no later than 60 days after the employee's or the school employee's own employer-paid coverage, Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage, or continuation coverage ends. The effective date of PEBB retiree insurance coverage is the first day of the month after the employee's or the school employee's employer-paid coverage, COBRA coverage, or continuation coverage ends;

| Note: | Enrollment in the PEBB program's medicare advantage (MA) plan, medicare advantage-prescription drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |
| --- | --- |

(b) The employee's or the school employee's first premium payment for PEBB retiree insurance coverage and applicable premium surcharges are due to the health care authority (HCA) no later than 45 days after the election period ends as described in (a) of this subsection, except as described in WAC 182-08-180 (1)(a). Following the employee's or the school employee's first premium payment, premiums and applicable premium surcharges must be paid as described in WAC 182-08-180 (1)(c); and

(c) If a retiring employee or a retiring school employee elects to enroll a dependent in PEBB health plan coverage, the dependent must be enrolled in the same PEBB medical and PEBB dental plan as the retiring employee or the retiring school employee;

| Exceptions: | (1) If a retiring employee or a retiring school employee selects a medicare supplement plan, a MA-PD plan, or the UMP Classic medicare plan, nonmedicare enrollees will be enrolled in the UMP Classic. If a retiring employee or a retiring school employee selects any other medicare plan, they must also select a nonmedicare plan with the same contracted vendor available to nonmedicare enrollees. (2) If a retiring employee or a retiring school employee selects a medicare supplement plan, MA-PD plan, or any other medicare plan, they may elect a PEBB vision plan available for any nonmedicare enrollees. |
| --- | --- |

(d) A nonmedicare retiring employee or retiring school employee must enroll in PEBB medical to be able to enroll in PEBB dental, in PEBB vision, or in both PEBB dental and PEBB vision. Any nonmedicare dependents they elect to enroll must be enrolled in the same PEBB medical, PEBB dental, and PEBB vision plan.

(e) To defer enrollment in PEBB retiree insurance coverage, the employee or the school employee must meet substantive eligibility requirements in subsection (2) of this section and defer enrollment as described in WAC 182-12-200 or 182-12-205.

(2) Substantive eligibility requirements. An employee who is eligible for PEBB benefits through an employing agency, or a school employee who is eligible for SEBB benefits through a SEBB organization, a SEBB participating employer group, or basic benefits through an educational service district as defined in RCW 28A.400.270 who ends public employment may enroll or defer enrollment in PEBB retiree insurance coverage if they meet procedural and substantive eligibility requirements.

To be eligible to continue enrollment or defer enrollment in PEBB retiree insurance coverage, the employee or the school employee must be vested in and eligible to retire under a Washington state-sponsored retirement plan when the employee's or school employee's own employer-paid coverage, COBRA coverage, or continuation coverage ends. An exception to the requirement to be vested in and eligible to retire under a Washington state-sponsored retirement plan is provided for employees of a PEBB participating employer group in (c)(i) of this subsection and for school employees of a SEBB participating employer group in (e)(i) of this subsection. To satisfy the requirement to immediately begin to receive a monthly retirement plan payment as described in (a), (b), (c)(ii), (d), and (e)(ii) of this subsection, the employee or school employee must begin receiving a monthly retirement plan payment no later than the first month following the employee's or school employee's own employer-paid coverage, COBRA coverage, or continuation coverage ending.

(a) A retiring employee of a state agency must immediately begin to receive a monthly retirement plan payment, with exceptions described below:

(i) A retiring employee who receives a lump sum payment instead of a monthly retirement plan payment is only eligible if the department of retirement systems offered the employee the choice between a lump sum actuarially equivalent payment and the ongoing monthly payment, as allowed by the plan; or

(ii) A retiring employee who is a member of the teachers' retirement system Plan 2, school employees' retirement system Plan 2, or public employees' retirement system Plan 2, also called a separated employee as defined in RCW 41.05.011 (25)(b), who separates from employment on or after January 1, 2024, and who is at least age 55 with at least 20 years of service; or

(iii) A retiring employee who is a member of a Plan 3 retirement plan, also called a separated employee as defined in RCW 41.05.011 (25)(a), who is at least age 55 with at least 10 years of service.

(b) A retiring employee of a Washington higher education institution who is a member of a higher education retirement plan (HERP) must immediately begin to receive a monthly retirement plan payment, or meet their HERP plan's retirement eligibility criteria, or be at least age 55 with 10 years of state service;

(c) A retiring employee of an employer group participating in PEBB insurance coverage under contractual agreement with the authority must be eligible to retire as described in (c)(i) or (ii) of this subsection to be eligible to continue PEBB retiree insurance coverage.

(i) A retiring employee who is eligible to retire under a retirement plan sponsored by an employer group or tribal government that is not a Washington state-sponsored retirement plan must meet the same age and years of service requirements as if they were a member of public employees retirement system Plan 1, if their date of hire with that employer group or tribal government was before October 1, 1977, or Plan 2, if their date of hire with that employer group or tribal government was on or after October 1, 1977.

(ii) A retiring employee who is eligible to retire under a Washington state-sponsored retirement plan must immediately begin to receive a monthly retirement plan payment, with exceptions described in (a)(i), (ii), or (iii) of this subsection.

(iii) A retired employee of an employer group that ends participation in PEBB insurance coverage is no longer eligible to continue enrollment in PEBB retiree insurance coverage if they enrolled after September 15, 1991. Any retiree who loses eligibility for this reason may continue health plan enrollment as described in WAC 182-12-232.

(iv) A retired employee of a tribal government employer that ends participation in PEBB insurance coverage is no longer eligible to continue enrollment in PEBB retiree insurance coverage. Any retiree who loses eligibility for this reason may continue health plan enrollment as described in WAC 182-12-232.

(d) A retiring school employee of a SEBB organization must immediately begin to receive a monthly retirement plan payment, with exceptions described below:

(i) A retiring school employee who ends employment before October 1, 1993; or

(ii) A retiring school employee who receives a lump sum payment instead of a monthly retirement plan payment is only eligible if the department of retirement systems offered the school employee the choice between a lump sum actuarially equivalent payment and the ongoing monthly payment, as allowed by the plan, or the school employee enrolled before 1995; or

(iii) A retiring school employee who is a member of the teachers' retirement system Plan 2, school employees' retirement system Plan 2, or public employees' retirement system Plan 2, also called a separated employee as defined in RCW 41.05.011 (25)(b), who separates from employment on or after January 1, 2024, and who is at least age 55 with at least 20 years of service; or

(iv) A retiring school employee who is a member of a Plan 3 retirement system, also called a separated employee as defined in RCW 41.05.011 (25)(a), who is at least age 55 with at least 10 years of service; or

(v) A school employee who retired as of September 30, 1993, and began receiving a monthly retirement plan payment from a Washington state-sponsored retirement system (as defined in chapters 41.32, 41.35 or 41.40 RCW) is eligible if they enrolled in a PEBB health plan no later than the HCA's annual open enrollment period for the year beginning January 1, 1995.

(e) A retiring school employee of an employer group participating in SEBB insurance coverage under contractual agreement with the authority must be eligible to retire as described in (e)(i) or (ii) of this subsection to be eligible to continue PEBB retiree insurance coverage.

(i) A retiring school employee who is eligible to retire under a retirement plan sponsored by an employer group that is not a Washington state-sponsored retirement plan must meet the same age and years of service requirements as if they were a member of teachers retirement system Plan 1, if their date of hire with that employer group was before October 1, 1977, or Plan 2, if their date of hire with that employer group was on or after October 1, 1977.

(ii) A retiring school employee who is eligible to retire under a Washington state-sponsored retirement plan must immediately begin to receive a monthly retirement plan payment, with exceptions described in (d)(ii), (iii), or (iv) of this subsection.

(iii) A retired school employee of an employer group that ends participation in SEBB insurance coverage is no longer eligible to continue enrollment in PEBB retiree insurance coverage. Any retiree who loses eligibility for this reason may continue health plan enrollment as described in WAC 182-12-232.

(3) A retiring employee or a retiring school employee and their enrolled dependents who are eligible for medicare must enroll and maintain enrollment in both medicare Parts A and B if the employee or the school employee retired after July 1, 1991. If a retiree or an enrolled dependent becomes eligible for medicare after enrollment in PEBB retiree insurance coverage, they must enroll and maintain enrollment in medicare Parts A and B. If an enrollee who is eligible for medicare does not meet this procedural requirement, the enrollee is no longer eligible for enrollment in a PEBB retiree health plan. The enrollee's eligibility will end as described in the termination notice sent by the PEBB program. The enrollee may continue PEBB health plan enrollment as described in WAC 182-12-146.

| Note: | For the exclusive purpose of medicare Part A as described in this subsection, "eligible" means the enrollee is eligible for medicare Part A without a monthly premium. |
| --- | --- |

(4) Washington state-sponsored retirement plans include:

(a) Higher education retirement plans;

(b) Law enforcement officers' and firefighters' retirement system;

(c) Public employees' retirement system;

(d) Public safety employees' retirement system;

(e) School employees' retirement system;

(f) State judges/judicial retirement system;

(g) Teachers' retirement system; and

(h) State patrol retirement system.

(i) The two federal retirement systems, Civil Service Retirement System and Federal Employees' Retirement System, are considered Washington state-sponsored retirement systems for Washington State University Extension for an employee covered under PEBB benefits at the time of retirement.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 25-14-081 (Admin #2025.01.02), s 182-12-171, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160, 2023 c 164 § 1, 2023 c 312 § 1, 2023 c 13 § 5, Policy Resolutions PEBB 2024-14, 2024-19, 2024-20, and 2024-21. WSR 24-18-080 (Admin #2024-01.04), § 182-12-171, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-12-171, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolution PEBB 2022-03. WSR 22-13-160 (Admin #2022-02.03), § 182-12-171, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160, 42 C.F.R. § 422.62(b) and § 423.38(c) and PEBB policy resolution 2020-05. WSR 20-16-063 (Admin #2020-02), § 182-12-171, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolution. WSR 19-17-073 (Admin #2019-01), § 182-12-171, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-171, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-171, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-171, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-171, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-171, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-171, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-171, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-12-171, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-12-171, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-12-171, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-12-171, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-12-171, filed 10/3/07, effective 11/3/07*
- *WSR 06-11-156 (Order 06-02), § 182-12-171, filed 5/24/06, effective 6/24/06. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. WSR 05-16-046 (Order 05-01), § 182-12-171, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-171, filed 8/26/04, effective 1/1/05.*

##### **Wash. Admin. Code § 182-12-180** When is an elected and full-time appointed official of the legislative and executive branch of state government, or their survivor eligible to continue enrollment in public employees benefits board (PEBB) retiree insurance coverage? {#sec-182-12-180 omnilex-key=us-wa-regs-official--title-182--182-12-180}

(1) An elected and full-time appointed official of the legislative and executive branch of state government is eligible to continue enrollment or defer enrollment in public employees benefits board (PEBB) retiree insurance coverage under the same terms as an outgoing legislator, when they voluntarily or involuntarily leave public office. The following officials are eligible if they meet the procedural requirements as described in subsection (3) of this section:

(a) A member of the state legislature;

(b) A statewide elected official of the executive branch;

(c) An executive official appointed directly by the governor as the single head of an executive branch agency; or

(d) An official appointed directly by a state legislative committee as the single head of a legislative branch agency or an official appointed to secretary of the senate or chief clerk of the house of representatives.

(2) The spouse, state registered domestic partner, or child of an official described in subsection (1) of this section who loses eligibility due to the death of the official may enroll as a survivor under PEBB retiree insurance coverage as described in (a) and (b) of this subsection and must meet procedural requirements to enroll or defer enrollment as described in subsection (3) of this section.

(a) The official's spouse or state registered domestic partner may continue health plan enrollment until death.

(b) The official's child may continue health plan enrollment until they lose eligibility as described in WAC 182-12-260.

(3) Procedural requirements. An official described in subsection (1) of this section or their survivor described in subsection (2) of this section must enroll or defer enrollment in PEBB retiree insurance coverage as described in (a) through (e) of this subsection:

(a) For an official to enroll in PEBB retiree insurance coverage the required forms must be received by the PEBB program no later than 60 days after the official leaves public office. The effective date of PEBB retiree insurance coverage is the first day of the month after the official leaves public office;

For a survivor to enroll in PEBB retiree insurance coverage, the required forms must be received by the PEBB program no later than 60 days after the later of the date of the official's death or the date the survivor's PEBB insurance coverage ends. The effective date of PEBB retiree insurance coverage is the first day of the month after the date of the official's death or the first day of the month after the survivor's PEBB insurance coverage ends;

| Note: | Enrollment in the PEBB program's medicare advantage (MA) plan, medicare advantage-prescription drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |
| --- | --- |

(b) The official's or survivor's first premium payment and applicable premium surcharges are due to the health care authority (HCA) no later than 45 days after the official's or survivor's election period ends as described in (a) of this subsection, except as described in WAC 182-08-180 (1)(a). Following the official's or survivor's first premium payment, premiums and applicable premium surcharges must be paid as described in WAC 182-08-180 (1)(c);

(c) If an official or a survivor elects to enroll a dependent in PEBB health plan coverage, the dependent must be enrolled in the same PEBB medical and PEBB dental plan as the official or survivor;

| Exceptions: | (1) If an official or a survivor selects a medicare supplement plan, a MA-PD plan, or the UMP Classic medicare plan, nonmedicare enrollees will be enrolled in the UMP Classic. If an official or a survivor selects any other medicare plan, they must also select a nonmedicare plan with the same contracted vendor available to nonmedicare enrollees. (2) If the official or survivor selects a medicare supplement plan, MA-PD plan, or any other medicare plan, they may elect a PEBB vision plan available for any nonmedicare enrollees. |
| --- | --- |

(d) An official or survivor who is nonmedicare must enroll in PEBB medical to be able to enroll in PEBB dental, in PEBB vision, or in both dental and vision. Any nonmedicare dependents they elect to enroll must be enrolled in the same PEBB medical, PEBB dental, and PEBB vision plan.

(e) To defer enrollment in PEBB retiree insurance coverage the official or the survivor must meet deferral enrollment requirements as described in WAC 182-12-200 or 182-12-205.

(4) If the official, an enrolled dependent, or their survivor is eligible for medicare or becomes eligible for medicare after enrollment in PEBB retiree insurance coverage, they must enroll and maintain enrollment in medicare Parts A and B. If an enrollee who is eligible for medicare does not meet this procedural requirement, the enrollee is no longer eligible for enrollment in a PEBB retiree health plan. The enrollee's eligibility will end as described in the termination notice sent by the PEBB program. The enrollee may continue PEBB health plan enrollment as described in WAC 182-12-146.

| Note: | For the exclusive purpose of medicare Part A as described in this subsection, "eligible" means the enrollee is eligible for medicare Part A without a monthly premium. |
| --- | --- |

(5) An official described in subsection (1) of this section shall be included in the term "retiree" or "retiring employee" as used in chapters 182-08, 182-12, and 182-16 WAC.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 25-14-081 (Admin #2025.01.02), s 182-12-180, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-083 (Admin #2024-02), § 182-12-180, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolution PEBB 2022-03. WSR 22-13-160 (Admin #2022-02.03), § 182-12-180, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160, 42 C.F.R. § 422.62(b) and § 423.38(c) and PEBB policy resolution 2020-05. WSR 20-16-063 (Admin #2020-02), § 182-12-180, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-180, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-180, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-180, filed 9/15/17, effective 1/1/18.*

##### **Wash. Admin. Code § 182-12-200** May a retiring employee, a retiring school employee, or a retiree enrolled as a dependent in a health plan sponsored by public employees benefits board (PEBB) or school employees benefits board (SEBB) defer enrollment under PEBB retiree insurance coverage? {#sec-182-12-200 omnilex-key=us-wa-regs-official--title-182--182-12-200}

WAC 182-12-200

***(Effective until January 1, 2027)***

(1) A retiring employee or a retiring school employee may defer enrollment in public employees benefits board (PEBB) retiree insurance coverage at retirement if they meet substantive eligibility requirements as described in WAC 182-12-171(2) or as described in WAC 182-12-180(1). An enrolled retiree may defer enrollment after enrolling in PEBB retiree insurance coverage. Enrollment in PEBB retiree insurance coverage may be deferred when they are enrolled as a dependent in a health plan sponsored by PEBB or school employees benefits board (SEBB), including such coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) or continuation coverage.

(2) A retiring employee, a retiring school employee, or a retiree who defers enrollment in PEBB retiree insurance coverage defers enrollment in PEBB medical, PEBB dental, and PEBB vision. A retiree must be enrolled in PEBB medical to enroll in PEBB dental except for a nonmedicare retiree must enroll in PEBB medical to be able to enroll in PEBB dental, in PEBB vision, or in both PEBB dental and PEBB vision. A retiree who defers enrollment also defers enrollment for all eligible dependents. A retiree may only defer enrollment in PEBB retiree term life insurance as described in WAC 182-12-209 (3)(b).

(3) A retiring employee, a retiring school employee, or a retiree who defers enrollment as described in this section may later enroll themselves and their dependents in a PEBB health plan by submitting the required forms as described below and evidence of continuous enrollment in a health plan sponsored by PEBB or SEBB. Evidence of continuous enrollment in a health plan sponsored by a Washington state educational service district may be required if a retiring employee, a retiring school employee, or a retiree deferred enrollment under this section prior to January 1, 2024. A gap of 31 days or less is allowed between the date PEBB retiree insurance coverage is deferred and the start date of enrollment in a health plan sponsored by PEBB, a Washington state educational service district, or SEBB, and between each period of enrollment in qualifying coverages as described in WAC 182-12-205 (3)(a) through (e) during the deferral period:

(a) During the PEBB annual open enrollment period. The required form must be received by the PEBB program no later than the last day of the open enrollment period. PEBB health plan coverage begins January 1st of the following year; or

(b) When enrollment in a health plan sponsored by PEBB, or SEBB ends, or such coverage under COBRA or continuation coverage ends. The required forms to enroll must be received by the PEBB program no later than 60 days after coverage ends. PEBB health plan coverage begins the first day of the month following the date the other coverage ends. To continue in a deferred status, the retiree must defer enrollment as described in WAC 182-12-205.

| Note: | Enrollment in the PEBB program's medicare advantage (MA) plan, medicare advantage-prescription drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |
| --- | --- |

(c) If a retiree elects to enroll a dependent in PEBB health plan coverage as described in this subsection, the dependent must be enrolled in the same PEBB medical or PEBB dental plan as the retiree.

| Exceptions: | (1) If a retiree selects a medicare supplement plan, a MA-PD plan, or the UMP Classic medicare plan, nonmedicare enrollees will be enrolled in the UMP Classic. If a retiree selects any other medicare plan, they must also select a nonmedicare plan with the same contracted vendor available to nonmedicare enrollees. (2) If a retiree selects a medicare supplement plan, MA-PD plan, or any other medicare plan, they may elect a PEBB vision plan available for any nonmedicare enrollees. |
| --- | --- |

(d) A nonmedicare retiree must enroll in PEBB medical to be able to enroll in PEBB dental, in PEBB vision, or in both PEBB dental and PEBB vision. Any nonmedicare dependents they elect to enroll must be enrolled in the same PEBB medical, PEBB dental, and PEBB vision plan.

***(Effective January 1, 2027)***

PDF WAC 182-12-200

May a retiring employee, a retiring school employee, or a retiree enrolled as a dependent in a health plan sponsored by public employees benefits board (PEBB) or school employees benefits board (SEBB) defer enrollment under PEBB retiree insurance coverage?

(1) A retiring employee or a retiring school employee may defer enrollment in public employees benefits board (PEBB) retiree insurance coverage at retirement if they meet substantive eligibility requirements as described in WAC 182-12-171(2) or as described in WAC 182-12-180(1). An enrolled retiree may defer enrollment after enrolling in PEBB retiree insurance coverage. Enrollment in PEBB retiree insurance coverage may be deferred when they are enrolled as a dependent in a medical plan sponsored by PEBB or school employees benefits board (SEBB), including such coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) or continuation coverage.

(2) A retiring employee, a retiring school employee, or a retiree who defers enrollment in PEBB retiree insurance coverage defers enrollment in PEBB medical, PEBB dental, and PEBB vision. A retiree must be enrolled in PEBB medical to enroll in PEBB dental except for a nonmedicare retiree must enroll in PEBB medical to be able to enroll in PEBB dental, in PEBB vision, or in both PEBB dental and PEBB vision. When a retiree defers enrollment, enrollment for all eligible dependents will be terminated. A retiree may only defer enrollment in PEBB retiree term life insurance as described in WAC 182-12-209 (3)(b).

(3) A retiring employee, a retiring school employee, or a retiree who defers enrollment as described in this section may later enroll themselves and their dependents in a PEBB health plan by submitting the required forms as described below and evidence of continuous enrollment in a medical plan sponsored by PEBB or SEBB. Evidence of continuous enrollment in a medical plan sponsored by a Washington state educational service district may be required if a retiring employee, a retiring school employee, or a retiree deferred enrollment under this section prior to January 1, 2024. A gap of 31 days or less is allowed between the date PEBB retiree insurance coverage is deferred and the start date of enrollment in a medical plan sponsored by PEBB, a Washington state educational service district, or SEBB, and between each period of enrollment in qualifying coverages as described in WAC 182-12-205 (3)(a) through (e) during the deferral period:

(a) During the PEBB annual open enrollment period. The required form must be received by the PEBB program no later than the last day of the open enrollment period. PEBB health plan coverage begins January 1st of the following year; or

(b) When enrollment in a medical plan sponsored by PEBB, or SEBB ends, or such coverage under COBRA or continuation coverage ends. The required forms to enroll must be received by the PEBB program no later than 60 days after coverage ends. PEBB health plan coverage begins the first day of the month following the date the other coverage ends. To continue in a deferred status, the retiree must defer enrollment as described in WAC 182-12-205.

| Note: | Enrollment in the PEBB program's medicare advantage (MA) plan, medicare advantage-prescription drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan may not be retroactive. |
| --- | --- |
| | (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. |
| | (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. |
| | (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |

(c) If a retiree elects to enroll a dependent in PEBB health plan coverage as described in this subsection, the dependent must be enrolled in the same PEBB medical or PEBB dental plan as the retiree.

| Exceptions: | (1) If a retiree selects a medicare supplement plan, a MA-PD plan, or the UMP Classic medicare plan, nonmedicare enrollees will be enrolled in the UMP Classic. If a retiree selects any other medicare plan, they must also select a nonmedicare plan with the same contracted vendor available to nonmedicare enrollees. |
| --- | --- |
| | (2) If a retiree selects a medicare supplement plan, MA-PD plan, or any other medicare plan, they may elect a PEBB vision plan available for any nonmedicare enrollees. |

(d) A nonmedicare retiree must enroll in PEBB medical to be able to enroll in PEBB dental, in PEBB vision, or in both PEBB dental and PEBB vision. Any nonmedicare dependents they elect to enroll must be enrolled in the same PEBB medical, PEBB dental, and PEBB vision plan.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-083 (Admin #2024-02), § 182-12-200, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-12-200, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolution PEBB 2022-03. WSR 22-13-160 (Admin #2022-02.03), § 182-12-200, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolution PEBB 2021-14. WSR 21-13-104 (Admin #2021-01.04), § 182-12-200, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160, 42 C.F.R. § 422.62(b) and § 423.38(c) and PEBB policy resolution 2020-05. WSR 20-16-063 (Admin #2020-02), § 182-12-200, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-200, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-200, filed 10/3/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-200, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-200, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-200, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160. WSR 09-23-102 (Order 09-02), § 182-12-200, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-12-200, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-12-200, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-200, filed 8/26/04, effective 1/1/05. Statutory Authority: RCW 41.05.160. WSR 01-17-041 (Order 01-00), § 182-12-200, filed 8/9/01, effective 9/9/01*
- *WSR 97-21-127, § 182-12-200, filed 10/21/97, effective 11/21/97. Statutory Authority: Chapter 41.05 RCW. WSR 96-08-043, § 182-12-200, filed 3/29/96, effective 4/29/96*
- *Order 4-77, § 182-12-200, filed 11/17/77.](Effective January 1, 2027) PDF WAC 182-12-200 May a retiring employee, a retiring school employee, or a retiree enrolled as a dependent in a health plan sponsored by public employees benefits board (PEBB) or school employees benefits board (SEBB) defer enrollment under PEBB retiree insurance coverage? (1) A retiring employee or a retiring school employee may defer enrollment in public employees benefits board (PEBB) retiree insurance coverage at retirement if they meet substantive eligibility requirements as described in WAC 182-12-171(2) or as described in WAC 182-12-180(1). An enrolled retiree may defer enrollment after enrolling in PEBB retiree insurance coverage. Enrollment in PEBB retiree insurance coverage may be deferred when they are enrolled as a dependent in a medical plan sponsored by PEBB or school employees benefits board (SEBB), including such coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) or continuation coverage.(2) A retiring employee, a retiring school employee, or a retiree who defers enrollment in PEBB retiree insurance coverage defers enrollment in PEBB medical, PEBB dental, and PEBB vision. A retiree must be enrolled in PEBB medical to enroll in PEBB dental except for a nonmedicare retiree must enroll in PEBB medical to be able to enroll in PEBB dental, in PEBB vision, or in both PEBB dental and PEBB vision. When a retiree defers enrollment, enrollment for all eligible dependents will be terminated. A retiree may only defer enrollment in PEBB retiree term life insurance as described in WAC 182-12-209 (3)(b).(3) A retiring employee, a retiring school employee, or a retiree who defers enrollment as described in this section may later enroll themselves and their dependents in a PEBB health plan by submitting the required forms as described below and evidence of continuous enrollment in a medical plan sponsored by PEBB or SEBB. Evidence of continuous enrollment in a medical plan sponsored by a Washington state educational service district may be required if a retiring employee, a retiring school employee, or a retiree deferred enrollment under this section prior to January 1, 2024. A gap of 31 days or less is allowed between the date PEBB retiree insurance coverage is deferred and the start date of enrollment in a medical plan sponsored by PEBB, a Washington state educational service district, or SEBB, and between each period of enrollment in qualifying coverages as described in WAC 182-12-205 (3)(a) through (e) during the deferral period:(a) During the PEBB annual open enrollment period. The required form must be received by the PEBB program no later than the last day of the open enrollment period. PEBB health plan coverage begins January 1st of the following year*
- *or(b) When enrollment in a medical plan sponsored by PEBB, or SEBB ends, or such coverage under COBRA or continuation coverage ends. The required forms to enroll must be received by the PEBB program no later than 60 days after coverage ends. PEBB health plan coverage begins the first day of the month following the date the other coverage ends. To continue in a deferred status, the retiree must defer enrollment as described in WAC 182-12-205.Note:Enrollment in the PEBB program's medicare advantage (MA) plan, medicare advantage-prescription drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins.(c) If a retiree elects to enroll a dependent in PEBB health plan coverage as described in this subsection, the dependent must be enrolled in the same PEBB medical or PEBB dental plan as the retiree.Exceptions:(1) If a retiree selects a medicare supplement plan, a MA-PD plan, or the UMP Classic medicare plan, nonmedicare enrollees will be enrolled in the UMP Classic. If a retiree selects any other medicare plan, they must also select a nonmedicare plan with the same contracted vendor available to nonmedicare enrollees. (2) If a retiree selects a medicare supplement plan, MA-PD plan, or any other medicare plan, they may elect a PEBB vision plan available for any nonmedicare enrollees.(d) A nonmedicare retiree must enroll in PEBB medical to be able to enroll in PEBB dental, in PEBB vision, or in both PEBB dental and PEBB vision. Any nonmedicare dependents they elect to enroll must be enrolled in the same PEBB medical, PEBB dental, and PEBB vision plan.[Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 26-14-080 (Admin #2026.01), s 182-12-200, filed 6/29/26, effective 1/1/27. Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-083 (Admin #2024-02), § 182-12-200, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-12-200, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolution PEBB 2022-03. WSR 22-13-160 (Admin #2022-02.03), § 182-12-200, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolution PEBB 2021-14. WSR 21-13-104 (Admin #2021-01.04), § 182-12-200, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160, 42 C.F.R. § 422.62(b) and § 423.38(c) and PEBB policy resolution 2020-05. WSR 20-16-063 (Admin #2020-02), § 182-12-200, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-200, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-200, filed 10/3/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-200, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-200, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-200, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160. WSR 09-23-102 (Order 09-02), § 182-12-200, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-12-200, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-12-200, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-200, filed 8/26/04, effective 1/1/05. Statutory Authority: RCW 41.05.160. WSR 01-17-041 (Order 01-00), § 182-12-200, filed 8/9/01, effective 9/9/01*
- *WSR 97-21-127, § 182-12-200, filed 10/21/97, effective 11/21/97. Statutory Authority: Chapter 41.05 RCW. WSR 96-08-043, § 182-12-200, filed 3/29/96, effective 4/29/96*
- *Order 4-77, § 182-12-200, filed 11/17/77.*

##### **Wash. Admin. Code § 182-12-205** May a retiree or a survivor defer enrollment or voluntarily terminate enrollment under public employees benefits board (PEBB) retiree insurance coverage? {#sec-182-12-205 omnilex-key=us-wa-regs-official--title-182--182-12-205}

WAC 182-12-205

***(Effective until January 1, 2027)***

(1) The following individuals may defer enrollment in public employees benefits board (PEBB) retiree insurance coverage:

(a) A retiring employee or a retiring school employee;

(b) A dependent becoming eligible as a survivor; or

(c) A retiree or a survivor enrolled in PEBB retiree insurance coverage.

(2) A subscriber described in subsection (1) of this section who defers enrollment in PEBB retiree insurance coverage also defers enrollment for all eligible dependents, except as described in subsection (3)(c) of this section.

(3) When a subscriber described in subsection (1) of this section chooses to defer enrollment in PEBB retiree insurance coverage as described in (a) through (e) of this subsection, they must maintain continuous enrollment in one or more qualifying coverages as described in (a) through (e) of this subsection or WAC 182-12-200. A gap of 31 days or less is allowed between the date PEBB retiree insurance coverage is deferred and the start date of a qualifying coverage, and between each period of enrollment in qualifying coverages during the deferral period. When a subscriber chooses to defer enrollment in PEBB retiree insurance coverage as described in (f) of this subsection; evidence of continuous enrollment in a qualified coverage is waived as described in subsection (6)(f) of this section.

A subscriber who chooses to defer enrollment, defers enrollment in PEBB medical, PEBB dental, and PEBB vision. A subscriber must be enrolled in PEBB medical to enroll in PEBB dental except for a nonmedicare retiree must enroll in PEBB medical to be able to enroll in PEBB dental, in PEBB vision, or in both PEBB dental and PEBB vision. A retiree may only defer enrollment in PEBB retiree term life insurance as described in WAC 182-12-209 (3)(b).

(a) Beginning January 1, 2001, enrollment in PEBB retiree insurance coverage may be deferred when the subscriber is enrolled in employer-based group medical as an employee or the dependent of an employee, or such medical insurance continued under Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage or continuation coverage.

(b) Beginning January 1, 2001, enrollment in PEBB retiree insurance coverage may be deferred when the subscriber is enrolled as a retiree or the dependent of a retiree in a federal retiree medical plan.

(c) Beginning January 1, 2006, enrollment in PEBB retiree insurance coverage may be deferred when the subscriber is enrolled in medicare Parts A and B and a medicaid program that provides creditable coverage as defined in WAC 182-12-109. Dependents may continue their PEBB health plan enrollment if they meet PEBB eligibility criteria and are not eligible for creditable coverage under a medicaid program.

(d) Beginning January 1, 2014, subscribers who are not eligible for Parts A and B of medicare may defer enrollment in PEBB retiree insurance coverage when the subscriber is enrolled in exchange coverage.

(e) Beginning July 17, 2018, enrollment in PEBB retiree insurance coverage may be deferred when the subscriber is enrolled in the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA).

(f) Beginning January 1, 2025, subscribers who are enrolled in medicare may defer enrollment in PEBB retiree insurance coverage when they permanently live in a location outside of the United States.

(4) To defer enrollment in PEBB retiree insurance coverage, the required forms must be submitted to the PEBB program.

(a) For a retiring employee or a retiring school employee who meets the substantive eligibility requirements as described in WAC 182-12-171(2), enrollment will be deferred the first of the month following the date their own employer-paid coverage, COBRA coverage, or continuation coverage ends. The forms must be received by the PEBB program no later than 60 days after their own employer-paid coverage, COBRA coverage, or continuation coverage ends.

(b) For an official leaving public office who meets the requirements as described in WAC 182-12-180(1), enrollment will be deferred the first of the month following the date the official leaves public office. The forms must be received by the PEBB program no later than 60 days after the official leaves public office.

(c) For an employee or a school employee determined to be retroactively eligible for disability retirement who meets the requirements as described in WAC 182-12-211 (1)(a) through (c), enrollment will be deferred as described in WAC 182-12-211 (2) or (3). The forms and formal determination letter must be received by the PEBB program no later than 60 days after the date on the determination letter.

(d) For an eligible survivor, the dependent must meet the requirements described below and the forms must be received by the PEBB program within the time described:

(i) For a survivor of an employee or a school employee who meets the requirements as described in WAC 182-12-265 (1) or (3), enrollment will be deferred the first of the month following the later of the date of the employee's or the school employee's death or the date the survivor's PEBB insurance coverage or school employees benefits board (SEBB) insurance coverage ends. The forms must be received by the PEBB program no later than 60 days after the later of the date of the employee's or the school employee's death or the date the survivor's PEBB insurance coverage or SEBB insurance coverage ends.

(ii) For a survivor of an official who meets the requirements as described in WAC 182-12-180(2), enrollment will be deferred the first of the month following the later of the date of the official's death or the date the survivor's PEBB insurance coverage ends. The forms must be received by the PEBB program no later than 60 days after the later of the date of the official's death or the date the survivor's PEBB insurance coverage ends.

(iii) For a survivor of a retiree who meets the requirements as described in WAC 182-12-265(2), enrollment will be deferred the first of the month following the date of the retiree's death. The forms must be received by the PEBB program no later than 60 days after the retiree's death.

(iv) For a survivor of an emergency service personnel killed in the line of duty who meets the requirements as described in WAC 182-12-250, enrollment will be deferred the first of the month following the later of one of the events described in WAC 182-12-250 (5)(a) through (d). The forms must be received by the PEBB program no later than 180 days after the later of one of the events described in WAC 182-12-250 (5)(a) through (d).

(e) For an enrolled retiree or survivor who submits the required forms to defer enrollment in PEBB retiree insurance coverage, enrollment will be deferred effective the first of the month following the date the required forms are received by the PEBB program. If the forms are received on the first day of the month, enrollment will be deferred effective that day.

| Exception: | When a subscriber or their dependent is enrolled in a medicare advantage (MA) plan, a medicare advantage-prescription drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan, the enrollment in PEBB retiree insurance coverage will be deferred effective the first of the month following the date the plan disenrollment form is received. |
| --- | --- |

(5) A retiree who meets substantive eligibility requirements in WAC 182-12-171(2) and whose own employer-paid coverage, COBRA coverage, or continuation coverage ended between January 1, 2001, and December 31, 2001, was not required to have submitted the deferral form at that time, but must meet all procedural requirements as stated in this section, WAC 182-12-171, and 182-12-200.

(6) A subscriber described in subsection (1) of this section who defers enrollment as described in subsection (3)(a) through (f) of this section may later enroll themselves and their dependents in a PEBB health plan by submitting the required forms as described below. A subscriber who defers enrollment as described in subsection (3)(a) through (e) of this section must provide evidence of continuous enrollment in one or more qualifying coverages as described in subsection (3)(a) through (e) of this section. A gap of 31 days or less is allowed between the date PEBB retiree insurance coverage is deferred and the start date of a qualifying coverage, and between each period of enrollment in qualifying coverages during the deferral period. A subscriber who defers enrollment as described in subsection (3)(f) of this section must provide proof of enrollment in medicare Parts A and B; evidence of continuous enrollment in a qualified coverage is waived as described in (f) of this subsection:

(a) A subscriber who defers enrollment while enrolled in employer-based group medical or such medical insurance continued under COBRA coverage or continuation coverage may enroll in a PEBB health plan by submitting the required forms and evidence of continuous enrollment to the PEBB program:

(i) During the PEBB annual open enrollment period. The required forms must be received by the PEBB program no later than the last day of the open enrollment period. PEBB health plan coverage begins January 1st of the following year; or

(ii) When their employer-based group medical or such coverage under COBRA coverage or continuation coverage ends. The required forms and evidence of continuous enrollment must be received by the PEBB program no later than 60 days after coverage ends. PEBB health plan coverage begins the first day of the month after the employer-based group medical coverage, COBRA coverage, or continuation coverage ends.

| Note: | Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |
| --- | --- |

(b) A subscriber who defers enrollment while enrolled as a retiree or dependent of a retiree in a federal retiree medical plan will have a one-time opportunity to enroll in a PEBB health plan by submitting the required forms and evidence of continuous enrollment to the PEBB program:

(i) During the PEBB annual open enrollment period. The required forms must be received by the PEBB program no later than the last day of the open enrollment period. PEBB health plan coverage begins January 1st of the following year; or

(ii) When the federal retiree medical plan coverage ends. The required forms and evidence of continuous enrollment must be received by the PEBB program no later than 60 days after coverage ends. PEBB health plan coverage begins the first day of the month after coverage under the federal retiree medical plan ends.

| Note: | Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |
| --- | --- |

(c) A subscriber who defers enrollment while enrolled in medicare Parts A and B and a medicaid program that provides creditable coverage as defined in WAC 182-12-109 may enroll in a PEBB health plan by submitting the required forms and evidence of continuous enrollment to the PEBB program:

(i) During the PEBB annual open enrollment period. The required forms must be received by the PEBB program no later than the last day of the open enrollment period. PEBB health plan coverage begins January 1st of the following year; or

(ii) When their medicaid coverage ends. The required forms and evidence of continuous enrollment must be received by the PEBB program no later than 60 days after coverage ends. PEBB health plan coverage begins the first day of the month after the medicaid coverage ends; or

| Note: | Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |
| --- | --- |

(iii) No later than the end of the calendar year when their medicaid coverage ends if the retiree or survivor was also determined eligible under 42 U.S.C. § 1395w-114 and subsequently enrolled in a medicare Part D plan. Enrollment in the PEBB health plan will begin January 1st following the end of the calendar year when the medicaid coverage ends. The required forms must be received by the PEBB program no later than the last day of the calendar year in which the medicaid coverage ends.

(d) A subscriber who defers enrollment while enrolled in exchange coverage will have a one-time opportunity to enroll or reenroll in a PEBB health plan by submitting the required forms and evidence of continuous enrollment to the PEBB program:

(i) During the PEBB annual open enrollment period. The required forms must be received by the PEBB program no later than the last day of the open enrollment period. PEBB health plan coverage begins January 1st of the following year; or

(ii) When exchange coverage ends. The required forms and evidence of continuous enrollment must be received by the PEBB program no later than 60 days after coverage ends. PEBB health plan coverage begins the first day of the month after exchange coverage ends.

| Note: | Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |
| --- | --- |

(e) A subscriber who defers enrollment while enrolled in CHAMPVA will have a one-time opportunity to enroll in a PEBB health plan by submitting the required forms and evidence of continuous enrollment to the PEBB program:

(i) During the PEBB annual open enrollment period. The required forms must be received by the PEBB program no later than the last day of the open enrollment period. PEBB health plan coverage begins January 1st of the following year; or

(ii) When CHAMPVA coverage ends. The required forms and evidence of continuous enrollment must be received by the PEBB program no later than 60 days after coverage ends. PEBB health plan coverage begins the first day of the month after CHAMPVA coverage ends.

| Note: | Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |
| --- | --- |

(f) A subscriber enrolled in medicare who defers enrollment while permanently living outside of the United States may enroll in a PEBB health plan when they return to the United States by submitting the required forms and proof of enrollment in medicare Parts A and B. Evidence of continuous enrollment in a qualified coverage is waived while a subscriber enrolled in medicare lives outside of the United States:

(i) During the PEBB annual open enrollment period. The required forms must be received by the PEBB program no later than the last day of the open enrollment period. PEBB health plan coverage begins January 1st of the following year; or

(ii) When the subscriber permanently moved back to the United States. The required forms and proof of enrollment in medicare Parts A and B must be received by the PEBB program no later than 60 days after the date of the permanent move or the date the subscriber provides notification of such move, whichever is later. PEBB health plan coverage begins the first day of the month after the permanent move or the date the subscriber provides notification of such move, whichever is later.

| Note: | Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |
| --- | --- |

(7) A subscriber described in subsection (1) of this section who defers enrollment as described in subsection (3)(a) through (f) of this section may later enroll themselves and their dependents in a PEBB health plan if they receive formal notice that the authority has determined it is more cost-effective to enroll them or their eligible dependents in PEBB medical than a medical assistance program.

(8) If a subscriber elects to enroll a dependent in PEBB health plan coverage as described in subsection (6) or (7) of this section, the dependent must be enrolled in the same PEBB medical and PEBB dental plan as the subscriber.

| Exceptions: | (1) If a subscriber selects a medicare supplement plan, a MA-PD plan, or the UMP Classic medicare plan, nonmedicare enrollees will be enrolled in the UMP Classic. If a subscriber selects any other medicare plan, they must also select a nonmedicare plan with the same contracted vendor available to nonmedicare enrollees. (2) If a subscriber selects a medicare supplement plan, MA-PD plan, or any other medicare plan, they may elect a PEBB vision plan available for any nonmedicare enrollees. |
| --- | --- |

(9) A nonmedicare subscriber must enroll in PEBB medical to be able to enroll in PEBB dental, in PEBB vision, or in both PEBB dental and PEBB vision. Any nonmedicare dependents they elect to enroll must be enrolled in the same PEBB medical, PEBB dental, and PEBB vision plan.

(10) An enrolled retiree or a survivor who requests to voluntarily terminate their enrollment in PEBB retiree insurance coverage must do so in writing. The written termination request must be received by the PEBB program. A retiree or a survivor who voluntarily terminates their enrollment in a PEBB health plan also terminates enrollment for all eligible dependents. Once coverage is terminated, a retiree or a survivor may not enroll again in the future unless they reestablish eligibility for PEBB insurance coverage by becoming newly eligible. Enrollment in a PEBB health plan will terminate on the last day of the month in which the PEBB program receives the termination request. If the termination request is received on the first day of the month, enrollment will terminate on the last day of the previous month.

| Exception: | When a subscriber or their dependent is enrolled in a MA plan, a MA-PD plan, or the UMP Classic medicare plan, the enrollment will terminate on the last day of the month when the plan disenrollment form is received. |
| --- | --- |

(11) The PEBB program will automatically defer PEBB retiree insurance coverage for the following individuals:

(a) When a retiree or a survivor becomes eligible for the employer contribution toward PEBB or SEBB benefits, PEBB retiree insurance coverage will be automatically deferred. The subscriber will be exempt from the deferral form requirement.

| Note: | When the subscriber is no longer eligible for the employer contribution toward PEBB or SEBB benefits, they may enroll in PEBB retiree insurance coverage as described in WAC 182-12-171, 182-12-180, or subsection (6)(a)(ii) of this section, or continue in a deferred status if they meet the requirements described in WAC 182-12-200 or this section. |
| --- | --- |

(b) Beginning January 30, 2025, retirees and survivors who are not on medicare and enrolled in PEBB retiree insurance coverage and permanently live outside of the United States, become eligible for medicare Parts A and B, and do not respond to HCA within the required time frame, will be automatically deferred from PEBB retiree insurance coverage. These subscribers will be exempt from the deferral form requirement. They may enroll in PEBB retiree insurance coverage when they return to the United States as described in subsection (6)(f) of this section.

***(Effective January 1, 2027)***

PDF WAC 182-12-205

May a retiree or a survivor defer enrollment or voluntarily terminate enrollment under public employees benefits board (PEBB) retiree insurance coverage?

(1) The following individuals may defer enrollment or may have their enrollment automatically deferred as described in subsection (11) of this section from public employees benefits board (PEBB) retiree insurance coverage:

(a) A retiring employee or a retiring school employee;

(b) A dependent becoming eligible as a survivor; or

(c) A retiree or a survivor enrolled in PEBB retiree insurance coverage.

(2) When a subscriber described in subsection (1) of this section chooses to defer enrollment in PEBB retiree insurance coverage or is automatically deferred by the PEBB program as described in subsection (11) of this section, enrollment for all eligible dependents will be terminated, except as described in subsection (3)(c) of this section.

(3) When a subscriber described in subsection (1) of this section chooses to defer enrollment in PEBB retiree insurance coverage as described in (a) through (e) of this subsection, they must maintain continuous enrollment in one or more qualifying coverages as described in (a) through (e) of this subsection or WAC 182-12-200. A gap of 31 days or less is allowed between the date PEBB retiree insurance coverage is deferred and the start date of a qualifying coverage, and between each period of enrollment in qualifying coverages during the deferral period. When a subscriber chooses to defer enrollment in PEBB retiree insurance coverage as described in (f) or (g) of this subsection or is automatically deferred as described in subsection (11)(b) or (c) of this section; evidence of continuous enrollment in a qualified coverage is not required as described in subsection (6)(f) of this section.

When a subscriber's enrollment is deferred, enrollment in PEBB medical, PEBB dental, and PEBB vision will also be deferred. A subscriber must be enrolled in PEBB medical to enroll in PEBB dental except for a nonmedicare retiree must enroll in PEBB medical to be able to enroll in PEBB dental, in PEBB vision, or in both PEBB dental and PEBB vision. A retiree may only defer enrollment in PEBB retiree term life insurance as described in WAC 182-12-209 (3)(b).

(a) Beginning January 1, 2001, enrollment in PEBB retiree insurance coverage may be deferred when the subscriber is enrolled in employer-based group medical as an employee or the dependent of an employee, or such medical insurance continued under Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage or continuation coverage.

(b) Beginning January 1, 2001, enrollment in PEBB retiree insurance coverage may be deferred when the subscriber is enrolled as a retiree or the dependent of a retiree in a federal retiree medical plan.

(c) Beginning January 1, 2006, enrollment in PEBB retiree insurance coverage may be deferred when the subscriber is enrolled in medicare Parts A and B and a medicaid program that provides creditable coverage as defined in WAC 182-12-109. Dependents may continue their PEBB health plan enrollment if they meet PEBB eligibility criteria and are not eligible for creditable coverage under a medicaid program.

(d) Beginning January 1, 2014, subscribers who are not eligible for Parts A and B of medicare may defer enrollment in PEBB retiree insurance coverage when the subscriber is enrolled in exchange coverage.

(e) Beginning July 17, 2018, enrollment in PEBB retiree insurance coverage may be deferred when the subscriber is enrolled in the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA).

(f) Beginning January 1, 2025, subscribers who are enrolled in medicare may defer enrollment in PEBB retiree insurance coverage when they permanently reside outside of the United States.

(g) Beginning January 1, 2026, subscribers who are enrolled in medicare may defer enrollment in PEBB retiree insurance coverage when they have a temporary absence from the United States that exceeds the permitted time allowed under the federal regulations and guidance of the Centers for Medicare and Medicaid Services (CMS).

(4) To defer enrollment in PEBB retiree insurance coverage, the required forms must be submitted to the PEBB program.

(a) For a retiring employee or a retiring school employee who meets the substantive eligibility requirements as described in WAC 182-12-171(2), enrollment will be deferred the first of the month following the date their own employer-paid coverage, COBRA coverage, or continuation coverage ends. The forms must be received by the PEBB program no later than 60 days after their own employer-paid coverage, COBRA coverage, or continuation coverage ends.

(b) For an official leaving public office who meets the requirements as described in WAC 182-12-180(1), enrollment will be deferred the first of the month following the date the official leaves public office. The forms must be received by the PEBB program no later than 60 days after the official leaves public office.

(c) For an employee or a school employee determined to be retroactively eligible for disability retirement who meets the requirements as described in WAC 182-12-211 (1)(a) through (c), enrollment will be deferred as described in WAC 182-12-211 (2) or (3). The forms and formal determination letter must be received by the PEBB program no later than 60 days after the date on the determination letter.

(d) For an eligible survivor, the dependent must meet the requirements described below and the forms must be received by the PEBB program within the time described:

(i) For a survivor of an employee or a school employee who meets the requirements as described in WAC 182-12-265 (1) or (3), enrollment will be deferred the first of the month following the later of the date of the employee's or the school employee's death or the date the survivor's PEBB insurance coverage or school employees benefits board (SEBB) insurance coverage ends. The forms must be received by the PEBB program no later than 60 days after the later of the date of the employee's or the school employee's death or the date the survivor's PEBB insurance coverage or SEBB insurance coverage ends.

(ii) For a survivor of an official who meets the requirements as described in WAC 182-12-180(2), enrollment will be deferred the first of the month following the later of the date of the official's death or the date the survivor's PEBB insurance coverage ends. The forms must be received by the PEBB program no later than 60 days after the later of the date of the official's death or the date the survivor's PEBB insurance coverage ends.

(iii) For a survivor of a retiree who meets the requirements as described in WAC 182-12-265(2), enrollment will be deferred the first of the month following the date of the retiree's death. The forms must be received by the PEBB program no later than 60 days after the retiree's death.

(iv) For a survivor of an emergency service personnel killed in the line of duty who meets the requirements as described in WAC 182-12-250, enrollment will be deferred the first of the month following the later of one of the events described in WAC 182-12-250 (5)(a) through (d). The forms must be received by the PEBB program no later than 180 days after the later of one of the events described in WAC 182-12-250 (5)(a) through (d).

(e) For an enrolled retiree or survivor who submits the required forms to defer enrollment in PEBB retiree insurance coverage, enrollment will be deferred effective the first of the month following the date the required forms are received by the PEBB program. If the forms are received on the first day of the month, enrollment will be deferred effective that day.

| Exception: | When a subscriber or their dependent is enrolled in a medicare advantage (MA) plan, a medicare advantage-prescription drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan, the enrollment in PEBB retiree insurance coverage will be deferred effective the first of the month following the date the plan disenrollment form is received. |
| --- | --- |

(5) A retiree who meets substantive eligibility requirements in WAC 182-12-171(2) and whose own employer-paid coverage, COBRA coverage, or continuation coverage ended between January 1, 2001, and December 31, 2001, was not required to have submitted the deferral form at that time, but must meet all procedural requirements as stated in this section, WAC 182-12-171, and 182-12-200.

(6) A subscriber described in subsection (1) of this section whose enrollment was deferred as described in subsection (3)(a) through (g) of this section may later enroll themselves and their dependents in a PEBB health plan by submitting the required forms as described below. A subscriber who deferred enrollment as described in subsection (3)(a) through (e) of this section must provide evidence of continuous enrollment in one or more qualifying coverages as described in subsection (3)(a) through (e) of this section. A gap of 31 days or less is allowed between the date PEBB retiree insurance coverage is deferred and the start date of a qualifying coverage, and between each period of enrollment in qualifying coverages during the deferral period. A subscriber who deferred enrollment as described in subsection (3)(f) or (g) of this section or who was automatically deferred as described in subsection (11)(b) or (c) of this section must provide proof of enrollment in medicare Parts A and B, proof of permanent residence in the United States, and proof they currently reside in the United States; evidence of continuous enrollment in a qualified coverage is not required as described in (f) of this subsection:

(a) A subscriber who deferred enrollment while enrolled in employer-based group medical or such medical insurance continued under COBRA coverage or continuation coverage may enroll in a PEBB health plan by submitting the required forms and evidence of continuous enrollment to the PEBB program:

(i) During the PEBB annual open enrollment period. The required forms must be received by the PEBB program no later than the last day of the open enrollment period. PEBB health plan coverage begins January 1st of the following year; or

(ii) When their employer-based group medical or such coverage under COBRA coverage or continuation coverage ends. The required forms and evidence of continuous enrollment must be received by the PEBB program no later than 60 days after coverage ends. PEBB health plan coverage begins the first day of the month after the employer-based group medical coverage, COBRA coverage, or continuation coverage ends.

| Note: | Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. |
| --- | --- |
| | (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. |
| | (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. |
| | (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |

(b) A subscriber who deferred enrollment while enrolled as a retiree or dependent of a retiree in a federal retiree medical plan will have a one-time opportunity to enroll in a PEBB health plan by submitting the required forms and evidence of continuous enrollment to the PEBB program:

(i) During the PEBB annual open enrollment period. The required forms must be received by the PEBB program no later than the last day of the open enrollment period. PEBB health plan coverage begins January 1st of the following year; or

(ii) When the federal retiree medical plan coverage ends. The required forms and evidence of continuous enrollment must be received by the PEBB program no later than 60 days after coverage ends. PEBB health plan coverage begins the first day of the month after coverage under the federal retiree medical plan ends.

| Note: | Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. |
| --- | --- |
| | (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. |
| | (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. |
| | (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |

(c) A subscriber who deferred enrollment while enrolled in medicare Parts A and B and a medicaid program that provides creditable coverage as defined in WAC 182-12-109 may enroll in a PEBB health plan by submitting the required forms and evidence of continuous enrollment to the PEBB program:

(i) During the PEBB annual open enrollment period. The required forms must be received by the PEBB program no later than the last day of the open enrollment period. PEBB health plan coverage begins January 1st of the following year; or

(ii) When their medicaid coverage ends. The required forms and evidence of continuous enrollment must be received by the PEBB program no later than 60 days after coverage ends. PEBB health plan coverage begins the first day of the month after the medicaid coverage ends; or

| Note: | Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. |
| --- | --- |
| | (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. |
| | (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. |
| | (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |

(iii) No later than the end of the calendar year when their medicaid coverage ends if the retiree or survivor was also determined eligible under 42 U.S.C. § 1395w-114 and subsequently enrolled in a medicare Part D plan. Enrollment in the PEBB health plan will begin January 1st following the end of the calendar year when the medicaid coverage ends. The required forms must be received by the PEBB program no later than the last day of the calendar year in which the medicaid coverage ends.

(d) A subscriber who deferred enrollment while enrolled in exchange coverage will have a one-time opportunity to enroll or reenroll in a PEBB health plan by submitting the required forms and evidence of continuous enrollment to the PEBB program:

(i) During the PEBB annual open enrollment period. The required forms must be received by the PEBB program no later than the last day of the open enrollment period. PEBB health plan coverage begins January 1st of the following year; or

(ii) When exchange coverage ends. The required forms and evidence of continuous enrollment must be received by the PEBB program no later than 60 days after coverage ends. PEBB health plan coverage begins the first day of the month after exchange coverage ends.

| Note: | Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. |
| --- | --- |
| | (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. |
| | (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. |
| | (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |

(e) A subscriber who deferred enrollment while enrolled in CHAMPVA will have a one-time opportunity to enroll in a PEBB health plan by submitting the required forms and evidence of continuous enrollment to the PEBB program:

(i) During the PEBB annual open enrollment period. The required forms must be received by the PEBB program no later than the last day of the open enrollment period. PEBB health plan coverage begins January 1st of the following year; or

(ii) When CHAMPVA coverage ends. The required forms and evidence of continuous enrollment must be received by the PEBB program no later than 60 days after coverage ends. PEBB health plan coverage begins the first day of the month after CHAMPVA coverage ends.

| Note: | Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. |
| --- | --- |
| | (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. |
| | (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. |
| | (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |

(f) A subscriber enrolled in medicare who deferred enrollment while permanently residing outside of the United States or due to a temporary absence from the United States as described in subsection (3)(f) or (g) of this section, or who was automatically deferred as described in subsection (11)(b) or (c) of this section, may enroll in a PEBB health plan when they return to the United States by submitting the required forms, proof of enrollment in medicare Parts A and B, proof of permanent residence in the United States, and proof they currently reside in the United States. The required forms and documents must be received by the PEBB program no later than 60 days after the date the permanent move begins or 60 days following the month of the permanent move, whichever is later. PEBB health plan coverage begins the first day of the month after the permanent move. Evidence of continuous enrollment in a qualified coverage is not required while a subscriber enrolled in medicare lives outside of the United States.

| Note: | Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. |
| --- | --- |
| | (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. |
| | (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. |
| | (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |

(7) A subscriber described in subsection (1) of this section who deferred enrollment as described in subsection (3)(a) through (g) of this section may later enroll themselves and their dependents in a PEBB health plan if they receive formal notice that the authority has determined it is more cost-effective to enroll them or their eligible dependents in PEBB medical than a medical assistance program.

(8) If a subscriber elects to enroll a dependent in PEBB health plan coverage as described in subsection (6) or (7) of this section, the dependent must be enrolled in the same PEBB medical and PEBB dental plan as the subscriber.

| Exceptions: | (1) If a subscriber selects a medicare supplement plan, a MA-PD plan, or the UMP Classic medicare plan, nonmedicare enrollees will be enrolled in the UMP Classic. If a subscriber selects any other medicare plan, they must also select a nonmedicare plan with the same contracted vendor available to nonmedicare enrollees. |
| --- | --- |
| | (2) If a subscriber selects a medicare supplement plan, MA-PD plan, or any other medicare plan, they may elect a PEBB vision plan available for any nonmedicare enrollees. |

(9) A nonmedicare subscriber must enroll in PEBB medical to be able to enroll in PEBB dental, in PEBB vision, or in both PEBB dental and PEBB vision. Any nonmedicare dependents they elect to enroll must be enrolled in the same PEBB medical, PEBB dental, and PEBB vision plan.

(10) An enrolled retiree or a survivor who requests to voluntarily terminate their enrollment in PEBB retiree insurance coverage must do so in writing. The written termination request must be received by the PEBB program. A retiree or a survivor who voluntarily terminates their enrollment in a PEBB health plan also terminates enrollment for all eligible dependents. Once coverage is terminated, a retiree or a survivor may not enroll again in the future unless they reestablish eligibility for PEBB insurance coverage by becoming newly eligible. Enrollment in a PEBB health plan will terminate on the last day of the month in which the PEBB program receives the termination request. If the termination request is received on the first day of the month, enrollment will terminate on the last day of the previous month.

| Exception: | When a subscriber or their dependent is enrolled in a MA plan, a MA-PD plan, or the UMP Classic medicare plan, the enrollment will terminate on the last day of the month when the plan disenrollment form is received. |
| --- | --- |

(11) The PEBB program will automatically defer PEBB retiree insurance coverage for the following individuals:

(a) When a retiree or a survivor becomes eligible for the employer contribution toward PEBB or SEBB benefits, PEBB retiree insurance coverage will be automatically deferred. The subscriber will be exempt from the deferral form requirement.

| Note: | When the subscriber is no longer eligible for the employer contribution toward PEBB or SEBB benefits, they may enroll in PEBB retiree insurance coverage as described in WAC 182-12-171, 182-12-180, or subsection (6)(a)(ii) of this section, or continue in a deferred status if they meet the requirements described in WAC 182-12-200 or this section. |
| --- | --- |

(b) Beginning January 30, 2025, retirees and survivors who are not on medicare and enrolled in PEBB retiree insurance coverage and permanently reside outside of the United States, become eligible for medicare Parts A and B, and do not respond to HCA within the required time frame, will be automatically deferred from PEBB retiree insurance coverage. These subscribers will be exempt from the deferral form requirement. They may enroll in PEBB retiree insurance coverage when they return to the United States as described in subsection (6)(f) of this section or continue in a deferred status if they meet the requirements described in WAC 182-12-200 or subsection (3)(a) through (e) of this section.

(c) Beginning January 1, 2026, when a retiree or a survivor must be disenrolled by a MA plan, MA-PD plan, or a medicare Part D plan as required by federal law, due to permanently residing outside of the United States or due to a temporary absence from the United States that exceeds the permitted time allowed under the federal regulations and guidance of CMS, PEBB retiree insurance coverage will be automatically deferred. The subscriber will be exempt from the deferral form requirement. They may enroll in PEBB retiree insurance coverage when they return to the United States as described in subsection (6)(f) of this section or continue in a deferred status if they meet the requirements described in WAC 182-12-200 or subsection (3)(a) through (e) of this section.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 25-14-084 (Admin #2025-02), s 182-12-205, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-083 (Admin #2024-02), § 182-12-205, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-12-205, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolutions PEBB 2022-03 and 2022-04. WSR 22-13-165 (Admin #2022-02.04), § 182-12-205, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolution PEBB 2021-14. WSR 21-13-104 (Admin #2021-01.04), § 182-12-205, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160, 42 C.F.R. § 422.62(b) and § 423.38(c) and PEBB policy resolution 2020-05. WSR 20-16-063 (Admin #2020-02), § 182-12-205, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-205, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-205, filed 10/3/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-205, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-205, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-205, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-205, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-205, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-12-205, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-12-205, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-12-205, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-12-205, filed 10/1/08, effective 1/1/09*
- *WSR 08-09-027 (Order 08-01), § 182-12-205, filed 4/8/08, effective 4/9/08*
- *WSR 07-20-129 (Order 07-01), § 182-12-205, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.068. WSR 06-23-165 (Order 06-09), § 182-12-205, filed 11/22/06, effective 12/23/06. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. WSR 05-16-046 (Order 05-01), § 182-12-205, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-205, filed 8/26/04, effective 1/1/05.](Effective January 1, 2027) PDF WAC 182-12-205 May a retiree or a survivor defer enrollment or voluntarily terminate enrollment under public employees benefits board (PEBB) retiree insurance coverage? (1) The following individuals may defer enrollment or may have their enrollment automatically deferred as described in subsection (11) of this section from public employees benefits board (PEBB) retiree insurance coverage:(a) A retiring employee or a retiring school employee*
- *(b) A dependent becoming eligible as a survivor*
- *or(c) A retiree or a survivor enrolled in PEBB retiree insurance coverage.(2) When a subscriber described in subsection (1) of this section chooses to defer enrollment in PEBB retiree insurance coverage or is automatically deferred by the PEBB program as described in subsection (11) of this section, enrollment for all eligible dependents will be terminated, except as described in subsection (3)(c) of this section.(3) When a subscriber described in subsection (1) of this section chooses to defer enrollment in PEBB retiree insurance coverage as described in (a) through (e) of this subsection, they must maintain continuous enrollment in one or more qualifying coverages as described in (a) through (e) of this subsection or WAC 182-12-200. A gap of 31 days or less is allowed between the date PEBB retiree insurance coverage is deferred and the start date of a qualifying coverage, and between each period of enrollment in qualifying coverages during the deferral period. When a subscriber chooses to defer enrollment in PEBB retiree insurance coverage as described in (f) or (g) of this subsection or is automatically deferred as described in subsection (11)(b) or (c) of this section*
- *evidence of continuous enrollment in a qualified coverage is not required as described in subsection (6)(f) of this section.When a subscriber's enrollment is deferred, enrollment in PEBB medical, PEBB dental, and PEBB vision will also be deferred. A subscriber must be enrolled in PEBB medical to enroll in PEBB dental except for a nonmedicare retiree must enroll in PEBB medical to be able to enroll in PEBB dental, in PEBB vision, or in both PEBB dental and PEBB vision. A retiree may only defer enrollment in PEBB retiree term life insurance as described in WAC 182-12-209 (3)(b).(a) Beginning January 1, 2001, enrollment in PEBB retiree insurance coverage may be deferred when the subscriber is enrolled in employer-based group medical as an employee or the dependent of an employee, or such medical insurance continued under Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage or continuation coverage.(b) Beginning January 1, 2001, enrollment in PEBB retiree insurance coverage may be deferred when the subscriber is enrolled as a retiree or the dependent of a retiree in a federal retiree medical plan.(c) Beginning January 1, 2006, enrollment in PEBB retiree insurance coverage may be deferred when the subscriber is enrolled in medicare Parts A and B and a medicaid program that provides creditable coverage as defined in WAC 182-12-109. Dependents may continue their PEBB health plan enrollment if they meet PEBB eligibility criteria and are not eligible for creditable coverage under a medicaid program.(d) Beginning January 1, 2014, subscribers who are not eligible for Parts A and B of medicare may defer enrollment in PEBB retiree insurance coverage when the subscriber is enrolled in exchange coverage.(e) Beginning July 17, 2018, enrollment in PEBB retiree insurance coverage may be deferred when the subscriber is enrolled in the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA).(f) Beginning January 1, 2025, subscribers who are enrolled in medicare may defer enrollment in PEBB retiree insurance coverage when they permanently reside outside of the United States.(g) Beginning January 1, 2026, subscribers who are enrolled in medicare may defer enrollment in PEBB retiree insurance coverage when they have a temporary absence from the United States that exceeds the permitted time allowed under the federal regulations and guidance of the Centers for Medicare and Medicaid Services (CMS).(4) To defer enrollment in PEBB retiree insurance coverage, the required forms must be submitted to the PEBB program.(a) For a retiring employee or a retiring school employee who meets the substantive eligibility requirements as described in WAC 182-12-171(2), enrollment will be deferred the first of the month following the date their own employer-paid coverage, COBRA coverage, or continuation coverage ends. The forms must be received by the PEBB program no later than 60 days after their own employer-paid coverage, COBRA coverage, or continuation coverage ends.(b) For an official leaving public office who meets the requirements as described in WAC 182-12-180(1), enrollment will be deferred the first of the month following the date the official leaves public office. The forms must be received by the PEBB program no later than 60 days after the official leaves public office.(c) For an employee or a school employee determined to be retroactively eligible for disability retirement who meets the requirements as described in WAC 182-12-211 (1)(a) through (c), enrollment will be deferred as described in WAC 182-12-211 (2) or (3). The forms and formal determination letter must be received by the PEBB program no later than 60 days after the date on the determination letter.(d) For an eligible survivor, the dependent must meet the requirements described below and the forms must be received by the PEBB program within the time described:(i) For a survivor of an employee or a school employee who meets the requirements as described in WAC 182-12-265 (1) or (3), enrollment will be deferred the first of the month following the later of the date of the employee's or the school employee's death or the date the survivor's PEBB insurance coverage or school employees benefits board (SEBB) insurance coverage ends. The forms must be received by the PEBB program no later than 60 days after the later of the date of the employee's or the school employee's death or the date the survivor's PEBB insurance coverage or SEBB insurance coverage ends.(ii) For a survivor of an official who meets the requirements as described in WAC 182-12-180(2), enrollment will be deferred the first of the month following the later of the date of the official's death or the date the survivor's PEBB insurance coverage ends. The forms must be received by the PEBB program no later than 60 days after the later of the date of the official's death or the date the survivor's PEBB insurance coverage ends.(iii) For a survivor of a retiree who meets the requirements as described in WAC 182-12-265(2), enrollment will be deferred the first of the month following the date of the retiree's death. The forms must be received by the PEBB program no later than 60 days after the retiree's death.(iv) For a survivor of an emergency service personnel killed in the line of duty who meets the requirements as described in WAC 182-12-250, enrollment will be deferred the first of the month following the later of one of the events described in WAC 182-12-250 (5)(a) through (d). The forms must be received by the PEBB program no later than 180 days after the later of one of the events described in WAC 182-12-250 (5)(a) through (d).(e) For an enrolled retiree or survivor who submits the required forms to defer enrollment in PEBB retiree insurance coverage, enrollment will be deferred effective the first of the month following the date the required forms are received by the PEBB program. If the forms are received on the first day of the month, enrollment will be deferred effective that day.Exception:When a subscriber or their dependent is enrolled in a medicare advantage (MA) plan, a medicare advantage-prescription drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan, the enrollment in PEBB retiree insurance coverage will be deferred effective the first of the month following the date the plan disenrollment form is received.(5) A retiree who meets substantive eligibility requirements in WAC 182-12-171(2) and whose own employer-paid coverage, COBRA coverage, or continuation coverage ended between January 1, 2001, and December 31, 2001, was not required to have submitted the deferral form at that time, but must meet all procedural requirements as stated in this section, WAC 182-12-171, and 182-12-200.(6) A subscriber described in subsection (1) of this section whose enrollment was deferred as described in subsection (3)(a) through (g) of this section may later enroll themselves and their dependents in a PEBB health plan by submitting the required forms as described below. A subscriber who deferred enrollment as described in subsection (3)(a) through (e) of this section must provide evidence of continuous enrollment in one or more qualifying coverages as described in subsection (3)(a) through (e) of this section. A gap of 31 days or less is allowed between the date PEBB retiree insurance coverage is deferred and the start date of a qualifying coverage, and between each period of enrollment in qualifying coverages during the deferral period. A subscriber who deferred enrollment as described in subsection (3)(f) or (g) of this section or who was automatically deferred as described in subsection (11)(b) or (c) of this section must provide proof of enrollment in medicare Parts A and B, proof of permanent residence in the United States, and proof they currently reside in the United States*
- *evidence of continuous enrollment in a qualified coverage is not required as described in (f) of this subsection:(a) A subscriber who deferred enrollment while enrolled in employer-based group medical or such medical insurance continued under COBRA coverage or continuation coverage may enroll in a PEBB health plan by submitting the required forms and evidence of continuous enrollment to the PEBB program:(i) During the PEBB annual open enrollment period. The required forms must be received by the PEBB program no later than the last day of the open enrollment period. PEBB health plan coverage begins January 1st of the following year*
- *or(ii) When their employer-based group medical or such coverage under COBRA coverage or continuation coverage ends. The required forms and evidence of continuous enrollment must be received by the PEBB program no later than 60 days after coverage ends. PEBB health plan coverage begins the first day of the month after the employer-based group medical coverage, COBRA coverage, or continuation coverage ends.Note:Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins.(b) A subscriber who deferred enrollment while enrolled as a retiree or dependent of a retiree in a federal retiree medical plan will have a one-time opportunity to enroll in a PEBB health plan by submitting the required forms and evidence of continuous enrollment to the PEBB program:(i) During the PEBB annual open enrollment period. The required forms must be received by the PEBB program no later than the last day of the open enrollment period. PEBB health plan coverage begins January 1st of the following year*
- *or(ii) When the federal retiree medical plan coverage ends. The required forms and evidence of continuous enrollment must be received by the PEBB program no later than 60 days after coverage ends. PEBB health plan coverage begins the first day of the month after coverage under the federal retiree medical plan ends.Note:Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins.(c) A subscriber who deferred enrollment while enrolled in medicare Parts A and B and a medicaid program that provides creditable coverage as defined in WAC 182-12-109 may enroll in a PEBB health plan by submitting the required forms and evidence of continuous enrollment to the PEBB program:(i) During the PEBB annual open enrollment period. The required forms must be received by the PEBB program no later than the last day of the open enrollment period. PEBB health plan coverage begins January 1st of the following year*
- *or(ii) When their medicaid coverage ends. The required forms and evidence of continuous enrollment must be received by the PEBB program no later than 60 days after coverage ends. PEBB health plan coverage begins the first day of the month after the medicaid coverage ends*
- *orNote:Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins.(iii) No later than the end of the calendar year when their medicaid coverage ends if the retiree or survivor was also determined eligible under 42 U.S.C. § 1395w-114 and subsequently enrolled in a medicare Part D plan. Enrollment in the PEBB health plan will begin January 1st following the end of the calendar year when the medicaid coverage ends. The required forms must be received by the PEBB program no later than the last day of the calendar year in which the medicaid coverage ends.(d) A subscriber who deferred enrollment while enrolled in exchange coverage will have a one-time opportunity to enroll or reenroll in a PEBB health plan by submitting the required forms and evidence of continuous enrollment to the PEBB program:(i) During the PEBB annual open enrollment period. The required forms must be received by the PEBB program no later than the last day of the open enrollment period. PEBB health plan coverage begins January 1st of the following year*
- *or(ii) When exchange coverage ends. The required forms and evidence of continuous enrollment must be received by the PEBB program no later than 60 days after coverage ends. PEBB health plan coverage begins the first day of the month after exchange coverage ends.Note:Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins.(e) A subscriber who deferred enrollment while enrolled in CHAMPVA will have a one-time opportunity to enroll in a PEBB health plan by submitting the required forms and evidence of continuous enrollment to the PEBB program:(i) During the PEBB annual open enrollment period. The required forms must be received by the PEBB program no later than the last day of the open enrollment period. PEBB health plan coverage begins January 1st of the following year*
- *or(ii) When CHAMPVA coverage ends. The required forms and evidence of continuous enrollment must be received by the PEBB program no later than 60 days after coverage ends. PEBB health plan coverage begins the first day of the month after CHAMPVA coverage ends.Note:Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins.(f) A subscriber enrolled in medicare who deferred enrollment while permanently residing outside of the United States or due to a temporary absence from the United States as described in subsection (3)(f) or (g) of this section, or who was automatically deferred as described in subsection (11)(b) or (c) of this section, may enroll in a PEBB health plan when they return to the United States by submitting the required forms, proof of enrollment in medicare Parts A and B, proof of permanent residence in the United States, and proof they currently reside in the United States. The required forms and documents must be received by the PEBB program no later than 60 days after the date the permanent move begins or 60 days following the month of the permanent move, whichever is later. PEBB health plan coverage begins the first day of the month after the permanent move. Evidence of continuous enrollment in a qualified coverage is not required while a subscriber enrolled in medicare lives outside of the United States.Note:Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins.(7) A subscriber described in subsection (1) of this section who deferred enrollment as described in subsection (3)(a) through (g) of this section may later enroll themselves and their dependents in a PEBB health plan if they receive formal notice that the authority has determined it is more cost-effective to enroll them or their eligible dependents in PEBB medical than a medical assistance program.(8) If a subscriber elects to enroll a dependent in PEBB health plan coverage as described in subsection (6) or (7) of this section, the dependent must be enrolled in the same PEBB medical and PEBB dental plan as the subscriber.Exceptions:(1) If a subscriber selects a medicare supplement plan, a MA-PD plan, or the UMP Classic medicare plan, nonmedicare enrollees will be enrolled in the UMP Classic. If a subscriber selects any other medicare plan, they must also select a nonmedicare plan with the same contracted vendor available to nonmedicare enrollees. (2) If a subscriber selects a medicare supplement plan, MA-PD plan, or any other medicare plan, they may elect a PEBB vision plan available for any nonmedicare enrollees.(9) A nonmedicare subscriber must enroll in PEBB medical to be able to enroll in PEBB dental, in PEBB vision, or in both PEBB dental and PEBB vision. Any nonmedicare dependents they elect to enroll must be enrolled in the same PEBB medical, PEBB dental, and PEBB vision plan.(10) An enrolled retiree or a survivor who requests to voluntarily terminate their enrollment in PEBB retiree insurance coverage must do so in writing. The written termination request must be received by the PEBB program. A retiree or a survivor who voluntarily terminates their enrollment in a PEBB health plan also terminates enrollment for all eligible dependents. Once coverage is terminated, a retiree or a survivor may not enroll again in the future unless they reestablish eligibility for PEBB insurance coverage by becoming newly eligible. Enrollment in a PEBB health plan will terminate on the last day of the month in which the PEBB program receives the termination request. If the termination request is received on the first day of the month, enrollment will terminate on the last day of the previous month.Exception:When a subscriber or their dependent is enrolled in a MA plan, a MA-PD plan, or the UMP Classic medicare plan, the enrollment will terminate on the last day of the month when the plan disenrollment form is received.(11) The PEBB program will automatically defer PEBB retiree insurance coverage for the following individuals:(a) When a retiree or a survivor becomes eligible for the employer contribution toward PEBB or SEBB benefits, PEBB retiree insurance coverage will be automatically deferred. The subscriber will be exempt from the deferral form requirement.Note:When the subscriber is no longer eligible for the employer contribution toward PEBB or SEBB benefits, they may enroll in PEBB retiree insurance coverage as described in WAC 182-12-171, 182-12-180, or subsection (6)(a)(ii) of this section, or continue in a deferred status if they meet the requirements described in WAC 182-12-200 or this section.(b) Beginning January 30, 2025, retirees and survivors who are not on medicare and enrolled in PEBB retiree insurance coverage and permanently reside outside of the United States, become eligible for medicare Parts A and B, and do not respond to HCA within the required time frame, will be automatically deferred from PEBB retiree insurance coverage. These subscribers will be exempt from the deferral form requirement. They may enroll in PEBB retiree insurance coverage when they return to the United States as described in subsection (6)(f) of this section or continue in a deferred status if they meet the requirements described in WAC 182-12-200 or subsection (3)(a) through (e) of this section.(c) Beginning January 1, 2026, when a retiree or a survivor must be disenrolled by a MA plan, MA-PD plan, or a medicare Part D plan as required by federal law, due to permanently residing outside of the United States or due to a temporary absence from the United States that exceeds the permitted time allowed under the federal regulations and guidance of CMS, PEBB retiree insurance coverage will be automatically deferred. The subscriber will be exempt from the deferral form requirement. They may enroll in PEBB retiree insurance coverage when they return to the United States as described in subsection (6)(f) of this section or continue in a deferred status if they meet the requirements described in WAC 182-12-200 or subsection (3)(a) through (e) of this section.[Statutory Authority: RCW 41.05.021, 41.05.065, 41.05.160, and PEBB policy resolutions. WSR 26-14-081 (Admin #2026.02), s 182-12-205, filed 6/29/26, effective 1/1/27. Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 25-14-084 (Admin #2025-02), s 182-12-205, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-083 (Admin #2024-02), § 182-12-205, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-12-205, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolutions PEBB 2022-03 and 2022-04. WSR 22-13-165 (Admin #2022-02.04), § 182-12-205, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolution PEBB 2021-14. WSR 21-13-104 (Admin #2021-01.04), § 182-12-205, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160, 42 C.F.R. § 422.62(b) and § 423.38(c) and PEBB policy resolution 2020-05. WSR 20-16-063 (Admin #2020-02), § 182-12-205, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-205, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-205, filed 10/3/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-205, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-205, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-205, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-205, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-205, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-12-205, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-12-205, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-12-205, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-12-205, filed 10/1/08, effective 1/1/09*
- *WSR 08-09-027 (Order 08-01), § 182-12-205, filed 4/8/08, effective 4/9/08*
- *WSR 07-20-129 (Order 07-01), § 182-12-205, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.068. WSR 06-23-165 (Order 06-09), § 182-12-205, filed 11/22/06, effective 12/23/06. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. WSR 05-16-046 (Order 05-01), § 182-12-205, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-205, filed 8/26/04, effective 1/1/05.*

##### **Wash. Admin. Code § 182-12-207** When can a retiree or an eligible dependent's public employees benefits board (PEBB) insurance coverage be terminated by the health care authority (HCA)? {#sec-182-12-207 omnilex-key=us-wa-regs-official--title-182--182-12-207}

A retiree or an eligible dependent's public employees benefits board (PEBB) insurance coverage can be terminated by the health care authority (HCA) for the following reasons:

(1) Failure to comply with the PEBB program's procedural requirements, including failure to provide information or documentation requested by the due date in written requests from the PEBB program;

(2) Knowingly providing false information;

(3) Failure to pay the monthly premium or applicable premium surcharges when due as described in WAC 182-08-180 (1)(c);

(4) Misconduct. If a retiree's PEBB insurance coverage is terminated for misconduct, PEBB retiree insurance coverage will not be reinstated at a later date. Examples of such termination include, but are not limited to the following:

(a) Fraud, intentional misrepresentation or withholding of information the subscriber knew or should have known was material or necessary to accurately determine eligibility or the correct premium; or

(b) Abusive or threatening conduct repeatedly directed to an HCA employee, a health plan or other HCA contracted vendor providing PEBB insurance coverage on behalf of the HCA, its employees, or other persons.

If a retiree's PEBB insurance coverage is terminated by HCA for the above reasons, PEBB insurance coverage for all of the retiree's eligible dependents is also terminated.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-12-207, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-207, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-207, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-207, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-207, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160. WSR 09-23-102 (Order 09-02), § 182-12-207, filed 11/17/09, effective 1/1/10*
- *WSR 07-20-129 (Order 07-01), § 182-12-207, filed 10/3/07, effective 11/3/07.*

##### **Wash. Admin. Code § 182-12-209** Who is eligible for retiree term life insurance? {#sec-182-12-209 omnilex-key=us-wa-regs-official--title-182--182-12-209}

Eligible employees who participate in public employees benefits board (PEBB) life insurance as an employee and eligible school employees who participate in school employees benefits board (SEBB) life insurance as an employee and meet qualifications for PEBB retiree insurance coverage as provided in WAC 182-12-171 or 182-12-180, are eligible for retiree term life insurance. They must submit the required forms to the PEBB program. Forms for a retiring employee or a retiring school employee as described in WAC 182-12-171, must be received by the PEBB program no later than sixty days after the date their PEBB or SEBB employee basic life insurance ends. Forms for an official leaving public office as described in WAC 182-12-180, must be received by the PEBB program no later than sixty days after the official leaves public office.

(1) Employees or school employees whose life insurance premiums are being waived under the terms of the life insurance contract are not eligible for retiree term life insurance until their waiver of premium benefit ends.

(2) Retirees may not defer enrollment in retiree term life insurance, except as allowed in subsection (3)(b) of this section.

(3) If a retiree returns to active employment status and becomes eligible for the employer contribution toward PEBB or SEBB employee basic life insurance, they may choose:

(a) To continue to self-pay premiums and keep retiree term life insurance, the employee or the school employee must pay retiree term life insurance premiums directly to the contracted vendor during the period they are eligible for PEBB or SEBB employee basic life insurance; or

(b) To stop self-paying retiree term life insurance premiums during the period they are eligible for PEBB or SEBB employee basic life insurance and elect retiree term life insurance when PEBB or SEBB employee basic life insurance ends.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-12-209, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-209, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-209, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-209, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-209, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-209, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-12-209, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 09-23-102 (Order 09-02), § 182-12-209, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-12-209, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-12-209, filed 10/3/07, effective 11/3/07.*

##### **Wash. Admin. Code § 182-12-211** May an employee or a school employee who is determined to be retroactively eligible for disability retirement enroll or defer enrollment in public employees benefits board (PEBB) retiree insurance coverage? {#sec-182-12-211 omnilex-key=us-wa-regs-official--title-182--182-12-211}

(1) An employee or a school employee who is determined to be retroactively eligible for a disability retirement is eligible to enroll or defer enrollment (as described in WAC 182-12-200 or 182-12-205) in public employees benefits board (PEBB) retiree insurance coverage if:

(a) The employee or the school employee submits the required form and a copy of the formal determination letter they received from the Washington state department of retirement systems (DRS) or the appropriate higher education authority;

(b) The employee's or the school employee's form and a copy of their Washington state-sponsored retirement system's formal determination letter are received by the PEBB program no later than 60 days after the date on the determination letter; and

(c) The employee or the school employee immediately begins to receive a monthly pension benefit or a supplemental retirement plan benefit under their higher education retirement plan (HERP), with exceptions described below from WAC 182-12-171(2):

(i) A retiring employee of a state agency, a retiring school employee of a school employees benefits board (SEBB) organization, or a retiring employee or a retiring school employee of an employer group participating under a Washington state sponsored retirement plan who receives a lump sum payment instead of a monthly retirement plan payment is only eligible if the department of retirement systems offered the employee the choice between a lump sum actuarially equivalent payment and the ongoing monthly payment, as allowed by the plan; or

(ii) A retiring employee of a state agency, a retiring school employee of a SEBB organization, or a retiring employee or retiring school employee of an employer group participating under a Washington state sponsored retirement plan who is a member of the teachers' retirement system Plan 2, school employees' retirement system Plan 2, or public employees' retirement system Plan 2, also called a separated employee as defined in RCW 41.05.011 (25)(b), who separates from employment on or after January 1, 2024, and who is at least age 55 with at least 20 years of service; or

(iii) A retiring employee of a state agency, a retiring school employee of a SEBB organization, or a retiring employee or a retiring school employee of an employer group participating under a Washington state sponsored retirement plan who is a member of a Plan 3 retirement plan, also called a separated employeeas defined in RCW 41.05.011 (25)(a), who is at least age 55 with at least 10 years of service; or

(iv) A retiring employee of a Washington higher education institution who is a member of a higher education retirement plan (HERP) must immediately begin to receive a monthly retirement plan payment, or meet their HERP plan's retirement eligibility criteria, or be at least age 55 with 10 years of state service.

(2) The employee or the school employee, at their option, must indicate the date of enrollment or deferment in PEBB retiree insurance coverage on the form. The employee or the school employee may choose from the following dates:

(a) The retirement date as stated in the formal determination letter; or

(b) The first day of the month following the date the formal determination letter was written.

| Note: | Enrollment in the PEBB program's medicare advantage (MA) plan, medicare advantage-prescription drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |
| --- | --- |

(3) The director may make an exception to the date of PEBB retiree insurance coverage described in subsection (2)(a) and (b) of this section; however, such request must demonstrate extraordinary circumstances beyond the control of the retiree.

(4) Premiums and applicable premium surcharges are due from the effective date of enrollment in PEBB retiree insurance coverage.

(5) If a retiring employee or a retiring school employee elects to enroll a dependent in PEBB health plan coverage, the dependent must be enrolled in the same PEBB medical and PEBB dental plan as the retiring employee or the retiring school employee.

| Exceptions: | (1) If a retiring employee or a retiring school employee selects a medicare supplement plan, MA-PD plan, or the UMP Classic medicare plan, nonmedicare enrollees will be enrolled in the UMP Classic. If a retiring employee or a retiring school employee selects any other medicare plan, they must also select a nonmedicare plan with the same contracted vendor available to nonmedicare enrollees. (2) If a retiring employee or a retiring school employee selects a medicare supplement plan, MA-PD plan, or any other medicare plan, they may elect a PEBB vision plan available for any nonmedicare enrollees. |
| --- | --- |

(6) A nonmedicare retiring employee or retiring school employee must enroll in PEBB medical to be able to enroll in PEBB dental, in PEBB vision, or in both PEBB dental and PEBB vision. Any nonmedicare dependents they elect to enroll must be enrolled in the same PEBB medical, PEBB dental, and PEBB vision plan.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160, 2023 c 164 § 1, 2023 c 312 § 1, 2023 c 13 § 5, Policy Resolutions PEBB 2024-14, 2024-19, 2024-20, and 2024-21. WSR 24-18-080 (Admin #2024-01.04), § 182-12-211, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolution PEBB 2022-03. WSR 22-13-160 (Admin #2022-02.03), § 182-12-211, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160, 42 C.F.R. § 422.62(b) and § 423.38(c) and PEBB policy resolution 2020-05. WSR 20-16-063 (Admin #2020-02), § 182-12-211, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-211, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-211, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-211, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-211, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-211, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-211, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-12-211, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 09-23-102 (Order 09-02), § 182-12-211, filed 11/17/09, effective 1/1/10*
- *WSR 07-20-129 (Order 07-01), § 182-12-211, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-211, filed 8/26/04, effective 1/1/05.*

##### **Wash. Admin. Code § 182-12-232** What options for continuing health plan enrollment are available to a retiree of an employer group that ended participation in public employees benefits board (PEBB) or school employees benefits board (SEBB) insurance coverage? {#sec-182-12-232 omnilex-key=us-wa-regs-official--title-182--182-12-232}

WAC 182-12-232

***(Effective until January 1, 2027)***

(1) A retired employee, a retired school employee, or an eligible survivor of an employee, school employee, or retiree of an employer group as defined in WAC 182-12-109 who loses eligibility for public employees benefits board (PEBB) retiree insurance coverage due to the employer group ending participation in PEBB or school employees benefits board (SEBB) insurance coverage may continue enrollment in PEBB health plan coverage by self-paying the premium and applicable premium surcharges set by the health care authority (HCA). A retired employee, a retired school employee, or a survivor enrolled under this section is not eligible for any subsidy provided under RCW 41.05.085.

(2) A retired employee, a retired school employee, or a survivor as described in subsection (1) of this section may enroll in PEBB medical, dental, or vision.

(a) The required forms must be received by the PEBB program no later than 60 days after the employer group's date of termination. The effective date of enrollment in PEBB health plan coverage will be the first day of the month following the day eligibility for PEBB retiree insurance coverage ended.

| Note: | Enrollment in the PEBB program's medicare advantage (MA) plan, medicare advantage prescription-drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB health plan coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB health plan coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB health plan coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |
| --- | --- |

(b) The first premium payment and applicable premium surcharges are due to HCA no later than 45 days after the election period ends as described in (a) of this subsection. Following the first premium payment, premiums and applicable premium surcharges must be paid as described in WAC 182-08-180 (1)(c).

| Note: | An employer group as defined in WAC 182-12-109 that enters into a contractual agreement with the HCA on or after May 4, 2023, and whose contractual agreement is subsequently terminated, shall make a one-time payment to the HCA for each of the employer group's retired or disabled employees who continue participation under this section as described in RCW 41.05.083. |
| --- | --- |

(c) If a retired employee, a retired school employee, or a survivor elects to enroll a dependent in PEBB health plan coverage, the dependent must be enrolled in the same PEBB medical and PEBB dental plan as the retired employee, retired school employee, or survivor.

| Exceptions: | (1) If a retired employee, a retired school employee, or a survivor selects a medicare supplement plan, a MA-PD plan, or the UMP Classic medicare plan, nonmedicare enrollees will be enrolled in the UMP classic. If a retired employee, a retired school employee, or a survivor selects any other medicare plan, they must also select a nonmedicare plan with the same contracted vendor available to nonmedicare enrollees. (2) If a retired employee, a retired school employee, or a survivor selects a medicare supplement plan, MA-PD plan, or any other medicare plan, they may elect a PEBB vision plan available for any nonmedicare enrollees. |
| --- | --- |

(3) A subscriber enrolled under this section may continue PEBB health plan coverage until they request to terminate enrollment as described in subsection (4) of this section, or premiums and applicable premium surcharges are no longer paid as described in WAC 182-08-180 (1)(c). If PEBB health plan coverage is terminated for these reasons, the subscriber and their enrolled dependents will not be eligible to reenroll under this section.

(4) A subscriber enrolled under this section who requests to voluntarily terminate their PEBB health plan coverage must do so in writing. PEBB health plan coverage will end on the last day of the month in which the PEBB program receives the termination request or on the last day of the month specified in the subscriber's termination request, whichever is later. If the termination request is received on the first day of the month, PEBB health plan coverage will end on the last day of the previous month.

| Exception: | When a subscriber or their dependent is enrolled in a MA plan, a MA-PD plan, or the UMP Classic medicare plan, the enrollment in PEBB health plan coverage will terminate on the last day of the month when the plan disenrollment form is received. |
| --- | --- |

***(Effective January 1, 2027)***

PDF WAC 182-12-232

What options for continuing health plan enrollment are available to a retiree of an employer group that ended participation in public employees benefits board (PEBB) or school employees benefits board (SEBB) insurance coverage?

(1) A retired employee, a retired school employee, or an eligible survivor of an employee, school employee, or retiree of an employer group as defined in WAC 182-12-109 who loses eligibility for public employees benefits board (PEBB) retiree insurance coverage due to the employer group ending participation in PEBB or school employees benefits board (SEBB) insurance coverage may continue enrollment in PEBB health plan coverage by self-paying the premium and applicable premium surcharges set by the health care authority (HCA). A retired employee, a retired school employee, or a survivor enrolled under this section is not eligible for any subsidy provided under RCW 41.05.085.

(2) A retired employee, a retired school employee, or a survivor as described in subsection (1) of this section may enroll in PEBB medical, dental, or vision.

(a) The required forms must be received by the PEBB program no later than 60 days after the employer group's date of termination. The effective date of enrollment in PEBB health plan coverage will be the first day of the month following the day eligibility for PEBB retiree insurance coverage ended.

| Note: | Enrollment in the PEBB program's medicare advantage (MA) plan, medicare advantage prescription-drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan may not be retroactive. |
| --- | --- |
| | (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB health plan coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. |
| | (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB health plan coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. |
| | (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB health plan coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |

(b) The first premium payment and applicable premium surcharges are due to HCA no later than 45 days after the election period ends as described in (a) of this subsection. Following the first premium payment, premiums and applicable premium surcharges must be paid as described in WAC 182-08-180 (1)(c).

| Note: | An employer group as defined in WAC 182-12-109 that enters into a contractual agreement with the HCA on or after May 4, 2023, and whose contractual agreement is subsequently terminated, shall make a one-time payment to the HCA for each of the employer group's retired or disabled employees who continue participation under this section as described in RCW 41.05.083. |
| --- | --- |

(c) If a retired employee, a retired school employee, or a survivor elects to enroll a dependent in PEBB health plan coverage, the dependent must be enrolled in the same PEBB medical and PEBB dental plan as the retired employee, retired school employee, or survivor.

| Exceptions: | (1) If a retired employee, a retired school employee, or a survivor selects a medicare supplement plan, a MA-PD plan, or the UMP Classic medicare plan, nonmedicare enrollees will be enrolled in the UMP classic. If a retired employee, a retired school employee, or a survivor selects any other medicare plan, they must also select a nonmedicare plan with the same contracted vendor available to nonmedicare enrollees. |
| --- | --- |
| | (2) If a retired employee, a retired school employee, or a survivor selects a medicare supplement plan, MA-PD plan, or any other medicare plan, they may elect a PEBB vision plan available for any nonmedicare enrollees. |

(3) A subscriber enrolled under this section may continue PEBB health plan coverage until they request to terminate enrollment as described in subsection (4) of this section, or premiums and applicable premium surcharges are no longer paid as described in WAC 182-08-180 (1)(c). If PEBB health plan coverage is terminated for these reasons, the subscriber and their enrolled dependents will not be eligible to reenroll under this section.

(4) A subscriber enrolled under this section who requests to voluntarily terminate their PEBB health plan coverage must do so in writing. PEBB health plan coverage will end on the last day of the month in which the PEBB program receives the termination request or on the last day of the month specified in the subscriber's termination request, whichever is later. If the termination request is received on the first day of the month, PEBB health plan coverage will end on the last day of the previous month.

| Exception: | When a subscriber or their dependent is enrolled in a MA plan, a MA-PD plan, or the UMP Classic medicare plan, the enrollment in PEBB health plan coverage will terminate on the last day of the month when the plan disenrollment form is received. |
| --- | --- |

(5) A subscriber enrolled under this section or their dependent may have their PEBB medical plan enrollment terminated as required by federal law as described in WAC 182-08-196(5). If PEBB medical plan enrollment is terminated for this reason, any enrollment in PEBB dental plan coverage may continue. If all health plan coverage is terminated, the subscriber or their dependent will not be eligible to reenroll under this section.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.065, 41.05.160, 2023 c 164 § 1, 2023 c 312 § 1, 2023 c 13 § 5, Policy Resolutions PEBB 2024-14, 2024-19, 2024-20, and 2024-21. WSR 24-18-081 (Admin #2024-01.05), § 182-12-232, filed 8/29/24, effective 1/1/25.](Effective January 1, 2027) PDF WAC 182-12-232 What options for continuing health plan enrollment are available to a retiree of an employer group that ended participation in public employees benefits board (PEBB) or school employees benefits board (SEBB) insurance coverage? (1) A retired employee, a retired school employee, or an eligible survivor of an employee, school employee, or retiree of an employer group as defined in WAC 182-12-109 who loses eligibility for public employees benefits board (PEBB) retiree insurance coverage due to the employer group ending participation in PEBB or school employees benefits board (SEBB) insurance coverage may continue enrollment in PEBB health plan coverage by self-paying the premium and applicable premium surcharges set by the health care authority (HCA). A retired employee, a retired school employee, or a survivor enrolled under this section is not eligible for any subsidy provided under RCW 41.05.085.(2) A retired employee, a retired school employee, or a survivor as described in subsection (1) of this section may enroll in PEBB medical, dental, or vision.(a) The required forms must be received by the PEBB program no later than 60 days after the employer group's date of termination. The effective date of enrollment in PEBB health plan coverage will be the first day of the month following the day eligibility for PEBB retiree insurance coverage ended.Note:Enrollment in the PEBB program's medicare advantage (MA) plan, medicare advantage prescription-drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB health plan coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB health plan coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB health plan coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins.(b) The first premium payment and applicable premium surcharges are due to HCA no later than 45 days after the election period ends as described in (a) of this subsection. Following the first premium payment, premiums and applicable premium surcharges must be paid as described in WAC 182-08-180 (1)(c).Note:An employer group as defined in WAC 182-12-109 that enters into a contractual agreement with the HCA on or after May 4, 2023, and whose contractual agreement is subsequently terminated, shall make a one-time payment to the HCA for each of the employer group's retired or disabled employees who continue participation under this section as described in RCW 41.05.083.(c) If a retired employee, a retired school employee, or a survivor elects to enroll a dependent in PEBB health plan coverage, the dependent must be enrolled in the same PEBB medical and PEBB dental plan as the retired employee, retired school employee, or survivor.Exceptions:(1) If a retired employee, a retired school employee, or a survivor selects a medicare supplement plan, a MA-PD plan, or the UMP Classic medicare plan, nonmedicare enrollees will be enrolled in the UMP classic. If a retired employee, a retired school employee, or a survivor selects any other medicare plan, they must also select a nonmedicare plan with the same contracted vendor available to nonmedicare enrollees. (2) If a retired employee, a retired school employee, or a survivor selects a medicare supplement plan, MA-PD plan, or any other medicare plan, they may elect a PEBB vision plan available for any nonmedicare enrollees.(3) A subscriber enrolled under this section may continue PEBB health plan coverage until they request to terminate enrollment as described in subsection (4) of this section, or premiums and applicable premium surcharges are no longer paid as described in WAC 182-08-180 (1)(c). If PEBB health plan coverage is terminated for these reasons, the subscriber and their enrolled dependents will not be eligible to reenroll under this section.(4) A subscriber enrolled under this section who requests to voluntarily terminate their PEBB health plan coverage must do so in writing. PEBB health plan coverage will end on the last day of the month in which the PEBB program receives the termination request or on the last day of the month specified in the subscriber's termination request, whichever is later. If the termination request is received on the first day of the month, PEBB health plan coverage will end on the last day of the previous month.Exception:When a subscriber or their dependent is enrolled in a MA plan, a MA-PD plan, or the UMP Classic medicare plan, the enrollment in PEBB health plan coverage will terminate on the last day of the month when the plan disenrollment form is received.(5) A subscriber enrolled under this section or their dependent may have their PEBB medical plan enrollment terminated as required by federal law as described in WAC 182-08-196(5). If PEBB medical plan enrollment is terminated for this reason, any enrollment in PEBB dental plan coverage may continue. If all health plan coverage is terminated, the subscriber or their dependent will not be eligible to reenroll under this section.[Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 26-14-080 (Admin #2026.01), s 182-12-232, filed 6/29/26, effective 1/1/27. Statutory Authority: RCW 41.05.021, 41.05.065, 41.05.160, 2023 c 164 § 1, 2023 c 312 § 1, 2023 c 13 § 5, Policy Resolutions PEBB 2024-14, 2024-19, 2024-20, and 2024-21. WSR 24-18-081 (Admin #2024-01.05), § 182-12-232, filed 8/29/24, effective 1/1/25.*

##### **Wash. Admin. Code § 182-12-250** Public employees benefits board (PEBB) insurance coverage eligibility for survivors of emergency service personnel killed in the line of duty. {#sec-182-12-250 omnilex-key=us-wa-regs-official--title-182--182-12-250}

WAC 182-12-250

***(Effective until January 1, 2027)***

Surviving spouses, state registered domestic partners, and dependent children of emergency service personnel who are killed in the line of duty are eligible to enroll or defer enrollment in public employees benefits board (PEBB) retiree insurance coverage.

(1) This section applies to the surviving spouse, the surviving state registered domestic partner, and dependent children of emergency service personnel "killed in the line of duty" as determined by the Washington state department of labor and industries.

(2) "Emergency service personnel" means law enforcement officers and firefighters as defined in RCW 41.26.030, members of the Washington state patrol retirement fund as defined in RCW 43.43.120, and reserve officers and firefighters as defined in RCW 41.24.010.

(3) "Surviving spouse, state registered domestic partner, and dependent children" means:

(a) A lawful spouse;

(b) An ex-spouse as defined in RCW 41.26.162;

(c) A state registered domestic partner as defined in RCW 26.60.020(1); and

(d) Children. The term "children" includes children of the emergency service worker up to age 26. Children with disabilities as defined in RCW 41.26.030(6) are eligible at any age. "Children" is defined as:

(i) Biological children (including the emergency service worker's posthumous children);

(ii) Stepchildren or children of a state registered domestic partner;

(iii) Legally adopted children;

(iv) Children for whom the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption of the child;

(v) Children specified in a court order or divorce decree; or

(vi) Children as defined in RCW 26.26A.100.

(4) Surviving spouses, state registered domestic partners, and children who are eligible for medicare must enroll in both Parts A and B of medicare.

| Note: | For the exclusive purpose of medicare Part A as described in this subsection, "eligible" means the enrollee is eligible for medicare Part A without a monthly premium. |
| --- | --- |

(5) The survivor (or agent acting on their behalf) must submit the required forms to the PEBB program to either enroll or defer enrollment in PEBB retiree insurance coverage as described in subsection (7) of this section. The forms must be received by the PEBB program no later than 180 days after the later of:

(a) The death of the emergency service worker;

(b) The date on the letter from the department of retirement systems or the board for volunteer firefighters and reserve officers that informs the survivor that they are determined to be an eligible survivor;

(c) The last day the surviving spouse, state registered domestic partner, or child was covered under any health plan through the emergency service worker's employer; or

(d) The last day the surviving spouse, state registered domestic partner, or child was covered under the Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage from the emergency service worker's employer.

(6) Survivors who do not choose to defer enrollment in PEBB retiree insurance coverage may choose among the following options for when their enrollment in a PEBB health plan will begin:

(a) June 1, 2006, for survivors whose required forms are received by the PEBB program no later than September 1, 2006;

(b) The first of the month that is not earlier than 60 days before the date that the PEBB program receives the required forms (for example, if the PEBB program receives the required forms on August 29th, the survivor may request health plan enrollment to begin on July 1st); or

(c) The first of the month after the date that the PEBB program receives the required forms.

| Note: | Enrollment in the PEBB program's medicare advantage (MA) plan, medicare advantage-prescription drug (MA-PD) plan , or the Uniform Medical Plan (UMP) Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |
| --- | --- |

For surviving spouses, state registered domestic partners, and children who enroll, monthly health plan premiums and applicable premium surcharges must be paid by the survivor as described in WAC 182-08-180 (1)(c) except as provided in RCW 41.26.510(5) and 43.43.285 (2)(b).

(7) Survivors must choose one of the following two options to maintain eligibility for PEBB retiree insurance coverage:

(a) Enroll in a PEBB health plan. Any of the following enrollment applies to survivors who are not enrolled in medicare. The enrollment described in (a)(i) and (ii) of this subsection applies to survivors enrolled in medicare:

(i) Enroll in PEBB medical;

(ii) Enroll in PEBB medical and PEBB dental;

(iii) Enroll in PEBB medical and PEBB vision; or

(iv) Enroll in PEBB medical, PEBB dental, and PEBB vision.

(b) Defer enrollment:

(i) Survivors may defer enrollment in PEBB retiree insurance coverage as described in WAC 182-12-205(3).

(ii) Survivors may enroll in a PEBB health plan as described in WAC 182-12-205(6). Survivors who defer enrollment as described in WAC 182-12-205 (3)(a) through (e) must provide evidence that they were continuously enrolled in one or more qualifying coverages as described in WAC 182-12-205 (3)(a) through (e) when enrolling in a PEBB health plan. Survivors who defer enrollment as described in WAC 182-12-205 (3)(f) must provide proof of enrollment in medicare Parts A and B; evidence of continuous enrollment in a qualified coverage is waived if the deferment is based on WAC 182-12-205 (3)(f).

| Note: | Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |
| --- | --- |

(iii) PEBB health plan enrollment for an eligible spouse and children who enroll will begin as described in WAC 182-12-205(6).

(8) Survivors may change their health plan during the annual open enrollment. In addition to the annual open enrollment, survivors may change health plans as described in WAC 182-08-198.

(9) Survivors will lose their right to enroll in PEBB retiree insurance coverage if they:

(a) Do not apply to enroll or defer enrollment within the timelines as described in subsection (5) of this section; or

(b) Do not meet the requirements to defer enrollment as described in subsection (7)(b) of this section.

***(Effective January 1, 2027)***

PDF WAC 182-12-250

Public employees benefits board (PEBB) insurance coverage eligibility for survivors of emergency service personnel killed in the line of duty.

Surviving spouses, state registered domestic partners, and dependent children of emergency service personnel who are killed in the line of duty are eligible to enroll or defer enrollment in public employees benefits board (PEBB) retiree insurance coverage.

(1) This section applies to the surviving spouse, the surviving state registered domestic partner, and dependent children of emergency service personnel "killed in the line of duty" as determined by the Washington state department of labor and industries.

(2) "Emergency service personnel" means law enforcement officers and firefighters as defined in RCW 41.26.030, members of the Washington state patrol retirement fund as defined in RCW 43.43.120, and reserve officers and firefighters as defined in RCW 41.24.010.

(3) "Surviving spouse, state registered domestic partner, and dependent children" means:

(a) A lawful spouse;

(b) An ex-spouse as defined in RCW 41.26.162;

(c) A state registered domestic partner as defined in RCW 26.60.020(1); and

(d) Children. The term "children" includes children of the emergency service worker up to age 26. Children with disabilities as defined in RCW 41.26.030(6) are eligible at any age. "Children" is defined as:

(i) Biological children (including the emergency service worker's posthumous children);

(ii) Stepchildren or children of a state registered domestic partner;

(iii) Legally adopted children;

(iv) Children for whom the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption of the child;

(v) Children specified in a court order or divorce decree; or

(vi) Children as defined in RCW 26.26A.100.

(4) Surviving spouses, state registered domestic partners, and children who are eligible for medicare must enroll in both Parts A and B of medicare.

| Note: | For the exclusive purpose of medicare Part A as described in this subsection, "eligible" means the enrollee is eligible for medicare Part A without a monthly premium. |
| --- | --- |

(5) The survivor (or agent acting on their behalf) must submit the required forms to the PEBB program to either enroll or defer enrollment in PEBB retiree insurance coverage as described in subsection (7) of this section. The forms must be received by the PEBB program no later than 180 days after the later of:

(a) The death of the emergency service worker;

(b) The date on the letter from the department of retirement systems or the board for volunteer firefighters and reserve officers that informs the survivor that they are determined to be an eligible survivor;

(c) The last day the surviving spouse, state registered domestic partner, or child was covered under any health plan through the emergency service worker's employer; or

(d) The last day the surviving spouse, state registered domestic partner, or child was covered under the Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage from the emergency service worker's employer.

(6) Survivors who do not choose to defer enrollment in PEBB retiree insurance coverage may choose among the following options for when their enrollment in a PEBB health plan will begin:

(a) June 1, 2006, for survivors whose required forms are received by the PEBB program no later than September 1, 2006;

(b) The first of the month that is not earlier than 60 days before the date that the PEBB program receives the required forms (for example, if the PEBB program receives the required forms on August 29th, the survivor may request health plan enrollment to begin on July 1st); or

(c) The first of the month after the date that the PEBB program receives the required forms.

| Note: | Enrollment in the PEBB program's medicare advantage (MA) plan, medicare advantage-prescription drug (MA-PD) plan , or the Uniform Medical Plan (UMP) Classic medicare plan may not be retroactive. |
| --- | --- |
| | (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. |
| | (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. |
| | (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |

For surviving spouses, state registered domestic partners, and children who enroll, monthly health plan premiums and applicable premium surcharges must be paid by the survivor as described in WAC 182-08-180 (1)(c) except as provided in RCW 41.26.510(5) and 43.43.285 (2)(b).

(7) Survivors must choose one of the following two options to maintain eligibility for PEBB retiree insurance coverage:

(a) Enroll in a PEBB health plan. Any of the following enrollment applies to survivors who are not enrolled in medicare. The enrollment described in (a)(i) and (ii) of this subsection applies to survivors enrolled in medicare:

(i) Enroll in PEBB medical;

(ii) Enroll in PEBB medical and PEBB dental;

(iii) Enroll in PEBB medical and PEBB vision; or

(iv) Enroll in PEBB medical, PEBB dental, and PEBB vision.

(b) Defer enrollment:

(i) Survivors may defer enrollment in PEBB retiree insurance coverage as described in WAC 182-12-205(3).

(ii) Survivors may enroll in a PEBB health plan as described in WAC 182-12-205(6). Survivors who defer enrollment as described in WAC 182-12-205 (3)(a) through (e) must provide evidence that they were continuously enrolled in one or more qualifying coverages as described in WAC 182-12-205 (3)(a) through (e) when enrolling in a PEBB health plan. Survivors who defer enrollment as described in WAC 182-12-205 (3)(f) or (g) must provide proof of enrollment in medicare Parts A and B, proof of permanent residence in the United States, and proof they currently reside in the United States; evidence of continuous enrollment in a qualified coverage is not required if the deferment is based on WAC 182-12-205 (3)(f) or (g).

| Note: | Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. |
| --- | --- |
| | (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. |
| | (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. |
| | (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |

(iii) PEBB health plan enrollment for an eligible spouse and children who enroll will begin as described in WAC 182-12-205(6).

(8) Survivors may change their health plan during the annual open enrollment. In addition to the annual open enrollment, survivors may change health plans as described in WAC 182-08-198.

(9) Survivors will lose their right to enroll in PEBB retiree insurance coverage if they:

(a) Do not apply to enroll or defer enrollment within the timelines as described in subsection (5) of this section; or

(b) Do not meet the requirements to defer enrollment as described in subsection (7)(b) of this section.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 25-14-081 (Admin #2025.01.02), s 182-12-250, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-083 (Admin #2024-02), § 182-12-250, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolution PEBB 2022-03. WSR 22-13-160 (Admin #2022-02.03), § 182-12-250, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolution PEBB 2021-01. WSR 21-13-101 (Admin #2021-01.01), § 182-12-250, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-12-250, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160 and PEBB policy resolutions. WSR 18-20-117 (Admin #2018-02), § 182-12-250, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-250, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-250, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-250, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-250, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-250, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-250, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-12-250, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-12-250, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-12-250, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-12-250, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-12-250, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.080. WSR 06-20-099 (Order 06-08), § 182-12-250, filed 10/3/06, effective 11/3/06. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-250, filed 8/26/04, effective 1/1/05.](Effective January 1, 2027) PDF WAC 182-12-250 Public employees benefits board (PEBB) insurance coverage eligibility for survivors of emergency service personnel killed in the line of duty. Surviving spouses, state registered domestic partners, and dependent children of emergency service personnel who are killed in the line of duty are eligible to enroll or defer enrollment in public employees benefits board (PEBB) retiree insurance coverage.(1) This section applies to the surviving spouse, the surviving state registered domestic partner, and dependent children of emergency service personnel "killed in the line of duty" as determined by the Washington state department of labor and industries.(2) "Emergency service personnel" means law enforcement officers and firefighters as defined in RCW 41.26.030, members of the Washington state patrol retirement fund as defined in RCW 43.43.120, and reserve officers and firefighters as defined in RCW 41.24.010.(3) "Surviving spouse, state registered domestic partner, and dependent children" means:(a) A lawful spouse*
- *(b) An ex-spouse as defined in RCW 41.26.162*
- *(c) A state registered domestic partner as defined in RCW 26.60.020(1)*
- *and(d) Children. The term "children" includes children of the emergency service worker up to age 26. Children with disabilities as defined in RCW 41.26.030(6) are eligible at any age. "Children" is defined as:(i) Biological children (including the emergency service worker's posthumous children)*
- *(ii) Stepchildren or children of a state registered domestic partner*
- *(iii) Legally adopted children*
- *(iv) Children for whom the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption of the child*
- *(v) Children specified in a court order or divorce decree*
- *or(vi) Children as defined in RCW 26.26A.100.(4) Surviving spouses, state registered domestic partners, and children who are eligible for medicare must enroll in both Parts A and B of medicare.Note:For the exclusive purpose of medicare Part A as described in this subsection, "eligible" means the enrollee is eligible for medicare Part A without a monthly premium.(5) The survivor (or agent acting on their behalf) must submit the required forms to the PEBB program to either enroll or defer enrollment in PEBB retiree insurance coverage as described in subsection (7) of this section. The forms must be received by the PEBB program no later than 180 days after the later of:(a) The death of the emergency service worker*
- *(b) The date on the letter from the department of retirement systems or the board for volunteer firefighters and reserve officers that informs the survivor that they are determined to be an eligible survivor*
- *(c) The last day the surviving spouse, state registered domestic partner, or child was covered under any health plan through the emergency service worker's employer*
- *or(d) The last day the surviving spouse, state registered domestic partner, or child was covered under the Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage from the emergency service worker's employer.(6) Survivors who do not choose to defer enrollment in PEBB retiree insurance coverage may choose among the following options for when their enrollment in a PEBB health plan will begin:(a) June 1, 2006, for survivors whose required forms are received by the PEBB program no later than September 1, 2006*
- *(b) The first of the month that is not earlier than 60 days before the date that the PEBB program receives the required forms (for example, if the PEBB program receives the required forms on August 29th, the survivor may request health plan enrollment to begin on July 1st)*
- *or(c) The first of the month after the date that the PEBB program receives the required forms.Note:Enrollment in the PEBB program's medicare advantage (MA) plan, medicare advantage-prescription drug (MA-PD) plan , or the Uniform Medical Plan (UMP) Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins.For surviving spouses, state registered domestic partners, and children who enroll, monthly health plan premiums and applicable premium surcharges must be paid by the survivor as described in WAC 182-08-180 (1)(c) except as provided in RCW 41.26.510(5) and 43.43.285 (2)(b).(7) Survivors must choose one of the following two options to maintain eligibility for PEBB retiree insurance coverage:(a) Enroll in a PEBB health plan. Any of the following enrollment applies to survivors who are not enrolled in medicare. The enrollment described in (a)(i) and (ii) of this subsection applies to survivors enrolled in medicare:(i) Enroll in PEBB medical*
- *(ii) Enroll in PEBB medical and PEBB dental*
- *(iii) Enroll in PEBB medical and PEBB vision*
- *or(iv) Enroll in PEBB medical, PEBB dental, and PEBB vision.(b) Defer enrollment:(i) Survivors may defer enrollment in PEBB retiree insurance coverage as described in WAC 182-12-205(3).(ii) Survivors may enroll in a PEBB health plan as described in WAC 182-12-205(6). Survivors who defer enrollment as described in WAC 182-12-205 (3)(a) through (e) must provide evidence that they were continuously enrolled in one or more qualifying coverages as described in WAC 182-12-205 (3)(a) through (e) when enrolling in a PEBB health plan. Survivors who defer enrollment as described in WAC 182-12-205 (3)(f) or (g) must provide proof of enrollment in medicare Parts A and B, proof of permanent residence in the United States, and proof they currently reside in the United States*
- *evidence of continuous enrollment in a qualified coverage is not required if the deferment is based on WAC 182-12-205 (3)(f) or (g).Note:Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins.(iii) PEBB health plan enrollment for an eligible spouse and children who enroll will begin as described in WAC 182-12-205(6).(8) Survivors may change their health plan during the annual open enrollment. In addition to the annual open enrollment, survivors may change health plans as described in WAC 182-08-198.(9) Survivors will lose their right to enroll in PEBB retiree insurance coverage if they:(a) Do not apply to enroll or defer enrollment within the timelines as described in subsection (5) of this section*
- *or(b) Do not meet the requirements to defer enrollment as described in subsection (7)(b) of this section.[Statutory Authority: RCW 41.05.021, 41.05.065, 41.05.160, and PEBB policy resolutions. WSR 26-14-081 (Admin #2026.02), s 182-12-250, filed 6/29/26, effective 1/1/27. Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 25-14-081 (Admin #2025.01.02), s 182-12-250, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-083 (Admin #2024-02), § 182-12-250, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolution PEBB 2022-03. WSR 22-13-160 (Admin #2022-02.03), § 182-12-250, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolution PEBB 2021-01. WSR 21-13-101 (Admin #2021-01.01), § 182-12-250, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-12-250, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160 and PEBB policy resolutions. WSR 18-20-117 (Admin #2018-02), § 182-12-250, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-250, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-250, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-250, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-250, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-250, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-250, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-12-250, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-12-250, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-12-250, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-12-250, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-12-250, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.080. WSR 06-20-099 (Order 06-08), § 182-12-250, filed 10/3/06, effective 11/3/06. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-250, filed 8/26/04, effective 1/1/05.*

##### **Wash. Admin. Code § 182-12-260** Who are eligible dependents? {#sec-182-12-260 omnilex-key=us-wa-regs-official--title-182--182-12-260}

To be enrolled in PEBB health plan coverage, a dependent must be eligible under this section and the subscriber must comply with enrollment procedures outlined in WAC 182-12-262.

The public employees benefits board (PEBB) program verifies the eligibility of all dependents and will request documents from subscribers that provide evidence of a dependent's eligibility. The PEBB program reserves the right to review a dependent's eligibility at any time. The PEBB program will remove a subscriber's enrolled dependents from health plan coverage if the PEBB program is unable to verify a dependent's eligibility. A dependent will not be enrolled in PEBB health plan coverage if the PEBB program or the employing agency is unable to verify the dependent's eligibility within the PEBB program enrollment timelines.

The subscriber must provide notice, in writing, when their dependent is not eligible under this section as described in WAC 182-12-262 (2)(a).

The following are eligible as dependents:

(1) Legal spouse. A former spouse is not an eligible dependent upon finalization of a divorce or annulment, even if a court order requires the subscriber to provide health insurance for the former spouse;

(2) State registered domestic partner. A former state registered domestic partner is not an eligible dependent upon dissolution or termination of a partnership, even if a court order requires the subscriber to provide health insurance for the former partner;

(3) Children. Children are eligible through the last day of the month in which their twenty-sixth birthday occurred except as described in (g) of this subsection. Children are defined as the subscriber's:

(a) Children based on establishment of a parent-child relationship as described in RCW 26.26A.100, except when parental rights have been terminated;

(b) Children of the subscriber's spouse, based on the spouse's establishment of a parent-child relationship, except when parental rights have been terminated. The stepchild's relationship to the subscriber (and eligibility as a dependent) ends on the same date the marriage with the spouse ends through divorce, annulment, dissolution, termination, or death;

(c) Children for whom the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption of the child;

(d) Children of the subscriber's state registered domestic partner, based on the state registered domestic partner's establishment of a parent-child relationship, except when parental rights have been terminated. The child's relationship to the subscriber (and eligibility as a dependent) ends on the same date the subscriber's legal relationship with the state registered domestic partner ends through divorce, annulment, dissolution, termination, or death;

(e) Children specified in a court order or divorce decree for whom the subscriber has a legal obligation to provide support or health care coverage;

(f) Extended dependent in the legal custody or legal guardianship of the subscriber, the subscriber's spouse, or subscriber's state registered domestic partner. The legal responsibility is demonstrated by a valid court order and the child's official residence with the custodian or guardian. Extended dependent child does not include a foster child unless the subscriber, the subscriber's spouse, or the subscriber's state registered domestic partner has assumed a legal obligation for total or partial support in anticipation of adoption; and

(g) Children of any age with a developmental or physical disability that renders the child incapable of self-sustaining employment and chiefly dependent upon the subscriber for support and maintenance provided such condition occurs before the age of twenty-six:

(i) The subscriber must provide proof of the disability and dependency within sixty days of the child's attainment of age twenty-six;

(ii) The subscriber must notify the PEBB program, in writing, when the child is no longer eligible under this subsection as described in WAC 182-12-262 (2)(a);

(iii) A child with a developmental or physical disability who becomes self-supporting is not eligible under this subsection as of the last day of the month in which they become capable of self-support;

(iv) A child with a developmental or physical disability age twenty-six and older who becomes capable of self-support does not regain eligibility if they later become incapable of self-support; and

(v) The PEBB program with input from the applicable contracted vendor will periodically verify the eligibility of a dependent child with a disability beginning at age twenty-six, but no more frequently than annually after the two-year period following the child's twenty-sixth birthday. Verification will require renewed proof of disability and dependence from the subscriber.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-12-260, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-260, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-260, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-260, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-260, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-260, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4s. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-260, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-260, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-260, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-12-260, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-12-260, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-12-260, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-12-260, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-12-260, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. WSR 05-16-046 (Order 05-01), § 182-12-260, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-260, filed 8/26/04, effective 1/1/05.*

##### **Wash. Admin. Code § 182-12-262** When may subscribers enroll or remove eligible dependents? {#sec-182-12-262 omnilex-key=us-wa-regs-official--title-182--182-12-262}

WAC 182-12-262

***(Effective until January 1, 2027)***

(1) Enrolling dependents in public employees benefits board (PEBB) health plan coverage, supplemental dependent life insurance, and accidental death and dismemberment (AD&D) insurance. A dependent must be enrolled in the same health plan coverage as the subscriber unless otherwise described in the Washington Administrative Code applicable to the subscriber. The subscriber must be enrolled in health plan coverage to enroll their dependent in health plan coverage except as provided in WAC 182-12-205 (3)(c). A dependent with more than one source of eligibility for enrollment in the PEBB and school employees benefits board (SEBB) programs is limited to a single enrollment in medical, dental, and vision plans in either the PEBB or SEBB program. Subscribers must satisfy the enrollment requirements as described in subsection (4) of this section and may enroll eligible dependents at the following times:

(a) When the subscriber becomes eligible and enrolls in PEBB benefits. If eligibility is verified the dependent's effective date will be as follows:

(i) PEBB health plan coverage will be the same as the subscriber's effective date;

(ii) Supplemental dependent life insurance or AD&D insurance, if elected, will be effective the first day of the month following the date the contracted vendor receives the required form or approves the enrollment. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage is effective.

(b) During the annual open enrollment. PEBB health plan coverage begins January 1st of the following year;

(c) During special open enrollment. Subscribers may enroll dependents during a special open enrollment as described in subsection (3) of this section;

(d) When a National Medical Support Notice (NMSN) requires a subscriber to cover a dependent child in health plan coverage as described in WAC 182-12-263; or

(e) Any time during the calendar year for supplemental dependent life insurance or AD&D insurance by submitting the required form to the contracted vendor for approval. Evidence of insurability may be required for supplemental dependent life insurance but will not be required for supplemental AD&D insurance. Supplemental dependent life insurance or AD&D insurance will be effective the first day of the month following the date the contracted vendor receives the required form or approves the enrollment. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage is effective.

(2) Removing dependents from a subscriber's PEBB health plan coverage or supplemental dependent life insurance or AD&D insurance.

(a) A dependent's eligibility for enrollment in PEBB health plan coverage or supplemental dependent life insurance or AD&D insurance ends the last day of the month the dependent meets the eligibility criteria as described in WAC 182-12-250 or 182-12-260. Subscribers must provide notice when a dependent is no longer eligible due to divorce, annulment, dissolution, or qualifying event of a dependent ceasing to be eligible as a dependent child, as described in WAC 182-12-260(3). For supplemental dependent life insurance or AD&D insurance, subscribers must notify the contracted vendor on the required form, in writing, or by telephone when a dependent is no longer eligible. Contact information for the contracted vendor may be found at hca.wa.gov/employees-contact-plan. For PEBB health plan coverage, the notice must be received within 60 days of the last day of the month the dependent loses eligibility. Employees must notify their employing agency when a dependent is no longer eligible for PEBB health plan coverage, except as required under WAC 182-12-260 (3)(g)(ii). All other subscribers must notify the PEBB program. Consequences for not submitting notice within the required 60 days include, but are not limited to:

(i) The dependent may lose eligibility to continue PEBB medical, dental, or vision under one of the continuation coverage options described in WAC 182-12-270;

(ii) The subscriber may be billed for claims paid by the health plan for services that were rendered after the dependent lost eligibility as described in WAC 182-12-270;

(iii) The subscriber may not be able to recover subscriber-paid insurance premiums for dependents that lost their eligibility; and

(iv) The subscriber may be responsible for premiums paid by the state for the dependent's health plan coverage after the dependent lost eligibility.

(b) Employees have the opportunity to remove eligible dependents:

(i) During the annual open enrollment. The dependent will be removed from PEBB health plan coverage the last day of December;

(ii) During a special open enrollment as described in subsections (3) and (4)(f) of this section;

(iii) When a NMSN requires a spouse, former spouse, or other individual to provide health plan coverage for a dependent who is already enrolled in PEBB coverage, and that health plan coverage is in fact provided as described in WAC 182-12-263(2); or

(iv) Any time during the calendar year from supplemental dependent life insurance or AD&D insurance by submitting a request to the contracted vendor on the required form, in writing, or by telephone. Contact information for the contracted vendor may be found at hca.wa.gov/employees-contact-plan.

(c) Retirees (see WAC 182-12-171, 182-12-180, or 182-12-211), survivors (see WAC 182-12-180, 182-12-250, or 182-12-265), PEBB continuation coverage enrollees (see WAC 182-12-133, 182-12-141, 182-12-142, 182-12-146, or 182-12-148), and retired employees, retired school employees, or survivors continuing PEBB health plan coverage after their employer group ceased participation (see WAC 182-12-232) may remove dependents from their PEBB health plan coverage outside of the annual open enrollment or a special open enrollment by providing written notice to the PEBB program. The dependent will be removed from the subscriber's PEBB health plan coverage prospectively. PEBB health plan coverage will end on the last day of the month in which the written notice is received by the PEBB program or on the last day of the month specified in the subscriber's written notice, whichever is later. If the written notice is received on the first day of the month, PEBB health plan coverage will end on the last day of the previous month. PEBB continuation coverage enrollees may remove dependents from supplemental dependent life insurance or AD&D insurance any time during the calendar year by submitting a request to the contracted vendor on the required form, in writing, or by telephone. Contact information for the contracted vendor may be found at hca.wa.gov/employees-contact-plan.

(d) When a retiree or a survivor's dependent becomes eligible for the employer contribution toward PEBB or SEBB benefits, the subscriber's dependent will be auto disenrolled from PEBB retiree insurance coverage.

(3) Special open enrollment.

(a) Subscribers may enroll or remove their eligible dependents outside of the annual open enrollment if a special open enrollment event occurs. The change in enrollment must be allowable under the Internal Revenue Code and Treasury Regulations, and correspond to and be consistent with the event that creates the special open enrollment for the subscriber, the subscriber's dependents, or both. To disenroll from a medicare advantage (MA) plan, a medicare advantage-prescription drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan, the change in enrollment must be allowable under 42 C.F.R. Secs. 422.62(b) and 423.38(c).

(i) PEBB health plan coverage will begin the first of the month following the later of the event date or the date the required form is received. If that day is the first of the month, the change in enrollment begins on that day except for a MA plan, a MA-PD plan, or the UMP Classic medicare plan, which will begin the first day of the month following the date the form is received.

(ii) PEBB health plan coverage for an extended dependent or a dependent with a disability will begin the first day of the month following the later of the event date or eligibility certification.

(iii) The dependent will be removed from the subscriber's PEBB health plan coverage the last day of the month following the later of the event date or the date the required form and proof of the event is received. If that day is the first of the month, the change in enrollment will be made the last day of the previous month.

(iv) If the special open enrollment is due to the birth or adoption of a child, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption of a child, PEBB health plan coverage will begin or end as follows:

• For the newly born child, PEBB health plan coverage will begin the date of birth;

• For a newly adopted child, PEBB health plan coverage will begin on the date of placement or the date a legal obligation is assumed in anticipation of adoption, whichever is earlier;

• For a spouse or state registered domestic partner of a subscriber, PEBB health plan coverage will begin the first day of the month in which the event occurs. The spouse or state registered domestic partner will be removed from PEBB health plan coverage the last day of the month in which the event occurred.

(v) Supplemental dependent life insurance or AD&D insurance will begin the first day of the month following the date the contracted vendor receives the required form or approves the enrollment. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage is effective.

(b) The events described in this subsection (3)(b)(i) of this section create a special open enrollment to enroll eligible dependents in supplemental dependent life insurance or AD&D insurance. Any one of the following events may create a special open enrollment to enroll or remove eligible dependents from PEBB health plan coverage:

(i) Subscriber acquires a new dependent due to:

• Marriage or registering a state registered domestic partnership;

• Birth, adoption, or when a subscriber has assumed a legal obligation for total or partial support in anticipation of adoption; or

• A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(ii) Subscriber or a subscriber's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA);

(iii) Subscriber has a change in employment status that affects the subscriber's eligibility for their employer contribution toward their employer-based group health plan;

(iv) The subscriber's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution under their employer-based group health plan;

| Note: | As used in (iv) of this subsection, "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 54.9801-6. |
| --- | --- |

(v) Subscriber or a subscriber's dependent has a change in enrollment under an employer-based group health plan during its annual open enrollment that does not align with the PEBB program's annual open enrollment;

(vi) Subscriber's dependent has a change in residence from outside of the United States to within the United States, or from within the United States to outside of the United States and that change in residence resulted in the dependent losing their health insurance;

(vii) A court order requires the subscriber or any other individual to provide insurance coverage for an eligible dependent of the subscriber (a former spouse or former state registered domestic partner is not an eligible dependent);

(viii) Subscriber or a subscriber's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the subscriber or a subscriber's dependent loses eligibility for coverage under medicaid or CHIP;

(ix) Subscriber or a subscriber's dependent becomes eligible for state premium assistance subsidy for PEBB health plan coverage from medicaid or CHIP;

(x) Subscriber's dependent enrolls in medicare, or loses eligibility for medicare;

(xi) Subscriber or a subscriber's dependent enrolled in a MA plan, MA-PD plan, medicare supplement plan, or the UMP Classic medicare plan who gains, loses, or has a change to their low-income subsidy eligibility as described in 42 C.F.R. § 423.38 (c)(9).

(4) Enrollment requirements. A subscriber must submit the required forms within the time frames described in this subsection. For PEBB health plan coverage, an employee must submit the required forms to their employing agency, any other subscriber must submit the required forms to the PEBB program. In addition to the required forms indicating dependent enrollment, the subscriber must provide the required documents as evidence of the dependent's eligibility; or as evidence of the event that created the special open enrollment. All required forms and documents must be received within the required time frames. An employee enrolling a dependent in supplemental dependent life insurance or AD&D insurance must submit the required form to the contracted vendor for approval within the required time frames.

| Note: | When enrolling a state registered domestic partner or a state registered domestic partner's child, a subscriber must certify that the state registered domestic partner or state registered domestic partner's child is a tax dependent on the required form; otherwise, the PEBB program will assume the state registered domestic partner or state registered domestic partner's child is not a tax dependent. |
| --- | --- |

(a) If a subscriber wants to enroll their eligible dependents in PEBB health plan coverage when the subscriber becomes eligible to enroll in PEBB benefits, the subscriber must include the dependent's enrollment information on the required forms and submit them within the required time frame described in WAC 182-08-197, 182-12-171, 182-12-180, 182-12-211, 182-12-232, or 182-12-250. If an employee enrolls a dependent in supplemental dependent life insurance or AD&D insurance, the required form must be submitted within the required time frame described in WAC 182-08-197.

(b) If a subscriber wants to enroll eligible dependents in PEBB health plan coverage during the PEBB annual open enrollment period, the required forms must be received no later than the last day of the annual open enrollment.

(c) If a subscriber wants to enroll newly eligible dependents, the required forms must be received no later than 60 days after the dependent becomes eligible. An employee enrolling a dependent in supplemental dependent life insurance or AD&D insurance must submit the required form to the contracted vendor for approval. An employee may enroll a dependent in supplemental dependent life insurance up to the guaranteed issue coverage amount without evidence of insurability if the required form is submitted to the contracted vendor as required. Evidence of insurability will be required for supplemental dependent life insurance over the guaranteed issue coverage amount. Evidence of insurability is not required for supplemental AD&D insurance.

(d) If a subscriber wants to enroll a newborn or child whom the subscriber has adopted or has assumed a legal obligation for total or partial support in anticipation of adoption in PEBB health plan coverage, the subscriber should notify the PEBB program by submitting the required forms as soon as possible to ensure timely payment of claims. If adding the child increases the premium, the required forms must be received no later than 60 days after the date of the birth, adoption, or the date the legal obligation is assumed for total or partial support in anticipation of adoption. An employee enrolling a dependent in supplemental dependent life insurance or AD&D insurance must submit the required form to the contracted vendor for approval no later than 60 days after the date of the birth, adoption, or the date the legal obligation is assumed for total or partial support in anticipation of adoption. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage can become effective.

(e) If the subscriber wants to enroll a child age 26 or older as a child with a disability in PEBB health plan coverage, the required forms must be received no later than 60 days after the child reaches age 26 or within the relevant time frame described in (a), (b), and (f) of this subsection. To recertify an enrolled child with a disability, the required forms must be received by the PEBB program or the contracted vendor by the child's scheduled PEBB health plan coverage termination date.

(f) If the subscriber wants to change a dependent's enrollment status in PEBB health plan coverage during a special open enrollment, the required forms must be received no later than 60 days after the event that creates the special open enrollment.

| Exception: | If the subscriber wants to change a dependent's enrollment or disenrollment in a MA plan, a MA-PD plan, or the UMP Classic medicare plan, the required forms must be received during a special enrollment period as allowed under 42 C.F.R. Secs. 422.62(b) and 423.38(c). |
| --- | --- |

(g) An employee may enroll a dependent in supplemental dependent life insurance or AD&D insurance at any time during the calendar year by submitting the required form to the contracted vendor for approval. Evidence of insurability may be required for supplemental dependent life insurance but will not be required for supplemental AD&D insurance.

***(Effective January 1, 2027)***

PDF WAC 182-12-262

When may subscribers enroll or remove eligible dependents?

(1) Enrolling dependents in public employees benefits board (PEBB) health plan coverage, supplemental dependent life insurance, and accidental death and dismemberment (AD&D) insurance. A dependent must be enrolled in the same health plan coverage as the subscriber unless otherwise described in the Washington Administrative Code applicable to the subscriber. The subscriber must be enrolled in health plan coverage to enroll their dependent in health plan coverage except as provided in WAC 182-12-205 (3)(c). A dependent with more than one source of eligibility for enrollment in the PEBB and school employees benefits board (SEBB) programs is limited to a single enrollment in medical, dental, and vision plans in either the PEBB or SEBB program. Subscribers must satisfy the enrollment requirements as described in subsection (4) of this section and may enroll eligible dependents at the following times:

(a) When the subscriber becomes eligible and enrolls in PEBB benefits. If eligibility is verified the dependent's effective date will be as follows:

(i) PEBB health plan coverage will be the same as the subscriber's effective date;

(ii) Supplemental dependent life insurance or AD&D insurance, if elected, will be effective the first day of the month following the date the contracted vendor receives the required form or approves the enrollment. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage is effective.

(b) During the annual open enrollment. PEBB health plan coverage begins January 1st of the following year;

(c) During special open enrollment. Subscribers may enroll dependents during a special open enrollment as described in subsection (3) of this section;

(d) When a National Medical Support Notice (NMSN) requires a subscriber to cover a dependent child in health plan coverage as described in WAC 182-12-263; or

(e) Any time during the calendar year for supplemental dependent life insurance or AD&D insurance by submitting the required form to the contracted vendor for approval. Evidence of insurability may be required for supplemental dependent life insurance but will not be required for supplemental AD&D insurance. Supplemental dependent life insurance or AD&D insurance will be effective the first day of the month following the date the contracted vendor receives the required form or approves the enrollment. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage is effective.

(2) Removing dependents from a subscriber's PEBB health plan coverage or supplemental dependent life insurance or AD&D insurance.

(a) A dependent's eligibility for enrollment in PEBB health plan coverage or supplemental dependent life insurance or AD&D insurance ends the last day of the month the dependent meets the eligibility criteria as described in WAC 182-12-250 or 182-12-260. Subscribers must provide notice when a dependent is no longer eligible due to divorce, annulment, dissolution, or qualifying event of a dependent ceasing to be eligible as a dependent child, as described in WAC 182-12-260(3). For supplemental dependent life insurance or AD&D insurance, subscribers must notify the contracted vendor on the required form, in writing, or by telephone when a dependent is no longer eligible. Contact information for the contracted vendor may be found at hca.wa.gov/employees-contact-plan. For PEBB health plan coverage, the notice must be received within 60 days of the last day of the month the dependent loses eligibility. Employees must notify their employing agency when a dependent is no longer eligible for PEBB health plan coverage, except as required under WAC 182-12-260 (3)(g)(ii). All other subscribers must notify the PEBB program. Consequences for not submitting notice within the required 60 days include, but are not limited to:

(i) The dependent may lose eligibility to continue PEBB medical, dental, or vision under one of the continuation coverage options described in WAC 182-12-270;

(ii) The subscriber may be billed for claims paid by the health plan for services that were rendered after the dependent lost eligibility as described in WAC 182-12-270;

(iii) The subscriber may not be able to recover subscriber-paid insurance premiums for dependents that lost their eligibility; and

(iv) The subscriber may be responsible for premiums paid by the state for the dependent's health plan coverage after the dependent lost eligibility.

(b) Employees have the opportunity to remove eligible dependents:

(i) During the annual open enrollment. The dependent will be removed from PEBB health plan coverage the last day of December;

(ii) During a special open enrollment as described in subsections (3) and (4)(f) of this section;

(iii) When a NMSN requires a spouse, former spouse, or other individual to provide health plan coverage for a dependent who is already enrolled in PEBB coverage, and that health plan coverage is in fact provided as described in WAC 182-12-263(2); or

(iv) Any time during the calendar year from supplemental dependent life insurance or AD&D insurance by submitting a request to the contracted vendor on the required form, in writing, or by telephone. Contact information for the contracted vendor may be found at hca.wa.gov/employees-contact-plan.

(c) Retirees (see WAC 182-12-171, 182-12-180, or 182-12-211), survivors (see WAC 182-12-180, 182-12-250, or 182-12-265), PEBB continuation coverage enrollees (see WAC 182-12-133, 182-12-141, 182-12-142, 182-12-146, or 182-12-148), and retired employees, retired school employees, or survivors continuing PEBB health plan coverage after their employer group ceased participation (see WAC 182-12-232) may remove dependents from their PEBB health plan coverage outside of the annual open enrollment or a special open enrollment by providing written notice to the PEBB program. The dependent will be removed from the subscriber's PEBB health plan coverage prospectively. PEBB health plan coverage will end on the last day of the month in which the written notice is received by the PEBB program or on the last day of the month specified in the subscriber's written notice, whichever is later. If the written notice is received on the first day of the month, PEBB health plan coverage will end on the last day of the previous month. PEBB continuation coverage enrollees may remove dependents from supplemental dependent life insurance or AD&D insurance any time during the calendar year by submitting a request to the contracted vendor on the required form, in writing, or by telephone. Contact information for the contracted vendor may be found at hca.wa.gov/employees-contact-plan.

(d) When a retiree or a survivor's dependent becomes eligible for the employer contribution toward PEBB or SEBB benefits, the subscriber's dependent will be auto disenrolled from PEBB retiree insurance coverage.

(3) Special open enrollment.

(a) Subscribers may enroll or remove their eligible dependents outside of the annual open enrollment if a special open enrollment event occurs. The change in enrollment must be allowable under the Internal Revenue Code and Treasury Regulations, and correspond to and be consistent with the event that creates the special open enrollment for the subscriber, the subscriber's dependents, or both. To disenroll from a medicare advantage (MA) plan, a medicare advantage-prescription drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan, the change in enrollment must be allowable under 42 C.F.R. Secs. 422.62(b) and 423.38(c).

(i) PEBB health plan coverage will begin the first of the month following the later of the event date or the date the required form is received. If that day is the first of the month, the change in enrollment begins on that day except for a MA plan, a MA-PD plan, or the UMP Classic medicare plan, which will begin the first day of the month following the date the form is received.

| Note: | As used in (a)(i) of this subsection, "the date the required form is received" may determine the effective date of coverage before proof of the event is received. |
| --- | --- |

(ii) PEBB health plan coverage for an extended dependent or a dependent with a disability will begin the first day of the month following the later of the event date or eligibility certification.

(iii) The dependent will be removed from the subscriber's PEBB health plan coverage the last day of the month following the later of the event date or the date the required form and proof of the event is received. If that day is the first of the month, the change in enrollment will be made the last day of the previous month.

(iv) If the special open enrollment is due to the birth or adoption of a child, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption of a child, PEBB health plan coverage will begin or end as follows:

• For the newly born child, PEBB health plan coverage will begin the date of birth;

• For a newly adopted child, PEBB health plan coverage will begin on the date of placement or the date a legal obligation is assumed in anticipation of adoption, whichever is earlier;

• For a spouse or state registered domestic partner of a subscriber, PEBB health plan coverage will begin the first day of the month in which the event occurs. The spouse or state registered domestic partner will be removed from PEBB health plan coverage the last day of the month in which the event occurred.

(v) Supplemental dependent life insurance or AD&D insurance will begin the first day of the month following the date the contracted vendor receives the required form or approves the enrollment. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage is effective.

(b) The events described in this subsection (3)(b)(i) of this section create a special open enrollment to enroll eligible dependents in supplemental dependent life insurance or AD&D insurance. Any one of the following events may create a special open enrollment to enroll or remove eligible dependents from PEBB health plan coverage:

(i) Subscriber acquires a new dependent due to:

• Marriage or registering a state registered domestic partnership;

• Birth, adoption, or when a subscriber has assumed a legal obligation for total or partial support in anticipation of adoption; or

• A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(ii) Subscriber or a subscriber's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA);

(iii) Subscriber has a change in employment status that affects the subscriber's eligibility for their employer contribution toward their employer-based group health plan;

(iv) The subscriber's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution under their employer-based group health plan;

| Note: | As used in (iv) of this subsection, "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 54.9801-6. |
| --- | --- |

(v) Subscriber or a subscriber's dependent has a change in enrollment under an employer-based group health plan during its annual open enrollment that does not align with the PEBB program's annual open enrollment;

(vi) Subscriber's dependent has a change in residence from outside of the United States to within the United States, or from within the United States to outside of the United States and that change in residence resulted in the dependent losing their health insurance;

(vii) A court order requires the subscriber or any other individual to provide insurance coverage for an eligible dependent of the subscriber (a former spouse or former state registered domestic partner is not an eligible dependent);

(viii) Subscriber or a subscriber's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the subscriber or a subscriber's dependent loses eligibility for coverage under medicaid or CHIP;

(ix) Subscriber or a subscriber's dependent becomes eligible for state premium assistance subsidy for PEBB health plan coverage from medicaid or CHIP;

(x) Subscriber's dependent enrolls in medicare, or loses eligibility for medicare;

(xi) Subscriber or a subscriber's dependent enrolled in a MA plan, MA-PD plan, medicare supplement plan, or the UMP Classic medicare plan who gains, loses, or has a change to their low-income subsidy eligibility as described in 42 C.F.R. § 423.38 (c)(9);

(xii) Subscriber or a subscriber's dependent becomes eligible and enrolls in a TRICARE plan or loses eligibility for a TRICARE plan.

(4) Enrollment requirements. A subscriber must submit the required forms within the time frames described in this subsection. For PEBB health plan coverage, an employee must submit the required forms to their employing agency, any other subscriber must submit the required forms to the PEBB program. In addition to the required forms indicating dependent enrollment, the subscriber must provide the required documents as evidence of the dependent's eligibility; or as evidence of the event that created the special open enrollment. All required forms and documents must be received within the required time frames. An employee enrolling a dependent in supplemental dependent life insurance or AD&D insurance must submit the required form to the contracted vendor for approval within the required time frames.

| Note: | When enrolling a state registered domestic partner or a state registered domestic partner's child, a subscriber must certify that the state registered domestic partner or state registered domestic partner's child is a tax dependent on the required form; otherwise, the PEBB program will assume the state registered domestic partner or state registered domestic partner's child is not a tax dependent. |
| --- | --- |

(a) If a subscriber wants to enroll their eligible dependents in PEBB health plan coverage when the subscriber becomes eligible to enroll in PEBB benefits, the subscriber must include the dependent's enrollment information on the required forms and submit them within the required time frame described in WAC 182-08-197, 182-12-171, 182-12-180, 182-12-211, 182-12-232, or 182-12-250. If an employee enrolls a dependent in supplemental dependent life insurance or AD&D insurance, the required form must be submitted within the required time frame described in WAC 182-08-197.

(b) If a subscriber wants to enroll eligible dependents in PEBB health plan coverage during the PEBB annual open enrollment period, the required forms must be received no later than the last day of the annual open enrollment.

(c) If a subscriber wants to enroll newly eligible dependents, the required forms must be received no later than 60 days after the dependent becomes eligible. An employee enrolling a dependent in supplemental dependent life insurance or AD&D insurance must submit the required form to the contracted vendor for approval. An employee may enroll a dependent in supplemental dependent life insurance up to the guaranteed issue coverage amount without evidence of insurability if the required form is submitted to the contracted vendor as required. Evidence of insurability will be required for supplemental dependent life insurance over the guaranteed issue coverage amount. Evidence of insurability is not required for supplemental AD&D insurance.

(d) If a subscriber wants to enroll a newborn or child whom the subscriber has adopted or has assumed a legal obligation for total or partial support in anticipation of adoption in PEBB health plan coverage, the subscriber should notify the PEBB program by submitting the required forms as soon as possible to ensure timely payment of claims. If adding the child increases the premium, the required forms must be received no later than 60 days after the date of the birth, adoption, or the date the legal obligation is assumed for total or partial support in anticipation of adoption. An employee enrolling a dependent in supplemental dependent life insurance or AD&D insurance must submit the required form to the contracted vendor for approval no later than 60 days after the date of the birth, adoption, or the date the legal obligation is assumed for total or partial support in anticipation of adoption. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage can become effective.

(e) If the subscriber wants to enroll a child age 26 or older as a child with a disability in PEBB health plan coverage, the required forms must be received no later than 60 days after the child reaches age 26 or within the relevant time frame described in (a), (b), and (f) of this subsection. To recertify an enrolled child with a disability, the required forms must be received by the PEBB program or the contracted vendor by the child's scheduled PEBB health plan coverage termination date.

(f) If the subscriber wants to change a dependent's enrollment status in PEBB health plan coverage during a special open enrollment, the required forms must be received no later than 60 days after the event that creates the special open enrollment.

| Exception: | If the subscriber wants to change a dependent's enrollment or disenrollment in a MA plan, a MA-PD plan, or the UMP Classic medicare plan, the required forms must be received during a special enrollment period as allowed under 42 C.F.R. Secs. 422.62(b) and 423.38(c). |
| --- | --- |

(g) An employee may enroll a dependent in supplemental dependent life insurance or AD&D insurance at any time during the calendar year by submitting the required form to the contracted vendor for approval. Evidence of insurability may be required for supplemental dependent life insurance but will not be required for supplemental AD&D insurance.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 25-14-084 (Admin #2025-02), s 182-12-262, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.05.065, 41.05.160, 2023 c 164 § 1, 2023 c 312 § 1, 2023 c 13 § 5, Policy Resolutions PEBB 2024-14, 2024-19, 2024-20, and 2024-21. WSR 24-18-081 (Admin #2024-01.05), § 182-12-262, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-12-262, filed 6/23/23, effective 1/1/24*
- *WSR 22-13-158 (Admin #2022-01), § 182-12-262, filed 6/21/22, effective 1/1/23*
- *WSR 21-13-106 (Admin #2021-01.06), § 182-12-262, filed 6/18/21, effective 1/1/22*
- *WSR 20-16-062 (Admin #2020-03), § 182-12-262, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-262, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-262, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-262, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-262, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-262, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-262, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160, 2013 2nd sp.s. c 4 and PEBB policy resolutions. WSR 14-08-040, § 182-12-262, filed 3/26/14, effective 4/26/14. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-262, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-262, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-12-262, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-12-262, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-12-262, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-12-262, filed 10/1/08, effective 1/1/09*
- *WSR 08-09-027 (Order 08-01), § 182-12-262, filed 4/8/08, effective 4/9/08.](Effective January 1, 2027) PDF WAC 182-12-262 When may subscribers enroll or remove eligible dependents? (1) Enrolling dependents in public employees benefits board (PEBB) health plan coverage, supplemental dependent life insurance, and accidental death and dismemberment (AD&D) insurance. A dependent must be enrolled in the same health plan coverage as the subscriber unless otherwise described in the Washington Administrative Code applicable to the subscriber. The subscriber must be enrolled in health plan coverage to enroll their dependent in health plan coverage except as provided in WAC 182-12-205 (3)(c). A dependent with more than one source of eligibility for enrollment in the PEBB and school employees benefits board (SEBB) programs is limited to a single enrollment in medical, dental, and vision plans in either the PEBB or SEBB program. Subscribers must satisfy the enrollment requirements as described in subsection (4) of this section and may enroll eligible dependents at the following times:(a) When the subscriber becomes eligible and enrolls in PEBB benefits. If eligibility is verified the dependent's effective date will be as follows:(i) PEBB health plan coverage will be the same as the subscriber's effective date*
- *(ii) Supplemental dependent life insurance or AD&D insurance, if elected, will be effective the first day of the month following the date the contracted vendor receives the required form or approves the enrollment. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage is effective.(b) During the annual open enrollment. PEBB health plan coverage begins January 1st of the following year*
- *(c) During special open enrollment. Subscribers may enroll dependents during a special open enrollment as described in subsection (3) of this section*
- *(d) When a National Medical Support Notice (NMSN) requires a subscriber to cover a dependent child in health plan coverage as described in WAC 182-12-263*
- *or(e) Any time during the calendar year for supplemental dependent life insurance or AD&D insurance by submitting the required form to the contracted vendor for approval. Evidence of insurability may be required for supplemental dependent life insurance but will not be required for supplemental AD&D insurance. Supplemental dependent life insurance or AD&D insurance will be effective the first day of the month following the date the contracted vendor receives the required form or approves the enrollment. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage is effective.(2) Removing dependents from a subscriber's PEBB health plan coverage or supplemental dependent life insurance or AD&D insurance.(a) A dependent's eligibility for enrollment in PEBB health plan coverage or supplemental dependent life insurance or AD&D insurance ends the last day of the month the dependent meets the eligibility criteria as described in WAC 182-12-250 or 182-12-260. Subscribers must provide notice when a dependent is no longer eligible due to divorce, annulment, dissolution, or qualifying event of a dependent ceasing to be eligible as a dependent child, as described in WAC 182-12-260(3). For supplemental dependent life insurance or AD&D insurance, subscribers must notify the contracted vendor on the required form, in writing, or by telephone when a dependent is no longer eligible. Contact information for the contracted vendor may be found at hca.wa.gov/employees-contact-plan. For PEBB health plan coverage, the notice must be received within 60 days of the last day of the month the dependent loses eligibility. Employees must notify their employing agency when a dependent is no longer eligible for PEBB health plan coverage, except as required under WAC 182-12-260 (3)(g)(ii). All other subscribers must notify the PEBB program. Consequences for not submitting notice within the required 60 days include, but are not limited to:(i) The dependent may lose eligibility to continue PEBB medical, dental, or vision under one of the continuation coverage options described in WAC 182-12-270*
- *(ii) The subscriber may be billed for claims paid by the health plan for services that were rendered after the dependent lost eligibility as described in WAC 182-12-270*
- *(iii) The subscriber may not be able to recover subscriber-paid insurance premiums for dependents that lost their eligibility*
- *and(iv) The subscriber may be responsible for premiums paid by the state for the dependent's health plan coverage after the dependent lost eligibility.(b) Employees have the opportunity to remove eligible dependents:(i) During the annual open enrollment. The dependent will be removed from PEBB health plan coverage the last day of December*
- *(ii) During a special open enrollment as described in subsections (3) and (4)(f) of this section*
- *(iii) When a NMSN requires a spouse, former spouse, or other individual to provide health plan coverage for a dependent who is already enrolled in PEBB coverage, and that health plan coverage is in fact provided as described in WAC 182-12-263(2)*
- *or(iv) Any time during the calendar year from supplemental dependent life insurance or AD&D insurance by submitting a request to the contracted vendor on the required form, in writing, or by telephone. Contact information for the contracted vendor may be found at hca.wa.gov/employees-contact-plan.(c) Retirees (see WAC 182-12-171, 182-12-180, or 182-12-211), survivors (see WAC 182-12-180, 182-12-250, or 182-12-265), PEBB continuation coverage enrollees (see WAC 182-12-133, 182-12-141, 182-12-142, 182-12-146, or 182-12-148), and retired employees, retired school employees, or survivors continuing PEBB health plan coverage after their employer group ceased participation (see WAC 182-12-232) may remove dependents from their PEBB health plan coverage outside of the annual open enrollment or a special open enrollment by providing written notice to the PEBB program. The dependent will be removed from the subscriber's PEBB health plan coverage prospectively. PEBB health plan coverage will end on the last day of the month in which the written notice is received by the PEBB program or on the last day of the month specified in the subscriber's written notice, whichever is later. If the written notice is received on the first day of the month, PEBB health plan coverage will end on the last day of the previous month. PEBB continuation coverage enrollees may remove dependents from supplemental dependent life insurance or AD&D insurance any time during the calendar year by submitting a request to the contracted vendor on the required form, in writing, or by telephone. Contact information for the contracted vendor may be found at hca.wa.gov/employees-contact-plan.(d) When a retiree or a survivor's dependent becomes eligible for the employer contribution toward PEBB or SEBB benefits, the subscriber's dependent will be auto disenrolled from PEBB retiree insurance coverage.(3) Special open enrollment.(a) Subscribers may enroll or remove their eligible dependents outside of the annual open enrollment if a special open enrollment event occurs. The change in enrollment must be allowable under the Internal Revenue Code and Treasury Regulations, and correspond to and be consistent with the event that creates the special open enrollment for the subscriber, the subscriber's dependents, or both. To disenroll from a medicare advantage (MA) plan, a medicare advantage-prescription drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan, the change in enrollment must be allowable under 42 C.F.R. Secs. 422.62(b) and 423.38(c).(i) PEBB health plan coverage will begin the first of the month following the later of the event date or the date the required form is received. If that day is the first of the month, the change in enrollment begins on that day except for a MA plan, a MA-PD plan, or the UMP Classic medicare plan, which will begin the first day of the month following the date the form is received.Note:As used in (a)(i) of this subsection, "the date the required form is received" may determine the effective date of coverage before proof of the event is received. (ii) PEBB health plan coverage for an extended dependent or a dependent with a disability will begin the first day of the month following the later of the event date or eligibility certification.(iii) The dependent will be removed from the subscriber's PEBB health plan coverage the last day of the month following the later of the event date or the date the required form and proof of the event is received. If that day is the first of the month, the change in enrollment will be made the last day of the previous month.(iv) If the special open enrollment is due to the birth or adoption of a child, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption of a child, PEBB health plan coverage will begin or end as follows:• For the newly born child, PEBB health plan coverage will begin the date of birth*
- *• For a newly adopted child, PEBB health plan coverage will begin on the date of placement or the date a legal obligation is assumed in anticipation of adoption, whichever is earlier*
- *• For a spouse or state registered domestic partner of a subscriber, PEBB health plan coverage will begin the first day of the month in which the event occurs. The spouse or state registered domestic partner will be removed from PEBB health plan coverage the last day of the month in which the event occurred.(v) Supplemental dependent life insurance or AD&D insurance will begin the first day of the month following the date the contracted vendor receives the required form or approves the enrollment. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage is effective.(b) The events described in this subsection (3)(b)(i) of this section create a special open enrollment to enroll eligible dependents in supplemental dependent life insurance or AD&D insurance. Any one of the following events may create a special open enrollment to enroll or remove eligible dependents from PEBB health plan coverage:(i) Subscriber acquires a new dependent due to:• Marriage or registering a state registered domestic partnership*
- *• Birth, adoption, or when a subscriber has assumed a legal obligation for total or partial support in anticipation of adoption*
- *or• A child becoming eligible as an extended dependent through legal custody or legal guardianship.(ii) Subscriber or a subscriber's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA)*
- *(iii) Subscriber has a change in employment status that affects the subscriber's eligibility for their employer contribution toward their employer-based group health plan*
- *(iv) The subscriber's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution under their employer-based group health plan*
- *Note:As used in (iv) of this subsection, "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 54.9801-6.(v) Subscriber or a subscriber's dependent has a change in enrollment under an employer-based group health plan during its annual open enrollment that does not align with the PEBB program's annual open enrollment*
- *(vi) Subscriber's dependent has a change in residence from outside of the United States to within the United States, or from within the United States to outside of the United States and that change in residence resulted in the dependent losing their health insurance*
- *(vii) A court order requires the subscriber or any other individual to provide insurance coverage for an eligible dependent of the subscriber (a former spouse or former state registered domestic partner is not an eligible dependent)*
- *(viii) Subscriber or a subscriber's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the subscriber or a subscriber's dependent loses eligibility for coverage under medicaid or CHIP*
- *(ix) Subscriber or a subscriber's dependent becomes eligible for state premium assistance subsidy for PEBB health plan coverage from medicaid or CHIP*
- *(x) Subscriber's dependent enrolls in medicare, or loses eligibility for medicare*
- *(xi) Subscriber or a subscriber's dependent enrolled in a MA plan, MA-PD plan, medicare supplement plan, or the UMP Classic medicare plan who gains, loses, or has a change to their low-income subsidy eligibility as described in 42 C.F.R. § 423.38 (c)(9)*
- *(xii) Subscriber or a subscriber's dependent becomes eligible and enrolls in a TRICARE plan or loses eligibility for a TRICARE plan.(4) Enrollment requirements. A subscriber must submit the required forms within the time frames described in this subsection. For PEBB health plan coverage, an employee must submit the required forms to their employing agency, any other subscriber must submit the required forms to the PEBB program. In addition to the required forms indicating dependent enrollment, the subscriber must provide the required documents as evidence of the dependent's eligibility*
- *or as evidence of the event that created the special open enrollment. All required forms and documents must be received within the required time frames. An employee enrolling a dependent in supplemental dependent life insurance or AD&D insurance must submit the required form to the contracted vendor for approval within the required time frames.Note:When enrolling a state registered domestic partner or a state registered domestic partner's child, a subscriber must certify that the state registered domestic partner or state registered domestic partner's child is a tax dependent on the required form*
- *otherwise, the PEBB program will assume the state registered domestic partner or state registered domestic partner's child is not a tax dependent.(a) If a subscriber wants to enroll their eligible dependents in PEBB health plan coverage when the subscriber becomes eligible to enroll in PEBB benefits, the subscriber must include the dependent's enrollment information on the required forms and submit them within the required time frame described in WAC 182-08-197, 182-12-171, 182-12-180, 182-12-211, 182-12-232, or 182-12-250. If an employee enrolls a dependent in supplemental dependent life insurance or AD&D insurance, the required form must be submitted within the required time frame described in WAC 182-08-197.(b) If a subscriber wants to enroll eligible dependents in PEBB health plan coverage during the PEBB annual open enrollment period, the required forms must be received no later than the last day of the annual open enrollment.(c) If a subscriber wants to enroll newly eligible dependents, the required forms must be received no later than 60 days after the dependent becomes eligible. An employee enrolling a dependent in supplemental dependent life insurance or AD&D insurance must submit the required form to the contracted vendor for approval. An employee may enroll a dependent in supplemental dependent life insurance up to the guaranteed issue coverage amount without evidence of insurability if the required form is submitted to the contracted vendor as required. Evidence of insurability will be required for supplemental dependent life insurance over the guaranteed issue coverage amount. Evidence of insurability is not required for supplemental AD&D insurance.(d) If a subscriber wants to enroll a newborn or child whom the subscriber has adopted or has assumed a legal obligation for total or partial support in anticipation of adoption in PEBB health plan coverage, the subscriber should notify the PEBB program by submitting the required forms as soon as possible to ensure timely payment of claims. If adding the child increases the premium, the required forms must be received no later than 60 days after the date of the birth, adoption, or the date the legal obligation is assumed for total or partial support in anticipation of adoption. An employee enrolling a dependent in supplemental dependent life insurance or AD&D insurance must submit the required form to the contracted vendor for approval no later than 60 days after the date of the birth, adoption, or the date the legal obligation is assumed for total or partial support in anticipation of adoption. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage can become effective.(e) If the subscriber wants to enroll a child age 26 or older as a child with a disability in PEBB health plan coverage, the required forms must be received no later than 60 days after the child reaches age 26 or within the relevant time frame described in (a), (b), and (f) of this subsection. To recertify an enrolled child with a disability, the required forms must be received by the PEBB program or the contracted vendor by the child's scheduled PEBB health plan coverage termination date.(f) If the subscriber wants to change a dependent's enrollment status in PEBB health plan coverage during a special open enrollment, the required forms must be received no later than 60 days after the event that creates the special open enrollment.Exception:If the subscriber wants to change a dependent's enrollment or disenrollment in a MA plan, a MA-PD plan, or the UMP Classic medicare plan, the required forms must be received during a special enrollment period as allowed under 42 C.F.R. Secs. 422.62(b) and 423.38(c).(g) An employee may enroll a dependent in supplemental dependent life insurance or AD&D insurance at any time during the calendar year by submitting the required form to the contracted vendor for approval. Evidence of insurability may be required for supplemental dependent life insurance but will not be required for supplemental AD&D insurance.[Statutory Authority: RCW 41.05.021, 41.05.065, and 41.05.160. WSR 26-14-080 (Admin #2026.01), s 182-12-262, filed 6/29/26, effective 1/1/27*
- *WSR 25-14-084 (Admin #2025-02), s 182-12-262, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.05.065, 41.05.160, 2023 c 164 § 1, 2023 c 312 § 1, 2023 c 13 § 5, Policy Resolutions PEBB 2024-14, 2024-19, 2024-20, and 2024-21. WSR 24-18-081 (Admin #2024-01.05), § 182-12-262, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-12-262, filed 6/23/23, effective 1/1/24*
- *WSR 22-13-158 (Admin #2022-01), § 182-12-262, filed 6/21/22, effective 1/1/23*
- *WSR 21-13-106 (Admin #2021-01.06), § 182-12-262, filed 6/18/21, effective 1/1/22*
- *WSR 20-16-062 (Admin #2020-03), § 182-12-262, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-262, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-262, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-262, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-262, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-262, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-262, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160, 2013 2nd sp.s. c 4 and PEBB policy resolutions. WSR 14-08-040, § 182-12-262, filed 3/26/14, effective 4/26/14. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-262, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-262, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-12-262, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-12-262, filed 10/6/10, effective 1/1/11*
- *WSR 09-23-102 (Order 09-02), § 182-12-262, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-12-262, filed 10/1/08, effective 1/1/09*
- *WSR 08-09-027 (Order 08-01), § 182-12-262, filed 4/8/08, effective 4/9/08.*

##### **Wash. Admin. Code § 182-12-263** National Medical Support Notice (NMSN). {#sec-182-12-263 omnilex-key=us-wa-regs-official--title-182--182-12-263}

(1) When a National Medical Support Notice (NMSN) requires a subscriber to provide health plan coverage for a dependent child the following provisions apply:

(a) The subscriber may enroll their dependent child and request changes to their health plan coverage as described under subsection (c) of this section. Employees submit the required forms to their employing agency. All other subscribers submit the required forms to the public employees benefits board (PEBB) program.

(b) If the subscriber fails to request enrollment or health plan coverage changes as directed by the NMSN, the employing agency or the PEBB program may make enrollment or health plan coverage changes according to (c) of this subsection upon request of:

(i) The child's other parent; or

(ii) Child support enforcement program.

(c) Changes to health plan coverage or enrollment are allowed as directed by the NMSN:

(i) The dependent will be enrolled under the subscriber's health plan coverage as directed by the NMSN;

(ii) An employee who has waived PEBB medical under WAC 182-12-128 will be enrolled in medical as directed by the NMSN, in order to enroll the dependent;

(iii) The subscriber's selected health plan will be changed if directed by the NMSN;

(iv) If the dependent is already enrolled under another PEBB subscriber, the dependent will be removed from the other health plan coverage and enrolled as directed by the NMSN;

(v) If the dependent is enrolled in both school employees benefits board medical and PEBB medical as a dependent as described in WAC 182-12-123 (6)(f) and there is a NMSN in place, enrollment will be in accordance with the NMSN; or

(vi) If the subscriber is eligible for and elects Consolidated Omnibus Budget Reconciliation Act (COBRA) or other continuation coverage, the NMSN will be enforced and the dependent must be covered in accordance with the NMSN.

(d) Changes to health plan coverage or enrollment as described in (c)(i) through (iii) of this subsection will begin the first day of the month following receipt by the employing agency or the PEBB program of the NMSN. If the NMSN is received on the first day of the month, the change to health plan coverage or enrollment begins on that day. A dependent will be removed from the subscriber's health plan coverage as described in (c)(iv) of this subsection the last day of the month the NMSN is received. If that day is the first of the month, the change in enrollment will be made the last day of the previous month.

(2) When a NMSN requires a spouse, former spouse, or other individual to provide health plan coverage for a dependent who is already enrolled in PEBB coverage, and that health plan coverage is in fact provided, the dependent may be removed from the subscriber's PEBB health plan coverage prospectively.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-12-263, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-12-263, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions PEBB 2021-02, 2021-03, 2021-04, 2021-05, 2021-06, 2021-07, 2021-08, 2021-09. WSR 21-13-102 (Admin #2021-01.02), § 182-12-263, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-12-263, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-263, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-263, filed 10/3/18, effective 1/1/19. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-263, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-263, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-12-263, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-263, filed 9/25/12, effective 11/1/12.*

##### **Wash. Admin. Code § 182-12-265** What options for continuing health plan enrollment are available to a surviving spouse, state registered domestic partner, or child, if an employee, a school employee, or a retiree dies? {#sec-182-12-265 omnilex-key=us-wa-regs-official--title-182--182-12-265}

WAC 182-12-265

***(Effective until January 1, 2027)***

The survivor of an eligible employee, an eligible school employee, or a retiree who meets the eligibility criteria and submits the required forms as described in subsection (1), (2), or (3) of this section is eligible to enroll or defer enrollment as a survivor under public employees benefits board (PEBB) retiree insurance coverage. If enrolling in PEBB retiree insurance coverage, the survivor's first premium payment and applicable premium surcharges are due to the health care authority (HCA) no later than 45 days after the election period ends as described in subsection (1), (2), or (3) of this section, except as described in WAC 182-08-180 (1)(a). Following the survivor's first premium payment, premiums and applicable premium surcharges must be paid as described in WAC 182-08-180 (1)(c).

(1) An employee's spouse, state registered domestic partner, or child who loses eligibility due to the death of an eligible employee may enroll or defer enrollment as a survivor under PEBB retiree insurance coverage provided they immediately begin receiving a monthly retirement benefit from any state of Washington sponsored retirement system. To satisfy the requirement to immediately receive a monthly retirement benefit they must begin receiving monthly benefit payments no later than 120 days from the date of death of the employee. The required forms to enroll or defer enrollment must be received by the PEBB program no later than 60 days after the later of the date of the employee's death or the date the survivor's PEBB insurance coverage ends.

| Note: | Enrollment in the PEBB program's medicare advantage (MA) plan, medicare advantage-prescription drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan may not be retroactive. |
| --- | --- |
| | (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. |
| | (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. |
| | (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |

(a) The employee's spouse or state registered domestic partner may continue health plan enrollment until death.

(b) The employee's children may continue health plan enrollment until they lose eligibility as described in WAC 182-12-260.

| Notes: | If a spouse, state registered domestic partner, or child of an eligible employee is not eligible for a monthly retirement benefit, they are not eligible to enroll as a survivor under PEBB retiree insurance coverage. However, they may continue health plan enrollment as described in WAC 182-12-146. |
| --- | --- |
| | Eligibility for continued enrollment in PEBB retiree insurance coverage for the surviving spouse, surviving state registered domestic partner, or surviving child of an employee of a PEBB participating employer group will cease at the end of the month in which the group's contract with the authority ends. Any survivor who loses eligibility for this reason may continue health plan enrollment as described in WAC 182-12-232. |
| | Eligibility for the surviving spouse, surviving state registered domestic partner, or surviving child of an elected and full-time appointed official of the legislative and executive branches of state government is described in WAC 182-12-180. |

(2) A retiree's spouse, state registered domestic partner, or child who loses eligibility due to the death of an eligible retiree may enroll or defer enrollment as a survivor under PEBB retiree insurance coverage as described in (a) through (d) of this subsection.

(a) The retiree's spouse or state registered domestic partner may continue health plan enrollment until death.

(b) The retiree's children may continue health plan enrollment until they lose eligibility as described in WAC 182-12-260.

(c) If a spouse, state registered domestic partner, or child of an eligible retiree is enrolled in a PEBB health plan at the time of the retiree's death, the survivors will be enrolled in the same PEBB health plan coverage they were enrolled in effective the first day of the month in which the retiree's death occurred. Eligible survivors may continue PEBB health plan coverage as described in (a) and (b) of this subsection. An eligible survivor may make changes to their PEBB health plan coverage or defer enrollment by submitting the required forms to the PEBB program. The required forms must be received no later than 60 days after the retiree's death. Changes in PEBB health plan coverage will be effective the first day of the month following the date of the retiree's death.

(d) If a spouse, state registered domestic partner, or child of an eligible retiree is not enrolled in a PEBB health plan at the time of the retiree's death, the survivor is eligible to enroll or defer enrollment as a survivor under PEBB retiree insurance coverage. The required forms to enroll or defer enrollment must be received by the PEBB program no later than 60 days after the retiree's death. For a survivor to enroll in a PEBB health plan who is not enrolled due to the retiree electing to defer enrollment in PEBB retiree insurance coverage as described in WAC 182-12-200 or 182-12-205 (3)(a) through (e), the survivor must also provide evidence of continuous enrollment in one or more qualifying coverages as described in WAC 182-12-205 (3)(a) through (e) from the most recent open enrollment for which the survivor was not enrolled in a PEBB medical plan prior to the retiree's death. A gap of 31 days or less is allowed between the date PEBB retiree insurance coverage was deferred and the start date of a qualifying coverage, and between each period of enrollment in qualifying coverages during the deferral period. If a retiree elected to defer enrollment in PEBB retiree insurance coverage as described in WAC 182-12-205 (3)(f), the survivor must provide proof of enrollment in medicare parts A and B; evidence of continuous enrollment in a qualified coverage is waived as described in WAC 182-12-205 (6)(f).

| Note: | Eligibility for continued enrollment in PEBB retiree insurance coverage for the surviving spouse, surviving state registered domestic partner, or surviving child of an employer group retiree will cease at the end of the month in which the group's contract with the authority ends. Any survivor who loses eligibility for this reason may continue health plan enrollment as described in WAC 182-12-232. |
| --- | --- |

(3) A school employee's spouse, state registered domestic partner, or child who loses eligibility due to the death of an eligible school employee may enroll or defer enrollment as a survivor under PEBB retiree insurance coverage at the time of the school employee's death, provided the employee died on or after October 1, 1993. The survivor must immediately begin receiving a retirement benefit allowance under chapter 41.32, 41.35 or 41.40 RCW. The required forms to enroll or defer enrollment must be received by the PEBB program no later than 60 days after the later of the date of the school employee's death or the date the survivor's school employees benefits board (SEBB) insurance coverage ends.

| Note: | Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. |
| --- | --- |
| | (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. |
| | (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. |
| | (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |

(a) The school employee's spouse or state registered domestic partner may continue health plan enrollment until death.

(b) The school employee's children may continue health plan enrollment until they lose eligibility as described in WAC 182-12-260.

| Notes: | If a spouse, state registered domestic partner, or child of an eligible school employee is not eligible for a retirement benefit allowance, they are not eligible to enroll as a survivor under PEBB retiree insurance coverage. However, a spouse, state registered domestic partner, or child of an eligible school employee enrolled in SEBB insurance coverage may continue health plan enrollment as described in WAC 182-31-090. |
| --- | --- |
| | Eligibility for continued enrollment in PEBB retiree insurance coverage for the surviving spouse, surviving state registered domestic partner, or surviving child of a school employee of a SEBB participating employer group will cease at the end of the month in which the group's contract with the authority ends. Any survivor who loses eligibility for this reason may continue health plan enrollment as described in WAC 182-12-232. |

(4) If premiums and applicable premium surcharges received by the HCA are sufficient as described in WAC 182-08-180 (1)(d)(ii) to maintain PEBB health plan enrollment after the employee, school employee, or retiree's death, the PEBB program will consider the payment as notice of the survivor's intent to continue enrollment.

If the survivor's enrollment ended due to the death of the employee, school employee, or retiree, the PEBB program will reinstate the survivor's enrollment without a gap subject to payment of premium and applicable premium surcharges.

(5) If a survivor elects to enroll a dependent in PEBB health plan coverage, the dependent must be enrolled in the same PEBB medical and PEBB dental plan as the survivor.

| Exceptions: | (1) If a survivor selects a medicare supplement plan, a MA-PD plan, or the UMP Classic medicare plan, nonmedicare enrollees will be enrolled in the UMP Classic. If a survivor selects any other medicare plan, they must also select a nonmedicare plan with the same contracted vendor available to nonmedicare enrollees. |
| --- | --- |
| | (2) If a survivor selects a medicare supplement plan, MA-PD plan, or any other medicare plan, they may elect a PEBB vision plan available for any nonmedicare enrollees. |

(6) A nonmedicare survivor must enroll in PEBB medical to be able to enroll in PEBB dental, in PEBB vision, or in both PEBB dental and PEBB vision. Any nonmedicare dependents they elect to enroll must be enrolled in the same PEBB medical, PEBB dental, and PEBB vision plan.

(7) In order to avoid duplication of group medical coverage, a survivor may defer enrollment in PEBB retiree insurance coverage as described in WAC 182-12-200 and 182-12-205.

***(Effective January 1, 2027)***

PDF WAC 182-12-265

What options for continuing health plan enrollment are available to a surviving spouse, state registered domestic partner, or child, if an employee, a school employee, or a retiree dies?

The survivor of an eligible employee, an eligible school employee, or a retiree who meets the eligibility criteria and submits the required forms as described in subsection (1), (2), or (3) of this section is eligible to enroll or defer enrollment as a survivor under public employees benefits board (PEBB) retiree insurance coverage. If enrolling in PEBB retiree insurance coverage, the survivor's first premium payment and applicable premium surcharges are due to the health care authority (HCA) no later than 45 days after the election period ends as described in subsection (1), (2), or (3) of this section, except as described in WAC 182-08-180 (1)(a). Following the survivor's first premium payment, premiums and applicable premium surcharges must be paid as described in WAC 182-08-180 (1)(c).

(1) An employee's spouse, state registered domestic partner, or child who loses eligibility due to the death of an eligible employee may enroll or defer enrollment as a survivor under PEBB retiree insurance coverage provided they immediately begin receiving a monthly retirement benefit from any state of Washington sponsored retirement system. To satisfy the requirement to immediately receive a monthly retirement benefit they must begin receiving monthly benefit payments no later than 120 days from the date of death of the employee. The required forms to enroll or defer enrollment must be received by the PEBB program no later than 60 days after the later of the date of the employee's death or the date the survivor's PEBB insurance coverage ends.

| Note: | Enrollment in the PEBB program's medicare advantage (MA) plan, medicare advantage-prescription drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan may not be retroactive. |
| --- | --- |
| | (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. |
| | (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. |
| | (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |

(a) The employee's spouse or state registered domestic partner may continue health plan enrollment until death.

(b) The employee's children may continue health plan enrollment until they lose eligibility as described in WAC 182-12-260.

| Notes: | If a spouse, state registered domestic partner, or child of an eligible employee is not eligible for a monthly retirement benefit, they are not eligible to enroll as a survivor under PEBB retiree insurance coverage. However, they may continue health plan enrollment as described in WAC 182-12-146. |
| --- | --- |
| | Eligibility for continued enrollment in PEBB retiree insurance coverage for the surviving spouse, surviving state registered domestic partner, or surviving child of an employee of a PEBB participating employer group will cease at the end of the month in which the group's contract with the authority ends. Any survivor who loses eligibility for this reason may continue health plan enrollment as described in WAC 182-12-232. |
| | Eligibility for the surviving spouse, surviving state registered domestic partner, or surviving child of an elected and full-time appointed official of the legislative and executive branches of state government is described in WAC 182-12-180. |

(2) A retiree's spouse, state registered domestic partner, or child who loses eligibility due to the death of an eligible retiree may enroll or defer enrollment as a survivor under PEBB retiree insurance coverage as described in (a) through (d) of this subsection.

(a) The retiree's spouse or state registered domestic partner may continue health plan enrollment until death.

(b) The retiree's children may continue health plan enrollment until they lose eligibility as described in WAC 182-12-260.

(c) If a spouse, state registered domestic partner, or child of an eligible retiree is enrolled in a PEBB health plan at the time of the retiree's death, the survivors will be enrolled in the same PEBB health plan coverage they were enrolled in effective the first day of the month in which the retiree's death occurred. Eligible survivors may continue PEBB health plan coverage as described in (a) and (b) of this subsection. An eligible survivor may make changes to their PEBB health plan coverage or defer enrollment by submitting the required forms to the PEBB program. The required forms must be received no later than 60 days after the retiree's death. Changes in PEBB health plan coverage will be effective the first day of the month following the date of the retiree's death.

(d) If a spouse, state registered domestic partner, or child of an eligible retiree is not enrolled in a PEBB health plan at the time of the retiree's death, the survivor is eligible to enroll or defer enrollment as a survivor under PEBB retiree insurance coverage. The required forms to enroll or defer enrollment must be received by the PEBB program no later than 60 days after the retiree's death. For a survivor to enroll in a PEBB health plan who is not enrolled due to the retiree electing to defer enrollment in PEBB retiree insurance coverage as described in WAC 182-12-200 or 182-12-205 (3)(a) through (e), the survivor must also provide evidence of continuous enrollment in one or more qualifying coverages as described in WAC 182-12-205 (3)(a) through (e) from the most recent open enrollment for which the survivor was not enrolled in a PEBB medical plan prior to the retiree's death. A gap of 31 days or less is allowed between the date PEBB retiree insurance coverage was deferred and the start date of a qualifying coverage, and between each period of enrollment in qualifying coverages during the deferral period. If a retiree elected to defer enrollment in PEBB retiree insurance coverage as described in WAC 182-12-205 (3)(f) or (g), the survivor must provide proof of enrollment in medicare Parts A and B, proof of permanent residence in the United States, and proof they currently reside in the United States; evidence of continuous enrollment in a qualified coverage is not required as described in WAC 182-12-205 (6)(f).

| Note: | Eligibility for continued enrollment in PEBB retiree insurance coverage for the surviving spouse, surviving state registered domestic partner, or surviving child of an employer group retiree will cease at the end of the month in which the group's contract with the authority ends. Any survivor who loses eligibility for this reason may continue health plan enrollment as described in WAC 182-12-232. |
| --- | --- |

(3) A school employee's spouse, state registered domestic partner, or child who loses eligibility due to the death of an eligible school employee may enroll or defer enrollment as a survivor under PEBB retiree insurance coverage at the time of the school employee's death, provided the employee died on or after October 1, 1993. The survivor must immediately begin receiving a retirement benefit allowance under chapter 41.32, 41.35 or 41.40 RCW. The required forms to enroll or defer enrollment must be received by the PEBB program no later than 60 days after the later of the date of the school employee's death or the date the survivor's school employees benefits board (SEBB) insurance coverage ends.

| Note: | Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. |
| --- | --- |
| | (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. |
| | (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. |
| | (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins. |

(a) The school employee's spouse or state registered domestic partner may continue health plan enrollment until death.

(b) The school employee's children may continue health plan enrollment until they lose eligibility as described in WAC 182-12-260.

| Notes: | If a spouse, state registered domestic partner, or child of an eligible school employee is not eligible for a retirement benefit allowance, they are not eligible to enroll as a survivor under PEBB retiree insurance coverage. However, a spouse, state registered domestic partner, or child of an eligible school employee enrolled in SEBB insurance coverage may continue health plan enrollment as described in WAC 182-31-090. |
| --- | --- |
| | Eligibility for continued enrollment in PEBB retiree insurance coverage for the surviving spouse, surviving state registered domestic partner, or surviving child of a school employee of a SEBB participating employer group will cease at the end of the month in which the group's contract with the authority ends. Any survivor who loses eligibility for this reason may continue health plan enrollment as described in WAC 182-12-232. |

(4) If premiums and applicable premium surcharges received by the HCA are sufficient as described in WAC 182-08-180 (1)(d)(ii) to maintain PEBB health plan enrollment after the employee, school employee, or retiree's death, the PEBB program will consider the payment as notice of the survivor's intent to continue enrollment.

If the survivor's enrollment ended due to the death of the employee, school employee, or retiree, the PEBB program will reinstate the survivor's enrollment without a gap subject to payment of premium and applicable premium surcharges.

(5) If a survivor elects to enroll a dependent in PEBB health plan coverage, the dependent must be enrolled in the same PEBB medical and PEBB dental plan as the survivor.

| Exceptions: | (1) If a survivor selects a medicare supplement plan, a MA-PD plan, or the UMP Classic medicare plan, nonmedicare enrollees will be enrolled in the UMP Classic. If a survivor selects any other medicare plan, they must also select a nonmedicare plan with the same contracted vendor available to nonmedicare enrollees. |
| --- | --- |
| | (2) If a survivor selects a medicare supplement plan, MA-PD plan, or any other medicare plan, they may elect a PEBB vision plan available for any nonmedicare enrollees. |

(6) A nonmedicare survivor must enroll in PEBB medical to be able to enroll in PEBB dental, in PEBB vision, or in both PEBB dental and PEBB vision. Any nonmedicare dependents they elect to enroll must be enrolled in the same PEBB medical, PEBB dental, and PEBB vision plan.

(7) In order to avoid duplication of group medical coverage, a survivor may defer enrollment in PEBB retiree insurance coverage as described in WAC 182-12-200 and 182-12-205.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.065, 41.05.160, 2023 c 312 § 1, 2024 c 185 § 1, Policy Resolutions PEBB 2024-14, 2024-19, 2024-20, 2024-21, and 2024-26. WSR 24-18-082 (Admin #2024-01.06), § 182-12-265, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-12-265, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolution PEBB 2022-03. WSR 22-13-160 (Admin #2022-02.03), § 182-12-265, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolution PEBB 2021-14. WSR 21-13-104 (Admin #2021-01.04), § 182-12-265, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160, 42 C.F.R. § 422.62(b) and § 423.38(c) and PEBB policy resolution 2020-05. WSR 20-16-063 (Admin #2020-02), § 182-12-265, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-265, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-265, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-265, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-265, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-265, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-265, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-12-265, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 09-23-102 (Order 09-02), § 182-12-265, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-12-265, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-12-265, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.068. WSR 06-23-165 (Order 06-09), § 182-12-265, filed 11/22/06, effective 12/23/06. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. WSR 05-16-046 (Order 05-01), § 182-12-265, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-265, filed 8/26/04, effective 1/1/05.](Effective January 1, 2027) PDF WAC 182-12-265 What options for continuing health plan enrollment are available to a surviving spouse, state registered domestic partner, or child, if an employee, a school employee, or a retiree dies? The survivor of an eligible employee, an eligible school employee, or a retiree who meets the eligibility criteria and submits the required forms as described in subsection (1), (2), or (3) of this section is eligible to enroll or defer enrollment as a survivor under public employees benefits board (PEBB) retiree insurance coverage. If enrolling in PEBB retiree insurance coverage, the survivor's first premium payment and applicable premium surcharges are due to the health care authority (HCA) no later than 45 days after the election period ends as described in subsection (1), (2), or (3) of this section, except as described in WAC 182-08-180 (1)(a). Following the survivor's first premium payment, premiums and applicable premium surcharges must be paid as described in WAC 182-08-180 (1)(c).(1) An employee's spouse, state registered domestic partner, or child who loses eligibility due to the death of an eligible employee may enroll or defer enrollment as a survivor under PEBB retiree insurance coverage provided they immediately begin receiving a monthly retirement benefit from any state of Washington sponsored retirement system. To satisfy the requirement to immediately receive a monthly retirement benefit they must begin receiving monthly benefit payments no later than 120 days from the date of death of the employee. The required forms to enroll or defer enrollment must be received by the PEBB program no later than 60 days after the later of the date of the employee's death or the date the survivor's PEBB insurance coverage ends.Note:Enrollment in the PEBB program's medicare advantage (MA) plan, medicare advantage-prescription drug (MA-PD) plan, or the Uniform Medical Plan (UMP) Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins.(a) The employee's spouse or state registered domestic partner may continue health plan enrollment until death.(b) The employee's children may continue health plan enrollment until they lose eligibility as described in WAC 182-12-260.Notes:If a spouse, state registered domestic partner, or child of an eligible employee is not eligible for a monthly retirement benefit, they are not eligible to enroll as a survivor under PEBB retiree insurance coverage. However, they may continue health plan enrollment as described in WAC 182-12-146. Eligibility for continued enrollment in PEBB retiree insurance coverage for the surviving spouse, surviving state registered domestic partner, or surviving child of an employee of a PEBB participating employer group will cease at the end of the month in which the group's contract with the authority ends. Any survivor who loses eligibility for this reason may continue health plan enrollment as described in WAC 182-12-232. Eligibility for the surviving spouse, surviving state registered domestic partner, or surviving child of an elected and full-time appointed official of the legislative and executive branches of state government is described in WAC 182-12-180.(2) A retiree's spouse, state registered domestic partner, or child who loses eligibility due to the death of an eligible retiree may enroll or defer enrollment as a survivor under PEBB retiree insurance coverage as described in (a) through (d) of this subsection.(a) The retiree's spouse or state registered domestic partner may continue health plan enrollment until death.(b) The retiree's children may continue health plan enrollment until they lose eligibility as described in WAC 182-12-260.(c) If a spouse, state registered domestic partner, or child of an eligible retiree is enrolled in a PEBB health plan at the time of the retiree's death, the survivors will be enrolled in the same PEBB health plan coverage they were enrolled in effective the first day of the month in which the retiree's death occurred. Eligible survivors may continue PEBB health plan coverage as described in (a) and (b) of this subsection. An eligible survivor may make changes to their PEBB health plan coverage or defer enrollment by submitting the required forms to the PEBB program. The required forms must be received no later than 60 days after the retiree's death. Changes in PEBB health plan coverage will be effective the first day of the month following the date of the retiree's death.(d) If a spouse, state registered domestic partner, or child of an eligible retiree is not enrolled in a PEBB health plan at the time of the retiree's death, the survivor is eligible to enroll or defer enrollment as a survivor under PEBB retiree insurance coverage. The required forms to enroll or defer enrollment must be received by the PEBB program no later than 60 days after the retiree's death. For a survivor to enroll in a PEBB health plan who is not enrolled due to the retiree electing to defer enrollment in PEBB retiree insurance coverage as described in WAC 182-12-200 or 182-12-205 (3)(a) through (e), the survivor must also provide evidence of continuous enrollment in one or more qualifying coverages as described in WAC 182-12-205 (3)(a) through (e) from the most recent open enrollment for which the survivor was not enrolled in a PEBB medical plan prior to the retiree's death. A gap of 31 days or less is allowed between the date PEBB retiree insurance coverage was deferred and the start date of a qualifying coverage, and between each period of enrollment in qualifying coverages during the deferral period. If a retiree elected to defer enrollment in PEBB retiree insurance coverage as described in WAC 182-12-205 (3)(f) or (g), the survivor must provide proof of enrollment in medicare Parts A and B, proof of permanent residence in the United States, and proof they currently reside in the United States*
- *evidence of continuous enrollment in a qualified coverage is not required as described in WAC 182-12-205 (6)(f).Note:Eligibility for continued enrollment in PEBB retiree insurance coverage for the surviving spouse, surviving state registered domestic partner, or surviving child of an employer group retiree will cease at the end of the month in which the group's contract with the authority ends. Any survivor who loses eligibility for this reason may continue health plan enrollment as described in WAC 182-12-232.(3) A school employee's spouse, state registered domestic partner, or child who loses eligibility due to the death of an eligible school employee may enroll or defer enrollment as a survivor under PEBB retiree insurance coverage at the time of the school employee's death, provided the employee died on or after October 1, 1993. The survivor must immediately begin receiving a retirement benefit allowance under chapter 41.32, 41.35 or 41.40 RCW. The required forms to enroll or defer enrollment must be received by the PEBB program no later than 60 days after the later of the date of the school employee's death or the date the survivor's school employees benefits board (SEBB) insurance coverage ends.Note:Enrollment in the PEBB program's MA plan, MA-PD plan, or the UMP Classic medicare plan may not be retroactive. (1) If a subscriber elects to enroll in a MA plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in a plan with the same contracted vendor during the gap month(s) prior to when the MA coverage begins. (2) If a subscriber elects to enroll in a MA-PD plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional coverage as designated by the director or designee during the gap month(s) prior to when the MA-PD coverage begins. (3) If a subscriber elects to enroll in the UMP Classic medicare plan, and the required forms are received by the PEBB program after the date the PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in transitional UMP coverage during the gap month(s) prior to when the UMP Classic medicare plan begins.(a) The school employee's spouse or state registered domestic partner may continue health plan enrollment until death.(b) The school employee's children may continue health plan enrollment until they lose eligibility as described in WAC 182-12-260.Notes:If a spouse, state registered domestic partner, or child of an eligible school employee is not eligible for a retirement benefit allowance, they are not eligible to enroll as a survivor under PEBB retiree insurance coverage. However, a spouse, state registered domestic partner, or child of an eligible school employee enrolled in SEBB insurance coverage may continue health plan enrollment as described in WAC 182-31-090. Eligibility for continued enrollment in PEBB retiree insurance coverage for the surviving spouse, surviving state registered domestic partner, or surviving child of a school employee of a SEBB participating employer group will cease at the end of the month in which the group's contract with the authority ends. Any survivor who loses eligibility for this reason may continue health plan enrollment as described in WAC 182-12-232.(4) If premiums and applicable premium surcharges received by the HCA are sufficient as described in WAC 182-08-180 (1)(d)(ii) to maintain PEBB health plan enrollment after the employee, school employee, or retiree's death, the PEBB program will consider the payment as notice of the survivor's intent to continue enrollment.If the survivor's enrollment ended due to the death of the employee, school employee, or retiree, the PEBB program will reinstate the survivor's enrollment without a gap subject to payment of premium and applicable premium surcharges.(5) If a survivor elects to enroll a dependent in PEBB health plan coverage, the dependent must be enrolled in the same PEBB medical and PEBB dental plan as the survivor.Exceptions:(1) If a survivor selects a medicare supplement plan, a MA-PD plan, or the UMP Classic medicare plan, nonmedicare enrollees will be enrolled in the UMP Classic. If a survivor selects any other medicare plan, they must also select a nonmedicare plan with the same contracted vendor available to nonmedicare enrollees. (2) If a survivor selects a medicare supplement plan, MA-PD plan, or any other medicare plan, they may elect a PEBB vision plan available for any nonmedicare enrollees.(6) A nonmedicare survivor must enroll in PEBB medical to be able to enroll in PEBB dental, in PEBB vision, or in both PEBB dental and PEBB vision. Any nonmedicare dependents they elect to enroll must be enrolled in the same PEBB medical, PEBB dental, and PEBB vision plan.(7) In order to avoid duplication of group medical coverage, a survivor may defer enrollment in PEBB retiree insurance coverage as described in WAC 182-12-200 and 182-12-205.[Statutory Authority: RCW 41.05.021, 41.05.065, 41.05.160, and PEBB policy resolutions. WSR 26-14-081 (Admin #2026.02), s 182-12-265, filed 6/29/26, effective 1/1/27. Statutory Authority: RCW 41.05.021, 41.05.065, 41.05.160, 2023 c 312 § 1, 2024 c 185 § 1, Policy Resolutions PEBB 2024-14, 2024-19, 2024-20, 2024-21, and 2024-26. WSR 24-18-082 (Admin #2024-01.06), § 182-12-265, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-12-265, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolution PEBB 2022-03. WSR 22-13-160 (Admin #2022-02.03), § 182-12-265, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolution PEBB 2021-14. WSR 21-13-104 (Admin #2021-01.04), § 182-12-265, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160, 42 C.F.R. § 422.62(b) and § 423.38(c) and PEBB policy resolution 2020-05. WSR 20-16-063 (Admin #2020-02), § 182-12-265, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-265, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-265, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-265, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-265, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-265, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-265, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-12-265, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 09-23-102 (Order 09-02), § 182-12-265, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-12-265, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-12-265, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.068. WSR 06-23-165 (Order 06-09), § 182-12-265, filed 11/22/06, effective 12/23/06. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. WSR 05-16-046 (Order 05-01), § 182-12-265, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-265, filed 8/26/04, effective 1/1/05.*

##### **Wash. Admin. Code § 182-12-270** What options for continuation coverage are available to dependents who cease to meet the eligibility criteria as described in WAC 182-12-260? {#sec-182-12-270 omnilex-key=us-wa-regs-official--title-182--182-12-270}

If eligible, dependents may continue health plan enrollment under one of the continuation coverage options in subsection (1) or (2) of this section by self-paying the premiums and applicable premium surcharges set by the health care authority (HCA), with no contribution from the employer, following their loss of eligibility under the subscriber's health plan coverage. The dependent's first premium payment and applicable premium surcharges are due no later than 45 days after the election period ends as described in WAC 182-12-146, 182-12-180, 182-12-250, or 182-12-265, whichever applies, except as described in WAC 182-08-180 (1)(a). Premiums and applicable premium surcharges associated with continuing PEBB medical, must be made to the HCA as well as premiums associated with continuing PEBB dental and PEBB vision insurance coverages. Following the dependent's first premium payment, the dependent must pay premium and applicable premium surcharges as they become due. If the monthly premium or applicable premium surcharges remain unpaid for 60 days from the original due date, PEBB insurance coverage will be terminated retroactive to the last day of the month for which the monthly premium and applicable premium surcharges were paid as described in WAC 182-08-180 (1)(c). The PEBB program must receive the required forms as outlined in the PEBB Initial Notice of COBRA and Continuation Coverage Rights. Options for continuing health plan enrollment are based on the reason that eligibility was lost.

(1) Spouses, state registered domestic partners, or children who lose eligibility due to the death of an employee or retiree may be eligible to continue health plan enrollment as described in WAC 182-12-180, 182-12-250, or 182-12-265; or

(2) Dependents who lose eligibility because they no longer meet the eligibility criteria as described in WAC 182-12-260 are eligible to continue PEBB medical, dental, vision, or any combination of these coverages under provisions of the federal Consolidated Omnibus Budget Reconciliation Act (COBRA). See WAC 182-12-146 for more information on COBRA.

(3) A subscriber's state registered domestic partner and the state registered domestic partner's children may continue PEBB medical, dental, vision, or any combination of these coverages on the same terms and conditions as spouses and other eligible dependents under COBRA as described under RCW 26.60.015.

(4) No continuation coverage will be offered unless the PEBB program is notified through hand-delivery or United States Postal Service mail of the qualifying event as outlined in the PEBB Initial Notice of COBRA and Continuation Coverage Rights.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-12-270, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-12-270, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-270, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-270, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-270, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-12-270, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-12-270, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-12-270, filed 9/25/12, effective 11/1/12*
- *WSR 09-23-102 (Order 09-02), § 182-12-270, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-12-270, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-12-270, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. WSR 05-16-046 (Order 05-01), § 182-12-270, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160 and 41.05.165. WSR 04-18-039, § 182-12-270, filed 8/26/04, effective 1/1/05.*

##### **Wash. Admin. Code § 182-12-300** Public employees benefits board (PEBB) wellness incentive program eligibility and procedural requirements. {#sec-182-12-300 omnilex-key=us-wa-regs-official--title-182--182-12-300}

The board annually determines the design of the PEBB wellness incentive program.

(1) All subscribers, except PEBB subscribers who are enrolled in both medicare Parts A and B, and in the medicare risk pool as described in RCW 41.05.080(3), are eligible to participate in the PEBB wellness incentive program.

(2) Effective January 1, 2020, to receive the PEBB wellness incentive of a reduction to the subscriber's medical plan deductible or a deposit to the subscriber's health savings account for the following plan year, eligible subscribers must complete PEBB wellness incentive program requirements during the current plan year by the following deadline:

(a) For subscribers continuing enrollment in PEBB medical and subscribers enrolling in PEBB medical with an effective date in January through September, the deadline is November 30th; or

(b) For subscribers enrolling in PEBB medical with an effective date in October through December, the deadline is December 31st.

(3) Subscribers who do not complete the requirements according to subsection (2) of this section, except as noted, within the time frame described are not eligible to receive a PEBB wellness incentive the following plan year.

| Note: | All eligible subscribers can earn a wellness incentive. Subscribers who cannot complete the wellness incentive program requirements may be able to earn the same incentive by different means. The contracted vendor will work with enrollees (and their physician, if they wish) to define an individual wellness program that provides the opportunity to qualify for the same incentive in light of the enrollee's health status. |
| --- | --- |

(4) A PEBB wellness incentive will be provided only if:

(a) For the wellness incentive described in subsection (2) of this section the subscriber is still eligible to participate in the PEBB wellness incentive program and is enrolled in a PEBB medical plan in the year the incentive applies;

(b) The funding rate provided by the legislature is designed to provide a PEBB wellness incentive program or a PEBB wellness incentive, or both; or

(c) Specific appropriations are provided for wellness incentives.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-12-300, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolution PEBB 2021-15. WSR 21-13-105 (Admin #2021-01.05), § 182-12-300, filed 6/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-12-300, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-12-300, filed 8/20/19, effective 1/1/20*
- *WSR 18-20-117 (Admin #2018-02), § 182-12-300, filed 10/3/18, effective 1/1/19*
- *WSR 17-19-077 (Order 2017-01), § 182-12-300, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-12-300, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160, 2013 2nd sp.s. c 4 and PEBB policy resolutions. WSR 14-08-040, § 182-12-300, filed 3/26/14, effective 4/26/14.*

## **Chapter 182-13** State resident—Medicare supplement. {#struct-chapter-182-13}

##### **Wash. Admin. Code § 182-13-010** Purpose. {#sec-182-13-010 omnilex-key=us-wa-regs-official--title-182--182-13-010}

The purpose of this chapter is to establish criteria for state residents for participation in medicare supplemental coverage available through the HCA.

**History**
- *Statutory Authority: RCW 41.05.197, 41.05.160. WSR 19-01-054 (Admin #2018-02), § 182-13-010, filed 12/14/18, effective 1/14/19. Statutory Authority: RCW 41.05.197. WSR 95-07-011, § 182-13-010, filed 3/3/95, effective 4/3/95.*

##### **Wash. Admin. Code § 182-13-020** Definitions. {#sec-182-13-020 omnilex-key=us-wa-regs-official--title-182--182-13-020}

Unless otherwise specifically provided, the definitions contained in this section apply throughout this chapter.

(1) "HCA" means the Washington state health care authority.

(2) "Health plan," or "plan" means any individual or group: Policy, agreement, or other contract providing coverage for medical, surgical, hospital, or emergency care services, whether issued, or issued for delivery, in Washington or any other state. "Health Plan" or "plan" also includes any group health plan that is maintained by any state and governed by the Public Health Services Act in 42 U.S.C. Chapter 6A, self-insured coverage governed by the federal Employee Retirement Income Security Act of 1974, coverage through the Washington state health insurance pool as described in chapter 48.41 RCW, coverage through the medicaid program as described in Title 74 RCW, and coverage through the Washington state health benefit exchange as described in chapter 43.71 RCW. "Health plan" or "plan" does not mean or include: Hospital confinement indemnity coverage as described in WAC 284-50-345; disability income protection coverage as described in WAC 284-50-355; accident only coverage as described in WAC 284-50-360; specified disease and specified accident coverage as described in WAC 284-50-365; limited benefit health insurance coverage as described in WAC 284-50-370; long-term care benefits as described in chapter 48.84 RCW; or limited health care coverage (e.g., dental only).

(3) "Lapse in coverage" means a period of time greater than sixty-three continuous days without coverage by a health plan.

(4) "Resident" means a person who demonstrates that they live in the state of Washington by providing evidence of residency.

**History**
- *Statutory Authority: RCW 41.05.197, 41.05.160. WSR 19-01-054 (Admin #2018-02), § 182-13-020, filed 12/14/18, effective 1/14/19. Statutory Authority: RCW 41.05.197. WSR 95-07-011, § 182-13-020, filed 3/3/95, effective 4/3/95.*

##### **Wash. Admin. Code § 182-13-030** Eligibility. {#sec-182-13-030 omnilex-key=us-wa-regs-official--title-182--182-13-030}

A resident is eligible to apply for medicare supplemental coverage available through the HCA provided the resident is:

(1) Enrolled in Parts A and B of medicare; and

(2) Not eligible to purchase coverage as a retired or disabled employee under RCW 41.05.195.

**History**
- *Statutory Authority: RCW 41.05.197, 41.05.160. WSR 19-01-054 (Admin #2018-02), § 182-13-030, filed 12/14/18, effective 1/14/19. Statutory Authority: RCW 41.05.197. WSR 95-07-011, § 182-13-030, filed 3/3/95, effective 4/3/95.*

##### **Wash. Admin. Code § 182-13-040** Application for medicare supplemental coverage. {#sec-182-13-040 omnilex-key=us-wa-regs-official--title-182--182-13-040}

Residents meeting eligibility requirements may apply for medicare supplemental coverage available through the HCA:

(1) No earlier than thirty days before they are enrolled in both Parts A and B of medicare;

(2) Within sixty-three days after becoming a resident of Washington state;

(3) During any open enrollment period established by federal or state law;

(4) During any open enrollment period established by the HCA subsequent to the initial open enrollment period provided that the applicant is replacing a health plan with no lapse in coverage; or

(5) When replacing coverage as described in RCW 48.66.045 or when enrolling during a guaranteed issue period as described in RCW 48.66.055.

**History**
- *Statutory Authority: RCW 41.05.197, 41.05.160. WSR 19-01-054, (Admin #2018-02) § 182-13-040, filed 12/14/18, effective 1/14/19. Statutory Authority: RCW 41.05.197. WSR 95-07-011, § 182-13-040, filed 3/3/95, effective 4/3/95.*

## **Chapter 182-16** Appeals practice and procedure. {#struct-chapter-182-16}

##### **Wash. Admin. Code § 182-16-010** Purpose. {#sec-182-16-010 omnilex-key=us-wa-regs-official--title-182--182-16-010}

This chapter describes the general rules and procedures that apply to the health care authority's brief adjudicative proceedings and formal administrative hearings for the public employees benefits board program.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-010, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-010, filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and PEBB policy resolutions. WSR 17-19-077 (Order 2017-01), § 182-16-010, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-010, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-010, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-16-010, filed 9/25/12, effective 11/1/12*
- *WSR 08-20-128 (Order 08-03), § 182-16-010, filed 10/1/08, effective 1/1/09. Statutory Authority: RCW 41.05.010 and 34.05.250. WSR 91-14-025, § 182-16-010, filed 6/25/91, effective 7/26/91.*

##### **Wash. Admin. Code § 182-16-020** Definitions. {#sec-182-16-020 omnilex-key=us-wa-regs-official--title-182--182-16-020}

The following definitions apply throughout this chapter unless the context clearly indicates another meaning:

"Accidental death and dismemberment insurance" or "AD&D" means basic accidental death and dismemberment (AD&D) insurance paid for by the employing agency, as well as supplemental accidental death and dismemberment insurance offered to and paid for by employees for themselves and their dependents.

"Appellant" means a person who requests a brief adjudicative proceeding with the PEBB appeals unit about the action of the employing agency, the HCA, or its contracted vendor.

"Authority" or "HCA" means the Washington state health care authority.

"Board" means the public employees benefits board established under provisions of RCW 41.05.055.

"Brief adjudicative proceeding" means the process described in RCW 34.05.482 through 34.05.494 and in WAC 182-16-2000 through 182-16-2160.

"Business days" means all days except Saturdays, Sundays, and all state legal holidays as set forth in RCW 1.16.050.

"Calendar days" or "days" means all days including Saturdays, Sundays, and all state legal holidays as set forth in RCW 1.16.050.

"Continuance" means a change in the date or time of when a brief adjudicative proceeding or formal administrative hearing will occur.

"Contracted vendor" means any person, persons, or entity under contract or agreement with the HCA to provide goods or services for the provision or administration of PEBB benefits. The term "contracted vendor" includes subcontractors of the HCA and subcontractors of any person, persons, or entity under contract or agreement with the HCA that provide goods or services for the provision or administration of PEBB benefits.

"Denial" or "denial notice" means an action by, or communication from, an employing agency, contracted vendor, or the PEBB program that aggrieves a subscriber, a dependent, or an applicant, with regard to PEBB benefits including, but not limited to, actions or communications expressly designated as a "denial," "denial notice," or "cancellation notice."

"Dependent" means a person who meets eligibility requirements in WAC 182-12-260, except that "surviving spouses, state registered domestic partners, and dependent children" of emergency service personnel who are killed in the line of duty is defined in WAC 182-12-250.

"Dependent care assistance program" or "DCAP" means a benefit plan whereby state employees may pay for certain employment related dependent care with pretax dollars as provided in the salary reduction plan under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 129 or other sections of the Internal Revenue Code.

"Director" means the director of the authority.

"Dispositive motion" means a motion made to a presiding officer, reviewing officer, or hearing officer to decide a claim or case in favor of the moving party without further proceedings.

"Documents" means papers, letters, writings, electronic mail, electronic files, or other printed or written items.

"Employee" for the public employees benefits board program includes all employees of the state, whether or not covered by civil service; elected and appointed officials of the executive branch of government, including full-time members of boards, commissions, or committees; justices of the supreme court and judges of the court of appeals and the superior courts; and members of the state legislature. Pursuant to contractual agreement with the authority, "employee" may also include: (a) Employees of a county, municipality, or other political subdivision of the state and members of the legislative authority of any county, city, or town who are elected to office after February 20, 1970, if the legislative authority of the county, municipality, or other political subdivision of the state submits application materials to the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.04.205 and 41.05.021 (1)(g); (b) employees of employee organizations representing state civil service employees, at the option of each such employee organization; (c) through December 31, 2019, employees of a school district if the authority agrees to provide any of the school districts' insurance programs by contract with the authority as provided in RCW 28A.400.350; (d) employees of a tribal government, if the governing body of the tribal government seeks and receives the approval of the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.05.021 (1)(f) and (g); (e) employees of the Washington health benefit exchange if the governing board of the exchange established in RCW 43.71.020 seeks and receives approval of the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.05.021 (1)(g) and (n); and (f) through December 31, 2019, employees of a charter school established under chapter 28A.710 RCW. "Employee" does not include: Adult family home providers; unpaid volunteers; patients of state hospitals; inmates; students of institutions of higher education as determined by their institution; and any others not expressly defined as employees under RCW 41.05.011 or by the authority under this chapter.

"Employer-based group medical" means group medical related to a current employment relationship. It does not include medical coverage available to retired employees, individual market medical coverage, or government-sponsored programs such as medicare or medicaid.

"Employer group" means:

• For the public employees benefits board as defined in RCW 41.05.011 (9)(a), those counties, municipalities, political subdivisions, the Washington health benefit exchange, tribal governments, and employee organizations representing state civil service employees obtaining employee benefits through a contractual agreement with the authority to participate in benefit plans developed by the public employees benefits board as described in WAC 182-08-245.

• For the school employees benefits board as defined in RCW 41.05.011 (9)(b), an employee organization representing school employees and a tribal school as defined in RCW 28A.715.010, obtaining school employee benefits through a contractual agreement with the authority to participate in benefit plans developed by the school employees benefits board as described in WAC 182-30-215.

"Employing agency" for the public employees benefits board program means a division, department, or separate agency of state government, including an institution of higher education; a county, municipality, or other political subdivision; and a tribal government covered by chapter 41.05 RCW.

"Enrollee" means a person who meets all eligibility requirements defined in chapter 182-12 WAC, who is enrolled in PEBB benefits, and for whom applicable premium payments have been made.

"File" or "filing" means the act of delivering documents to the office of the presiding officer, reviewing officer, or hearing officer. A document is considered filed when it is received by the authority or its designee. A document may be filed by one or more of the following:

• Personal delivery to the authority at Cherry Street Plaza, 626 8th Avenue S.E., Olympia, Washington 98501;

• First class, registered, or certified mail to the authority to the following mailing address:

Health Care Authority

Attn: PEBB Appeals Unit

P.O. Box 45504

Olympia, WA 98504-5504;

• Fax: 360-763-4709; or

• Submission online through the designated submission portal.

The identified methods are the exclusive methods for a document to be filed, and submission of documents by any other fashion to the authority shall not constitute filing unless agreed to in advance by the authority.

"Final order" means an order that is the final health care authority decision.

"Flexible spending arrangement" or "FSA" means a benefit plan whereby eligible state employees may reduce their salary before taxes to pay for medical expenses not reimbursed by insurance as provided in the salary reduction plan established under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"Formal administrative hearing" means a proceeding before a hearing officer that gives an appellant an opportunity for an evidentiary hearing as described in RCW 34.05.413 through 34.05.476 and WAC 182-16-3000 through 182-16-3200.

"HCA hearing representative" means a person who is authorized to represent the PEBB program in a formal administrative hearing. The person may be an assistant attorney general or authorized HCA employee.

"Health plan" means a plan offering medical, dental, vision, or any combination of these coverages, developed by the board and provided by a contracted vendor or self-insured plans administered by the HCA.

"Hearing officer" means an impartial decision maker who presides at a formal administrative hearing, and is:

• A director-designated HCA employee; or

• When the director has designated the office of administrative hearings (OAH) as a hearing body, an administrative law judge employed by the OAH.

"Institutions of higher education" means the state public research universities, the public regional universities, The Evergreen State College, the community and technical colleges, and the state board for community and technical colleges.

"Life insurance" means basic life insurance paid for by the employing agency, as well as supplemental life insurance or supplemental dependent life insurance offered to and paid for by employees for themselves and their dependents. Life insurance for eligible retirees includes retiree term life insurance offered to and paid for by retirees.

"Limited purpose flexible spending arrangement" or "limited purpose FSA" means a benefit plan whereby eligible state employees may reduce their salary before taxes to pay for dental and vision expenses not reimbursed by insurance as provided in the salary reduction plan established under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"Long-term disability insurance" or "LTD insurance" means employer-paid long-term disability insurance and employee-paid long-term disability insurance offered by the PEBB program.

"PEBB" means the public employees benefits board.

"PEBB benefits" means one or more insurance coverages or other employee benefits administered by the PEBB program within the health care authority.

"PEBB insurance coverage" means any health plan, life insurance, accidental death and dismemberment insurance, long-term disability (LTD) insurance, long-term care insurance, or property and casualty insurance administered as a PEBB benefit.

"PEBB program" means the program within the HCA that administers insurance and other benefits for eligible employees (as described in WAC 182-12-114), eligible retired employees (as described in WAC 182-12-171, 182-12-180, and 182-12-211), eligible survivors (as described in WAC 182-12-180, 182-12-250, and 182-12-265), eligible dependents (as described in WAC 182-12-250 and 182-12-260), and others as defined in RCW 41.05.011 or as described in RCW 41.05.080 (1)(a)(ii).

"Prehearing conference" means a proceeding scheduled and conducted by a hearing officer to address issues in preparation for a formal administrative hearing.

"Premium payment plan" means a benefit plan whereby public employees may pay their share of group health plan premiums with pretax dollars as provided in the salary reduction plan under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"Premium surcharge" means a payment required from a subscriber, in addition to the subscriber's medical premium contribution, due to an enrollee's tobacco use or an enrolled subscriber's spouse or state registered domestic partner choosing not to enroll in their employer-based group medical when:

• The spouse's or state registered domestic partner's share of the medical premiums is less than 95 percent of the additional cost an employee would be required to pay to enroll a spouse or state registered domestic partner in the public employees benefits board (PEBB) Uniform Medical Plan (UMP) Classic; and

• The benefits have an actuarial value of at least 95 percent of the actuarial value of PEBB UMP Classic benefits.

"Presiding officer" means an impartial decision maker who conducts a brief adjudicative proceeding and is a director-designated HCA employee.

"Public employee" has the same meaning as employee.

"Reviewing officer or officers" means one or more delegates from the director that consider appeals relating to the administration of PEBB benefits by the PEBB program.

"Salary reduction plan" means a benefit plan whereby public employees may agree to a reduction of salary on a pretax basis to participate in the dependent care assistance program, flexible spending arrangement, limited purpose flexible spending arrangement, or premium payment plan offered pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"School employee" means all employees of school districts and charter schools established under chapter 28A.710 RCW; represented employees of educational service districts; effective January 1, 2024, all employees of educational service districts; and effective January 1, 2024, pursuant to a contractual agreement with the authority, "school employee" may also include: (a) Employees of employee organizations representing school employees, at the option of each such employee organization; and (b) Employees of a tribal school as defined in RCW 28A.715.010, if the governing body of the tribal school seeks and receives the approval of the authority to provide any of its insurance programs by contracts with the authority, as provided in RCW 41.05.021 (1)(f) and (g).

"Service" or "serve" means the process described in WAC 182-16-058.

"State agency" means an office, department, board, commission, institution, or other separate unit or division, however designated, of the state government. It includes the legislature, executive branch, and agencies or courts within the judicial branch, as well as institutions of higher education, and any unit of state government established by law.

"State registered domestic partner" has the same meaning as defined in RCW 26.60.020(1) and substantially equivalent legal unions from other jurisdictions as defined in RCW 26.60.090.

"Subscriber" means the employee, retiree, continuation coverage enrollee, retired employee or retired school employee continuing health plan coverage when their employer group ceases participation with the authority, or survivor who has been determined eligible by the PEBB program, PEBB participating employer group, or state agency, is enrolled in PEBB benefits, and is the individual to whom the PEBB program and contracted vendors will issue all notices, information, requests, and premium bills on behalf of an enrollee.

"Tobacco products" means any product made with or derived from tobacco that is intended for human consumption, including any component, part, or accessory of a tobacco product. This includes, but is not limited to, cigars, cigarettes, pipe tobacco, chewing tobacco, snuff, and other tobacco products. It does not include e-cigarettes or United States Food and Drug Administration (FDA) approved quit aids.

"Tobacco use" means any use of tobacco products within the past two months. Tobacco use, however, does not include the religious or ceremonial use of tobacco.

"Tribal government" means an Indian tribal government as defined in Section 3(32) of the Employee Retirement Income Security Act of 1974 (ERISA), as amended, or an agency or instrumentality of the tribal government, that has government offices principally located in this state.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], 41.05.160, 2023 c 312 § 1, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-18-077 (Admin #2024-01.02), § 182-16-020, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-16-020, filed 6/21/22, effective 1/1/23*
- *WSR 21-13-106 (Admin #2021-01.06), § 182-16-020, filed 6/18/21, effective 1/1/22*
- *WSR 20-16-062 (Admin #2020-03), § 182-16-020, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-020, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-020, filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and PEBB policy resolutions. WSR 17-19-077 (Order 2017-01), § 182-16-020, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-020, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-16-020, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-020, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160, 2013 2nd sp.s. c 4 and PEBB policy resolutions. WSR 14-08-040, § 182-16-020, filed 3/26/14, effective 4/26/14. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-16-020, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-16-020, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-16-020, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 09-23-102 (Order 09-02), § 182-16-020, filed 11/17/09, effective 1/1/10*
- *WSR 08-20-128 (Order 08-03), § 182-16-020, filed 10/1/08, effective 1/1/09*
- *WSR 07-20-129 (Order 07-01), § 182-16-020, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.010 and 34.05.250. WSR 91-14-025, § 182-16-020, filed 6/25/91, effective 7/26/91.*

##### **Wash. Admin. Code § 182-16-055** Mailing address changes. {#sec-182-16-055 omnilex-key=us-wa-regs-official--title-182--182-16-055}

(1) During the appeal process if the appellant's mailing address changes, the appellant must notify the public employees benefits board (PEBB) appeals unit as soon as possible.

(2) If the appellant does not notify the PEBB appeals unit of a change in the appellant's mailing address and the PEBB appeals unit continues to serve notices and other important documents to the appellant's last known mailing address, the documents will be deemed served on the appellant.

(3) This requirement to provide notice of an address change is in addition to WAC 182-08-191 that require a subscriber to update their address.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-055, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-055, filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-055, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-055, filed 9/25/14, effective 1/1/15.*

##### **Wash. Admin. Code § 182-16-058** Service or serve. {#sec-182-16-058 omnilex-key=us-wa-regs-official--title-182--182-16-058}

(1) When the rules in this chapter or in other public employees benefits board (PEBB) program rules or statutes require a party to serve copies of documents on other parties, a party must send copies of the documents to all other parties or their representatives as described in this chapter. In this section, requirements for service or delivery by a party apply also when service is required by the presiding officer, reviewing officer or officers, or hearing officer.

(2) Unless otherwise stated in applicable law, documents may be sent only as identified in this chapter to accomplish service. A party may serve someone by:

(a) Personal service (hand delivery);

(b) First class, registered, or certified mail sent via the United States Postal Service or Washington state consolidated mail services;

(c) Fax;

(d) Commercial delivery service; or

(e) Legal messenger service.

(3) A party must serve all other parties or their representatives whenever the party files a motion, pleading, brief, or other document with the presiding officer, reviewing officer or officers, or hearing officer's office, or when required by law.

(4) Unless otherwise stated in applicable law, service is complete when:

(a) Personal service is made;

(b) Mail is properly stamped, addressed, and deposited in the United States Postal Service;

(c) Mail is properly addressed, and deposited in the Washington state consolidated mail services;

(d) Fax produces proof of transmission;

(e) A parcel is delivered to a commercial delivery service with charges prepaid; or

(f) A parcel is delivered to a legal messenger service with charges prepaid.

(5) A party may prove service by providing any of the following:

(a) A signed affidavit of mailing or certificate of service;

(b) The certified mail receipt signed by the person who received the parcel;

(c) A signed receipt from the person who accepted the commercial delivery service or legal messenger service parcel;

(d) Proof of fax transmission.

(6) Service cannot be made by electronic mail unless mutually agreed to in advance and in writing by the parties.

(7) If the document is a subpoena, follow the compliance procedure as described in WAC 182-16-3130.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-16-058, filed 6/21/22, effective 1/1/23*
- *WSR 20-16-062 (Admin #2020-03), § 182-16-058, filed 7/28/20, effective 1/1/21*
- *WSR 18-22-033 (Admin #2018-03), § 182-16-058, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-064** Applicable rules and laws. {#sec-182-16-064 omnilex-key=us-wa-regs-official--title-182--182-16-064}

(1) An employing agency must apply public employees benefits board (PEBB) program rules adopted in the Washington Administrative Code (WAC) and follow instructions from the authority.

(2) A presiding officer, reviewing officer or officers, or hearing officer must first apply the applicable PEBB program rules adopted in the WAC. If no PEBB program rule applies, the presiding officer, reviewing officer or officers, or hearing officer must decide the issue according to the best legal authority and reasoning available, including federal and Washington state constitutions, statutes, regulations, significant decisions indexed as described in WAC 182-16-130, and court decisions.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-16-064, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-064, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-064, filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-064, filed 9/25/14, effective 1/1/15.*

##### **Wash. Admin. Code § 182-16-066** Burden of proof, standard of proof, and presumptions. {#sec-182-16-066 omnilex-key=us-wa-regs-official--title-182--182-16-066}

(1) The burden of proof is a party's responsibility to provide evidence regarding disputed facts and persuade the presiding officer, reviewing officer or officers, or hearing officer that a position is correct based on the standard of proof. Unless stated otherwise in rules or law, the appellant has the burden of proof in a brief adjudicative proceeding or formal administrative hearing.

(2) Standard of proof refers to the amount of evidence needed to prove a party's position. Unless stated otherwise in rules or law, the standard of proof in a brief adjudicative proceeding or formal administrative hearing is a preponderance of the evidence, meaning that something is more likely to be true than not.

(3) Public officers and state agencies are presumed to have properly performed their duties and acted as described in the law, unless preponderance of the evidence to the contrary is presented. A party challenging this presumption bears the burden of proof.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-16-066, filed 6/21/22, effective 1/1/23*
- *WSR 20-16-062 (Admin #2020-03), § 182-16-066, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-066, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033, § 182-16-066 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-066, filed 9/25/14, effective 1/1/15.*

##### **Wash. Admin. Code § 182-16-120** Computation of time. {#sec-182-16-120 omnilex-key=us-wa-regs-official--title-182--182-16-120}

(1) In computing any period of time prescribed by this chapter, the day of the event from which the time begins to run is not included. (For example, if an initial order is served on Friday and the party has twenty-one days to request a review, start counting the days with Saturday.)

(2) As provided in subsection (3) of this section, the last day of the period so computed is included unless it is a Saturday, Sunday, or legal holiday as defined in RCW 1.16.050, in which case the period extends to the next business day.

(3) When the period of time prescribed or allowed is ten days or less, intermediate Saturdays, Sundays and state legal holidays must be excluded in the computation.

(4) The deadline is 5:00 p.m. on the last day of the computed period.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-16-120, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-120, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-120, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-130** Index of significant decisions. {#sec-182-16-130 omnilex-key=us-wa-regs-official--title-182--182-16-130}

(1) A final order may be relied upon, used, or cited as precedent by a party only if the final order has been indexed in the authority's index of significant decisions in accordance with RCW 34.05.473 (1)(b).

(2) An index of significant decisions is available to the public on the health care authority's (HCA) website. As decisions are indexed they will be available on the website.

(3) A final order published in the index of significant decisions may be removed from the index when:

(a) A published decision entered by the court of appeals or the supreme court reverses an indexed final order; or

(b) HCA determines that the indexed final order is no longer precedential due to changes in statute, rule, or policy.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-16-130, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-130, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-130, filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-130, filed 9/25/14, effective 1/1/15.*

##### **Wash. Admin. Code § 182-16-2000** Brief adjudicative proceedings. {#sec-182-16-2000 omnilex-key=us-wa-regs-official--title-182--182-16-2000}

Pursuant to RCW 34.05.482, the authority may use brief adjudicative proceedings for issues identified in this chapter when doing so would not violate law, or when protection of the public interest does not require the authority to give notice and an opportunity to participate to persons other than the parties, or the issue and interests involved in the controversy do not warrant use of the procedures of RCW 34.05.413 through 34.05.476 which govern formal administrative hearings.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-16-2000, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2000, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2000, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-2005** Record—Brief adjudicative proceeding. {#sec-182-16-2005 omnilex-key=us-wa-regs-official--title-182--182-16-2005}

The record in a brief adjudicative proceeding consists of any documents regarding the matter, considered or prepared by the presiding officer for the brief adjudicative proceeding or by the reviewing officer or officers for any review. The authority's record does not have to constitute the exclusive basis for agency action, unless otherwise required by law.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-16-2005, filed 6/21/22, effective 1/1/23*
- *WSR 18-22-033 (Admin #2018-03), § 182-16-2005, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-2010** Appealing a decision regarding public employees benefits board (PEBB) eligibility, enrollment, premium payments, premium surcharges, a wellness incentive, or the administration of benefits. {#sec-182-16-2010 omnilex-key=us-wa-regs-official--title-182--182-16-2010}

(1) Any current or former employee of a state agency or their dependent aggrieved by a decision made by the state agency with regard to public employees benefits board (PEBB) eligibility, enrollment, or premium surcharges may appeal that decision to the state agency by the process described in WAC 182-16-2020.

| Note: | Eligibility decisions address whether a subscriber or a subscriber's dependent is entitled to PEBB benefits, as described in PEBB rules and policies. Enrollment decisions address the application for PEBB benefits as described in PEBB rules and policies including, but not limited to, the submission of proper documentation and meeting enrollment deadlines. |
| --- | --- |

(2) Any current or former employee of a PEBB participating employer group or their dependent who is aggrieved by a decision made by the employer group with regard to PEBB eligibility, enrollment, or premium surcharges may appeal that decision to the employer group through the process established by the employer group.

| Exception: | Any current or former employee of a PEBB participating employer group aggrieved by a decision regarding life insurance, long-term disability (LTD) insurance, eligibility to participate in the PEBB wellness incentive program, or eligibility to receive a PEBB wellness incentive may appeal that decision to the PEBB appeals unit by the process described in WAC 182-16-2030. |
| --- | --- |

(3) Any subscriber or dependent aggrieved by a decision made by the PEBB program with regard to PEBB eligibility, enrollment, premium payments, premium surcharges, eligibility to participate in the PEBB wellness incentive program, or eligibility to receive a PEBB wellness incentive, may appeal that decision to the PEBB appeals unit by the process described in WAC 182-16-2030.

(4) Any enrollee aggrieved by a decision regarding the administration of PEBB medical, dental, vision, life insurance, accidental death and dismemberment (AD&D) insurance, or long-term disability insurance may appeal that decision by following the appeal provisions of those plans, with the exception of:

(a) Enrollment decisions;

(b) Premium payment decisions other than life insurance or AD&D insurance premium payment decisions; and

(c) Eligibility decisions.

(5) Any PEBB enrollee aggrieved by a decision regarding the administration of PEBB long-term care insurance or property and casualty insurance may appeal that decision by following the appeal provisions of those plans.

(6) Any PEBB employee aggrieved by a decision regarding the administration of a benefit offered under the salary reduction plan may appeal that decision by the process described in WAC 182-16-2050.

(7) Any subscriber aggrieved by a decision made by the PEBB wellness incentive program contracted vendor regarding the completion of the PEBB wellness incentive program requirements, or a request for a reasonable alternative to a wellness incentive program requirement, may appeal that decision by the process described in WAC 182-16-2040.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-16-2010, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-16-2010, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2010, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2010, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-2020** Appealing a decision made by a state agency about eligibility, premium surcharges, or enrollment in benefits. {#sec-182-16-2020 omnilex-key=us-wa-regs-official--title-182--182-16-2020}

(1) An eligibility, premium surcharges, or enrollment decision made by a state agency may be appealed by submitting a written request for administrative review to the state agency. The state agency must receive the request for administrative review no later than thirty days after the date of the denial notice. The contents of the request for administrative review are to be provided as described in WAC 182-16-2070.

(a) Upon receiving the request for administrative review, the state agency must perform a complete review of the denial by one or more staff who did not take part in the decision resulting in the denial.

(b) The state agency must render a written decision within thirty days of receiving the written request for administrative review. The written decision must be sent to the employee or employee's dependent who submitted the request for administrative review and must include a description of the appeal rights. The state agency must also send a copy of the state agency's written decision to the state agency's administrator (or designee) and to the public employees benefits board (PEBB) appeals unit. If a state agency fails to render a written decision within thirty days of receiving the written request for administrative review, the request for administrative review may be considered denied as of the thirty-first day and the original underlying state agency decision may be appealed to the PEBB appeals unit by following the process in this section.

(c) The state agency may reverse eligibility, premium surcharges, or enrollment decisions as permitted by WAC 182-08-187.

(2) Any current or former employee or employee's dependent who disagrees with the state agency's decision in response to a written request for administrative review, as described in subsection (1) of this section, may request a brief adjudicative proceeding to be conducted by the authority by submitting a written request to the PEBB appeals unit.

(a) The PEBB appeals unit must receive the request for a brief adjudicative proceeding no later than thirty days after the date of the state agency's written decision on the request for administrative review. If a state agency fails to render a written decision within thirty days of receiving a written request for administrative review, the PEBB appeals unit must receive the request for a brief adjudicative proceeding no later than thirty days after the date the request for administrative review was deemed denied. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.

(i) The PEBB appeals unit must notify the appellant in writing when the request for a brief adjudicative proceeding has been received.

(ii) Once the PEBB appeals unit receives a request for a brief adjudicative proceeding, the PEBB appeals unit will send a request for documentation and information to the applicable state agency. The state agency will then have two business days to respond to the request and provide the requested documentation and information. The state agency will also send a copy of the documentation and information to the appellant.

(iii) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.

(b) If an employee fails to timely request a brief adjudicative proceeding, the state agency's prior written decision becomes the authority's final order without further action.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-16-2020, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2020, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2020, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-2030** Appealing a public employees benefits board (PEBB) program decision regarding eligibility, enrollment, premium payments, premium surcharges, a PEBB wellness incentive, or certain decisions made by an employer group. {#sec-182-16-2030 omnilex-key=us-wa-regs-official--title-182--182-16-2030}

(1) A decision made by the public employees benefits board (PEBB) program regarding eligibility, enrollment, premium payments, premium surcharges, or a PEBB wellness incentive, may be appealed by submitting a request to the PEBB appeals unit for a brief adjudicative proceeding to be conducted by the authority.

(2) A decision made by a PEBB participating employer group regarding life insurance, LTD insurance, eligibility to participate in the PEBB wellness incentive program, or eligibility to receive a PEBB wellness incentive, may be appealed by submitting a request to the PEBB appeals unit for a brief adjudicative proceeding to be conducted by the authority.

(3) The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.

(4) The request for a brief adjudicative proceeding from a current or former employee or employee's dependent must be received by the PEBB appeals unit no later than 30 days after the date of the denial notice.

(5) The request for a brief adjudicative proceeding from a retiree, a continuation coverage enrollee, a retired employee or retired school employee continuing PEBB health plan coverage when their employer group ceases participation, a survivor, or their dependent must be received by the PEBB appeals unit no later than 60 days after the date of the denial notice.

(6) The PEBB appeals unit must notify the appellant in writing when the request for a brief adjudicative proceeding has been received.

(7) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.

(8) Failing to timely request a brief adjudicative proceeding will result in the prior PEBB program decision becoming the authority's final order without further action.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-16-2030, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-16-2030, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2030, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2030, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-2040** How can a subscriber appeal a decision regarding the administration of wellness incentive program requirements? {#sec-182-16-2040 omnilex-key=us-wa-regs-official--title-182--182-16-2040}

(1) Any subscriber aggrieved by a decision made by the public employees benefits board (PEBB) wellness incentive program contracted vendor regarding the completion of the wellness incentive program requirements, or request for a reasonable alternative to a wellness incentive program requirement, may appeal that decision to the PEBB program.

(2) Any subscriber who disagrees with a decision in response to an appeal filed with the PEBB program may appeal the decision by submitting a request for a brief adjudicative proceeding to the PEBB appeals unit.

(a) The request for a brief adjudicative proceeding from a current or former employee must be received by the PEBB appeals unit no later than 30 days after the date of the denial notice. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.

(b) The request for a brief adjudicative proceeding from a retiree, a continuation coverage enrollee, a retired employee or retired school employee continuing PEBB health plan coverage when their employer group ceases participation, or a survivor must be received by the PEBB appeals unit no later than 60 days after the date of the denial notice. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.

(3) The PEBB appeals unit must notify the appellant in writing when the request for a brief adjudicative proceeding has been received.

(4) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.

(5) If a subscriber fails to timely request a brief adjudicative proceeding, the decision of the PEBB wellness incentive program contracted vendor becomes the authority's final order without further action.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-12-049 (Admin #2025.01.01), s 182-16-2040, filed 5/29/25, effective 7/1/25. Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-16-2040, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-16-2040, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2040, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2040, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-2050** How can an employee appeal a decision regarding the administration of benefits offered under the salary reduction plan? {#sec-182-16-2050 omnilex-key=us-wa-regs-official--title-182--182-16-2050}

(1) Any employee who disagrees with a decision that denies eligibility for, or enrollment in, a benefit offered under the salary reduction plan may appeal that decision by submitting a written request for administrative review to their state agency. The state agency must receive the written request for administrative review no later than 30 days after the date of the denial. The contents of the written request for administrative review are to be provided as described in WAC 182-16-2070.

(a) Upon receiving the written request for administrative review, the state agency must perform a complete review of the denial by one or more staff who did not take part in the decision resulting in the denial.

(b) The state agency must render a written decision within 30 days of receiving the written request for administrative review. The written decision must be sent to the employee who submitted the written request for review and must include a description of appeal rights. The state agency must also send a copy of the state agency's written decision to the state agency's administrator (or designee) and to the PEBB appeals unit. If a state agency fails to render a written decision within 30 days of receiving the written request for administrative review, the request for administrative review may be considered denied as of the 31st day and the original underlying state agency decision may be appealed to the PEBB appeals unit by following the process in this section.

(2) Any employee who disagrees with the state agency's decision in response to a written request for administrative review, as described in this section, may request a brief adjudicative proceeding to be conducted by the authority by submitting a written request to the PEBB appeals unit.

(a) The PEBB appeals unit must receive the request for a brief adjudicative proceeding no later than 30 days after the date of the state agency's written decision on the request for administrative review. If a state agency fails to render a written decision within 30 days of receiving a written request for administrative review, the PEBB appeals unit must receive the request for a brief adjudicative proceeding no later than 30 days after the date the request for administrative review was deemed denied. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.

(i) The PEBB appeals unit must notify the appellant in writing when the request for a brief adjudicative proceeding has been received.

(ii) Once the PEBB appeals unit receives a request for a brief adjudicative proceeding, the PEBB appeals unit will send a request for documentation and information to the applicable state agency. The state agency will then have two business days to respond to the request and provide the documentation and information requested. The state agency will also send a copy of the documentation and information to the employee.

(iii) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.

(b) If an employee fails to timely request a brief adjudicative proceeding, the state agency's prior written decision becomes the authority's final order without further action.

(3) Any employee aggrieved by a decision regarding a claim for benefits under the flexible spending arrangement or limited purpose flexible spending arrangement (FSA) or dependent care assistance program (DCAP) offered under the salary reduction plan may appeal that decision to the authority's contracted vendor by following the appeal process of that contracted vendor.

(a) Any employee who disagrees with a decision in response to an appeal filed with the contracted vendor that administers the FSA, limited purpose FSA, and DCAP under the salary reduction plan may request a brief adjudicative proceeding by submitting a written request to the PEBB appeals unit. The PEBB appeals unit must receive the request for a brief adjudicative proceeding no later than 30 days after the date of the contracted vendor's appeal decision. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.

(i) The PEBB appeals unit must notify the appellant in writing when the request for a brief adjudicative proceeding has been received.

(ii) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.

(b) If an employee fails to timely request a brief adjudicative proceeding, the contracted vendor's prior written decision becomes the authority's final order without further action.

(4) Any employee aggrieved by a decision regarding the administration of the premium payment plan offered under the salary reduction plan may request a brief adjudicative proceeding to be conducted by the authority by submitting a written request to the PEBB appeals unit for a brief adjudicative proceeding.

(a) The PEBB appeals unit must receive the request for a brief adjudicative proceeding no later than 30 days after the date of the denial notice by the PEBB program. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.

(i) The PEBB appeals unit must notify the appellant in writing when the notice of appeal has been received.

(ii) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.

(b) If an employee fails to timely request a brief adjudicative proceeding, the PEBB program's prior written decision becomes the authority's final order without further action.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-16-2050, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-16-2050, filed 6/21/22, effective 1/1/23*
- *WSR 20-16-062 (Admin #2020-03), § 182-16-2050, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2050, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2050, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-2060** How can an entity or organization appeal a decision of the health care authority to deny an employer group application? {#sec-182-16-2060 omnilex-key=us-wa-regs-official--title-182--182-16-2060}

(1) An entity or organization whose employer group application to participate in public employees benefits board (PEBB) insurance coverage is denied by the authority may appeal the decision by submitting a request for a brief adjudicative proceeding to the PEBB appeals unit. For rules regarding eligible entities, see WAC 182-12-111.

(2) The PEBB appeals unit must receive the request for a brief adjudicative proceeding no later than 30 days after the date of the denial notice. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.

(3) The PEBB appeals unit must notify the appellant in writing when the request for a brief adjudicative proceeding has been received.

(4) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.

(5) Failing to timely request a brief adjudicative proceeding will result in the prior PEBB program decision becoming the authority's final order without further action.

**History**
- *Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-16-2060, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-16-2060, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2060, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2060, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-2070** What should a written request for administrative review and a request for brief adjudicative proceeding contain? {#sec-182-16-2070 omnilex-key=us-wa-regs-official--title-182--182-16-2070}

(1) A written request for administrative review of the employing agency decision and a request for brief adjudicative proceeding should contain the following:

(a) The name and mailing address of the party requesting an administrative review or the brief adjudicative proceeding;

(b) The name and mailing address of the appealing party's representative, if any;

(c) Documentation, or reference to documentation, of decisions previously rendered through the appeal process, if any;

(d) A statement identifying the specific portion of the decision being appealed and clarifying what is believed to be unlawful or in error;

(e) A statement of facts in support of the appealing party's position;

(f) Any information or documentation that the appealing party would like considered;

(g) The type of relief sought;

(h) The signature of the appealing party or the appealing party's representative; and

(i) A statement that describes the appealing party or the appealing party's representative has read the notice of request for an appeal and believes the contents to be true and correct.

(2) Failing to provide documentation, or reference to documentation, of decisions previously rendered through the appeal process as described in subsection (1)(c) of this section, may result in a rejection of the item being appealed.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-12-049 (Admin #2025.01.01), s 182-16-2070, filed 5/29/25, effective 7/1/25*
- *WSR 20-16-062 (Admin #2020-03), § 182-16-2070, filed 7/28/20, effective 1/1/21*
- *WSR 18-22-033 (Admin #2018-03), § 182-16-2070, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-2080** Who can appeal or represent a party in a brief adjudicative proceeding? {#sec-182-16-2080 omnilex-key=us-wa-regs-official--title-182--182-16-2080}

(1) The appellant may act as their own representative or may choose to be represented by another person, except that employees of the health care authority (HCA) or HCA's authorized agents may not represent an appellant, unless approved by a presiding officer or reviewing officer.

(2) If the appellant is represented by a person who is not an attorney admitted to practice in Washington state, the representative must provide the presiding officer and other parties with the representative's name, address, and telephone number. In cases involving confidential information, the nonattorney representative must provide the PEBB appeals unit and other parties with a signed, written consent permitting release to the nonattorney representative of the appellant's health information protected by state or federal law.

(3) An attorney admitted to practice law in Washington state representing the appellant must file a written notice of appearance containing the attorney's name, address, and telephone number with the presiding officer's office and serve all parties with the notice. In cases involving confidential information, the attorney must provide the PEBB appeals unit and other parties with a signed, written consent permitting release to the attorney of the appellant's health information protected by state or federal law. If the appellant's attorney representative no longer represents the appellant, then the attorney must file a written notice of withdrawal of representation with the presiding officer or reviewing officer or officers' office and serve all parties with the notice.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-16-2080, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2080, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2080, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-2085** Continuances. {#sec-182-16-2085 omnilex-key=us-wa-regs-official--title-182--182-16-2085}

The presiding officer or reviewing officer or officers may grant, in their sole discretion, a request for a continuance on motion of the appellant, the authority, or on their own. The continuance may be up to 30 calendar days.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-16-2085, filed 6/21/22, effective 1/1/23*
- *WSR 20-16-062 (Admin #2020-03), § 182-16-2085, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2085, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2085, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-2090** Initial order. {#sec-182-16-2090 omnilex-key=us-wa-regs-official--title-182--182-16-2090}

Unless a continuance has been granted, the presiding officer will render a written initial order that addresses the issue or issues raised by the appellant in their appeal within 10 days after the presiding officer receives the contents of the request for a brief adjudicative proceeding. The presiding officer must serve a copy of the initial order on all parties and the initial order must contain information on how the appellant may request review of the initial order.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-12-049 (Admin #2025.01.01), s 182-16-2090, filed 5/29/25, effective 7/1/25*
- *WSR 20-16-062 (Admin #2020-03), § 182-16-2090, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2090, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2090, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-2100** How to request a review of an initial order resulting from a brief adjudicative proceeding. {#sec-182-16-2100 omnilex-key=us-wa-regs-official--title-182--182-16-2100}

(1) Both the appellant and the authority may request review of an initial order. An appellant who has received an initial order upholding an employing agency decision, public employees benefits board (PEBB) program decision, or a decision made by a PEBB program contracted vendor, may request review of the initial order by the authority. The appellant may request review of the initial order by filing a written request for review of the initial order or making an oral request with the PEBB appeals unit within 21 days after service of the initial order. The written or oral request for review of the initial order must be made by using the contact information included in the initial order. If the appellant fails to request review of the initial order within 21 days, the initial order becomes the authority's final order without further action.

(2) Upon timely request by the appellant, a review of an initial order will be performed by one or more reviewing officers designated by the director of the authority.

(3) If the appellant has not requested review, the authority may review an order resulting from a brief adjudicative proceeding on its own, and without notice to the parties, but it may not take action on review less favorable to any party than the initial order without giving that party notice and an opportunity to explain that party's view of the matter.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-16-2100, filed 6/21/22, effective 1/1/23*
- *WSR 20-16-062 (Admin #2020-03), § 182-16-2100, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2100, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2100, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-2105** Withdrawing the request for a brief adjudicative proceeding or review of an initial order. {#sec-182-16-2105 omnilex-key=us-wa-regs-official--title-182--182-16-2105}

(1) The appellant may withdraw the request for a brief adjudicative proceeding or review of an initial order for any reason, and at any time, by contacting the public employees benefits board (PEBB) appeals unit. The PEBB appeals unit will present the withdrawal request to the presiding officer or reviewing officer or officers.

(2) The request for withdrawal must be made in writing.

(3) After a withdrawal request is received, the presiding officer or reviewing officer or officers must enter and serve a written order dismissing the brief adjudicative proceeding or review of an initial order.

(4) If an appellant withdraws a request for a brief adjudicative proceeding or review of an initial order, the appellant may not reinstate the request for a brief adjudicative proceeding or review of an initial order unless time remains on their original appeal period.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-16-2105, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2105, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2105, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-2110** Final order. {#sec-182-16-2110 omnilex-key=us-wa-regs-official--title-182--182-16-2110}

(1) A final order issued by the reviewing officer or officers will be in writing and include a brief statement of the reasons for the decision.

(2) The final order must be served within 20 days of the date of the initial order or of the date the request for review of the initial order was received by the PEBB appeals unit, whichever is later.

(3) The final order will include a notice that reconsideration and judicial review may be available.

(4) A request for review of the initial order is deemed denied if the authority does not issue a final order within 20 days after the request for review of the initial order is filed.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-16-2110, filed 6/21/22, effective 1/1/23*
- *WSR 20-16-062 (Admin #2020-03), § 182-16-2110, filed 7/28/20, effective 1/1/21*
- *WSR 18-22-033 (Admin #2018-03), § 182-16-2110, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-2120** Request for reconsideration. {#sec-182-16-2120 omnilex-key=us-wa-regs-official--title-182--182-16-2120}

(1) A request for reconsideration asks the reviewing officer or officers to reconsider the final order because the party believes the reviewing officer or officers made a mistake of law, mistake of fact, or clerical error.

(2) A request for reconsideration must state in writing why the party wants the final order to be reconsidered.

(3) Requests for reconsideration must be filed with the reviewing officer or officers who entered the final order.

(4) If a party files a request for reconsideration:

(a) The reviewing officer or officers must receive the request for reconsideration on or before the tenth business day after the service date of the final order;

(b) The party filing the request must send copies of the request to all other parties; and

(c) Within five business days of receiving a request for reconsideration, the reviewing officer or officers must serve all parties a notice that provides the date the request for reconsideration was received.

(5) The other parties may respond to the request for reconsideration. The response must state in writing why the final order should stand. Responses are optional. If a party chooses not to respond, that party will not be prejudiced because of that choice.

(a) Responses to a request for reconsideration must be received by the reviewing officer or officers no later than seven business days after the service date of the reviewing officer or officers' notice as described in subsection (4)(c) of this section, or the response will not be considered.

(b) Service of responses to a request for reconsideration must be made to all parties.

(6) If a party needs more time to file a request for reconsideration or respond to a request for reconsideration, the reviewing officer or officers may extend the required time frame if the party makes a written request providing a good reason for the request within the required time frame.

(7) Unless the request for reconsideration is denied as untimely filed under subsection (4)(a) of this section, the same reviewing officer or officers who entered the final order, if reasonably available, will also consider the request as well as any responses received.

(8) The decision on the request for reconsideration must be in the form of a written order denying the request, granting the request in whole or in part and issuing a new written final order, or granting the request and setting the matter for further hearing.

(9) If the reviewing officer or officers do not send an order on the request for reconsideration within 20 calendar days of the date of the notice described in subsection (4)(c) of this section, the request is deemed denied.

(10) If any party files a request for reconsideration of the final order, the reconsideration process must be completed before any judicial review may be requested. However, the filing of a request for reconsideration is not required before requesting judicial review.

(11) An order denying a request for reconsideration is not subject to judicial review.

(12) No evidence may be offered in support of a motion for reconsideration, except newly discovered evidence that is material for the party moving for reconsideration and that the party could not with reasonable diligence have discovered and produced prior to the final order being issued.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-16-2120, filed 6/21/22, effective 1/1/23*
- *WSR 20-16-062 (Admin #2020-03), § 182-16-2120, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2120, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2120, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-2130** Judicial review of final order. {#sec-182-16-2130 omnilex-key=us-wa-regs-official--title-182--182-16-2130}

(1) Judicial review is the process of appealing a final order to a court.

(2) The appellant may appeal a final order by filing a written petition for judicial review that meets the requirements of RCW 34.05.510 through 34.05.598. Neither the public employees benefits board (PEBB) program nor the employing agency may request judicial review.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2130, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2130, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-2135** Petitions for judicial review—Service on the authority. {#sec-182-16-2135 omnilex-key=us-wa-regs-official--title-182--182-16-2135}

Delivery pursuant to RCW 34.05.542(4) shall be deemed to have been made when a copy of the petition for judicial review has been received by the public employees benefits board (PEBB) appeals unit at Cherry Street Plaza, 626 8th Avenue S.E., Olympia, WA 98501 or received by mail at the PEBB appeals unit, P.O. Box 45504, Olympia, WA 98504-5504.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-16-2135, filed 6/21/22, effective 1/1/23.*

##### **Wash. Admin. Code § 182-16-2140** Presiding officer—Designation and authority. {#sec-182-16-2140 omnilex-key=us-wa-regs-official--title-182--182-16-2140}

The designation of a presiding officer must be consistent with the requirements of RCW 34.05.485 and the presiding officer must not have personally participated in the decision made by the employing agency or PEBB program.

(1) The presiding officer will decide the issue based on the information provided by the parties during the presiding officer's review of the appeal.

(2) A presiding officer is limited to those powers granted by the state constitution, statutes, rules, or applicable case law.

(3) A presiding officer may not decide that a rule is invalid or unenforceable.

(4) In addition to the record, the presiding officer may employ the authority's expertise as a basis for the decision.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2140, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2140, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-2150** Reviewing officer or officers—Designation and authority. {#sec-182-16-2150 omnilex-key=us-wa-regs-official--title-182--182-16-2150}

(1) The designation of a reviewing officer or officers must be consistent with the requirements of RCW 34.05.491 and the reviewing officer or officers must not have personally participated in the decision made by the employing agency or PEBB program.

(2) The reviewing officer or officers must review the initial order and the record to determine if the initial order was correctly decided and make any inquiries necessary to ascertain whether the proceeding must be converted to a formal administrative hearing.

(3) The reviewing officer or officers will issue a final order that will either:

(a) Affirm the initial order in whole or in part; or

(b) Reverse the initial order in whole or in part; or

(c) Remand to the presiding officer in whole or in part.

(4) A reviewing officer or officers are limited to those powers granted by the state constitution, statutes, rules, or applicable case law.

(5) A reviewing officer or officers may not decide that a rule is invalid or unenforceable.

(6) In addition to the record, the reviewing officer or officers may employ the authority's expertise as a basis for the decision.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-16-2150, filed 6/21/22, effective 1/1/23*
- *WSR 20-16-062 (Admin #2020-03), § 182-16-2150, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2150, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2150, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-2160** Conversion of a brief adjudicative proceeding to a formal administrative hearing. {#sec-182-16-2160 omnilex-key=us-wa-regs-official--title-182--182-16-2160}

(1) The presiding officer or the reviewing officer or officers, in their sole discretion, may convert a brief adjudicative proceeding to a formal administrative hearing at any time before the final order is issued on motion by:

(a) The appellant;

(b) The representative of the appellant;

(c) The authority; or

(d) The presiding officer or reviewing officer or officers.

(2) The presiding officer or reviewing officer or officers must convert the brief adjudicative proceeding to a formal administrative hearing when it is found that the use of the brief adjudicative proceeding violates any provision of law, when the protection of the public interest requires the authority to give notice and an opportunity to participate to persons other than the parties, or when the issues and interests involved in the controversy warrant the use of the procedures or RCW 34.05.413 through 34.05.476 that govern formal administrative hearings.

(3) When a brief adjudicative proceeding is converted to a formal administrative hearing, the director designates a hearing officer to conduct the formal administrative hearing upon notice to the appellant and the authority.

(4) When a brief adjudicative proceeding is converted to a formal administrative hearing, WAC 182-16-010 through 182-16-130 and 182-16-3000 through 182-16-3200 apply to the formal administrative hearing.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-16-2160, filed 6/21/22, effective 1/1/23*
- *WSR 20-16-062 (Admin #2020-03), § 182-16-2160, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2160, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2160, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-3000** Formal administrative hearings. {#sec-182-16-3000 omnilex-key=us-wa-regs-official--title-182--182-16-3000}

(1) When a brief adjudicative proceeding is converted to a formal administrative hearing consistent with WAC 182-16-2160, the director designates a hearing officer to conduct the formal administrative hearing.

(2) Formal administrative hearings are conducted consistent with the Administrative Procedure Act, RCW 34.05.413 through 34.05.476.

(3) Part III describes the general rules and procedures that apply to public employees benefits board (PEBB) benefits formal administrative hearings.

(a) Part III supplements the Administrative Procedure Act (APA), chapter 34.05 RCW, and the model rules of procedure in chapter 10-08 WAC. The model rules of procedure adopted by the chief administrative law judge pursuant to RCW 34.05.250, as now or hereafter amended, are hereby adopted for use by the authority in public employees benefits board (PEBB) benefits formal administrative hearings. Other procedural rules adopted in chapters 182-08, 182-12, and 182-16 WAC are supplementary to the model rules of procedure.

(b) In the case of a conflict between the model rules of procedure and Part III, the procedural rules adopted in Part III must govern.

(c) If there is a conflict between Part III and specific PEBB program rules, the specific PEBB program rules prevail. PEBB program rules are found in chapters 182-08 and 182-12 WAC.

(d) Nothing in Part III is intended to affect the constitutional rights of any person or to limit or change additional requirements imposed by statute or other rule. Other laws or rules determine if a hearing right exists, including the APA and program rules or laws.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-16-3000, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3000, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3000, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-3005** Record—Formal administrative hearings. {#sec-182-16-3005 omnilex-key=us-wa-regs-official--title-182--182-16-3005}

The record in a formal administrative hearing consists of the official documentation of the hearing process. The record includes, but is not limited to, recordings or transcripts, admitted exhibits, decisions, briefs, notices, orders, and other filed documents.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3005, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-3010** Requirements to appear and represent a party in the formal administrative hearing process. {#sec-182-16-3010 omnilex-key=us-wa-regs-official--title-182--182-16-3010}

(1) All parties must provide the hearing officer and all other parties with their name, address, and telephone number.

(2) The appellant may act as their own representative or have another person represent them, except that employees of the health care authority (HCA) or HCA's authorized agents may not represent an appellant, unless approved by a hearing officer.

(3) If the appellant is represented by a person who is not an attorney admitted to practice in Washington state, the representative must provide the hearing officer and all other parties with the representative's name, address, and telephone number. In cases involving confidential information, the nonattorney representative must provide the HCA hearing representative with a signed, written consent permitting release to the nonattorney representative of health information protected by state or federal law.

(4) An attorney admitted to practice law in Washington state, who wishes to represent the appellant, must file a written notice of appearance containing the attorney's name, address, and telephone number with the hearing officer's office and serve all parties with the notice. In cases involving confidential information, the attorney representative must provide the HCA hearing representative with a signed, written consent permitting release to the attorney representative of the appellant's health information protected by state or federal law. If the appellant's attorney representative no longer represents the appellant, then the attorney must file a written notice of withdrawal of representation with the hearing officer's office and serve all parties with the notice.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3010, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3010, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-3015** Hearing officers—Assignment, motions of prejudice, and disqualification. {#sec-182-16-3015 omnilex-key=us-wa-regs-official--title-182--182-16-3015}

(1) Assignment. A hearing officer will be assigned at least five business days before a hearing. A party may ask which hearing officer is assigned to a hearing by contacting the hearing officer's office listed on the notice of hearing. If requested by a party, the hearing officer's office must send the name of the assigned hearing officer to all parties, by electronic mail or in writing, at least five business days before the scheduled hearing date.

(2) Motion of prejudice. Any party requesting a different hearing officer may file a written motion of prejudice against the hearing officer assigned to the matter before the hearing officer rules on a discretionary issue in the case, admits evidence, or takes testimony.

(a) A motion of prejudice must include a declaration stating that a party does not believe the hearing officer can hear the case fairly. Service of copies of the motion must also be made to all parties listed on the notice of hearing.

(b) Any party's first motion of prejudice will be automatically granted. Any subsequent motion of prejudice made by a party may be granted or denied at the discretion of the hearing officer no later than seven days after receiving the motion.

(c) A party may make an oral motion of prejudice at the beginning of a hearing before the hearing officer rules on a discretionary issue in the matter, admits evidence, or takes testimony if:

(i) The hearing officer was not assigned at least five business days before the date of the hearing; or

(ii) The hearing officer was changed within five business days of the date of the hearing.

(3) Disqualification. A hearing officer may be disqualified from presiding over a hearing for bias, prejudice, conflict of interest, or ex parte contact with a party to the hearing.

(a) Any party may file a petition to disqualify a hearing officer as described in RCW 34.05.425. A petition to disqualify must be in writing and service promptly made to all parties and the hearing officer upon discovering facts of possible grounds for disqualification.

(b) The hearing officer whose disqualification is requested will determine whether to grant or deny the petition in a written order, stating facts and reasons for the determination. The hearing officer must serve the order no later than seven days after receiving the petition for disqualification.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3015, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-3030** Authority of the hearing officer. {#sec-182-16-3030 omnilex-key=us-wa-regs-official--title-182--182-16-3030}

(1) A hearing officer must hear and decide the issues based on the evidence and oral or written arguments presented during a formal administrative hearing and admitted into the record.

(2) A hearing officer has no inherent or common law powers, and is limited to those powers granted by the state constitution, statutes, or rules.

(3) A hearing officer may not decide that a rule is invalid or unenforceable. If the validity of a rule is raised during a formal administrative hearing, the hearing officer may allow argument only to preserve the record for judicial review.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-16-3030, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3030, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3030, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-3080** Time requirements for service of notices made by the hearing officer. {#sec-182-16-3080 omnilex-key=us-wa-regs-official--title-182--182-16-3080}

(1) The hearing officer or their designee must serve a notice of a formal administrative hearing to all parties and their representatives at least twenty-one calendar days before the hearing date. The parties may agree to, but the hearing officer cannot impose, a shorter notice period.

(2) If a prehearing conference or dispositive motion hearing is scheduled, the hearing officer must serve a notice of the prehearing conference or dispositive motion hearing to the parties and their representatives at least seven business days before the date of the prehearing conference or dispositive motion hearing except:

(a) The hearing officer may change any scheduled formal administrative hearing into a prehearing conference or dispositive motion hearing and provide less than seven business days' notice of the prehearing conference or dispositive motion hearing; and

(b) The hearing officer may give less than seven business days' notice if the only purpose of the prehearing conference is to consider whether to grant a continuance.

(3) The hearing officer must reschedule a formal administrative hearing if necessary to comply with the notice requirements in Part III of this chapter.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3080, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3080, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-3090** Formal administrative hearing location. {#sec-182-16-3090 omnilex-key=us-wa-regs-official--title-182--182-16-3090}

(1) A hearing officer must be present at all hearings. Hearings may be held either in person or telephonically.

(a) A telephonic hearing is where all parties and the hearing officer are present by telephone.

(b) An in-person hearing is where the appellant appears face-to-face with the hearing officer. The other parties can choose to appear either in person or by telephone, but cannot be ordered to appear in person.

(2) Whether a hearing is held in person or telephonically, the parties have the right to see all documents, hear all testimony, and question all witnesses.

(3) If a hearing is originally scheduled to be held in person, the appellant may ask the hearing officer to change the in-person hearing to a telephonic hearing. Once a telephonic hearing begins, the hearing officer may stop, reschedule, and change the telephonic hearing to an in-person hearing if any party makes such a request.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3090, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-3100** Rescheduling and continuances for formal administrative hearings. {#sec-182-16-3100 omnilex-key=us-wa-regs-official--title-182--182-16-3100}

(1) Any party may request the hearing officer to reschedule a formal administrative hearing if a rule requires notice of a hearing and the amount of notice required was not provided.

(a) The hearing officer must reschedule the formal administrative hearing under circumstances identified in this chapter if requested by any party.

(b) The parties may agree to shorten the amount of notice required by any rule.

(2) Any party may request a continuance of a formal administrative hearing either orally or in writing.

(a) In each formal administrative hearing, the hearing officer must grant each party's first request for a continuance. The continuance may be up to thirty calendar days.

(b) The hearing officer may grant each party up to one additional continuance of up to thirty calendar days because of extraordinary circumstances.

(c) After granting a continuance, the hearing officer or their designee must serve an order of continuance on the parties no later than fourteen days before the new formal administrative hearing date. All orders of continuance must provide a new deadline for filing documents with the hearing officer. The new filing deadline can be no less than ten calendar days prior to the new formal administrative hearing date. If the continuance is granted pursuant to (b) of this subsection, then the order of continuance must also include findings of fact that state with specificity the extraordinary circumstances for which the hearing officer granted the continuance.

(3) Regardless of whether a party has been granted a continuance as described in subsection (2)(b) of this section, the hearing officer must grant a continuance if a new material issue is raised during the formal administrative hearing and a party requests a continuance.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-16-3100, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3100, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3100, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-3110** Prehearing conferences. {#sec-182-16-3110 omnilex-key=us-wa-regs-official--title-182--182-16-3110}

(1) A prehearing conference is a formal proceeding conducted on the record by a hearing officer to prepare for a formal administrative hearing.

(a) The hearing officer must record a prehearing conference using audio recording equipment.

(b) The hearing officer may conduct a prehearing conference in person, by telephone conference call, or in any other manner acceptable to the parties.

(2) Any party can request a prehearing conference. The hearing officer must grant each party's first request for a prehearing conference if it is filed with the hearing officer at least seven business days before the next scheduled hearing date. The hearing officer may grant requests for additional prehearing conferences.

(3) The appellant must attend or participate in any scheduled prehearing conference. If the appellant does not attend or participate in a scheduled prehearing conference, the hearing officer will enter an order of default dismissing the matter.

(4) During a prehearing conference the parties and the hearing officer may:

(a) Identify the issue or issues to be decided;

(b) Agree to the date, time, and place of any requested or necessary hearing or hearings;

(c) Identify accommodation and safety issues; or

(d) Establish a schedule for:

(i) The exchange and filing of briefs;

(ii) Providing a list of proposed witnesses;

(iii) Providing exhibit lists; and

(iv) Providing proposed exhibits before the hearing.

(5) After the prehearing conference ends, the hearing officer must enter a written order that recites the action taken at the prehearing conference, a case schedule outlining hearing dates and deadlines for exchanging witness lists and exhibits, and any other agreements reached by the parties.

(6) The hearing officer must serve the prehearing order to the parties at least fourteen calendar days before the next scheduled hearing.

(7) A party may object to the prehearing order by filing an objection with the hearing officer in writing no later than ten days after the service date of the order. The hearing officer must serve a written ruling on the objection.

(8) If no objection is made to the prehearing order, the order determines how the case will be conducted by the hearing officer, including whether a hearing will be in person or held by telephone conference, unless the hearing officer enters an amended prehearing conference order.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3110, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-3120** Dispositive motions. {#sec-182-16-3120 omnilex-key=us-wa-regs-official--title-182--182-16-3120}

(1) A dispositive motion could dispose of one or all the issues in a formal administrative hearing, such as a motion to dismiss or motion for summary judgment.

(2) To request a dispositive motion hearing a party must file a written dispositive motion with the hearing officer and serve a copy of the motion to all other parties. The hearing officer may also set a dispositive motion hearing, and request briefing from the parties, to address any possible dispositive issues the hearing officer believes must be addressed before the hearing.

(3) The deadline to file a timely dispositive motion must be ten calendar days before the scheduled hearing.

(4) Upon receiving a dispositive motion, a hearing officer:

(a) Must convert the scheduled hearing to a dispositive motion hearing when:

(i) The dispositive motion is timely filed with the hearing officer at least ten calendar days before the date of the hearing; and

(ii) The party filing the dispositive motion has not previously filed a dispositive motion.

(b) May schedule a dispositive motion hearing in all instances other than described in (a) of this subsection.

(5) The hearing officer may conduct the dispositive motion hearing in person or by telephone conference. For dispositive motion hearings scheduled to be held in person, the HCA hearing representative may choose to attend and participate in person or by telephone conference call.

(6) The party requesting the dispositive motion hearing must attend and participate in the dispositive motion hearing in person or by telephone. If the party requesting the motion hearing does not attend and participate in the dispositive motion hearing, the hearing officer will enter an order dismissing the dispositive motion.

(7) During a dispositive motion hearing, the hearing officer can only consider the filed dispositive motions, any response to the motions, evidence submitted to support or oppose the motions, and argument on the motions. Prior to rescheduling any necessary hearings, the hearing officer must serve a written order on the dispositive motions.

(8) The hearing officer must serve the written order on the dispositive motions to all parties no later than eighteen calendar days after the dispositive motion hearing is held. Orders on dispositive motions are subject to motions for reconsideration or petitions for judicial review as described in WAC 182-16-3180 and 182-16-3200.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-16-3120, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3120, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3120, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-3130** Subpoenas. {#sec-182-16-3130 omnilex-key=us-wa-regs-official--title-182--182-16-3130}

(1) Hearing officers, the health care authority (HCA) hearing representative, and attorneys for the parties may prepare subpoenas as described in Washington state civil rule 45, unless otherwise prohibited by law. Any party may request the hearing officer prepare a subpoena on their behalf.

(2) The hearing officer may schedule a prehearing conference to decide whether to issue a subpoena.

(3) If a party requests the hearing officer prepare a subpoena on its behalf, the party is responsible for:

(a) Service of the subpoena; and

(b) Any costs associated with:

(i) Compliance with the subpoena; and

(ii) Witness fees as described in RCW 34.05.446(7).

(4) Service of a subpoena must be made by a person who is at least eighteen years old and not a party to the hearing. Service of the subpoena is complete when the person serving the subpoena:

(a) Gives the person or entity named in the subpoena a copy of the subpoena; or

(b) Leaves a copy of the subpoena with a person over the age of eighteen at the residence or place of business of the person or entity named in the subpoena.

(5) To prove service of a subpoena on a witness, the person serving the subpoena must file with the hearing officer's office a signed, written, and dated statement that includes:

(a) The name of the person to whom service of the subpoena occurred;

(b) The date the service of the subpoena occurred;

(c) The address where the service of the subpoena occurred; and

(d) The name, age, and address of the person who provided service of the subpoena.

(6) A person or entity subject to or affected by the subpoena may request the hearing officer quash (set aside) or change a subpoena request at any time before the deadline given in the subpoena.

(7) A hearing officer may quash (set aside) or change a subpoena if it is unreasonable.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-16-3130, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3130, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3130, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-3140** Orders of dismissal—Reinstating a formal administrative hearing after an order of dismissal. {#sec-182-16-3140 omnilex-key=us-wa-regs-official--title-182--182-16-3140}

(1) An order of dismissal is an order from the hearing officer ending the matter. The order is entered because the party who made the appeal withdrew from the proceeding, the appellant is no longer aggrieved, the hearing officer granted a dispositive motion dismissing the matter, or the hearing officer entered an order of default because the party who made the appeal failed to attend or refused to participate in a prehearing conference or the formal administrative hearing.

(2) The order of dismissal becomes a final order if no party files a request to vacate the order as described in subsections (3) through (7) of this section.

(3) If the hearing officer enters and serves an order dismissing the formal administrative hearing, the appellant may file a written request to vacate (set aside) the order of dismissal. Upon receipt of a request to vacate an order of dismissal, the hearing officer must schedule and serve notice of a prehearing conference as described in WAC 182-16-3080. At the prehearing conference, the party asking that the order of dismissal be vacated has the burden to show good cause according to subsection (8) of this section for an order of dismissal to be vacated and the matter to be reinstated.

(4) The request to vacate an order of dismissal must be filed with the hearing officer and the other parties. The party requesting that an order of dismissal be vacated should specify in the request with good cause why the order of dismissal should be vacated.

(5) The request to vacate an order of dismissal must be filed with the hearing officer no later than twenty-one calendar days after the date the order of dismissal was entered. If no request is received within that deadline, the dismissal order becomes the health care authority's final decision without further action.

(6) If the hearing officer finds good cause, as described in subsection (8) of this section, for the order of dismissal to be vacated, the hearing officer must enter and serve a written order to the parties setting forth the findings of fact, conclusions of law, and the reinstatement of the matter.

(7) If the order of dismissal is vacated, the hearing officer will conduct a formal administrative hearing at which the parties may present argument and evidence about issues raised in the original appeal. The formal administrative hearing may occur immediately following the prehearing conference on the request to vacate only if agreed to by the parties and the hearing officer, otherwise a formal administrative hearing date must be scheduled by the hearing officer.

(8) Good cause is a substantial reason or legal justification for failing to appear, act, or respond to an action using the provisions of Superior Court civil rule 60 as a guideline. This good cause exception does not apply to any other chapter in Title 182 WAC except WAC 182-32-3140(8).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-16-3140, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3140, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3140, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-3160** Withdrawing a formal administrative hearing. {#sec-182-16-3160 omnilex-key=us-wa-regs-official--title-182--182-16-3160}

(1) The appellant may withdraw a formal administrative hearing for any reason, and at any time, by contacting the health care authority (HCA) hearing representative who will coordinate the withdrawal with the hearing officer.

(2) The request for withdrawal must generally be made in writing. An oral withdrawal by the appellant is permitted during a formal administrative hearing when both the hearing officer and HCA hearing representative are present.

(3) After a withdrawal request is received, the hearing officer must cancel any scheduled hearings and enter and serve a written order dismissing the case.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3160, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3160, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-3170** Office of administrative hearings—Initial or final order—Required information. {#sec-182-16-3170 omnilex-key=us-wa-regs-official--title-182--182-16-3170}

(1) Initial order: When the office of administrative hearings is holding a formal administrative hearing on behalf of the authority, the hearing officer must render a written initial order that addresses the issue or issues raised by the appellant in their appeal. The hearing officer must serve a copy of the initial order on all parties and the initial order must contain information on how the appellant may request review of the initial order.

(2) Final order: The final order will only be issued by the authority. After the reviewing officer or officers receives a request for review, the reviewing officer or officers has 20 calendar days to enter and serve a final order to all parties unless the reviewing officer serves notice allowing more time.

(3) In the written final order, the hearing officer must:

(a) Identify the order as a final order of the public employees benefits board (PEBB) program;

(b) List the name and docket number of the case and the names of all parties and representatives;

(c) Enter findings of fact used to resolve the dispute based on the evidence admitted in the record;

(d) Explain why evidence is, or is not, credible when describing the weight given to evidence related to disputed facts;

(e) State the law that applies to the dispute;

(f) Apply the law to the facts of the case in the conclusions of law;

(g) Discuss the reasons for the decision based on the facts and the law;

(h) State the result and remedy ordered; and

(i) Include any other information required by law or program rules.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-16-3170, filed 6/21/22, effective 1/1/23*
- *WSR 20-16-062 (Admin #2020-03), § 182-16-3170, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3170, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3170, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-3175** How to request a review of an initial order by the office of administrative hearings. {#sec-182-16-3175 omnilex-key=us-wa-regs-official--title-182--182-16-3175}

(1) Both the appellant and the authority may request review of an initial order. An appellant who has received an initial order upholding an employing agency decision, a public employees benefits board (PEBB) program decision, or a decision made by a PEBB program contracted vendor, may request review of the initial order or an oral request with the PEBB appeals unit within 20 days after service of the initial order. The written or oral request for review of the initial order must be made by using the contact information included in the initial order. If such review is requested, the hearing officer or their designee from the authority, shall issue a final order in accordance with WAC 182-16-3030. If the appellant fails to request review of the initial order within 20 days, the initial order becomes the authority's final order without further action.

(2) Upon timely request by the appellant, a review of an initial order will be performed by one or more reviewing officers designated by the director of the authority.

(3) If the appellant has not requested review of the initial order, the authority may review an initial order issued by the office of administrative hearings on its own, and without notice to the parties, but it may not take action on review less favorable to any party than the initial order without giving that party notice and an opportunity to explain that party's view of the matter.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-16-3175, filed 6/21/22, effective 1/1/23.*

##### **Wash. Admin. Code § 182-16-3180** Request for reconsideration and response—Process. {#sec-182-16-3180 omnilex-key=us-wa-regs-official--title-182--182-16-3180}

(1) A request for reconsideration asks the hearing officer to reconsider the final order because the party believes the hearing officer made a mistake of law, mistake of fact, or clerical error.

(2) A request for reconsideration must state in writing why the party wants the final order to be reconsidered.

(3) Requests for reconsideration must be filed with the hearing officer who entered the final order.

(4) If a party files a request for reconsideration:

(a) The hearing officer must receive the request for reconsideration on or before the tenth business day after the service date of the final order;

(b) The party filing the request must serve copies of the request on all other parties on the same day the request is served on the hearing officer; and

(c) Within five business days of receiving a request for reconsideration, the hearing officer must serve to all parties a notice that provides the date the request for reconsideration was received.

(5) The other parties may respond to the request for reconsideration. The response must state in writing why the final order should stand. Responses are optional. If a party chooses not to respond, that party will not be prejudiced because of that choice.

(a) Responses to a request for reconsideration must be received by the hearing officer no later than seven business days after the service date of the hearing officer's notice as described in subsection (4)(c) of this section, or the response will not be considered.

(b) Service of responses to a request for reconsideration must be made to all parties.

(6) If a party needs more time to file a request for reconsideration or respond to a request for reconsideration, the hearing officer may extend the required time frame if the party makes a written request providing a good reason for the request within the required time frame.

(7) No evidence may be offered in support of a motion for reconsideration, except newly discovered evidence that is material for the party moving for reconsideration and that the party could not with reasonable diligence have discovered and produced prior to the final order being issued.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-16-3180, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3180, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3180, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-3190** Decisions on requests for reconsideration. {#sec-182-16-3190 omnilex-key=us-wa-regs-official--title-182--182-16-3190}

(1) Unless the request for reconsideration is denied as untimely filed under WAC 182-16-3180, the same hearing officer who entered the final order, if reasonably available, will also decide the request as well as any responses received.

(2) The decision on the request for reconsideration must be in the form of a written order denying or granting the request in whole or in part and if the request is granted issuing a new written final order.

(3) If the hearing officer does not send an order on the request for reconsideration within twenty calendar days of the date of the notice described in WAC 182-16-3180 (4)(c), the request is deemed denied.

(4) If any party files a request for reconsideration of the final order, the reconsideration process must be completed before any judicial review may be requested. However, the filing of a request for reconsideration is not required before requesting judicial review.

(5) An order denying a request for reconsideration is not subject to judicial review.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-16-062 (Admin #2020-03), § 182-16-3190, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3190, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3190, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-3200** Judicial review of final order. {#sec-182-16-3200 omnilex-key=us-wa-regs-official--title-182--182-16-3200}

(1) Judicial review is the process of appealing a final order to a court.

(2) The appellant may appeal a final order by filing a written petition for judicial review that meets the requirements of RCW 34.05.510 through 34.05.598. The public employees benefits board (PEBB) program may not request judicial review.

(3) The appellant should consult RCW 34.05.510 through 34.05.598 for further details and requirements of the judicial review process.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3200, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3200, filed 10/29/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-16-3210** Petitions for judicial review—Service on the authority. {#sec-182-16-3210 omnilex-key=us-wa-regs-official--title-182--182-16-3210}

Delivery pursuant to RCW 34.05.542(4) shall be deemed to have been made when a copy of the petition for judicial review has been received by the public employees benefits board (PEBB) appeals unit at Cherry Street Plaza, 626 8th Avenue S.E., Olympia, WA 98501 or received by mail at the PEBB appeals unit, P.O. Box 45504, Olympia, WA 98504-5504.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-158 (Admin #2022-01), § 182-16-3210, filed 6/21/22, effective 1/1/23.*

## **Chapter 182-30** Procedures. {#struct-chapter-182-30}

##### **Wash. Admin. Code § 182-30-010** Purpose. {#sec-182-30-010 omnilex-key=us-wa-regs-official--title-182--182-30-010}

The purpose of this chapter is to establish school employees benefits board (SEBB) program enrollment criteria and procedures for school employees eligible for SEBB benefits under RCW 41.05.740(6) and for school board members eligible for SEBB benefits under RCW 41.05.743.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-30-010, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-30-010, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-30-010, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-30-020** Definitions. {#sec-182-30-020 omnilex-key=us-wa-regs-official--title-182--182-30-020}

The following definitions apply throughout this chapter unless the context clearly indicates another meaning:

"Accidental death and dismemberment insurance" or "AD&D" means basic accidental death and dismemberment (AD&D) insurance paid for by the SEBB organization, as well as supplemental accidental death and dismemberment insurance offered to and paid for by school employees for themselves and their dependents.

"Annual open enrollment" means an annual event set aside for a period of time by the HCA when subscribers may make changes to their health plan enrollment and salary reduction elections for the following plan year. During the annual open enrollment, subscribers may transfer from one health plan to another, enroll or remove dependents from coverage, enroll in coverage, or waive enrollment (see definition of "waive" in this section). School employees eligible to participate in the salary reduction plan may enroll in or change their election under the dependent care assistance program (DCAP), the flexible spending arrangement (FSA), or limited purpose FSA. They may also enroll in or opt out of the premium payment plan.

"Authority" or "HCA" means the Washington state health care authority.

"Benefits administrator" means any person or persons designated by the SEBB organization that trains, communicates, and interacts with school employees as the subject matter expert for eligibility, enrollment, and appeals for SEBB benefits.

"Board" means the school employees benefits board established under provisions of RCW 41.05.740.

"Calendar days" or "days" means all days including Saturdays, Sundays, and all state legal holidays as set forth in RCW 1.16.050.

"Consolidated Omnibus Budget Reconciliation Act" or "COBRA" means continuation coverage as administered under 42 U.S.C. Secs. 300bb-1 through 300bb-8.

"Continuation coverage" means the temporary continuation of SEBB benefits available to enrollees under the Consolidated Omnibus Budget Reconciliation Act (COBRA), 42 U.S.C. Secs. 300bb-1 through 300bb-8, the Uniformed Services Employment and Reemployment Rights Act (USERRA), 38 U.S.C. Secs. 4301 through 4335, or SEBB policies.

"Contracted vendor" means any person, persons, or entity under contract or agreement with the HCA to provide goods or services for the provision or administration of SEBB benefits. The term "contracted vendor" includes subcontractors of the HCA and subcontractors of any person, persons, or entity under contract or agreement with the HCA that provide goods or services for the provision or administration of SEBB benefits.

"Dependent" means a person who meets eligibility requirements in WAC 182-31-140.

"Dependent care assistance program" or "DCAP" means a benefit plan whereby school employees may pay for certain employment related dependent care with pretax dollars as provided in the salary reduction plan under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 129 or other sections of the Internal Revenue Code.

"Director" means the director of the authority.

"Employer-based group health plan" means group medical, group vision, and group dental related to a current employment relationship. It does not include medical, vision, or dental coverage available to retired employees, individual market medical or dental coverage, or government-sponsored programs such as medicare or medicaid.

"Employer-based group medical" means group medical related to a current employment relationship. It does not include medical coverage available to retired employees, individual market medical coverage, or government-sponsored programs such as medicare or medicaid.

"Employer contribution" means the funding amount paid to the HCA by a school employees benefits board (SEBB) organization for its eligible school employees as described under WAC 182-31-040 or 182-30-130.

"Employer group" means an employee organization representing school employees and a tribal school as defined in RCW 28A.715.010, obtaining school employee benefits through a contractual agreement with the authority to participate in benefit plans developed by the school employees benefits board as described in WAC 182-30-215.

"Employer group rate surcharge" means the rate surcharge described in RCW 41.05.050(2).

"Enrollee" means a person who meets all eligibility requirements defined in chapter 182-31 WAC or WAC 182-30-130, who is enrolled in SEBB benefits, and for whom applicable premium payments have been made.

"Flexible spending arrangement" or "FSA" means a benefit plan whereby eligible school employees may reduce their salary before taxes to pay for medical expenses not reimbursed by insurance as provided in the salary reduction plan established under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"Forms" or "form" means both paper forms and forms completed electronically.

"Health plan" means a plan offering medical, vision, dental, or any combination of these coverages, developed by the board and provided by a contracted vendor or self-insured plans administered by the HCA.

"Insignificant shortfall" means a premium balance owed that is less than or equal to the lesser of $50 or 10 percent of the premium required by the health plan as described in Treasury Regulation 26 C.F.R. 54.4980B-8.

"Large claim" means a claim of more than $25,000 in allowed costs for services in a quarter.

"Life insurance" means basic life insurance paid for by the SEBB organization, as well as supplemental life insurance or supplemental dependent life insurance offered to and paid for by school employees for themselves and their dependents.

"Limited purpose flexible spending arrangement" or "limited purpose FSA" means a benefit plan whereby eligible school employees may reduce their salary before taxes to pay for dental and vision expenses not reimbursed by insurance as provided in the salary reduction plan established under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"Long-term disability insurance" or "LTD insurance" means employer-paid long-term disability insurance and any employee-paid long-term disability insurance offered by the SEBB program.

"Ongoing large claim" means a claim where the patient is expected to need ongoing case management into the next quarter for which the expected allowed cost is greater than $25,000 in the quarter.

"PEBB" means the public employees benefits board.

"PEBB program" means the program within the HCA that administers insurance and other benefits for eligible employees (as described in WAC 182-12-114), eligible retired employees (as described in WAC 182-12-171, 182-12-180, and 182-12-211), eligible survivors (as described in WAC 182-12-180, 182-12-250, and 182-12-265), eligible dependents (as described in WAC 182-12-250 and 182-12-260), and others as defined in RCW 41.05.011 or as described in RCW 41.05.080 (1)(a)(ii).

"Plan year" means the time period established by the authority.

"Premium payment plan" means a benefit plan whereby school employees may pay their share of group health plan premiums with pretax dollars as provided in the salary reduction plan under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"Premium surcharge" means a payment required from a subscriber, in addition to the subscriber's medical premium contribution, due to an enrollee's tobacco use or an enrolled subscriber's spouse or state registered domestic partner choosing not to enroll in their employer-based group medical when:

• The spouse's or state registered domestic partner's share of the medical premium is less than 95 percent of the additional cost an employee would be required to pay to enroll a spouse or state registered domestic partner in the public employees benefits board (PEBB) Uniform Medical Plan (UMP) Classic; and

• The benefits have an actuarial value of at least 95 percent of the actuarial value of PEBB UMP Classic benefits.

"Salary reduction plan" means a benefit plan whereby school employees may agree to a reduction of salary on a pretax basis to participate in the dependent care assistance program, flexible spending arrangement, limited purpose flexible spending arrangement, or premium payment plan offered pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"School board member" means the board of directors of a school district as governed by chapter 28A.343 RCW or the board of directors of an educational district as governed by chapter 28A.310 RCW.

"School employee" means all employees of school districts and charter schools established under chapter 28A.710 RCW; represented employees of educational service districts; effective January 1, 2024, all employees of educational service districts; and effective January 1, 2024, pursuant to a contractual agreement with the authority, "school employee" may also include (a) employees of employee organizations representing school employees, at the option of each such employee organization; and (b) employees of a tribal school as defined in RCW 28A.715.010, if the governing body of the tribal school seeks and receives the approval of the authority to provide any of its insurance programs by contracts with the authority, as provided in RCW 41.05.021 (1)(f) and (g).

"School employees benefits board organization" or "SEBB organization" means a public school district or educational service district or charter school established under chapter 28A.710 RCW that is required to participate in benefit plans provided by the school employees benefits board.

"School year" means school year as defined in RCW 28A.150.203(11).

"SEBB" means the school employees benefits board.

"SEBB benefits" means one or more insurance coverages or other school employee benefits administered by the SEBB program within the HCA.

"SEBB insurance coverage" means any health plan, life insurance, accidental death and dismemberment insurance, or long-term disability insurance administered as a SEBB benefit.

"SEBB program" means the program within the HCA that administers insurance and other benefits for eligible school employees (as described in WAC 182-31-040 or 182-30-130), eligible dependents (as described in WAC 182-31-140), and eligible school board members (as described in WAC 182-31-200).

"Special open enrollment" means a period of time when subscribers may make changes to their health plan enrollment and salary reduction elections outside of the annual open enrollment period when specific life events occur. During the special open enrollment subscribers may change health plans and enroll or remove dependents from coverage. Additionally, school employees may enroll in or waive enrollment (see definition of "waive" in this section). School employees eligible to participate in the salary reduction plan may enroll in or revoke their election under the DCAP, FSA, limited purpose FSA, or the premium payment plan and make a new election. For special open enrollment events related to specific SEBB benefits, see WAC 182-30-090, 182-30-100, 182-31-080, and 182-31-150.

"State registered domestic partner" has the same meaning as defined in RCW 26.60.020(1) and substantially equivalent legal unions from other jurisdictions as defined in RCW 26.60.090.

"Subscriber" means the school employee, continuation coverage enrollee, or school board member who has been determined eligible by the SEBB program, SEBB organization, or employer group, is enrolled in SEBB benefits, and is the individual to whom the SEBB program and contracted vendors will issue all notices, information, requests, and premium bills on behalf of an enrollee.

"Supplemental coverage" means any life insurance or accidental death and dismemberment (AD&D) insurance coverage purchased by the school employee in addition to the coverage provided by the school employees benefits board (SEBB) organization.

"Tobacco products" means any product made with or derived from tobacco that is intended for human consumption, including any component, part, or accessory of a tobacco product. This includes, but is not limited to, cigars, cigarettes, pipe tobacco, chewing tobacco, snuff, and other tobacco products. It does not include e-cigarettes or United States Food and Drug Administration (FDA) approved quit aids.

"Tobacco use" means any use of tobacco products within the past two months. Tobacco use, however, does not include the religious or ceremonial use of tobacco.

"Tribal school" has the same meaning as defined in RCW 28A.715.010.

"Waive" means an eligible school employee affirmatively declining enrollment in SEBB medical because the school employee is enrolled in other employer-based group medical, a TRICARE plan, or medicare Part A and Part B as allowed under WAC 182-31-080. A school employee may waive enrollment in SEBB medical to enroll in PEBB medical only if they are enrolled in PEBB dental and PEBB vision. A school employee who waives enrollment in SEBB medical to enroll in PEBB medical also waives enrollment in SEBB dental and SEBB vision.

"Week" means a seven-day period starting on Sunday and ending on Saturday.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.740. WSR 25-14-083 (Admin #2025-01.02), s 182-30-020, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-30-020, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-30-020, filed 6/21/22, effective 1/1/23*
- *WSR 21-13-117 (Admin #2021-01.04), § 182-30-020, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-30-020, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-30-020, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-30-020, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-30-030** Employer contribution for school employees benefits board (SEBB) benefits. {#sec-182-30-030 omnilex-key=us-wa-regs-official--title-182--182-30-030}

The employer contribution must be used to provide school employees benefits board (SEBB) insurance coverage for the basic life insurance benefit, basic accidental death and dismemberment (AD&D) insurance benefit, employer-paid long-term disability (LTD) insurance benefit, medical insurance, vision insurance, dental insurance, SEBB program administrative costs, the school employee remittance required in RCW 28A.400.410 and to establish a reserve for any remaining balance. There is no employer contribution available for any other insurance coverage for school employees employed by SEBB organizations.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-13-117 (Admin #2021-01.04), § 182-30-030, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-30-030, filed 7/1/19, effective 8/1/19.*

##### **Wash. Admin. Code § 182-30-040** Premium payments and premium refunds. {#sec-182-30-040 omnilex-key=us-wa-regs-official--title-182--182-30-040}

School employees benefits board (SEBB) insurance coverage premiums and applicable premium surcharges for all subscribers are due as described in this section, except when a SEBB organization is correcting its enrollment error as described in WAC 182-30-060 (4) or (5).

(1) Premium payments. SEBB insurance coverage premiums and applicable premium surcharges for all subscribers become due the first of the month in which SEBB insurance coverage is effective.

Premiums and applicable premium surcharges are due from the subscriber for the entire month of SEBB insurance coverage and will not be prorated during any month.

(a) For subscribers not eligible for the employer contribution that are electing to enroll in continuation coverage as described in WAC 182-31-090, 182-31-100, 182-31-120, or 182-31-130, or electing to enroll as a school board member as described in WAC 182-31-200, the first premium payment and applicable premium surcharges are due to the health care authority (HCA) or the contracted vendor no later than 45 days after the election period ends as described within the Washington Administrative Code applicable to the subscriber. Premiums and applicable premium surcharges associated with continuing SEBB medical must be made to the HCA as well as premiums associated with continuing SEBB dental or vision insurance coverage. Premiums associated with life insurance coverage and accidental death and dismemberment (AD&D) coverage must be made to the contracted vendor. Following the first premium payment, premiums and applicable premium surcharges must be paid as premiums become due.

| Exception: | A subscriber enrolled in continuation coverage as defined in WAC 182-30-020 who is electing to enroll in another type of continuation coverage is not required to make the first premium payment and applicable premium surcharges to begin the new enrollment. |
| --- | --- |

(b) For school employees who are eligible for the employer contribution, premiums and applicable premium surcharges are due to the SEBB organization or contracted vendor. If a school employee elects supplemental coverage or employee-paid long-term disability (LTD) insurance, or is enrolled in employee-paid LTD insurance, as described in WAC 182-30-080 (1)(a) or (3)(a) or is enrolled in employee-paid LTD insurance as described in WAC 182-30-080 (1)(b) the school employee is responsible for payment of premiums from the month the supplemental coverage or employee-paid LTD insurance begins.

| Exception: | A school employee who is on a leave of absence and maintains eligibility for the employer contribution, will have their premiums waived for their employee-paid LTD insurance for the first 90 days. For this purpose, "leave of absence" is defined as a paid or unpaid temporary or indefinite administrative leave, involuntary leave, sick leave, or insurance continued under the federal Family and Medical Leave Act, or paid family and medical leave program as described in WAC 182-31-110. |
| --- | --- |

(c) Unpaid or underpaid premiums or applicable premium surcharges for all subscribers must be paid, and are due from the SEBB organization, subscriber, or a subscriber's legal representative to the HCA or the contracted vendor. For subscribers not eligible for the employer contribution, monthly premiums or applicable premium surcharges that remain unpaid for 30 days will be considered delinquent. A subscriber is allowed a grace period of 30 days from the date the monthly premiums or applicable premium surcharges become delinquent to pay the unpaid premium balance or applicable premium surcharges. If a subscriber, who is not eligible for the employer contribution, has monthly premiums or applicable premium surcharges remain unpaid for 60 days from the original due date, the subscriber's SEBB insurance coverage will be terminated retroactive to the last day of the month for which the monthly premiums and any applicable premium surcharges were paid. If it is determined by the HCA that payment of the unpaid balance in a lump sum would be considered a hardship, the HCA may develop a reasonable payment plan up to 12 months in duration with the subscriber or the subscriber's legal representative upon request.

(d) Monthly premiums or applicable premium surcharges due from a subscriber who is not eligible for the employer contribution will be considered unpaid if one of the following occurs:

(i) No payment of premiums or applicable premium surcharges are received by the HCA or the contracted vendor and the monthly premiums or applicable premium surcharges remain unpaid for 30 days; or

(ii) Premium payments or applicable premium surcharges received by the HCA or the contracted vendor are underpaid by an amount greater than an insignificant shortfall and the monthly premiums or applicable premium surcharges remain underpaid for 30 days past the date the monthly premiums or applicable premium surcharges were due.

(2) Premium refunds. SEBB insurance coverage premiums and applicable premium surcharges will be refunded using the following methods:

(a) When a subscriber submits an enrollment change affecting subscriber or dependent eligibility, HCA may allow up to three months of accounting adjustments. HCA will refund to the individual or the SEBB organization any excess premiums and applicable premium surcharges paid during the 60-day adjustment period, except as indicated in WAC 182-31-120.

(b) If a SEBB subscriber, dependent, or beneficiary submits a written appeal as described in WAC 182-32-2010, and provides clear and convincing evidence of extraordinary circumstances, such that the subscriber could not timely submit the necessary information to accomplish an allowable enrollment change within 60 days after the event that created a change of premiums, the SEBB director, the SEBB director's designee, or the SEBB appeals unit may:

(i) Approve a refund of premiums and applicable premium surcharges that does not exceed 12 months of premiums; and

(ii) Approve the enrollment change that was originally requested and which forms the basis for the refund.

(c) If a federal government entity determines that an enrollee is retroactively enrolled in coverage (for example, medicare) the subscriber or beneficiary may be eligible for a refund of premiums and applicable premium surcharges paid during the time they were enrolled under the federal program if approved by the SEBB director or the SEBB director's designee.

(d) HCA errors will be corrected by returning all excess premiums and applicable premium surcharges paid by the SEBB organization, subscriber, or beneficiary.

(e) SEBB organization errors will be corrected by returning all excess premiums and applicable premium surcharges paid by the school employee or beneficiary as described in WAC 182-30-060 (4) and (5).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-30-040, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-30-040, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions SEBB 2021-11 and 2021-12. WSR 21-13-116 (Admin #2021-01.03), § 182-30-040, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-30-040, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-30-040, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-30-040, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-30-050** What are the requirements regarding premium surcharges? {#sec-182-30-050 omnilex-key=us-wa-regs-official--title-182--182-30-050}

WAC 182-30-050

***(Effective until January 1, 2027)***

(1) A subscriber's account will incur a premium surcharge in addition to the subscriber's monthly medical premium, when any enrollee, 13 years and older, engages in tobacco use.

(a) A subscriber must attest to whether any enrollee, 13 years and older, enrolled in their school employees benefits board (SEBB) medical engages in tobacco use. The subscriber must attest as described in (a)(i) through (vi) of this subsection:

(i) A school employee who is newly eligible or regains eligibility for the employer contribution toward SEBB benefits must complete the required form to enroll in SEBB medical as described in WAC 182-30-080 (1) or (3). The school employee must include their attestation on that form. The school employee must submit the form to their SEBB organization. If the school employee's attestation results in a premium surcharge, it will take effect the same date as SEBB medical begins;

(ii) If there is a change in the tobacco use status of any enrollee, 13 years and older on the subscriber's SEBB medical, the subscriber must update their attestation on the required form. A school employee must submit the form to their SEBB organization. Any other subscriber must submit their form to the SEBB program. The attestation change will apply as follows:

• A change that results in a premium surcharge will begin the first day of the month following the status change. If that day is the first of the month, the change to the surcharge begins on that day.

• A change that results in removing the premium surcharge will begin the first day of the month following receipt of the attestation. If that day is the first of the month, the change to the surcharge begins on that day.

(iii) If a subscriber submits the required form to enroll a dependent, 13 years and older, in SEBB medical as described in WAC 182-31-150, the subscriber must attest for their dependent on the required form. A school employee must submit the form to their SEBB organization. Any other subscriber must submit their form to the SEBB program. A change that results in a premium surcharge will take effect the same date as SEBB medical begins;

(iv) An enrollee, 13 years and older, who elects to continue medical coverage as described in WAC 182-31-090, must provide an attestation on the required form if they have not previously attested as described in (a) of this subsection. The enrollee must submit their form to the SEBB program. An attestation that results in a premium surcharge will take effect the same date as SEBB medical begins;

(v) A school board member who enrolls in SEBB medical as described in WAC 182-31-200, must provide an attestation on the required form. The school board member must submit their form to the SEBB program. An attestation that results in a premium surcharge will take effect the same date as SEBB medical begins; or

(vi) A school employee who previously waived SEBB medical must complete the required form to enroll in SEBB medical as described in WAC 182-31-080(3). The school employee must submit their attestation on that form. A school employee must submit the form to their SEBB organization. An attestation that results in a premium surcharge will take effect the same date as SEBB medical begins.

| Note: | A school employee who waives SEBB medical as described in WAC 182-31-080 is not required to provide an attestation and no premium surcharge will be applied to their account as long as the school employee remains in waived status. |
| --- | --- |

(b) A subscriber's account will incur a premium surcharge when a subscriber fails to attest to the tobacco use status of all enrollees as described in (a) of this subsection.

(c) The SEBB program will provide reasonable alternatives for enrollees who use tobacco products. A subscriber can avoid the tobacco use premium surcharge if the subscriber attests on the required form that all enrollees who use tobacco products enrolled in or accessed one of the applicable reasonable alternatives offered below:

(i) An enrollee who is 18 years and older and uses tobacco products is currently enrolled in the free tobacco cessation program through their SEBB medical.

(ii) An enrollee who is 13 through 17 years old and uses tobacco products accessed the information and resources aimed at teens on the Washington state department of health's website at https://teen.smokefree.gov.

(iii) A subscriber may contact the SEBB program to accommodate a physician's recommendation that addresses an enrollee's use of tobacco products or for information on how to avoid the tobacco use premium surcharge.

(2) A subscriber will incur a premium surcharge, in addition to the subscriber's monthly medical premium, if an enrolled spouse or state registered domestic partner has chosen not to enroll in another employer-based group medical where the spouse's or state registered domestic partner's share of the medical premium is less than 95 percent of the additional cost a school employee would be required to pay to enroll a spouse or state registered domestic partner in the public employees benefits board (PEBB) Uniform Medical Plan (UMP) Classic and the benefits have an actuarial value of at least 95 percent of the actuarial value of the PEBB UMP Classic's benefits.

(a) A subscriber who enrolled a spouse or state registered domestic partner under their SEBB medical may only attest during the following times:

(i) When a subscriber becomes eligible to enroll a spouse or state registered domestic partner in SEBB medical as described in WAC 182-31-150. The subscriber must complete the required form to enroll their spouse or state registered domestic partner, and include their attestation on that form. The school employee must submit the form to their SEBB organization. Any other subscriber must submit the form to the SEBB program. If the subscriber's attestation results in a premium surcharge it will take effect the same date as SEBB medical begins.

(ii) During the annual open enrollment. A subscriber must attest if during the month prior to the annual open enrollment the subscriber was:

• Incurring the surcharge;

• Not incurring the surcharge because the spouse's or state registered domestic partner's share of the medical premium through their employer-based group medical was more than 95 percent of the additional cost a school employee would be required to pay to enroll a spouse or state registered domestic partner in the PEBB UMP Classic; or

• Not incurring the surcharge because the actuarial value of benefits provided through the spouse's or state registered domestic partner's employer-based group medical was less than 95 percent of the actuarial value of the PEBB UMP Classic's benefits.

A subscriber must update their attestation on the required form. A school employee must submit the form to their SEBB organization. Any other subscriber must submit the form to the SEBB program. The subscriber's attestation or any correction to a subscriber's attestation must be received no later than December 31st of the year in which the annual open enrollment occurs. If the subscriber's attestation results in a premium surcharge, being added or removed, the change to the surcharge will take effect January 1st of the following year.

(iii) When there is a change in the spouse's or state registered domestic partner's employer-based group medical. A subscriber must provide evidence of the event and update their attestation on the required form. A school employee must submit the form to their SEBB organization no later than 60 days after the spouse's or state registered domestic partner's employer-based group medical status changes. Any other subscriber must submit the form to the SEBB program no later than 60 days after the spouse's or state registered domestic partner's employer-based group medical status changes.

• A change that results in a premium surcharge will begin the first day of the month following the status change. If that day is the first day of the month, the change to the premium surcharge begins on that day.

• A change that results in removing the premium surcharge will begin the first day of the month following receipt of the attestation. If that day is the first day of the month, the change to the premium surcharge begins on that day.

| Exceptions: | (1) A school employee who waives SEBB medical as described in WAC 182-31-080 is not required to provide an attestation and no premium surcharge will be applied to their account as long as the employee remains in waived status. |
| --- | --- |
| | (2) A school employee who covers their spouse or state registered domestic partner who has waived their own SEBB medical must attest as described in this subsection, but will not incur a premium surcharge if the school employee provides an attestation that their spouse or state registered domestic partner is eligible for SEBB medical. |
| | (3) A subscriber who covers their spouse or state registered domestic partner who elected not to enroll in a TRICARE plan must attest as described in this subsection, but will not incur a premium surcharge if the subscriber provides an attestation that their spouse or state registered domestic partner is eligible for a TRICARE plan. |

(b) A premium surcharge will be applied to a subscriber who does not attest as described in (a) of this subsection.

***(Effective January 1, 2027)***

PDF WAC 182-30-050

What are the requirements regarding premium surcharges?

(1) A subscriber's account will incur a premium surcharge in addition to the subscriber's monthly medical premium, when any enrollee, 13 years and older, engages in tobacco use.

(a) A subscriber must attest to whether any enrollee, 13 years and older, enrolled in their school employees benefits board (SEBB) medical engages in tobacco use. The subscriber must attest as described in (a)(i) through (vi) of this subsection:

(i) A school employee who is newly eligible or regains eligibility for the employer contribution toward SEBB benefits must complete the required form to enroll in SEBB medical as described in WAC 182-30-080 (1) or (3). The school employee must include their attestation on that form. The school employee must submit the form to their SEBB organization. If the school employee's attestation results in a premium surcharge, it will take effect the same date as SEBB medical begins;

(ii) If there is a change in the tobacco use status of any enrollee, 13 years and older on the subscriber's SEBB medical, the subscriber must update their attestation on the required form. A school employee must submit the form to their SEBB organization. Any other subscriber must submit their form to the SEBB program. The attestation change will apply as follows:

• A change that results in a premium surcharge will begin the first day of the month following the status change. If that day is the first of the month, the change to the surcharge begins on that day.

• A change that results in removing the premium surcharge will begin the first day of the month following receipt of the attestation. If that day is the first of the month, the change to the surcharge begins on that day.

(iii) If a subscriber submits the required form to enroll a dependent, 13 years and older, in SEBB medical as described in WAC 182-31-150, the subscriber must attest for their dependent on the required form. A school employee must submit the form to their SEBB organization. Any other subscriber must submit their form to the SEBB program. A change that results in a premium surcharge will take effect the same date as SEBB medical begins;

(iv) An enrollee, 13 years and older, who elects to continue medical coverage as described in WAC 182-31-090, must provide an attestation on the required form if they have not previously attested as described in (a) of this subsection. The enrollee must submit their form to the SEBB program. An attestation that results in a premium surcharge will take effect the same date as SEBB medical begins;

(v) A school board member who enrolls in SEBB medical as described in WAC 182-31-200, must provide an attestation on the required form. The school board member must submit their form to the SEBB program. An attestation that results in a premium surcharge will take effect the same date as SEBB medical begins; or

(vi) A school employee who previously waived SEBB medical must complete the required form to enroll in SEBB medical as described in WAC 182-31-080(3). The school employee must submit their attestation on that form. A school employee must submit the form to their SEBB organization. An attestation that results in a premium surcharge will take effect the same date as SEBB medical begins.

| Note: | A school employee who waives SEBB medical as described in WAC 182-31-080 is not required to provide an attestation and no premium surcharge will be applied to their account as long as the school employee remains in waived status. |
| --- | --- |

(b) A subscriber's account will incur a premium surcharge when a subscriber fails to attest to the tobacco use status of all enrollees as described in (a) of this subsection.

(c) The SEBB program will provide reasonable alternatives for enrollees who use tobacco products. A subscriber can avoid the tobacco use premium surcharge if the subscriber attests on the required form that all enrollees who use tobacco products enrolled in or accessed one of the applicable reasonable alternatives offered below:

(i) An enrollee who is 18 years and older and uses tobacco products is currently enrolled in the free tobacco cessation program through their SEBB medical.

(ii) An enrollee who is 13 through 17 years old and uses tobacco products accessed the information and resources aimed at teens on the Washington state department of health's website at https://teen.smokefree.gov.

(iii) A subscriber may contact the SEBB program to accommodate a physician's recommendation that addresses an enrollee's use of tobacco products or for information on how to avoid the tobacco use premium surcharge.

(2) A subscriber will incur a premium surcharge, in addition to the subscriber's monthly medical premium, if an enrolled spouse or state registered domestic partner has chosen not to enroll in another employer-based group medical where the spouse's or state registered domestic partner's share of the medical premium is less than 95 percent of the additional cost a school employee would be required to pay to enroll a spouse or state registered domestic partner in the public employees benefits board (PEBB) Uniform Medical Plan (UMP) Classic and the benefits have an actuarial value of at least 95 percent of the actuarial value of the PEBB UMP Classic's benefits.

(a) A subscriber who enrolled a spouse or state registered domestic partner under their SEBB medical may only attest during the following times:

(i) When a subscriber becomes eligible to enroll a spouse or state registered domestic partner in SEBB medical as described in WAC 182-31-150. The subscriber must complete the required form to enroll their spouse or state registered domestic partner, and include their attestation on that form. The school employee must submit the form to their SEBB organization. Any other subscriber must submit the form to the SEBB program. If the subscriber's attestation results in a premium surcharge it will take effect the same date as SEBB medical begins.

(ii) During the annual open enrollment. A subscriber must attest if during the month prior to the annual open enrollment the subscriber was:

• Incurring the surcharge;

• Not incurring the surcharge because the spouse's or state registered domestic partner's share of the medical premium through their employer-based group medical was more than 95 percent of the additional cost a school employee would be required to pay to enroll a spouse or state registered domestic partner in the PEBB UMP Classic; or

• Not incurring the surcharge because the actuarial value of benefits provided through the spouse's or state registered domestic partner's employer-based group medical was less than 95 percent of the actuarial value of the PEBB UMP Classic's benefits.

A subscriber must update their attestation on the required form. A school employee must submit the form to their SEBB organization. Any other subscriber must submit the form to the SEBB program. The subscriber's attestation or any correction to a subscriber's attestation must be received no later than December 31st of the year in which the annual open enrollment occurs. If the subscriber's attestation results in a premium surcharge, being added or removed, the change to the surcharge will take effect January 1st of the following year.

(iii) When there is a change in the spouse's or state registered domestic partner's employer-based group medical. A subscriber must provide evidence of the event and update their attestation on the required form. A school employee must submit the form to their SEBB organization no later than 60 days after the spouse's or state registered domestic partner's employer-based group medical status changes. Any other subscriber must submit the form to the SEBB program no later than 60 days after the spouse's or state registered domestic partner's employer-based group medical status changes.

• A change that results in a premium surcharge will begin the first day of the month following the status change. If that day is the first day of the month, the change to the premium surcharge begins on that day.

• A change that results in removing the premium surcharge will begin the first day of the month following receipt of the attestation. If that day is the first day of the month, the change to the premium surcharge begins on that day.

| Exceptions: | (1) A school employee who waives SEBB medical as described in WAC 182-31-080 is not required to provide an attestation and no premium surcharge will be applied to their account as long as the employee remains in waived status. |
| --- | --- |
| | (2) A school employee who covers their spouse or state registered domestic partner who has waived their own SEBB or PEBB medical must attest as described in this subsection, but will not incur a premium surcharge if the school employee provides an attestation that their spouse or state registered domestic partner is eligible for SEBB or PEBB medical. |
| | (3) A subscriber who covers their spouse or state registered domestic partner who elected not to enroll in a TRICARE plan must attest as described in this subsection, but will not incur a premium surcharge if the subscriber provides an attestation that their spouse or state registered domestic partner is eligible for a TRICARE plan. |

(b) A premium surcharge will be applied to a subscriber who does not attest as described in (a) of this subsection.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.740. WSR 25-14-083 (Admin #2025-01.02), s 182-30-050, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-30-050, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-30-050, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-30-050, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-30-050, filed 12/14/18, effective 1/14/19.](Effective January 1, 2027) PDF WAC 182-30-050 What are the requirements regarding premium surcharges? (1) A subscriber's account will incur a premium surcharge in addition to the subscriber's monthly medical premium, when any enrollee, 13 years and older, engages in tobacco use.(a) A subscriber must attest to whether any enrollee, 13 years and older, enrolled in their school employees benefits board (SEBB) medical engages in tobacco use. The subscriber must attest as described in (a)(i) through (vi) of this subsection:(i) A school employee who is newly eligible or regains eligibility for the employer contribution toward SEBB benefits must complete the required form to enroll in SEBB medical as described in WAC 182-30-080 (1) or (3). The school employee must include their attestation on that form. The school employee must submit the form to their SEBB organization. If the school employee's attestation results in a premium surcharge, it will take effect the same date as SEBB medical begins*
- *(ii) If there is a change in the tobacco use status of any enrollee, 13 years and older on the subscriber's SEBB medical, the subscriber must update their attestation on the required form. A school employee must submit the form to their SEBB organization. Any other subscriber must submit their form to the SEBB program. The attestation change will apply as follows:• A change that results in a premium surcharge will begin the first day of the month following the status change. If that day is the first of the month, the change to the surcharge begins on that day.• A change that results in removing the premium surcharge will begin the first day of the month following receipt of the attestation. If that day is the first of the month, the change to the surcharge begins on that day.(iii) If a subscriber submits the required form to enroll a dependent, 13 years and older, in SEBB medical as described in WAC 182-31-150, the subscriber must attest for their dependent on the required form. A school employee must submit the form to their SEBB organization. Any other subscriber must submit their form to the SEBB program. A change that results in a premium surcharge will take effect the same date as SEBB medical begins*
- *(iv) An enrollee, 13 years and older, who elects to continue medical coverage as described in WAC 182-31-090, must provide an attestation on the required form if they have not previously attested as described in (a) of this subsection. The enrollee must submit their form to the SEBB program. An attestation that results in a premium surcharge will take effect the same date as SEBB medical begins*
- *(v) A school board member who enrolls in SEBB medical as described in WAC 182-31-200, must provide an attestation on the required form. The school board member must submit their form to the SEBB program. An attestation that results in a premium surcharge will take effect the same date as SEBB medical begins*
- *or(vi) A school employee who previously waived SEBB medical must complete the required form to enroll in SEBB medical as described in WAC 182-31-080(3). The school employee must submit their attestation on that form. A school employee must submit the form to their SEBB organization. An attestation that results in a premium surcharge will take effect the same date as SEBB medical begins.Note:A school employee who waives SEBB medical as described in WAC 182-31-080 is not required to provide an attestation and no premium surcharge will be applied to their account as long as the school employee remains in waived status.(b) A subscriber's account will incur a premium surcharge when a subscriber fails to attest to the tobacco use status of all enrollees as described in (a) of this subsection.(c) The SEBB program will provide reasonable alternatives for enrollees who use tobacco products. A subscriber can avoid the tobacco use premium surcharge if the subscriber attests on the required form that all enrollees who use tobacco products enrolled in or accessed one of the applicable reasonable alternatives offered below:(i) An enrollee who is 18 years and older and uses tobacco products is currently enrolled in the free tobacco cessation program through their SEBB medical.(ii) An enrollee who is 13 through 17 years old and uses tobacco products accessed the information and resources aimed at teens on the Washington state department of health's website at https://teen.smokefree.gov.(iii) A subscriber may contact the SEBB program to accommodate a physician's recommendation that addresses an enrollee's use of tobacco products or for information on how to avoid the tobacco use premium surcharge.(2) A subscriber will incur a premium surcharge, in addition to the subscriber's monthly medical premium, if an enrolled spouse or state registered domestic partner has chosen not to enroll in another employer-based group medical where the spouse's or state registered domestic partner's share of the medical premium is less than 95 percent of the additional cost a school employee would be required to pay to enroll a spouse or state registered domestic partner in the public employees benefits board (PEBB) Uniform Medical Plan (UMP) Classic and the benefits have an actuarial value of at least 95 percent of the actuarial value of the PEBB UMP Classic's benefits.(a) A subscriber who enrolled a spouse or state registered domestic partner under their SEBB medical may only attest during the following times:(i) When a subscriber becomes eligible to enroll a spouse or state registered domestic partner in SEBB medical as described in WAC 182-31-150. The subscriber must complete the required form to enroll their spouse or state registered domestic partner, and include their attestation on that form. The school employee must submit the form to their SEBB organization. Any other subscriber must submit the form to the SEBB program. If the subscriber's attestation results in a premium surcharge it will take effect the same date as SEBB medical begins.(ii) During the annual open enrollment. A subscriber must attest if during the month prior to the annual open enrollment the subscriber was:• Incurring the surcharge*
- *• Not incurring the surcharge because the spouse's or state registered domestic partner's share of the medical premium through their employer-based group medical was more than 95 percent of the additional cost a school employee would be required to pay to enroll a spouse or state registered domestic partner in the PEBB UMP Classic*
- *or• Not incurring the surcharge because the actuarial value of benefits provided through the spouse's or state registered domestic partner's employer-based group medical was less than 95 percent of the actuarial value of the PEBB UMP Classic's benefits.A subscriber must update their attestation on the required form. A school employee must submit the form to their SEBB organization. Any other subscriber must submit the form to the SEBB program. The subscriber's attestation or any correction to a subscriber's attestation must be received no later than December 31st of the year in which the annual open enrollment occurs. If the subscriber's attestation results in a premium surcharge, being added or removed, the change to the surcharge will take effect January 1st of the following year.(iii) When there is a change in the spouse's or state registered domestic partner's employer-based group medical. A subscriber must provide evidence of the event and update their attestation on the required form. A school employee must submit the form to their SEBB organization no later than 60 days after the spouse's or state registered domestic partner's employer-based group medical status changes. Any other subscriber must submit the form to the SEBB program no later than 60 days after the spouse's or state registered domestic partner's employer-based group medical status changes.• A change that results in a premium surcharge will begin the first day of the month following the status change. If that day is the first day of the month, the change to the premium surcharge begins on that day.• A change that results in removing the premium surcharge will begin the first day of the month following receipt of the attestation. If that day is the first day of the month, the change to the premium surcharge begins on that day.Exceptions:(1) A school employee who waives SEBB medical as described in WAC 182-31-080 is not required to provide an attestation and no premium surcharge will be applied to their account as long as the employee remains in waived status. (2) A school employee who covers their spouse or state registered domestic partner who has waived their own SEBB or PEBB medical must attest as described in this subsection, but will not incur a premium surcharge if the school employee provides an attestation that their spouse or state registered domestic partner is eligible for SEBB or PEBB medical. (3) A subscriber who covers their spouse or state registered domestic partner who elected not to enroll in a TRICARE plan must attest as described in this subsection, but will not incur a premium surcharge if the subscriber provides an attestation that their spouse or state registered domestic partner is eligible for a TRICARE plan.(b) A premium surcharge will be applied to a subscriber who does not attest as described in (a) of this subsection.[Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.740. WSR 26-14-083 (Admin #2026.01), s 182-30-050, filed 6/29/26, effective 1/1/27*
- *WSR 25-14-083 (Admin #2025-01.02), s 182-30-050, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-30-050, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-30-050, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-30-050, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-30-050, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-30-060** How do school employees benefits board (SEBB) organizations and contracted vendors correct enrollment errors? {#sec-182-30-060 omnilex-key=us-wa-regs-official--title-182--182-30-060}

WAC 182-30-060

***(Effective until January 1, 2027)***

(1) A school employees benefits board (SEBB) organization or contracted vendor that makes one or more of the following enrollment errors must correct the error as described in subsections (2) through (5) of this section.

(a) Failure to timely notify a school employee of their eligibility for SEBB benefits and the employer contribution as described in WAC 182-31-030;

(b) Failure to enroll a school employee or their dependents in SEBB benefits as elected by the school employee, if the election was timely;

(c) Failure to enroll a school employee and their dependents in SEBB benefits as described in WAC 182-30-080 (1)(b) or (3)(c);

(d) Failure to accurately reflect a school employee's premium surcharge attestation on the school employee's account;

(e) Enrolling a school employee or their dependents in SEBB insurance coverage when they are not eligible as described in WAC 182-31-040 or 182-31-140 and it is clear there was no fraud or intentional misrepresentation by the school employee involved; or

(f) Providing incorrect information, via a benefits administrator or contracted vendor, regarding SEBB benefits to the school employee that they relied upon.

(2) The SEBB organization or the applicable contracted vendor must enroll the school employee and the school employee's dependents, as elected, or terminate enrollment in SEBB benefits as described in subsection (3) of this section, reconcile premium payments and applicable premium surcharges as described in subsection (4) of this section, and provide recourse as described in subsection (5) of this section.

(3) Enrollment or termination.

(a) SEBB medical, vision, and dental enrollment is effective the first day of the month following the date the enrollment error is identified, unless the authority determines additional recourse is warranted, as described in subsection (5) of this section;

| Exception: | When a school employee who is called to active duty in the uniformed services under Uniformed Services Employment and Reemployment Rights Act (USERRA) loses eligibility for the employer contribution toward SEBB benefits, they regain eligibility for the employer contribution toward SEBB benefits the day they return from active duty. Employer-paid SEBB benefits will begin the first day of the month in which they return from active duty. |
| --- | --- |

(b) Basic life, supplemental life, basic accidental death and dismemberment (AD&D), supplemental AD&D, employer-paid long-term disability (LTD) insurance, and employee-paid LTD insurance will begin for a newly eligible school employee as described in WAC 182-31-040, and for a school employee who regains eligibility as described in WAC 182-30-080(3). A school employee who regains eligibility may need to submit evidence of insurability for supplemental life insurance as required in WAC 182-30-080(3);

(c) If the school employee is eligible and elects (or elected) to enroll in the flexible spending arrangement (FSA), limited purpose FSA, or dependent care assistance program (DCAP), enrollment is limited to 60 days prior to the date enrollment is processed, but not earlier than the current plan year. If a school employee was not enrolled in a FSA, limited purpose FSA, or DCAP as elected, the school employee may either participate at the amount originally elected with a corresponding increase in contributions for the balance of the plan year, or participate at a reduced amount for the plan year by maintaining the per-pay period contribution in effect;

(d) If the school employee or their dependent was not eligible but still enrolled as described in subsection (1)(e) of this section, the employee's or their dependent's SEBB benefits will be terminated prospectively effective as of the last day of the month.

(4) Premium payments.

(a) The SEBB organization must remit to the authority the employer contribution and the school employee contribution for health plan premiums, applicable premium surcharges, basic life, basic AD&D, and employer-paid LTD insurance starting the date SEBB benefits begin as described in subsections (3) and (5)(a)(i) of this section. If a SEBB organization failed to notify a newly eligible school employee of their eligibility for SEBB benefits, the SEBB organization may only collect the school employee contribution for health plan premiums and applicable premium surcharges for coverage for the months after the school employee was notified.

(b) When a SEBB organization fails to correctly enroll the amount of employee-paid LTD insurance elected by the school employee, premiums will be corrected as follows:

(i) When additional premiums are due to the authority, the school employee is responsible for premiums for the most recent 24 months of coverage. The SEBB organization is responsible for additional months of premiums; and

(ii) When a premium refund is due to the school employee, the LTD insurance contracted vendor is responsible for premium refunds for the most recent 24 months of coverage. The SEBB organization is responsible for additional months of premium refunds after the 24 months of coverage and the overall refunding process to the school employee.

(c) When a SEBB organization mistakenly enrolls a school employee or their dependents as described in subsection (1)(e) of this section, premiums and any applicable premium surcharges will be refunded by the SEBB organization to the school employee without rescinding the insurance coverage.

(5) Recourse.

(a) A school employee who establishes eligibility will have benefits begin as described in WAC 182-31-040. A school employee who regains eligibility for the employer contribution toward SEBB benefits will have benefits begin as described in WAC 182-30-080(3). Dependent eligibility is described in WAC 182-31-140, and dependent enrollment is described in WAC 182-31-150. When retroactive correction of an enrollment error is limited as described in subsection (3)(a), (b), and (c) of this section, the SEBB organization must work with the school employee, and receive approval from the authority, to implement retroactive SEBB benefits within the following parameters:

(i) Retroactive enrollment in a SEBB insurance coverage;

(ii) Reimbursement of claims paid;

(iii) Reimbursement of amounts paid by the school employee or dependent for medical, vision, and dental premiums;

(iv) Reimbursement of amounts paid by the school employee for the premium surcharges;

(v) Other legal remedy received or offered; or

(vi) Other recourse, upon approval by the authority.

(b) Recourse must not contradict a specific provision of federal law or statute and does not apply to requests for noncovered services or in the case of an individual who is not eligible for SEBB benefits.

***(Effective January 1, 2027)***

PDF WAC 182-30-060

How do school employees benefits board (SEBB) organizations and contracted vendors correct enrollment errors?

(1) A school employees benefits board (SEBB) organization or contracted vendor that makes one or more of the following enrollment errors must correct the error as described in subsections (2) through (5) of this section.

(a) Failure to timely notify a school employee of their eligibility for SEBB benefits and the employer contribution as described in WAC 182-31-030;

(b) Failure to enroll a school employee or their dependents in SEBB benefits as elected by the school employee, if the election was timely;

(c) Failure to enroll a school employee and their dependents in SEBB benefits as described in WAC 182-30-080 (1)(b) or (3)(c);

(d) Failure to accurately reflect a school employee's premium surcharge attestation on the school employee's account;

(e) Enrolling a school employee or their dependents in SEBB insurance coverage when they are not eligible as described in WAC 182-31-040 or 182-31-140 and it is clear there was no fraud or intentional misrepresentation by the school employee involved; or

(f) Providing incorrect information, via a benefits administrator or contracted vendor, regarding SEBB benefits to the school employee that they relied upon.

(2) The SEBB organization or the applicable contracted vendor must enroll the school employee and the school employee's dependents, as elected, or terminate enrollment in SEBB benefits as described in subsection (3) of this section, reconcile premium payments and applicable premium surcharges as described in subsection (4) of this section, and provide recourse as described in subsection (5) of this section.

(3) Enrollment or termination.

(a) SEBB medical, vision, and dental enrollment is effective the first day of the month following the date the enrollment error is identified, unless the authority determines additional recourse is warranted, as described in subsection (5) of this section;

| Exception: | When a school employee who is called to active duty in the uniformed services under Uniformed Services Employment and Reemployment Rights Act (USERRA) loses eligibility for the employer contribution toward SEBB benefits, they regain eligibility for the employer contribution toward SEBB benefits the day they return from active duty. Employer-paid SEBB benefits will begin the first day of the month in which they return from active duty. |
| --- | --- |

(b) Basic life, supplemental life, basic accidental death and dismemberment (AD&D), supplemental AD&D, employer-paid long-term disability (LTD) insurance, and employee-paid LTD insurance will begin for a newly eligible school employee as described in WAC 182-31-040, and for a school employee who regains eligibility as described in WAC 182-30-080(3). A school employee who regains eligibility may need to submit evidence of insurability for supplemental life insurance as required in WAC 182-30-080(3);

| Exception: | When a SEBB organization fails to timely notify a school employee that they are eligible for SEBB benefits, the school employee may elect to prospectively enroll, without requiring evidence of insurability, in supplemental life insurance, supplemental AD&D insurance, and employee-paid LTD insurance effective the first day of the month following the date the enrollment error is identified, unless the authority determines additional recourse is warranted, as described in subsection (5) of this section. |
| --- | --- |

(c) If the school employee is eligible and elects (or elected) to enroll in the flexible spending arrangement (FSA), limited purpose FSA, or dependent care assistance program (DCAP), enrollment is limited to 60 days prior to the date enrollment is processed, but not earlier than the current plan year. If a school employee was not enrolled in a FSA, limited purpose FSA, or DCAP as elected, the school employee may either participate at the amount originally elected with a corresponding increase in contributions for the balance of the plan year, or participate at a reduced amount for the plan year by maintaining the per-pay period contribution in effect;

(d) If the school employee or their dependent was not eligible but still enrolled as described in subsection (1)(e) of this section, the employee's or their dependent's SEBB benefits will be terminated prospectively effective as of the last day of the month.

(4) Premium payments.

(a) The SEBB organization must remit to the authority the employer contribution and the school employee contribution for health plan premiums, applicable premium surcharges, basic life, basic AD&D, and employer-paid LTD insurance starting the date SEBB benefits begin as described in subsections (3) and (5)(a)(i) of this section. If a SEBB organization failed to notify a newly eligible school employee of their eligibility for SEBB benefits, the SEBB organization may only collect the school employee contribution for health plan premiums and applicable premium surcharges for coverage for the months after the school employee was notified.

(b) When a SEBB organization fails to correctly enroll the amount of employee-paid LTD insurance elected by the school employee, premiums will be corrected as follows:

(i) When additional premiums are due to the authority, the school employee is responsible for premiums for the most recent 24 months of coverage. The SEBB organization is responsible for additional months of premiums; and

(ii) When a premium refund is due to the school employee, the LTD insurance contracted vendor is responsible for premium refunds for the most recent 24 months of coverage. The SEBB organization is responsible for additional months of premium refunds after the 24 months of coverage and the overall refunding process to the school employee.

(c) When a SEBB organization mistakenly enrolls a school employee or their dependents as described in subsection (1)(e) of this section, premiums and any applicable premium surcharges will be refunded by the SEBB organization to the school employee without rescinding the insurance coverage.

(5) Recourse.

(a) A school employee who establishes eligibility will have benefits begin as described in WAC 182-31-040. A school employee who regains eligibility for the employer contribution toward SEBB benefits will have benefits begin as described in WAC 182-30-080(3). Dependent eligibility is described in WAC 182-31-140, and dependent enrollment is described in WAC 182-31-150. When retroactive correction of an enrollment error is limited as described in subsection (3)(a), (b), and (c) of this section, the SEBB organization must work with the school employee, and receive approval from the authority, to implement retroactive SEBB benefits within the following parameters:

(i) Retroactive enrollment in a SEBB insurance coverage;

(ii) Reimbursement of claims paid;

(iii) Reimbursement of amounts paid by the school employee or dependent for medical, vision, and dental premiums;

(iv) Reimbursement of amounts paid by the school employee for the premium surcharges;

(v) Other legal remedy received or offered; or

(vi) Other recourse, upon approval by the authority.

(b) Recourse must not contradict a specific provision of federal law or statute and does not apply to requests for noncovered services or in the case of an individual who is not eligible for SEBB benefits.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.740. WSR 25-14-083 (Admin #2025-01.02), s 182-30-060, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-30-060, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolution SEBB 2022-01. WSR 23-14-021 (Admin #2023-02.03), § 182-30-060, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-30-060, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions SEBB 2021-11 and 2021-12. WSR 21-13-116 (Admin #2021-01.03), § 182-30-060, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolution 2020-06. WSR 20-16-066 (Admin #2020-03), § 182-30-060, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-30-060, filed 7/1/19, effective 8/1/19.](Effective January 1, 2027) PDF WAC 182-30-060 How do school employees benefits board (SEBB) organizations and contracted vendors correct enrollment errors? (1) A school employees benefits board (SEBB) organization or contracted vendor that makes one or more of the following enrollment errors must correct the error as described in subsections (2) through (5) of this section.(a) Failure to timely notify a school employee of their eligibility for SEBB benefits and the employer contribution as described in WAC 182-31-030*
- *(b) Failure to enroll a school employee or their dependents in SEBB benefits as elected by the school employee, if the election was timely*
- *(c) Failure to enroll a school employee and their dependents in SEBB benefits as described in WAC 182-30-080 (1)(b) or (3)(c)*
- *(d) Failure to accurately reflect a school employee's premium surcharge attestation on the school employee's account*
- *(e) Enrolling a school employee or their dependents in SEBB insurance coverage when they are not eligible as described in WAC 182-31-040 or 182-31-140 and it is clear there was no fraud or intentional misrepresentation by the school employee involved*
- *or(f) Providing incorrect information, via a benefits administrator or contracted vendor, regarding SEBB benefits to the school employee that they relied upon.(2) The SEBB organization or the applicable contracted vendor must enroll the school employee and the school employee's dependents, as elected, or terminate enrollment in SEBB benefits as described in subsection (3) of this section, reconcile premium payments and applicable premium surcharges as described in subsection (4) of this section, and provide recourse as described in subsection (5) of this section.(3) Enrollment or termination.(a) SEBB medical, vision, and dental enrollment is effective the first day of the month following the date the enrollment error is identified, unless the authority determines additional recourse is warranted, as described in subsection (5) of this section*
- *Exception:When a school employee who is called to active duty in the uniformed services under Uniformed Services Employment and Reemployment Rights Act (USERRA) loses eligibility for the employer contribution toward SEBB benefits, they regain eligibility for the employer contribution toward SEBB benefits the day they return from active duty. Employer-paid SEBB benefits will begin the first day of the month in which they return from active duty.(b) Basic life, supplemental life, basic accidental death and dismemberment (AD&D), supplemental AD&D, employer-paid long-term disability (LTD) insurance, and employee-paid LTD insurance will begin for a newly eligible school employee as described in WAC 182-31-040, and for a school employee who regains eligibility as described in WAC 182-30-080(3). A school employee who regains eligibility may need to submit evidence of insurability for supplemental life insurance as required in WAC 182-30-080(3)*
- *Exception:When a SEBB organization fails to timely notify a school employee that they are eligible for SEBB benefits, the school employee may elect to prospectively enroll, without requiring evidence of insurability, in supplemental life insurance, supplemental AD&D insurance, and employee-paid LTD insurance effective the first day of the month following the date the enrollment error is identified, unless the authority determines additional recourse is warranted, as described in subsection (5) of this section. (c) If the school employee is eligible and elects (or elected) to enroll in the flexible spending arrangement (FSA), limited purpose FSA, or dependent care assistance program (DCAP), enrollment is limited to 60 days prior to the date enrollment is processed, but not earlier than the current plan year. If a school employee was not enrolled in a FSA, limited purpose FSA, or DCAP as elected, the school employee may either participate at the amount originally elected with a corresponding increase in contributions for the balance of the plan year, or participate at a reduced amount for the plan year by maintaining the per-pay period contribution in effect*
- *(d) If the school employee or their dependent was not eligible but still enrolled as described in subsection (1)(e) of this section, the employee's or their dependent's SEBB benefits will be terminated prospectively effective as of the last day of the month.(4) Premium payments.(a) The SEBB organization must remit to the authority the employer contribution and the school employee contribution for health plan premiums, applicable premium surcharges, basic life, basic AD&D, and employer-paid LTD insurance starting the date SEBB benefits begin as described in subsections (3) and (5)(a)(i) of this section. If a SEBB organization failed to notify a newly eligible school employee of their eligibility for SEBB benefits, the SEBB organization may only collect the school employee contribution for health plan premiums and applicable premium surcharges for coverage for the months after the school employee was notified.(b) When a SEBB organization fails to correctly enroll the amount of employee-paid LTD insurance elected by the school employee, premiums will be corrected as follows:(i) When additional premiums are due to the authority, the school employee is responsible for premiums for the most recent 24 months of coverage. The SEBB organization is responsible for additional months of premiums*
- *and(ii) When a premium refund is due to the school employee, the LTD insurance contracted vendor is responsible for premium refunds for the most recent 24 months of coverage. The SEBB organization is responsible for additional months of premium refunds after the 24 months of coverage and the overall refunding process to the school employee.(c) When a SEBB organization mistakenly enrolls a school employee or their dependents as described in subsection (1)(e) of this section, premiums and any applicable premium surcharges will be refunded by the SEBB organization to the school employee without rescinding the insurance coverage.(5) Recourse.(a) A school employee who establishes eligibility will have benefits begin as described in WAC 182-31-040. A school employee who regains eligibility for the employer contribution toward SEBB benefits will have benefits begin as described in WAC 182-30-080(3). Dependent eligibility is described in WAC 182-31-140, and dependent enrollment is described in WAC 182-31-150. When retroactive correction of an enrollment error is limited as described in subsection (3)(a), (b), and (c) of this section, the SEBB organization must work with the school employee, and receive approval from the authority, to implement retroactive SEBB benefits within the following parameters:(i) Retroactive enrollment in a SEBB insurance coverage*
- *(ii) Reimbursement of claims paid*
- *(iii) Reimbursement of amounts paid by the school employee or dependent for medical, vision, and dental premiums*
- *(iv) Reimbursement of amounts paid by the school employee for the premium surcharges*
- *(v) Other legal remedy received or offered*
- *or(vi) Other recourse, upon approval by the authority.(b) Recourse must not contradict a specific provision of federal law or statute and does not apply to requests for noncovered services or in the case of an individual who is not eligible for SEBB benefits.[Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.740. WSR 26-14-083 (Admin #2026.01), s 182-30-060, filed 6/29/26, effective 1/1/27*
- *WSR 25-14-083 (Admin #2025-01.02), s 182-30-060, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-30-060, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolution SEBB 2022-01. WSR 23-14-021 (Admin #2023-02.03), § 182-30-060, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-30-060, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions SEBB 2021-11 and 2021-12. WSR 21-13-116 (Admin #2021-01.03), § 182-30-060, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolution 2020-06. WSR 20-16-066 (Admin #2020-03), § 182-30-060, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-30-060, filed 7/1/19, effective 8/1/19.*

##### **Wash. Admin. Code § 182-30-070** The employer contribution is set by the health care authority (HCA) and paid to the HCA for all eligible school employees. {#sec-182-30-070 omnilex-key=us-wa-regs-official--title-182--182-30-070}

WAC 182-30-070

***(Effective until January 1, 2027)***

School employees benefits board (SEBB) organizations must pay the employer contributions to the health care authority (HCA) for SEBB insurance coverage for all eligible school employees and their enrolled dependents.

(1) Employer contributions are set by the HCA, and are subject to the approval of the governor for availability of funds as specifically appropriated by the legislature for that purpose. The employer contribution for school employees eligible under RCW 41.05.740 (6)(e) are set by the HCA.

(2) Employer contributions must include an amount determined by the HCA to pay administrative costs to administer SEBB benefits for school employees.

(3) Each school employee of a SEBB organization on leave under the federal Family and Medical Leave Act (FMLA) or the paid family medical leave program is eligible for the employer contribution as described in WAC 182-31-110.

(4) School employees of employer groups eligible under the criteria stipulated under the contract with the HCA are eligible for the employer contribution.

(5) The entire employer contribution is due and payable to HCA even if enrollment is waived as described in WAC 182-31-080, except for school employees eligible under WAC 182-30-130.

(6) The terms of payment to HCA for employer groups shall be stipulated under contract with HCA.

***(Effective January 1, 2027)***

PDF WAC 182-30-070

The employer contribution is set by the health care authority (HCA) and paid to the HCA for all eligible school employees.

School employees benefits board (SEBB) organizations must pay the employer contributions to the health care authority (HCA) for SEBB benefits for all eligible school employees and their enrolled dependents.

(1) Employer contributions are set by the HCA, and are subject to the approval of the governor for availability of funds as specifically appropriated by the legislature for that purpose. The employer contribution for school employees eligible under RCW 41.05.740 (6)(e) are set by the HCA.

(2) Employer contributions must include an amount determined by the HCA to pay administrative costs to administer SEBB benefits for school employees.

(3) Each school employee of a SEBB organization on leave under the federal Family and Medical Leave Act (FMLA) or the paid family medical leave program is eligible for the employer contribution as described in WAC 182-31-110.

(4) School employees of employer groups eligible under the criteria stipulated under the contract with the HCA are eligible for the employer contribution.

(5) The entire employer contribution is due and payable to HCA from the date the school employee is eligible for SEBB benefits to begin, even if enrollment is waived as described in WAC 182-31-080, except for school employees eligible under WAC 182-30-130.

(6) The terms of payment to HCA for employer groups shall be stipulated under contract with HCA.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-30-070, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions SEBB 2021-02, 2021-03, 2021-04, 2021-05, 2021-06, 2021-07, 2021-08, 2021-09, 2021-11. WSR 21-13-115 (Admin #2021-01.02), § 182-30-070, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-30-070, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-30-070, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-30-070, filed 12/14/18, effective 1/14/19.](Effective January 1, 2027) PDF WAC 182-30-070 The employer contribution is set by the health care authority (HCA) and paid to the HCA for all eligible school employees. School employees benefits board (SEBB) organizations must pay the employer contributions to the health care authority (HCA) for SEBB benefits for all eligible school employees and their enrolled dependents.(1) Employer contributions are set by the HCA, and are subject to the approval of the governor for availability of funds as specifically appropriated by the legislature for that purpose. The employer contribution for school employees eligible under RCW 41.05.740 (6)(e) are set by the HCA.(2) Employer contributions must include an amount determined by the HCA to pay administrative costs to administer SEBB benefits for school employees.(3) Each school employee of a SEBB organization on leave under the federal Family and Medical Leave Act (FMLA) or the paid family medical leave program is eligible for the employer contribution as described in WAC 182-31-110.(4) School employees of employer groups eligible under the criteria stipulated under the contract with the HCA are eligible for the employer contribution.(5) The entire employer contribution is due and payable to HCA from the date the school employee is eligible for SEBB benefits to begin, even if enrollment is waived as described in WAC 182-31-080, except for school employees eligible under WAC 182-30-130.(6) The terms of payment to HCA for employer groups shall be stipulated under contract with HCA.[Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.740. WSR 26-14-083 (Admin #2026.01), s 182-30-070, filed 6/29/26, effective 1/1/27. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-30-070, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions SEBB 2021-02, 2021-03, 2021-04, 2021-05, 2021-06, 2021-07, 2021-08, 2021-09, 2021-11. WSR 21-13-115 (Admin #2021-01.02), § 182-30-070, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-30-070, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-30-070, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-30-070, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-30-075** Subscriber address requirements. {#sec-182-30-075 omnilex-key=us-wa-regs-official--title-182--182-30-075}

(1) All school employees must provide their school employees benefits board (SEBB) organization with their correct address and update their address if it changes. Any other subscriber must provide the SEBB program with their correct address and updates to their address if it changes.

(2) In the event of an appeal, the appellant must update their address as required in WAC 182-32-055.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-30-075, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-30-075, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-30-075, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-30-075, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-30-080** When must a newly eligible school employee, or a school employee who regains eligibility for the employer contribution, elect school employees benefits board (SEBB) benefits and complete required forms? {#sec-182-30-080 omnilex-key=us-wa-regs-official--title-182--182-30-080}

A school employee who is newly eligible or who regains eligibility for the employer contribution toward school employees benefits board (SEBB) benefits enrolls as described in this section.

(1) When a school employee is newly eligible for SEBB benefits:

(a) A school employee must complete the required forms indicating their enrollment elections, including an election to waive enrollment provided the school employee is eligible to waive as described in WAC 182-31-080. The required forms must be returned to the school employee's SEBB organization or contracted vendor. Their SEBB organization or contracted vendor must receive the forms no later than 31 days after the school employee becomes eligible for SEBB benefits under WAC 182-31-040.

(i) The school employee may enroll in supplemental life insurance up to the guaranteed issue coverage amount without evidence of insurability if the required forms are returned to the school employee's SEBB organization or contracted vendor as required. A school employee may apply for enrollment in supplemental life insurance over the guaranteed issue coverage amount at any time during the calendar year by submitting the required form to the contracted vendor for approval. For a school employee who requests a change in their supplemental life insurance after the election period described in this subsection, the change begins the first day of the month following the date the contracted vendor approves the request. A school employee may enroll in supplemental accidental death and dismemberment (AD&D) insurance at anytime without evidence of insurability by submitting the required form to the contracted vendor.

(ii) School employees are enrolled in employee-paid long-term disability (LTD) insurance automatically. A school employee may elect to reduce their employee-paid LTD insurance or decline their employee-paid LTD insurance by returning the form to their SEBB organization. A school employee may apply for a change in their employee-paid LTD insurance at any time during the calendar year by submitting the required form to their SEBB organization or the contracted vendor. For a school employee who requests a change in their employee-paid LTD insurance after the election period described in this subsection, the change begins the first day of the month following the date the SEBB organization receives the required form requesting to reduce or decline the employee-paid LTD insurance, or the day of the month the contracted vendor approves the required form to increase the employee-paid LTD insurance.

(iii) If the school employee is eligible to participate in the salary reduction plan (see WAC 182-31-060), the school employee will automatically enroll in the premium payment plan upon enrollment in SEBB medical allowing medical premiums to be taken on a pretax basis. To opt out of the premium payment plan, a new school employee must complete the required form and return it to their SEBB organization. The form must be received by their SEBB organization no later than 31 days after the employee becomes eligible for SEBB benefits.

(iv) If a school employee is eligible to participate in the salary reduction plan (see WAC 182-31-060), the school employee may enroll in the state's flexible spending arrangement (FSA), limited purpose FSA, dependent care assistance program (DCAP), or both an FSA and DCAP, except as limited by subsection (4) of this section. To enroll in these SEBB benefits, the school employee must return the required form to their SEBB organization. The form must be received by the SEBB organization no later than 31 days after the school employee becomes eligible for SEBB benefits.

(b) If a newly eligible school employee's SEBB organization, or the authority's contracted vendor in the case of life insurance and AD&D, does not receive the school employee's required forms indicating medical, dental, vision, life insurance, AD&D insurance, and LTD insurance elections, and the school employee's tobacco use status attestation within 31 days of the school employee becoming eligible, their enrollment will be as follows for those elections not received within 31 days:

(i) A medical plan determined by the health care authority (HCA);

(ii) A dental plan determined by the HCA;

(iii) A vision plan determined by the HCA;

(iv) Basic life insurance;

(v) Basic AD&D insurance;

(vi) Employer-paid LTD insurance and employee-paid LTD insurance;

(vii) Dependents will not be enrolled; and

(viii) A tobacco use premium surcharge will be incurred as described in WAC 182-30-050 (1)(b).

(2) The employer contribution toward SEBB benefits ends according to WAC 182-31-050. When a school employee's employment ends, participation in the salary reduction plan ends.

(3) When a school employee regains eligibility for the employer contribution toward SEBB benefits, including following a period of leave as described in WAC 182-31-100(1) or 182-31-040 (4)(d), SEBB medical, dental, and vision begin the first day of the month following the school employee's return to work if the SEBB organization anticipates the school employee is eligible for the employer contribution.

| Note: | When a school employee who is called to active duty in the uniformed services under Uniformed Services Employment and Reemployment Rights Act (USERRA) loses eligibility for the employer contribution toward SEBB benefits, they regain eligibility for the employer contribution toward SEBB benefits the day they return from active duty. Employer-paid SEBB benefits will begin the first day of the month in which they return from active duty. |
| --- | --- |

(a) A school employee must complete the required forms indicating their enrollment elections, including an election to waive enrollment if the school employee chooses to waive enrollment as described in WAC 182-31-080. The required forms must be returned to the school employee's SEBB organization except as described in (d) of this subsection. Forms must be received by the SEBB organization, life insurance contracted vendor, or AD&D contracted vendor, if required, no later than 31 days after the school employee regains eligibility except as described in (a)(i) and (b) of this subsection:

(i) A school employee who self-paid for supplemental life insurance or supplemental AD&D coverage after losing eligibility will maintain that level of coverage upon return;

(ii) A school employee who was eligible to continue supplemental life insurance but discontinued that supplemental coverage must submit evidence of insurability to the contracted vendor if they choose to reenroll when they regain eligibility for the employer contribution.

(b) A school employee does not have to return a form indicating employee-paid LTD insurance elections. Their employee-paid LTD insurance will be automatically reinstated effective the first day of the month following the date they regain eligibility for the employer contribution toward SEBB benefits.

(c) If a school employee's SEBB organization, or contracted vendor accepting forms directly, does not receive the required forms within 31 days of the school employee regaining eligibility, the school employee's enrollment for those elections not received will be as described in subsection (1)(b)(i) through (viii) of this section, except as described in (a)(i) and (b) of this subsection.

(d) If a school employee is eligible to participate in the salary reduction plan (see WAC 182-31-060), the school employee may enroll in the FSA, limited purpose FSA, DCAP, or both an FSA and DCAP, except as limited by subsection (4) of this section. To enroll in these SEBB benefits, the school employee must return the required form to the contracted vendor or their SEBB organization. The contracted vendor or school employee's SEBB organization must receive the form no later than 31 days after the school employee becomes eligible for SEBB benefits.

(4) If a school employee who is eligible to participate in the salary reduction plan (see WAC 182-31-060) is hired into a new position that is anticipated to be eligible for SEBB benefits in the same year, the school employee may not resume participation in a DCAP, a FSA, or a limited purpose FSA until the beginning of the next plan year, unless the time between employments is 30 days or less and within the current plan year. The school employee must notify the new SEBB organization of the transfer by providing the new SEBB organization the required form no later than 31 days after the school employee's first day of work with the new SEBB organization.

(5) A school employee will have uninterrupted coverage when moving from one SEBB organization to another within the same month or a consecutive month if they are eligible for the employer contribution towards SEBB benefits in the position they are leaving and are anticipated to be eligible for the employer contribution in the new position. SEBB benefits elections also remain the same when a school employee has a break in employment that does not interrupt their employer contribution toward SEBB benefits.

(6) A school employee returning to the same SEBB organization who is anticipated to work at least 630 hours in the coming school year, and who was receiving the employer contribution in August of the prior school year, will receive uninterrupted coverage from one school year to the next.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-30-080, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy Resolution SEBB 2022-01. WSR 22-13-170 (Admin #2022-02), § 182-30-080, filed 6/22/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions SEBB 2021-11 and 2021-12. WSR 21-13-116 (Admin #2021-01.03), § 182-30-080, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-30-080, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-30-080, filed 7/1/19, effective 8/1/19.*

##### **Wash. Admin. Code § 182-30-085** What happens if my health plan becomes unavailable? {#sec-182-30-085 omnilex-key=us-wa-regs-official--title-182--182-30-085}

(1) A subscriber must select a new health plan when their previously selected health plan becomes unavailable due to a change in contracting service area as described below:

(a) When a health plan becomes unavailable during the plan year, a subscriber must elect a new health plan no later than 60 days after the date their previously selected health plan becomes unavailable.

(i) A school employee must submit the required form to their school employees benefits board (SEBB) organization electing their new health plan.

(ii) All other subscribers must submit the required forms to the SEBB program electing their new health plan.

(iii) The effective date of the change in health plan will be the first day of the month following the later of the date the health plan becomes unavailable or the date the form is received. If that day is the first of the month, the change in health plans begins on that day.

(b) When a health plan becomes unavailable at the beginning of the next plan year, a subscriber must elect a new health plan no later than the last day of the SEBB annual open enrollment.

(i) A school employee must submit the required forms to their SEBB organization electing their new health plan.

(ii) Any other subscriber must submit the required forms to the SEBB program electing their new health plan.

(iii) The effective date of the change in health plan will be January 1st of the following year.

(c) A subscriber who fails to elect a new health plan within the required time period as required in (a) or (b) of this subsection will be enrolled in a health plan designated by the director or their designee.

(2) A subscriber must elect a new health plan when their previously selected health plan becomes unavailable due to the subscriber or subscriber's dependent ceasing to be eligible for their current health plan because of enrollment in medicare as described below:

(a) The required forms electing a new health plan must be received no later than 60 days after the date their previously selected health plan becomes unavailable.

(i) A school employee must submit the required forms to their SEBB organization electing their new health plan.

(ii) All other subscribers must submit the required forms to the SEBB program electing their new health plan.

(iii) The effective date of the change in their health plan will be the first day of the month following the later of the date the health plan becomes unavailable or the date the form is received. If that day is the first of the month, the change in the health plan begins on that day.

(b) A subscriber who is enrolled in a high deductible health plan (HDHP) with a health savings account (HSA), will not be eligible to receive contributions to the HSA, and will be liable for any tax penalties resulting from contributions made when they are no longer eligible.

(3) A subscriber must elect a new medical plan when their previously selected medical plan becomes unavailable due to a change in their residence or employment location as described below:

(a) When a subscriber's medical plan becomes unavailable during the plan year, a subscriber must elect a new medical plan no later than 60 days after the date their previously selected medical plan becomes unavailable as described in WAC 182-30-090 (2)(d) or (f).

(i) A school employee must submit the required forms to their SEBB organization electing their new medical plan.

(ii) Any other subscriber must submit the required forms to the SEBB program electing their new medical plan.

(iii) The effective date of the change in medical plan will be the first day of the month following the later of the date the medical plan becomes unavailable or the date the form is received. If that day is the first of the month, the change in medical plan begins on that day.

(b) A subscriber who fails to elect a new medical plan within the required time period as required in (a) of this subsection will be enrolled in a school employees benefits board medical plan designated by the director or their designee.

(4) A subscriber enrolled in a health plan as described in subsection (1)(c), (2)(b), or (3)(b) of this section may not change health plans except as allowed in WAC 182-30-090.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolution SEBB 2023-04. WSR 23-14-020 (Admin #2023-02.02), § 182-30-085, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-30-085, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-30-085, filed 7/1/19, effective 8/1/19.*

##### **Wash. Admin. Code § 182-30-090** When may a subscriber change health plans? {#sec-182-30-090 omnilex-key=us-wa-regs-official--title-182--182-30-090}

WAC 182-30-090

***(Effective until January 1, 2027)***

A subscriber may change health plans at the following times:

(1) During the annual open enrollment: A subscriber may change health plans during the school employees benefits board (SEBB) annual open enrollment period. The subscriber must submit the required enrollment forms to change their health plan. A school employee submits the enrollment forms to their SEBB organization. Any other subscriber submits the enrollment forms to the SEBB program. The required enrollment forms must be received no later than the last day of the annual open enrollment. Enrollment in the new health plan will begin January 1st of the following year.

(2) During a special open enrollment: A subscriber may revoke their health plan election and make a new election outside of the annual open enrollment if a special open enrollment event occurs. A special open enrollment event must be an event other than a school employee gaining initial eligibility for SEBB benefits as described in WAC 182-31-040 or regaining eligibility for SEBB benefits as described in WAC 182-30-080. The change in enrollment must be allowable under Internal Revenue Code (IRC) and Treasury regulations, and correspond to and be consistent with the event that creates the special open enrollment for the subscriber, the subscriber's dependent, or both.

A subscriber may not change their health plan during a special open enrollment if their state registered domestic partner or state registered domestic partner's child is not a tax dependent. A subscriber may change their health plan as described in subsection (1) of this section.

To make a health plan change, a subscriber must submit the required enrollment forms. The forms must be received no later than 60 days after the event occurs. A school employee submits the enrollment forms to their SEBB organization. Any other subscriber submits the enrollment forms to the SEBB program. In addition to the required forms, a subscriber must provide evidence of the event that created the special open enrollment. New health plan coverage will begin the first day of the month following the later of the event date or the date the form is received. If that day is the first of the month, the change in enrollment begins on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, health plan coverage will begin the month in which the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption occurs. If the special open enrollment is due to the enrollment of an extended dependent or a dependent with a disability, the change in health plan coverage will begin the first day of the month following the later of the event date or the eligibility certification. Any one of the following events may create a special open enrollment:

(a) Subscriber acquires a new dependent due to:

(i) Marriage or registering a state registered domestic partnership;

(ii) Birth, adoption, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption; or

(iii) A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(b) Subscriber or a subscriber's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA);

(c) Subscriber has a change in employment status that affects the subscriber's eligibility for the employer contribution toward their employer-based group health plan;

(d) Subscriber has a change in employment location that affects medical plan availability. If the subscriber changes employment locations and the subscriber's current medical plan is no longer available, the subscriber must select a new medical plan as described in WAC 182-30-085(3). If the subscriber has one or more new medical plans available, the subscriber may select to enroll in a newly available plan.

(e) The subscriber's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution under their employer-based group health plan;

| Note: | As used in (e) of this subsection "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 26 C.F.R. 54.9801-6. |
| --- | --- |

(f) Subscriber or a subscriber's dependent has a change in residence that affects health plan availability.

(i) If the subscriber has a change in residence and the subscriber's current medical plan is no longer available, the subscriber must select a new medical plan, as described in WAC 182-30-085(3).

(ii) If the subscriber or the subscriber's dependent has a change in residence and the subscriber's current dental plan does not have available providers within 50 miles of the subscriber or the subscriber's dependent's new residence, the subscriber may select a new dental plan.

(g) A court order requires the subscriber or any other individual to provide insurance coverage for an eligible dependent of the subscriber (a former spouse or former state registered domestic partner is not an eligible dependent);

(h) Subscriber or a subscriber's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the subscriber or a subscriber's dependent loses eligibility for coverage under medicaid or CHIP;

(i) Subscriber or a subscriber's dependent becomes eligible for state premium assistance subsidy for SEBB health plan coverage from medicaid or CHIP;

(j) Subscriber or a subscriber's dependent enrolls in coverage under medicare, or the subscriber or a subscriber's dependent loses eligibility for coverage under medicare. If the subscriber's current medical plan becomes unavailable due to the subscriber's or a subscriber's dependent's enrollment in medicare, the subscriber must select a new medical plan as described in WAC 182-30-085(2);

(k) Subscriber or a subscriber's dependent's current medical plan becomes unavailable because the subscriber or enrolled dependent is no longer eligible for a health savings account (HSA). The authority may require evidence that the subscriber or subscriber's dependent is no longer eligible for an HSA;

(l) Subscriber or a subscriber's dependent experiences a disruption of care for active and ongoing treatment that could function as a reduction in benefits for the subscriber or the subscriber's dependent. The subscriber may not change their health plan election if the subscriber's or dependent's physician stops participation with the subscriber's health plan unless the SEBB program determines that a continuity of care issue exists. The SEBB program will consider but not limit its consideration to the following:

(i) Active cancer treatment such as chemotherapy or radiation therapy;

(ii) Treatment following a recent organ transplant;

(iii) A scheduled surgery;

(iv) Recent major surgery still within the postoperative period; or

(v) Treatment for a high-risk pregnancy.

(m) The SEBB program determines that there has been a substantial decrease in the providers available under a SEBB medical plan.

(3) If the school employee is having premiums taken from payroll on a pretax basis, a medical plan change will not be approved if it would conflict with provisions of the salary reduction plan authorized under RCW 41.05.300.

***(Effective January 1, 2027)***

PDF WAC 182-30-090

When may a subscriber change health plans?

A subscriber may change health plans at the following times:

(1) During the annual open enrollment: A subscriber may change health plans during the school employees benefits board (SEBB) annual open enrollment period. The subscriber must submit the required enrollment forms to change their health plan. A school employee submits the enrollment forms to their SEBB organization. Any other subscriber submits the enrollment forms to the SEBB program. The required enrollment forms must be received no later than the last day of the annual open enrollment. Enrollment in the new health plan will begin January 1st of the following year.

(2) During a special open enrollment: A subscriber may revoke their health plan election and make a new election outside of the annual open enrollment if a special open enrollment event occurs. A special open enrollment event must be an event other than a school employee gaining initial eligibility for SEBB benefits as described in WAC 182-31-040 or regaining eligibility for SEBB benefits as described in WAC 182-30-080. The change in enrollment must be allowable under Internal Revenue Code (IRC) and Treasury regulations, and correspond to and be consistent with the event that creates the special open enrollment for the subscriber, the subscriber's dependent, or both.

A subscriber may not change their health plan during a special open enrollment if their state registered domestic partner or state registered domestic partner's child is not a tax dependent. A subscriber may change their health plan as described in subsection (1) of this section.

To make a health plan change, a subscriber must submit the required enrollment forms. The forms must be received no later than 60 days after the event occurs. A school employee submits the enrollment forms to their SEBB organization. Any other subscriber submits the enrollment forms to the SEBB program. In addition to the required forms, a subscriber must provide evidence of the event that created the special open enrollment. New health plan coverage will begin the first day of the month following the later of the event date or the date the form is received. If that day is the first of the month, the change in enrollment begins on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, health plan coverage will begin the month in which the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption occurs. If the special open enrollment is due to the enrollment of an extended dependent or a dependent with a disability, the change in health plan coverage will begin the first day of the month following the later of the event date or the eligibility certification. Any one of the following events may create a special open enrollment:

(a) Subscriber acquires a new dependent due to:

(i) Marriage or registering a state registered domestic partnership;

(ii) Birth, adoption, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption; or

(iii) A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(b) Subscriber or a subscriber's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA);

(c) Subscriber has a change in employment status that affects the subscriber's eligibility for the employer contribution toward their employer-based group health plan;

(d) Subscriber has a change in employment location that affects medical plan availability. If the subscriber changes employment locations and the subscriber's current medical plan is no longer available, the subscriber must select a new medical plan as described in WAC 182-30-085(3). If the subscriber has one or more new medical plans available, the subscriber may select to enroll in a newly available plan;

(e) The subscriber's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution under their employer-based group health plan;

| Note: | As used in (e) of this subsection "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 26 C.F.R. 54.9801-6. |
| --- | --- |

(f) Subscriber or a subscriber's dependent has a change in residence that affects health plan availability;

(i) If the subscriber has a change in residence and the subscriber's current medical plan is no longer available, the subscriber must select a new medical plan, as described in WAC 182-30-085(3).

(ii) If the subscriber or the subscriber's dependent has a change in residence and the subscriber's current dental plan does not have available providers within 50 miles of the subscriber or the subscriber's dependent's new residence, the subscriber may select a new dental plan.

(g) A court order requires the subscriber or any other individual to provide insurance coverage for an eligible dependent of the subscriber (a former spouse or former state registered domestic partner is not an eligible dependent);

(h) Subscriber or a subscriber's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the subscriber or a subscriber's dependent loses eligibility for coverage under medicaid or CHIP;

(i) Subscriber or a subscriber's dependent becomes eligible for state premium assistance subsidy for SEBB health plan coverage from medicaid or CHIP;

(j) Subscriber or a subscriber's dependent enrolls in coverage under medicare, or the subscriber or a subscriber's dependent loses eligibility for coverage under medicare. If the subscriber's current medical plan becomes unavailable due to the subscriber's or a subscriber's dependent's enrollment in medicare, the subscriber must select a new medical plan as described in WAC 182-30-085(2);

(k) Subscriber or a subscriber's dependent's current medical plan becomes unavailable because the subscriber or enrolled dependent is no longer eligible for a health savings account (HSA). The authority may require evidence that the subscriber or subscriber's dependent is no longer eligible for an HSA;

(l) Subscriber or a subscriber's dependent experiences a disruption of care for active and ongoing treatment that could function as a reduction in benefits for the subscriber or the subscriber's dependent. The subscriber may not change their health plan election if the subscriber's or dependent's physician stops participation with the subscriber's health plan unless the SEBB program determines that a continuity of care issue exists. The SEBB program will consider but not limit its consideration to the following:

(i) Active cancer treatment such as chemotherapy or radiation therapy;

(ii) Treatment following a recent organ transplant;

(iii) A scheduled surgery;

(iv) Recent major surgery still within the postoperative period; or

(v) Treatment for a high-risk pregnancy.

(m) Subscriber or a subscriber's dependent becomes eligible and enrolls in a TRICARE plan or loses eligibility for a TRICARE plan;

(n) The SEBB program determines that there has been a substantial decrease in the providers available under a SEBB medical plan;

(o) The SEBB program determines that there has been a substantial increase in the school employee's premiums when the school employee moves to another SEBB organization or employer group.

(3) If the school employee is having premiums taken from payroll on a pretax basis, a medical plan change will not be approved if it would conflict with provisions of the salary reduction plan authorized under RCW 41.05.300.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-30-090, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolution SEBB 2023-04. WSR 23-14-020 (Admin #2023-02.02), § 182-30-090, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-30-090, filed 6/21/22, effective 1/1/23*
- *WSR 21-13-117 (Admin #2021-01.04), § 182-30-090, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-30-090, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160 and 2018 c 260. WSR 20-01-082, § 182-30-090, filed 12/12/19, effective 1/12/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-30-090, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-30-090, filed 12/14/18, effective 1/14/19.](Effective January 1, 2027) PDF WAC 182-30-090 When may a subscriber change health plans? A subscriber may change health plans at the following times:(1) During the annual open enrollment: A subscriber may change health plans during the school employees benefits board (SEBB) annual open enrollment period. The subscriber must submit the required enrollment forms to change their health plan. A school employee submits the enrollment forms to their SEBB organization. Any other subscriber submits the enrollment forms to the SEBB program. The required enrollment forms must be received no later than the last day of the annual open enrollment. Enrollment in the new health plan will begin January 1st of the following year.(2) During a special open enrollment: A subscriber may revoke their health plan election and make a new election outside of the annual open enrollment if a special open enrollment event occurs. A special open enrollment event must be an event other than a school employee gaining initial eligibility for SEBB benefits as described in WAC 182-31-040 or regaining eligibility for SEBB benefits as described in WAC 182-30-080. The change in enrollment must be allowable under Internal Revenue Code (IRC) and Treasury regulations, and correspond to and be consistent with the event that creates the special open enrollment for the subscriber, the subscriber's dependent, or both.A subscriber may not change their health plan during a special open enrollment if their state registered domestic partner or state registered domestic partner's child is not a tax dependent. A subscriber may change their health plan as described in subsection (1) of this section. To make a health plan change, a subscriber must submit the required enrollment forms. The forms must be received no later than 60 days after the event occurs. A school employee submits the enrollment forms to their SEBB organization. Any other subscriber submits the enrollment forms to the SEBB program. In addition to the required forms, a subscriber must provide evidence of the event that created the special open enrollment. New health plan coverage will begin the first day of the month following the later of the event date or the date the form is received. If that day is the first of the month, the change in enrollment begins on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, health plan coverage will begin the month in which the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption occurs. If the special open enrollment is due to the enrollment of an extended dependent or a dependent with a disability, the change in health plan coverage will begin the first day of the month following the later of the event date or the eligibility certification. Any one of the following events may create a special open enrollment:(a) Subscriber acquires a new dependent due to:(i) Marriage or registering a state registered domestic partnership*
- *(ii) Birth, adoption, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption*
- *or(iii) A child becoming eligible as an extended dependent through legal custody or legal guardianship.(b) Subscriber or a subscriber's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA)*
- *(c) Subscriber has a change in employment status that affects the subscriber's eligibility for the employer contribution toward their employer-based group health plan*
- *(d) Subscriber has a change in employment location that affects medical plan availability. If the subscriber changes employment locations and the subscriber's current medical plan is no longer available, the subscriber must select a new medical plan as described in WAC 182-30-085(3). If the subscriber has one or more new medical plans available, the subscriber may select to enroll in a newly available plan*
- *(e) The subscriber's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution under their employer-based group health plan*
- *Note:As used in (e) of this subsection "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 26 C.F.R. 54.9801-6.(f) Subscriber or a subscriber's dependent has a change in residence that affects health plan availability*
- *(i) If the subscriber has a change in residence and the subscriber's current medical plan is no longer available, the subscriber must select a new medical plan, as described in WAC 182-30-085(3).(ii) If the subscriber or the subscriber's dependent has a change in residence and the subscriber's current dental plan does not have available providers within 50 miles of the subscriber or the subscriber's dependent's new residence, the subscriber may select a new dental plan.(g) A court order requires the subscriber or any other individual to provide insurance coverage for an eligible dependent of the subscriber (a former spouse or former state registered domestic partner is not an eligible dependent)*
- *(h) Subscriber or a subscriber's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the subscriber or a subscriber's dependent loses eligibility for coverage under medicaid or CHIP*
- *(i) Subscriber or a subscriber's dependent becomes eligible for state premium assistance subsidy for SEBB health plan coverage from medicaid or CHIP*
- *(j) Subscriber or a subscriber's dependent enrolls in coverage under medicare, or the subscriber or a subscriber's dependent loses eligibility for coverage under medicare. If the subscriber's current medical plan becomes unavailable due to the subscriber's or a subscriber's dependent's enrollment in medicare, the subscriber must select a new medical plan as described in WAC 182-30-085(2)*
- *(k) Subscriber or a subscriber's dependent's current medical plan becomes unavailable because the subscriber or enrolled dependent is no longer eligible for a health savings account (HSA). The authority may require evidence that the subscriber or subscriber's dependent is no longer eligible for an HSA*
- *(l) Subscriber or a subscriber's dependent experiences a disruption of care for active and ongoing treatment that could function as a reduction in benefits for the subscriber or the subscriber's dependent. The subscriber may not change their health plan election if the subscriber's or dependent's physician stops participation with the subscriber's health plan unless the SEBB program determines that a continuity of care issue exists. The SEBB program will consider but not limit its consideration to the following:(i) Active cancer treatment such as chemotherapy or radiation therapy*
- *(ii) Treatment following a recent organ transplant*
- *(iii) A scheduled surgery*
- *(iv) Recent major surgery still within the postoperative period*
- *or(v) Treatment for a high-risk pregnancy.(m) Subscriber or a subscriber's dependent becomes eligible and enrolls in a TRICARE plan or loses eligibility for a TRICARE plan*
- *(n) The SEBB program determines that there has been a substantial decrease in the providers available under a SEBB medical plan*
- *(o) The SEBB program determines that there has been a substantial increase in the school employee's premiums when the school employee moves to another SEBB organization or employer group.(3) If the school employee is having premiums taken from payroll on a pretax basis, a medical plan change will not be approved if it would conflict with provisions of the salary reduction plan authorized under RCW 41.05.300.[Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.740. WSR 26-14-083 (Admin #2026.01), s 182-30-090, filed 6/29/26, effective 1/1/27. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-30-090, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolution SEBB 2023-04. WSR 23-14-020 (Admin #2023-02.02), § 182-30-090, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-30-090, filed 6/21/22, effective 1/1/23*
- *WSR 21-13-117 (Admin #2021-01.04), § 182-30-090, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-30-090, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160 and 2018 c 260. WSR 20-01-082, § 182-30-090, filed 12/12/19, effective 1/12/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-30-090, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-30-090, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-30-100** When may a school employee enroll, or revoke an election and make a new election under the premium payment plan, flexible spending arrangement (FSA), limited purpose FSA, or dependent care assistance program (DCAP)? {#sec-182-30-100 omnilex-key=us-wa-regs-official--title-182--182-30-100}

WAC 182-30-100

***(Effective until January 1, 2027)***

A school employee who is eligible to participate in the salary reduction plan as described in WAC 182-31-060 may enroll, or revoke their election and make a new election under the premium payment plan, flexible spending arrangement (FSA), limited purpose FSA, or dependent care assistance program (DCAP) at the following times:

(1) When newly eligible under WAC 182-31-040 and enrolling as described in WAC 182-30-080(1).

(2) During annual open enrollment: An eligible school employee may elect to enroll in or opt out of participation under the premium payment plan during the annual open enrollment by submitting the required form to their school employees benefits board (SEBB) organization. An eligible school employee may elect to enroll or reenroll in the FSA, limited purpose FSA, DCAP, or both an FSA and DCAP during the annual open enrollment by submitting the required forms to their SEBB organization or applicable contracted vendor as instructed. All required forms must be received no later than the last day of the annual open enrollment. The enrollment or new election becomes effective January 1st of the following year.

(a) School employees cannot enroll in a FSA and a limited purpose FSA in the same year.

(b) School employees enrolled in a high deductible health plan (HDHP) with a health savings account (HSA) cannot also enroll in a FSA in the same plan year. School employees who elect enrollment in the HDHP with a HSA and a FSA will only be enrolled in a HDHP with a HSA.

(c) If a school employee enrolls in a HDHP with a HSA during annual open enrollment and has a carryover amount from a FSA, the school employee will be enrolled in a limited purpose FSA and the carryover amount will be deposited into the limited FSA.

(d) School employees who are not enrolled in a HDHP with a HSA and elect both a FSA and a limited purpose FSA will be enrolled in the FSA.

(3) During a special open enrollment: A school employee who is eligible to participate in the salary reduction plan may enroll or revoke their election and make a new election under the premium payment plan, FSA, limited purpose FSA, or DCAP outside of the annual open enrollment if a special open enrollment event occurs. The enrollment or change in election must be allowable under Internal Revenue Code (IRC) and Treasury regulations, and correspond to and be consistent with the event that creates the special open enrollment. To make a change or enroll, the school employee must submit the required form to their SEBB organization. The SEBB organization must receive the required form and evidence of the event that created the special open enrollment no later than 60 days after the event occurs.

For purposes of this section, an eligible dependent includes any person who qualifies as a dependent of the school employee for tax purposes under IRC 26 U.S.C. Sec. 152 without regard to the income limitations of that section. It does not include a state registered domestic partner unless the state registered domestic partner otherwise qualifies as a dependent for tax purposes under IRC 26 U.S.C. Sec. 152.

(a) Premium payment plan. A school employee may enroll or revoke their election and elect to opt out of the premium payment plan when any of the following special open enrollment events occur, if the requested change corresponds to and is consistent with the event. The enrollment or election to opt out will be effective the first day of the month following the later of the event date or the date the required form is received. If that day is the first of the month, the enrollment or change in election begins on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, the enrollment or change in election will begin the first of the month in which the event occurs.

(i) School employee acquires a new dependent due to:

• Marriage;

• Registering a state registered domestic partnership when the dependent is a tax dependent of the school employee;

• Birth, adoption, or when the school employee has assumed a legal obligation for total or partial support in anticipation of adoption; or

• A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(ii) School employee's dependent no longer meets SEBB eligibility criteria because:

• School employee has a change in marital status;

• School employee's domestic partnership with a state registered domestic partner who is a tax dependent is dissolved or terminated;

• An eligible dependent child turns age 26 or otherwise does not meet dependent child eligibility criteria;

• An eligible dependent ceases to be eligible as an extended dependent or as a dependent with a disability; or

• An eligible dependent dies.

(iii) School employee or a school employee's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by Health Insurance Portability and Accountability Act (HIPAA);

(iv) School employee has a change in employment status that affects the school employee's eligibility for their employer contribution toward their employer-based group health plan;

(v) The school employee's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution toward their employer-based group health plan;

| Exception: | As used in (a)(v) of this subsection, "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 26 C.F.R. 54.9801-6. |
| --- | --- |

(vi) School employee or a school employee's dependent has a change in enrollment under an employer-based group health plan during its annual open enrollment that does not align with the SEBB annual open enrollment;

(vii) School employee or a school employee's dependent has a change in residence that affects health plan availability. If the school employee has a change in residence and the school employee's current medical plan is no longer available, the school employee must select a new medical plan as described in WAC 182-30-085(3);

(viii) School employee's dependent has a change in residence from outside of the United States to within the United States, or from within the United States to outside of the United States, and that change in residence resulted in the dependent losing their health insurance;

(ix) A court order requires the school employee or any other individual to provide insurance coverage for an eligible dependent of the school employee (a former spouse or former state registered domestic partner is not an eligible dependent);

(x) School employee or a school employee's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the school employee or a school employee's dependent loses eligibility for coverage under medicaid or CHIP;

(xi) School employee or a school employee's dependent becomes eligible for state premium assistance subsidy for SEBB health plan coverage from medicaid or CHIP;

(xii) School employee or a school employee's dependent enrolls in coverage under medicare or the school employee or a school employee's dependent loses eligibility for coverage under medicare;

(xiii) School employee or a school employee's dependent's current medical plan becomes unavailable because the school employee or enrolled dependent is no longer eligible for a HSA. The HCA may require evidence that the school employee or a school employee's dependent is no longer eligible for a HSA;

(xiv) School employee or a school employee's dependent experiences a disruption of care for active and ongoing treatment, that could function as a reduction in benefits for the school employee or a school employee's dependent. The school employee may not change their health plan election if the school employee's or dependent's physician stops participation with the school employee's health plan unless the SEBB program determines that a continuity of care issue exists. The SEBB program will consider but not limit its consideration to the following:

• Active cancer treatment such as chemotherapy or radiation therapy;

• Treatment following a recent organ transplant;

• A scheduled surgery;

• Recent major surgery still within the postoperative period; or

• Treatment for a high-risk pregnancy.

(xv) School employee or school employee's dependent becomes eligible and enrolls in a TRICARE plan, or loses eligibility for a TRICARE plan.

(xvi) School employee has a change in employment location that affects medical plan availability.

If the school employee changes employment locations and their current medical plan is no longer available, the school employee must select a new medical plan as described in WAC 182-30-085(3).

If the school employee has one or more new medical plans available, the school employee may select to enroll in a newly available plan.

(xvii) The SEBB program determines that there has been a substantial decrease in the providers available under a SEBB medical plan.

If the school employee is having premiums taken from payroll on a pretax basis, a medical plan change will not be approved if it would conflict with provisions of the salary reduction plan authorized under RCW 41.05.300.

(b) FSA and limited purpose FSA. A school employee may enroll or revoke their election and make a new election under the FSA or limited purpose FSA when any one of the following special open enrollment events occur, if the requested change corresponds to and is consistent with the event. The enrollment or new election will be effective the first day of the month following the later of the event date or the date the required form and evidence of the event that created the special open enrollment is received by the SEBB organization. If that day is the first of the month, the enrollment or change in election begins on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, the enrollment or change in election will begin the first of the month in which the event occurs.

(i) School employee acquires a new dependent due to:

• Marriage;

• Registering a state registered domestic partnership when the dependent is a tax dependent of the school employee;

• Birth, adoption, or when the school employee has assumed a legal obligation for total or partial support in anticipation of adoption; or

• A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(ii) School employee's dependent no longer meets SEBB eligibility criteria because:

• School employee has a change in marital status;

• School employee's domestic partnership with a state registered domestic partner who qualifies as a tax dependent is dissolved or terminated;

• An eligible dependent child turns age 26 or otherwise does not meet dependent child eligibility criteria;

• An eligible dependent ceases to be eligible as an extended dependent or as a dependent with a disability; or

• An eligible dependent dies.

(iii) School employee or a school employee's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by HIPAA;

(iv) School employee or a school employee's dependent has a change in employment status that affects the school employee's or a dependent's eligibility for the FSA or limited purpose FSA;

(v) A court order requires the school employee or any other individual to provide insurance coverage for an eligible dependent of the school employee (a former spouse or former state registered domestic partner is not an eligible dependent);

(vi) School employee or a school employee's dependent enrolls in coverage under medicaid or CHIP, or the school employee or a school employee's dependent loses eligibility for coverage under medicaid or CHIP;

(vii) School employee or a school employee's dependent enrolls in coverage under medicare.

(c) DCAP. A school employee may enroll or revoke their election and make a new election under the DCAP when any one of the following special open enrollment events occur, if the requested change corresponds to and is consistent with the event. The enrollment or new election will be effective the first day of the month following the later of the event date or the date the required form and evidence of the event that created the special open enrollment is received by the SEBB organization. If that day is the first of the month, the enrollment or change in election begins on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, the enrollment or change in election will begin the first of the month in which the event occurs.

(i) School employee acquires a new dependent due to:

• Marriage;

• Registering a state registered domestic partnership if the state registered domestic partner qualifies as a tax dependent of the school employee;

• Birth, adoption, or when the school employee has assumed a legal obligation for total or partial support in anticipation of adoption; or

• A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(ii) School employee or a school employee's dependent has a change in employment status that affects the school employee's or a dependent's eligibility for DCAP;

(iii) School employee or school employee's dependent has a change in enrollment under an employer-based DCAP during its annual open enrollment that does not align with the SEBB annual open enrollment;

(iv) School employee changes dependent care provider; the change to the DCAP election amount can reflect the cost of the new provider;

(v) School employee or school employee's spouse experiences a change in the number of qualifying individuals as defined in IRC 26 U.S.C. Sec. 21 (b)(1);

(vi) School employee's dependent care provider imposes a change in the cost of dependent care; school employee may make a change in the DCAP election amount to reflect the new cost if the dependent care provider is not a qualifying relative of the school employee as defined in IRC 26 U.S.C. Sec. 152.

***(Effective January 1, 2027)***

PDF WAC 182-30-100

When may a school employee enroll, or revoke an election and make a new election under the premium payment plan, flexible spending arrangement (FSA), limited purpose FSA, or dependent care assistance program (DCAP)?

A school employee who is eligible to participate in the salary reduction plan as described in WAC 182-31-060 may enroll, or revoke their election and make a new election under the premium payment plan, flexible spending arrangement (FSA), limited purpose FSA, or dependent care assistance program (DCAP) at the following times:

(1) When newly eligible under WAC 182-31-040 and enrolling as described in WAC 182-30-080(1).

(2) During annual open enrollment: An eligible school employee may elect to enroll in or opt out of participation under the premium payment plan during the annual open enrollment by submitting the required form to their school employees benefits board (SEBB) organization. An eligible school employee may elect to enroll or reenroll in the FSA, limited purpose FSA, DCAP, or both an FSA and DCAP during the annual open enrollment by submitting the required forms to their SEBB organization or applicable contracted vendor as instructed. All required forms must be received no later than the last day of the annual open enrollment. The enrollment or new election becomes effective January 1st of the following year.

(a) School employees cannot enroll in a FSA and a limited purpose FSA in the same year.

(b) School employees enrolled in a high deductible health plan (HDHP) with a health savings account (HSA) cannot also enroll in a FSA in the same plan year. School employees who elect enrollment in the HDHP with a HSA and a FSA will only be enrolled in a HDHP with a HSA.

(c) If a school employee enrolls in a HDHP with a HSA during annual open enrollment and has a carryover amount from a FSA, the school employee will be enrolled in a limited purpose FSA and the carryover amount will be deposited into the limited FSA.

(d) School employees who are not enrolled in a HDHP with a HSA and elect both a FSA and a limited purpose FSA will be enrolled in the FSA.

(3) During a special open enrollment: A school employee who is eligible to participate in the salary reduction plan may enroll or revoke their election and make a new election under the premium payment plan, FSA, limited purpose FSA, or DCAP outside of the annual open enrollment if a special open enrollment event occurs. The enrollment or change in election must be allowable under Internal Revenue Code (IRC) and Treasury regulations, and correspond to and be consistent with the event that creates the special open enrollment. To make a change or enroll, the school employee must submit the required form to their SEBB organization. The SEBB organization must receive the required form and evidence of the event that created the special open enrollment no later than 60 days after the event occurs.

For purposes of this section, an eligible dependent includes any person who qualifies as a dependent of the school employee for tax purposes under IRC 26 U.S.C. Sec. 152 without regard to the income limitations of that section. It does not include a state registered domestic partner unless the state registered domestic partner otherwise qualifies as a dependent for tax purposes under IRC 26 U.S.C. Sec. 152.

(a) Premium payment plan. A school employee may enroll or revoke their election and elect to opt out of the premium payment plan when any of the following special open enrollment events occur, if the requested change corresponds to and is consistent with the event. The enrollment or election to opt out will be effective the first day of the month following the later of the event date or the date the required form is received. If that day is the first of the month, the enrollment or change in election begins on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, the enrollment or change in election will begin the first of the month in which the event occurs.

(i) School employee acquires a new dependent due to:

• Marriage;

• Registering a state registered domestic partnership when the dependent is a tax dependent of the school employee;

• Birth, adoption, or when the school employee has assumed a legal obligation for total or partial support in anticipation of adoption; or

• A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(ii) School employee's dependent no longer meets SEBB eligibility criteria because:

• School employee has a change in marital status;

• School employee's domestic partnership with a state registered domestic partner who is a tax dependent is dissolved or terminated;

• An eligible dependent child turns age 26 or otherwise does not meet dependent child eligibility criteria;

• An eligible dependent ceases to be eligible as an extended dependent or as a dependent with a disability; or

• An eligible dependent dies.

(iii) School employee or a school employee's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by Health Insurance Portability and Accountability Act (HIPAA);

(iv) School employee has a change in employment status that affects the school employee's eligibility for their employer contribution toward their employer-based group health plan;

(v) The school employee's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution toward their employer-based group health plan;

| Exception: | As used in (a)(v) of this subsection, "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 26 C.F.R. 54.9801-6. |
| --- | --- |

(vi) School employee or a school employee's dependent has a change in enrollment under an employer-based group health plan during its annual open enrollment that does not align with the SEBB annual open enrollment;

(vii) School employee or a school employee's dependent has a change in residence that affects health plan availability. If the school employee has a change in residence and the school employee's current medical plan is no longer available, the school employee must select a new medical plan as described in WAC 182-30-085(3);

(viii) School employee's dependent has a change in residence from outside of the United States to within the United States, or from within the United States to outside of the United States, and that change in residence resulted in the dependent losing their health insurance;

(ix) A court order requires the school employee or any other individual to provide insurance coverage for an eligible dependent of the school employee (a former spouse or former state registered domestic partner is not an eligible dependent);

(x) School employee or a school employee's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the school employee or a school employee's dependent loses eligibility for coverage under medicaid or CHIP;

(xi) School employee or a school employee's dependent becomes eligible for state premium assistance subsidy for SEBB health plan coverage from medicaid or CHIP;

(xii) School employee or a school employee's dependent enrolls in coverage under medicare or the school employee or a school employee's dependent loses eligibility for coverage under medicare;

(xiii) School employee or a school employee's dependent's current medical plan becomes unavailable because the school employee or enrolled dependent is no longer eligible for a HSA. The HCA may require evidence that the school employee or a school employee's dependent is no longer eligible for a HSA;

(xiv) School employee or a school employee's dependent experiences a disruption of care for active and ongoing treatment, that could function as a reduction in benefits for the school employee or a school employee's dependent. The school employee may not change their health plan election if the school employee's or dependent's physician stops participation with the school employee's health plan unless the SEBB program determines that a continuity of care issue exists. The SEBB program will consider but not limit its consideration to the following:

• Active cancer treatment such as chemotherapy or radiation therapy;

• Treatment following a recent organ transplant;

• A scheduled surgery;

• Recent major surgery still within the postoperative period; or

• Treatment for a high-risk pregnancy.

(xv) School employee or school employee's dependent becomes eligible and enrolls in a TRICARE plan, or loses eligibility for a TRICARE plan.

(xvi) School employee has a change in employment location that affects medical plan availability.

If the school employee changes employment locations and their current medical plan is no longer available, the school employee must select a new medical plan as described in WAC 182-30-085(3).

If the school employee has one or more new medical plans available, the school employee may select to enroll in a newly available plan.

(xvii) The SEBB program determines that there has been a substantial decrease in the providers available under a SEBB medical plan;

(xviii) The SEBB program determines that there has been a substantial increase in the school employee's premiums when the school employee moves to another SEBB organization or employer group.

If the school employee is having premiums taken from payroll on a pretax basis, a medical plan change will not be approved if it would conflict with provisions of the salary reduction plan authorized under RCW 41.05.300.

(b) FSA and limited purpose FSA. A school employee may enroll or revoke their election and make a new election under the FSA or limited purpose FSA when any one of the following special open enrollment events occur, if the requested change corresponds to and is consistent with the event. The enrollment or new election will be effective the first day of the month following the later of the event date or the date the required form and evidence of the event that created the special open enrollment is received by the SEBB organization. If that day is the first of the month, the enrollment or change in election begins on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, the enrollment or change in election will begin the first of the month in which the event occurs.

(i) School employee acquires a new dependent due to:

• Marriage;

• Registering a state registered domestic partnership when the dependent is a tax dependent of the school employee;

• Birth, adoption, or when the school employee has assumed a legal obligation for total or partial support in anticipation of adoption; or

• A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(ii) School employee's dependent no longer meets SEBB eligibility criteria because:

• School employee has a change in marital status;

• School employee's domestic partnership with a state registered domestic partner who qualifies as a tax dependent is dissolved or terminated;

• An eligible dependent child turns age 26 or otherwise does not meet dependent child eligibility criteria;

• An eligible dependent ceases to be eligible as an extended dependent or as a dependent with a disability; or

• An eligible dependent dies.

(iii) School employee or a school employee's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by HIPAA;

(iv) School employee or a school employee's dependent has a change in employment status that affects the school employee's or a dependent's eligibility for the FSA or limited purpose FSA;

(v) A court order requires the school employee or any other individual to provide insurance coverage for an eligible dependent of the school employee (a former spouse or former state registered domestic partner is not an eligible dependent);

(vi) School employee or a school employee's dependent enrolls in coverage under medicaid or CHIP, or the school employee or a school employee's dependent loses eligibility for coverage under medicaid or CHIP;

(vii) School employee or a school employee's dependent enrolls in coverage under medicare.

(c) DCAP. A school employee may enroll or revoke their election and make a new election under the DCAP when any one of the following special open enrollment events occur, if the requested change corresponds to and is consistent with the event. The enrollment or new election will be effective the first day of the month following the later of the event date or the date the required form and evidence of the event that created the special open enrollment is received by the SEBB organization. If that day is the first of the month, the enrollment or change in election begins on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, the enrollment or change in election will begin the first of the month in which the event occurs.

(i) School employee acquires a new dependent due to:

• Marriage;

• Registering a state registered domestic partnership if the state registered domestic partner qualifies as a tax dependent of the school employee;

• Birth, adoption, or when the school employee has assumed a legal obligation for total or partial support in anticipation of adoption; or

• A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(ii) School employee or a school employee's dependent has a change in employment status that affects the school employee's or a dependent's eligibility for DCAP;

(iii) School employee or school employee's dependent has a change in enrollment under an employer-based DCAP during its annual open enrollment that does not align with the SEBB annual open enrollment;

(iv) School employee changes dependent care provider; the change to the DCAP election amount can reflect the cost of the new provider;

(v) School employee or school employee's spouse experiences a change in the number of qualifying individuals as defined in IRC 26 U.S.C. Sec. 21 (b)(1);

(vi) School employee's dependent care provider imposes a change in the cost of dependent care; school employee may make a change in the DCAP election amount to reflect the new cost if the dependent care provider is not a qualifying relative of the school employee as defined in IRC 26 U.S.C. Sec. 152.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, and Policy Resolution SEBB 2023-04. WSR 24-15-112 (Admin #2024-02.05), § 182-30-100, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-018 (Admin #2023-01), § 182-30-100, filed 6/23/23, effective 1/1/24*
- *WSR 22-13-168 (Admin #2022-01), § 182-30-100, filed 6/21/22, effective 1/1/23*
- *WSR 21-13-117 (Admin #2021-01.04), § 182-30-100, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-30-100, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160 and 2018 c 260. WSR 20-01-082, § 182-30-100, filed 12/12/19, effective 1/12/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-30-100, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-30-100, filed 12/14/18, effective 1/14/19.](Effective January 1, 2027) PDF WAC 182-30-100 When may a school employee enroll, or revoke an election and make a new election under the premium payment plan, flexible spending arrangement (FSA), limited purpose FSA, or dependent care assistance program (DCAP)? A school employee who is eligible to participate in the salary reduction plan as described in WAC 182-31-060 may enroll, or revoke their election and make a new election under the premium payment plan, flexible spending arrangement (FSA), limited purpose FSA, or dependent care assistance program (DCAP) at the following times:(1) When newly eligible under WAC 182-31-040 and enrolling as described in WAC 182-30-080(1).(2) During annual open enrollment: An eligible school employee may elect to enroll in or opt out of participation under the premium payment plan during the annual open enrollment by submitting the required form to their school employees benefits board (SEBB) organization. An eligible school employee may elect to enroll or reenroll in the FSA, limited purpose FSA, DCAP, or both an FSA and DCAP during the annual open enrollment by submitting the required forms to their SEBB organization or applicable contracted vendor as instructed. All required forms must be received no later than the last day of the annual open enrollment. The enrollment or new election becomes effective January 1st of the following year.(a) School employees cannot enroll in a FSA and a limited purpose FSA in the same year.(b) School employees enrolled in a high deductible health plan (HDHP) with a health savings account (HSA) cannot also enroll in a FSA in the same plan year. School employees who elect enrollment in the HDHP with a HSA and a FSA will only be enrolled in a HDHP with a HSA.(c) If a school employee enrolls in a HDHP with a HSA during annual open enrollment and has a carryover amount from a FSA, the school employee will be enrolled in a limited purpose FSA and the carryover amount will be deposited into the limited FSA.(d) School employees who are not enrolled in a HDHP with a HSA and elect both a FSA and a limited purpose FSA will be enrolled in the FSA.(3) During a special open enrollment: A school employee who is eligible to participate in the salary reduction plan may enroll or revoke their election and make a new election under the premium payment plan, FSA, limited purpose FSA, or DCAP outside of the annual open enrollment if a special open enrollment event occurs. The enrollment or change in election must be allowable under Internal Revenue Code (IRC) and Treasury regulations, and correspond to and be consistent with the event that creates the special open enrollment. To make a change or enroll, the school employee must submit the required form to their SEBB organization. The SEBB organization must receive the required form and evidence of the event that created the special open enrollment no later than 60 days after the event occurs.For purposes of this section, an eligible dependent includes any person who qualifies as a dependent of the school employee for tax purposes under IRC 26 U.S.C. Sec. 152 without regard to the income limitations of that section. It does not include a state registered domestic partner unless the state registered domestic partner otherwise qualifies as a dependent for tax purposes under IRC 26 U.S.C. Sec. 152.(a) Premium payment plan. A school employee may enroll or revoke their election and elect to opt out of the premium payment plan when any of the following special open enrollment events occur, if the requested change corresponds to and is consistent with the event. The enrollment or election to opt out will be effective the first day of the month following the later of the event date or the date the required form is received. If that day is the first of the month, the enrollment or change in election begins on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, the enrollment or change in election will begin the first of the month in which the event occurs.(i) School employee acquires a new dependent due to:• Marriage*
- *• Registering a state registered domestic partnership when the dependent is a tax dependent of the school employee*
- *• Birth, adoption, or when the school employee has assumed a legal obligation for total or partial support in anticipation of adoption*
- *or• A child becoming eligible as an extended dependent through legal custody or legal guardianship.(ii) School employee's dependent no longer meets SEBB eligibility criteria because:• School employee has a change in marital status*
- *• School employee's domestic partnership with a state registered domestic partner who is a tax dependent is dissolved or terminated*
- *• An eligible dependent child turns age 26 or otherwise does not meet dependent child eligibility criteria*
- *• An eligible dependent ceases to be eligible as an extended dependent or as a dependent with a disability*
- *or• An eligible dependent dies.(iii) School employee or a school employee's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by Health Insurance Portability and Accountability Act (HIPAA)*
- *(iv) School employee has a change in employment status that affects the school employee's eligibility for their employer contribution toward their employer-based group health plan*
- *(v) The school employee's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution toward their employer-based group health plan*
- *Exception:As used in (a)(v) of this subsection, "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 26 C.F.R. 54.9801-6.(vi) School employee or a school employee's dependent has a change in enrollment under an employer-based group health plan during its annual open enrollment that does not align with the SEBB annual open enrollment*
- *(vii) School employee or a school employee's dependent has a change in residence that affects health plan availability. If the school employee has a change in residence and the school employee's current medical plan is no longer available, the school employee must select a new medical plan as described in WAC 182-30-085(3)*
- *(viii) School employee's dependent has a change in residence from outside of the United States to within the United States, or from within the United States to outside of the United States, and that change in residence resulted in the dependent losing their health insurance*
- *(ix) A court order requires the school employee or any other individual to provide insurance coverage for an eligible dependent of the school employee (a former spouse or former state registered domestic partner is not an eligible dependent)*
- *(x) School employee or a school employee's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the school employee or a school employee's dependent loses eligibility for coverage under medicaid or CHIP*
- *(xi) School employee or a school employee's dependent becomes eligible for state premium assistance subsidy for SEBB health plan coverage from medicaid or CHIP*
- *(xii) School employee or a school employee's dependent enrolls in coverage under medicare or the school employee or a school employee's dependent loses eligibility for coverage under medicare*
- *(xiii) School employee or a school employee's dependent's current medical plan becomes unavailable because the school employee or enrolled dependent is no longer eligible for a HSA. The HCA may require evidence that the school employee or a school employee's dependent is no longer eligible for a HSA*
- *(xiv) School employee or a school employee's dependent experiences a disruption of care for active and ongoing treatment, that could function as a reduction in benefits for the school employee or a school employee's dependent. The school employee may not change their health plan election if the school employee's or dependent's physician stops participation with the school employee's health plan unless the SEBB program determines that a continuity of care issue exists. The SEBB program will consider but not limit its consideration to the following:• Active cancer treatment such as chemotherapy or radiation therapy*
- *• Treatment following a recent organ transplant*
- *• A scheduled surgery*
- *• Recent major surgery still within the postoperative period*
- *or• Treatment for a high-risk pregnancy.(xv) School employee or school employee's dependent becomes eligible and enrolls in a TRICARE plan, or loses eligibility for a TRICARE plan.(xvi) School employee has a change in employment location that affects medical plan availability.If the school employee changes employment locations and their current medical plan is no longer available, the school employee must select a new medical plan as described in WAC 182-30-085(3).If the school employee has one or more new medical plans available, the school employee may select to enroll in a newly available plan.(xvii) The SEBB program determines that there has been a substantial decrease in the providers available under a SEBB medical plan*
- *(xviii) The SEBB program determines that there has been a substantial increase in the school employee's premiums when the school employee moves to another SEBB organization or employer group.If the school employee is having premiums taken from payroll on a pretax basis, a medical plan change will not be approved if it would conflict with provisions of the salary reduction plan authorized under RCW 41.05.300.(b) FSA and limited purpose FSA. A school employee may enroll or revoke their election and make a new election under the FSA or limited purpose FSA when any one of the following special open enrollment events occur, if the requested change corresponds to and is consistent with the event. The enrollment or new election will be effective the first day of the month following the later of the event date or the date the required form and evidence of the event that created the special open enrollment is received by the SEBB organization. If that day is the first of the month, the enrollment or change in election begins on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, the enrollment or change in election will begin the first of the month in which the event occurs.(i) School employee acquires a new dependent due to:• Marriage*
- *• Registering a state registered domestic partnership when the dependent is a tax dependent of the school employee*
- *• Birth, adoption, or when the school employee has assumed a legal obligation for total or partial support in anticipation of adoption*
- *or• A child becoming eligible as an extended dependent through legal custody or legal guardianship.(ii) School employee's dependent no longer meets SEBB eligibility criteria because:• School employee has a change in marital status*
- *• School employee's domestic partnership with a state registered domestic partner who qualifies as a tax dependent is dissolved or terminated*
- *• An eligible dependent child turns age 26 or otherwise does not meet dependent child eligibility criteria*
- *• An eligible dependent ceases to be eligible as an extended dependent or as a dependent with a disability*
- *or• An eligible dependent dies.(iii) School employee or a school employee's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by HIPAA*
- *(iv) School employee or a school employee's dependent has a change in employment status that affects the school employee's or a dependent's eligibility for the FSA or limited purpose FSA*
- *(v) A court order requires the school employee or any other individual to provide insurance coverage for an eligible dependent of the school employee (a former spouse or former state registered domestic partner is not an eligible dependent)*
- *(vi) School employee or a school employee's dependent enrolls in coverage under medicaid or CHIP, or the school employee or a school employee's dependent loses eligibility for coverage under medicaid or CHIP*
- *(vii) School employee or a school employee's dependent enrolls in coverage under medicare.(c) DCAP. A school employee may enroll or revoke their election and make a new election under the DCAP when any one of the following special open enrollment events occur, if the requested change corresponds to and is consistent with the event. The enrollment or new election will be effective the first day of the month following the later of the event date or the date the required form and evidence of the event that created the special open enrollment is received by the SEBB organization. If that day is the first of the month, the enrollment or change in election begins on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, the enrollment or change in election will begin the first of the month in which the event occurs.(i) School employee acquires a new dependent due to:• Marriage*
- *• Registering a state registered domestic partnership if the state registered domestic partner qualifies as a tax dependent of the school employee*
- *• Birth, adoption, or when the school employee has assumed a legal obligation for total or partial support in anticipation of adoption*
- *or• A child becoming eligible as an extended dependent through legal custody or legal guardianship.(ii) School employee or a school employee's dependent has a change in employment status that affects the school employee's or a dependent's eligibility for DCAP*
- *(iii) School employee or school employee's dependent has a change in enrollment under an employer-based DCAP during its annual open enrollment that does not align with the SEBB annual open enrollment*
- *(iv) School employee changes dependent care provider*
- *the change to the DCAP election amount can reflect the cost of the new provider*
- *(v) School employee or school employee's spouse experiences a change in the number of qualifying individuals as defined in IRC 26 U.S.C. Sec. 21 (b)(1)*
- *(vi) School employee's dependent care provider imposes a change in the cost of dependent care*
- *school employee may make a change in the DCAP election amount to reflect the new cost if the dependent care provider is not a qualifying relative of the school employee as defined in IRC 26 U.S.C. Sec. 152.[Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.740. WSR 26-14-083 (Admin #2026.01), s 182-30-100, filed 6/29/26, effective 1/1/27. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, and Policy Resolution SEBB 2023-04. WSR 24-15-112 (Admin #2024-02.05), § 182-30-100, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-018 (Admin #2023-01), § 182-30-100, filed 6/23/23, effective 1/1/24*
- *WSR 22-13-168 (Admin #2022-01), § 182-30-100, filed 6/21/22, effective 1/1/23*
- *WSR 21-13-117 (Admin #2021-01.04), § 182-30-100, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-30-100, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160 and 2018 c 260. WSR 20-01-082, § 182-30-100, filed 12/12/19, effective 1/12/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-30-100, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-30-100, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-30-110** Which school employees benefits board (SEBB) organization is responsible to pay the employer contribution for eligible school employees changing SEBB organizations? {#sec-182-30-110 omnilex-key=us-wa-regs-official--title-182--182-30-110}

When an eligible school employee's employment relationship terminates with a school employees benefits board (SEBB) organization at any time during the month for which a premium contribution is due and that school employee moves to another SEBB organization, the SEBB organization losing the school employee is responsible for the payment of the employer contribution for the school employee for that month. The SEBB organization the school employee is moving to is responsible for payment of the employer contribution for the school employee beginning the first day of the month following the move if the school employee is eligible.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-30-110, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-30-120** Advertising or promotion of school employees benefits board (SEBB) benefit plans. {#sec-182-30-120 omnilex-key=us-wa-regs-official--title-182--182-30-120}

(1) In order to assure equal and unbiased representation of school employees benefits board (SEBB) benefits, contracted vendors must comply with all of the following:

(a) All materials describing SEBB benefits must be prepared by or approved by the heath care authority (HCA) before use.

(b) Distribution or mailing of all benefit descriptions must be performed by or under the direction of the HCA.

(c) All media announcements or advertising by a contracted vendor which includes any mention of the "school employees benefits board," "SEBB," "health care authority," "HCA," any reference to benefits for "school employees," or any group of enrollees covered by SEBB benefits, must receive the advance written approval of the HCA.

(2) Failure to comply with any or all of these requirements by a SEBB contracted vendor or subcontractor may result in contract termination by the HCA, refusal to continue or renew a contract with the noncomplying party, or both.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-30-120, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-30-120, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-30-130** What are the requirements for a school employees benefits board (SEBB) organization engaging in local negotiations regarding SEBB benefits eligibility criteria? {#sec-182-30-130 omnilex-key=us-wa-regs-official--title-182--182-30-130}

This section describes the terms and conditions for a school employees benefits board (SEBB) organization that is engaging in local negotiations regarding eligibility for school employees as described in RCW 41.05.740 (6)(e).

(1) A SEBB organization must provide a current ratified collective bargaining agreement (CBA) and information on all eligible school employees under the CBA to the health care authority (HCA) by the start of the school year.

(2) A SEBB organization must offer all of, and only, the following SEBB benefits to employees and their dependents:

(a) Medical (includes the wellness incentive);

(b) Dental;

(c) Vision;

(d) Basic life;

(e) Basic accidental death and dismemberment (AD&D) insurance.

(3) A SEBB organization must provide an employer contribution as described below:

(a) The subscriber-only employer medical contribution (EMC) amount for school employees eligible under RCW 41.05.740 (6)(d) multiplied by the premium tier ratio associated with the enrollment tier selected by the school employee;

(b) One hundred percent of the cost for the school employee dental plan multiplied by the enrollment tier selected by the school employee;

(c) One hundred percent of the cost for the school employee vision plan multiplied by the enrollment tier selected by the school employee;

(d) One hundred percent of the cost for basic life and accidental death and dismemberment (AD&D) insurance;

(e) One hundred percent of the cost of the administrative fee charged by the HCA; and

(f) One hundred percent of the monthly K-12 remittance for deposit in the retired school employees' subsidy account.

(4) A SEBB organization providing SEBB benefits as described in this section may do so by group as described in (a) through (d) of this subsection:

(a) The entire SEBB organization;

(b) An entire collective bargaining unit;

(c) A group containing all nonrepresented school employees; or

(d) A combination of (b) and (c) of this subsection.

(5) A SEBB organization must establish a threshold of anticipated work hours no less than 180 hours but less than the minimum hours to meet SEBB eligibility under WAC 182-31-040 within a school year.

(6) All of the rules in chapters 182-30, 182-31, and 182-32 WAC apply, except for all rules governing SEBB benefits that are not available to school employees whose eligibility is established under this section. The following benefits are not available to school employees whose eligibility is established under this section:

(a) Long-term disability (LTD);

(b) Flexible spending arrangement (FSA) or limited purpose FSA;

(c) Dependent care assistance program (DCAP);

(d) Supplemental life insurance; and

(e) Supplemental accidental death and dismemberment insurance.

(7) If a school employee waives medical under this section, there is no requirement to send the employer contribution to the HCA as required in WAC 182-30-070(5).

(8) Eligibility determinations must align with the SEBB program's status as a governmental plan under Section 3(32) of the Employee Retirement Income Security Act of 1974 (ERISA) as amended. This means the SEBB organization may only consider school employees whose services are substantially all in the performance of essential governmental functions, but not in the performance of commercial activities, whether or not those activities qualify as essential governmental functions to be eligible.

(9) A SEBB organization providing SEBB benefits to a group of school employees under this section must notify the SEBB program each time the CBA is renegotiated.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-30-130, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-30-130, filed 6/21/22, effective 1/1/23*
- *WSR 21-13-117 (Admin #2021-01.04), § 182-30-130, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions 2020-04. WSR 20-16-065 (Admin #2020-02), § 182-30-130, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-30-130, filed 7/1/19, effective 8/1/19.*

##### **Wash. Admin. Code § 182-30-140** What is the process for school districts to offer optional benefits? {#sec-182-30-140 omnilex-key=us-wa-regs-official--title-182--182-30-140}

(1) School districts may offer optional benefits that do not compete with any form of the basic or optional benefits offered in the school employees' benefits board (SEBB) program either under the SEBB's authority in RCW 41.05.740 or offered under the health care authority's (HCA) authority in the salary reduction plan authorized in RCW 41.05.300 and 41.05.310. Optional benefits must be paid for by the school employee without an employer contribution, except for when a school employee participates in voluntary employees' beneficiary association accounts (VEBA), which may have an employer contribution as described in RCW 28A.400.210(3). Optional benefits may include:

(a) Emergency transportation;

(b) Identity protection;

(c) Legal aid;

(d) Long-term care insurance;

(e) Noncommercial personal automobile insurance;

(f) Personal homeowner's or renter's insurance;

(g) Pet insurance;

(h) Specified disease or illness-triggered fixed payment insurance, hospital confinement fixed payment insurance, or other fixed payment insurance offered as an independent, noncoordinated benefit regulated by the office of the insurance commissioner;

(i) Travel insurance; and

(j) VEBA.

(2) Any school districts providing optional benefits must:

(a) Report optional benefits on the form designed and communicated by the HCA; and

(b) Submit the form so it is received by December 1st of each year for the following calendar year as required in RCW 28A.400.280 (2)(b).

(3) The HCA, in consultation with the SEBB will review the optional benefits offered by school districts as described in RCW 41.05.745(2).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-30-140, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-13-117 (Admin #2021-01.04), § 182-30-140, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-30-140, filed 7/28/20, effective 8/28/20.*

##### **Wash. Admin. Code § 182-30-200** Employer group application process. {#sec-182-30-200 omnilex-key=us-wa-regs-official--title-182--182-30-200}

This section applies to employer groups as defined in WAC 182-30-020. An employer group may apply to obtain school employees benefits board (SEBB) insurance coverage through a contract with the health care authority (HCA).

(1) Employer groups with less than 500 school employees must apply at least 60 days before the requested coverage effective date. Employer groups with 500 or more school employees but with less than 5,000 school employees must apply at least 90 days before the requested effective date.

Employer groups with 5,000 or more school employees must apply at least 120 days before the requested coverage effective date.

To apply, employer groups must submit the documents and information described in subsection (2) of this section to the SEBB program as follows:

(a) Tribal schools are required to provide the documents and information described in subsection (2)(a) through (f) of this section; and

(b) All employee organizations representing school employees, regardless of the number of school employees, will have their application approved or denied through the evaluation criteria described in WAC 182-30-210 and are required to provide the documents and information described in subsection (2)(a) through (d), (f), and (g) of this section.

(2) Documents and information required with application:

(a) A letter of application that includes the information described in (a)(i) through (iv) of this subsection:

(i) A reference to the group's authorizing statute;

(ii) A description of the organizational structure of the group and a description of the employee bargaining unit or group of nonrepresented employees for which the group is applying;

(iii) Tax identification number; and

(iv) A statement of whether the group is applying to obtain only medical or all available SEBB insurance coverages.

(b) A resolution from the group's governing body authorizing the purchase of SEBB insurance coverage.

(c) A signed governmental function attestation document that attests to the fact that employees for whom the group is applying are governmental employees whose services are substantially all in the performance of essential governmental functions.

(d) A member level census file for all of the school employees for whom the group is applying. The file must be provided in the format required by the authority and contain the following demographic data, by member, with each member classified as school employee, spouse or state registered domestic partner, or child:

(i) Employee ID (any identifier which uniquely identifies the school employee; for dependents the school employee's unique identifier must be used);

(ii) Age;

(iii) Birth sex;

(iv) First three digits of the member's zip code based on residence;

(v) Indicator of whether the school employee is active or retired, if the group is requesting to include retirees; and

(vi) Indicator of whether the member is enrolled in coverage.

(e) Historical claims and cost information that include the following:

(i) Large claims history for 24 months by quarter that excludes the most recent three months;

(ii) Ongoing large claims management report for the most recent quarter provided in the large claims history;

(iii) Summary of historical plan costs; and

(iv) The director or the director's designee may make an exception to the claims and cost information requirements based on the size of the group, except that the current health plan does not have a case management program, then the primary diagnosis code designated by the authority must be reported for each large claimant. If the code indicates a condition which is expected to continue into the next quarter, the claim is counted as an ongoing large claim. If historical claims and cost information as described in (e)(i) through (iii) of this subsection are unavailable, the director or the director's designee may make an exception to allow all of the following alternative requirements:

• A letter from their carrier indicating they will not or cannot provide claims data.

• Provide information about the health plan most school employees are enrolled in by completing the actuarial calculator authorized by the SEBB program.

• Current premiums for the health plan.

(f) If the application is for a subset of the group's school employees (e.g., bargaining unit), the group must provide a member level census file of all school employees eligible under their current health plan who are not included on the member level census file in (d) of this subsection. This includes retired school employees participating under the group's current health plan. The file must include the same demographic data by member.

(g) Employer groups described in subsection (1)(b) of this section must submit to an actuarial evaluation of the group provided by an actuary designated by the SEBB program. The group must pay for the cost of the evaluation. This cost is nonrefundable. A group that is approved will not have to pay for an additional actuarial evaluation if it applies to add another bargaining unit within two years of the evaluation. Employer groups of this size must provide the following:

(i) Large claims history for 24 months, by quarter that excludes the most recent three months;

(ii) Ongoing large claims management report for the most recent quarter provided in the large claims history;

(iii) Executive summary of benefits;

(iv) Summary of benefits and certificate of coverage; and

(v) Summary of historical plan costs.

| Exception: | If the current health plan does not have a case management program, then the primary diagnosis code designated by the authority must be reported for each large claimant. If the code indicates a condition which is expected to continue into the next quarter, the claim is counted as an ongoing large claim. |
| --- | --- |

(3) The authority may automatically deny a group application if the group fails to provide the required information and documents described in this section.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-30-200, filed 7/22/24, effective 1/1/25.*

##### **Wash. Admin. Code § 182-30-205** May employer groups applying for participation in school employees benefits board (SEBB) insurance coverage include their retirees? {#sec-182-30-205 omnilex-key=us-wa-regs-official--title-182--182-30-205}

WAC 182-30-205

An employer group that applies for participation in school employees benefits board (SEBB) insurance coverage under WAC 182-30-200 will have a one-time opportunity to request inclusion of retired school employees who are covered under its retiree health plan at the time of application. The retirees included will be enrolled in public employees benefits board (PEBB) retiree insurance coverage.

(1) The authority will use the following criteria to approve or deny a request to include retirees:

(a) The employer group retiree health plan must have existed at least three years before the date of the employer group application;

(b) Eligibility for coverage under the employer groups' retiree health plan must have required immediate enrollment in retiree health plan coverage upon termination of school employee coverage; and

(c) The retirees must have maintained continuous enrollment in the employer group retiree health plan.

(2) If the employer group's application is for a subset of their school employees (e.g., bargaining unit) only retirees previously within the bargaining unit may be included in the transfer.

(3) Retirees and dependents included in the transfer unit are subject to the enrollment and eligibility rules outlined in chapters 182-08, 182-12, and 182-16 WAC.

(4) School employees eligible for retirement subsequent to the employer group transferring to SEBB health plan coverage must meet retiree eligibility as outlined in chapter 182-12 WAC.

(5) To protect the integrity of the risk pool, if total employer group retiree enrollment exceeds 10 percent of the total PEBB retiree population, the PEBB program may:

(a) Stop approving inclusion of retirees with employer group transfers; or

(b) Adopt a new rating methodology reflective of the cost of covering employer group retirees.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-30-205, filed 7/22/24, effective 1/1/25.*

##### **Wash. Admin. Code § 182-30-210** How will the health care authority (HCA) decide to approve or deny a group application? {#sec-182-30-210 omnilex-key=us-wa-regs-official--title-182--182-30-210}

WAC 182-30-210

This section applies to employee organizations representing school employees regardless of the number of school employees. Group applications for participation in school employees benefits board (SEBB) insurance coverage provided through the SEBB program are approved or denied by the health care authority (HCA) based upon the information and documents submitted by the group and the employer group evaluation (EGE) criteria described in this rule.

(1) Groups are evaluated as a single unit. To support this requirement the group must provide a census file, as described in WAC 182-30-200 (2)(d), and additional information as described in WAC 182-30-200 (2)(g) for all school employees eligible to participate under the group's current health plan. If the group's application is for both school employees and retirees, the census file data and additional information for retired employees participating under the group's current health plan must also be included.

(a) If the group's application is only for participation of its school employees, the SEBB enrollment data used to evaluate the group will be SEBB organization school employee data.

(b) If a group's application is for participation of both its school employees and retirees, the SEBB enrollment data used to evaluate the group will include data from the public employees benefits board (PEBB) nonmedicare risk pool limited to state retiree enrollment data and state agency employee data.

(2) A group must pass the EGE criteria or the actuarial evaluation required in subsection (3) of this section as a single unit before the application can be approved. For purposes of this section, a single unit includes all school employees eligible under the group's current health plan. If the application is only for a bargaining unit, then the bargaining unit must be evaluated using the EGE criteria in addition to all eligible school employees of the group as a single unit. If the group passes the EGE criteria as a single unit, but an individual bargaining unit does not, the group may only participate if all eligible employees of the entity participate.

(3) The authority will use the following criteria to evaluate the group.

(a) The member level census file demographic data must indicate a relative underwriting factor that is equal to or better than the relative underwriting factor as determined by the authority for the like population within the SEBB and nonmedicare PEBB risk pool as described in subsection (1) of this section;

(b) One of the following two conditions must be met:

(i) The frequency of large claims must be less than or equal to the SEBB historical benchmark frequency for the SEBB like population within the SEBB and nonmedicare PEBB population as described in subsection (1) of this section;

(ii) The ongoing large claims management report must demonstrate that the frequency of ongoing large claims is less than or equal to the recurring benchmark frequency for the SEBB like population within the SEBB and nonmedicare PEBB population as described in subsection (1) of this section.

(c) Provide an executive summary of benefits;

(d) Provide a summary of benefits and certificate of coverage;

(e) Provide a summary of historical plan costs; and

(f) The evaluation of criteria in (c), (d), and (e) of this subsection must indicate that the historical cost of benefits for the group is equal to or less than the historical cost of the PEBB like population within the nonmedicare population as described in subsection (1) of this section for a comparable plan design.

(4) An approved group application is valid for 365 calendar days after the date the application is approved by the authority. If a group applies to add additional bargaining units after the 365 calendar day period has ended, the group must be reevaluated.

(5) An entity whose group application is denied may appeal the authority's decision to the SEBB appeals unit through the process described in WAC 182-32-2060.

(6) An entity whose group application is approved may purchase insurance for its employees under the participation requirements described in WAC 182-30-215.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-30-210, filed 7/22/24, effective 1/1/25.*

##### **Wash. Admin. Code § 182-30-215** Employer group participation requirements. {#sec-182-30-215 omnilex-key=us-wa-regs-official--title-182--182-30-215}

This section applies to an employer group as defined in WAC 182-30-020 that is approved to purchase insurance for its employees through a contract with the health care authority (HCA).

(1) Prior to enrollment in school employees benefits board (SEBB) insurance coverage the employer group must:

(a) Remit to the authority the required start-up fee in the amount publicized by the SEBB program;

(b) Sign a contract with the authority;

(c) Determine employee and dependent eligibility and terms of enrollment for SEBB insurance coverage by the criteria outlined in this chapter and chapter 182-31 WAC unless otherwise approved by the authority in the employer group's contract with the authority;

(d) Determine eligibility in order to ensure the SEBB program's continued status as a governmental plan under Section 3(32) of the Employee Retirement Income Security Act of 1974 (ERISA) as amended. This means the employer group may only consider employees whose services are substantially all in the performance of essential governmental functions, but not in the performance of commercial activities, whether or not those activities qualify as essential governmental functions to be eligible; and

(e) Ensure SEBB insurance coverage is the only employer-sponsored coverage available to groups of employees eligible for SEBB insurance coverage under the contract.

(2) Pay premiums under its contract with the authority. The premium rate structure for employer groups will be a tiered rate based on health plan election and family enrollment. Employer groups must collect an amount equal to the premium surcharges applied to an employee's account by the authority from their employees and include the funds in their payment to the authority.

(3) If an employer group wants to make subsequent changes to the contract, the changes must be submitted to the authority for approval.

(4) The employer group must maintain participation in SEBB insurance coverage for at least one full year. An employer group may only end participation at the end of a plan year unless the authority approves a mid-year termination. To end participation, an employer group must provide written notice to the SEBB program at least 60 days before the requested termination date. If an employer group terminates participation in SEBB insurance coverage, they must:

(a) Notify all their school employees and dependents who are enrolled in SEBB insurance coverage 45 days prior to the employer group's date of termination; and

(b) Retirees enrolled in PEBB retiree insurance coverage must be notified 45 days prior to the employer group's date of termination.

(5) Upon approval to purchase insurance through a contract with the authority, the employer group must provide a list of school employees and dependents that are enrolled in Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage and the remaining number of months available to them based on their qualifying event. These school employees and dependents may enroll in a SEBB health plan as COBRA subscribers for the remainder of the months available to them based on their qualifying event.

(6) Enrollees in SEBB insurance coverage under one of the continuation of coverage provisions allowed under chapter 182-31 WAC or retirees included in the transfer unit as allowed under WAC 182-30-205 cease to be eligible as of the last day of the contract and may not continue enrollment beyond the end of the month in which the contract is terminated.

| Exception: | If an employer group ends participation, retired and disabled school employees who are enrolled in public employees benefits board (PEBB) retiree insurance coverage cease to be eligible under WAC 182-12-171, but may continue health plan enrollment as described in WAC 182-12-232. |
| --- | --- |

(7) Employer groups that enter into a contractual agreement with the authority on or after May 4, 2023, and whose contractual agreement is subsequently terminated, shall make a one-time payment to the authority for each of the employer group's retired or disabled employees who continue their participation in insurance plans and contracts under WAC 182-12-232.

(a) For each of the employer group's retired or disabled employees who will be continuing their participation, the authority shall determine the one-time payment by:

(i) Calculating the difference in cost between the rate charged to retired or disabled employees as described in RCW 41.05.080(2); and

(ii) The actuarially determined value of the medical benefits for retired and disabled employees who are not eligible for parts A and B of medicare; and

(iii) Multiplying that difference by the number of months until the retired or disabled employee would become eligible for medicare.

(b) Employer groups shall not be entitled to any refund of the amount paid to the authority as described in this subsection.

(8) Employer groups eligible for SEBB benefits are subject to the terms and conditions set forth by the HCA. Employer groups are subject to the same rules as SEBB organizations in chapters 182-30, 182-31, and 182-32 WAC, except for rules governing SEBB benefits that are not available to school employees of an employer group.

(9) School employees of an employer group are subject to the same rules as school employees of a SEBB organization in chapters 182-30, 182-31, and 182-32 WAC, except for rules governing SEBB benefits that are not available to school employees of an employer group.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-30-215, filed 7/22/24, effective 1/1/25.*

## **Chapter 182-31** Eligible school employees. {#struct-chapter-182-31}

##### **Wash. Admin. Code § 182-31-010** Purpose. {#sec-182-31-010 omnilex-key=us-wa-regs-official--title-182--182-31-010}

The purpose of this chapter is to establish school employees benefits board (SEBB) eligibility criteria for and the effective date of enrollment in SEBB approved benefits. The rules within this chapter are applicable for school employees eligible for SEBB benefits under RCW 41.05.740(6) and for school board members eligible for SEBB benefits under RCW 41.05.743.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-31-010, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-31-010, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-31-010, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-31-020** Definitions. {#sec-182-31-020 omnilex-key=us-wa-regs-official--title-182--182-31-020}

The following definitions apply throughout this chapter unless the context clearly indicates another meaning:

"Accidental death and dismemberment insurance" or "AD&D" means basic accidental death and dismemberment (AD&D) insurance paid for by the SEBB organization, as well as supplemental accidental death and dismemberment insurance offered to and paid for by school employees for themselves and their dependents.

"Annual open enrollment" means an annual event set aside for a period of time by the HCA when subscribers may make changes to their health plan enrollment and salary reduction elections for the following plan year. During the annual open enrollment, subscribers may transfer from one health plan to another, enroll or remove dependents from coverage, enroll in coverage, or waive enrollment (see definition of "waive" in this section). School employees eligible to participate in the salary reduction plan may enroll in or change their election under the dependent care assistance program (DCAP), the flexible spending arrangement (FSA), or limited purpose FSA. They may also enroll in or opt out of the premium payment plan.

"Authority" or "HCA" means the Washington state health care authority.

"Board" means the school employees benefits board established under provisions of RCW 41.05.740.

"Calendar days" or "days" means all days including Saturdays, Sundays, and all state legal holidays as set forth in RCW 1.16.050.

"Consolidated Omnibus Budget Reconciliation Act" or "COBRA" means continuation coverage as administered under 42 U.S.C. Secs. 300bb-1 through 300bb-8.

"Continuation coverage" means the temporary continuation of SEBB benefits available to enrollees under the Consolidated Omnibus Budget Reconciliation Act (COBRA), 42 U.S.C. Secs. 300bb-1 through 300bb-8, the Uniformed Services Employment and Reemployment Rights Act (USERRA), 38 U.S.C. Secs. 4301 through 4335, or SEBB policies.

"Contracted vendor" means any person, persons, or entity under contract or agreement with the HCA to provide goods or services for the provision or administration of SEBB benefits. The term "contracted vendor" includes subcontractors of the HCA and subcontractors of any person, persons, or entity under contract or agreement with the HCA that provide goods or services for the provision or administration of SEBB benefits.

"Dependent" means a person who meets eligibility requirements in WAC 182-31-140.

"Dependent care assistance program" or "DCAP" means a benefit plan whereby school employees may pay for certain employment related dependent care with pretax dollars as provided in the salary reduction plan under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 129 or other sections of the Internal Revenue Code.

"Director" means the director of the authority.

"Documents" means papers, letters, writings, electronic mail, electronic files, or other printed or written items.

"Effective date of enrollment" means the first date when an enrollee is entitled to receive covered benefits.

"Employer-based group health plan" means group medical, group vision, and group dental related to a current employment relationship. It does not include medical, vision, or dental coverage available to retired employees, individual market medical or dental coverage, or government-sponsored programs such as medicare or medicaid.

"Employer-based group medical" means group medical related to a current employment relationship. It does not include medical coverage available to retired employees, individual market medical coverage, or government-sponsored programs such as medicare or medicaid.

"Employer contribution" means the funding amount paid to the HCA by a school employees benefits board (SEBB) organization for its eligible school employees as described under WAC 182-30-130 and 182-31-040.

"Employer group" means an employee organization representing school employees and a tribal school as defined in RCW 28A.715.010, obtaining school employee benefits through a contractual agreement with the authority to participate in benefit plans developed by the school employees benefits board as described in WAC 182-30-215.

"Enrollee" means a person who meets all eligibility requirements defined in chapter 182-31 WAC or WAC 182-30-130, who is enrolled in school employees benefits board (SEBB) benefits, and for whom applicable premium payments have been made.

"Flexible spending arrangement" or "FSA" means a benefit plan whereby eligible school employees may reduce their salary before taxes to pay for medical expenses not reimbursed by insurance as provided in the salary reduction plan established under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"Forms" or "form" means both paper forms and forms completed electronically.

"Health plan" means a plan offering medical, vision, dental, or any combination of these coverages, developed by the board and provided by a contracted vendor or self-insured plans administered by the HCA.

"Layoff," for purposes of this chapter, means a change in employment status due to a SEBB organization's lack of funds or a SEBB organization's organizational change.

"Life insurance" means basic life insurance paid for by the SEBB organization, as well as supplemental life insurance or supplemental dependent life insurance offered to and paid for by school employees for themselves and their dependents.

"Limited purpose flexible spending arrangement" or "limited purpose FSA" means a benefit plan whereby eligible school employees may reduce their salary before taxes to pay for dental and vision expenses not reimbursed by insurance as provided in the salary reduction plan established under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"Long-term disability insurance" or "LTD insurance" means employer-paid long-term disability insurance and employee-paid long-term disability insurance offered by the SEBB program.

"PEBB" means the public employees benefits board.

"PEBB program" means the program within the HCA that administers insurance and other benefits for eligible employees (as described in WAC 182-12-114), eligible retired employees (as described in WAC 182-12-171, 182-12-180, and 182-12-211), eligible survivors (as described in WAC 182-12-180, 182-12-250, and 182-12-265), eligible dependents (as described in WAC 182-12-250 and 182-12-260) and others as defined in RCW 41.05.011 or as described in RCW 41.05.080 (1)(a)(ii).

"Plan year" means the time period established by the authority.

"Premium payment plan" means a benefit plan whereby school employees may pay their share of group health plan premiums with pretax dollars as provided in the salary reduction plan under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"Premium surcharge" means a payment required from a subscriber, in addition to the subscriber's medical premium contribution, due to an enrollee's tobacco use or an enrolled subscriber's spouse or state registered domestic partner choosing not to enroll in their employer-based group medical when:

• The spouse's or state registered domestic partner's share of the medical premium is less than 95 percent of the additional cost an employee would be required to pay to enroll a spouse or state registered domestic partner in the public employees benefits board (PEBB) Uniform Medical Plan (UMP) Classic; and

• The benefits have an actuarial value of at least 95 percent of the actuarial value of PEBB UMP Classic benefits.

"Salary reduction plan" means a benefit plan whereby school employees may agree to a reduction of salary on a pretax basis to participate in the dependent care assistance program, flexible spending arrangement, limited purpose flexible spending arrangement, or premium payment plan offered pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"School board member" means the board of directors of a school district as governed by chapter 28A.343 RCW or the board of directors of an educational service district as governed by chapter 28A.310 RCW.

"School employee" means all employees of school districts and charter schools established under chapter 28A.710 RCW; represented employees of educational service districts; effective January 1, 2024, all employees of educational service districts; and effective January 1, 2024, pursuant to a contractual agreement with the authority, "school employee" may also include (a) employees of employee organizations representing school employees, at the option of each such employee organization; and (b) employees of a tribal school as defined in RCW 28A.715.010, if the governing body of the tribal school seeks and receives the approval of the authority to provide any of its insurance programs by contracts with the authority, as provided in RCW 41.05.021 (1)(f) and (g).

"School employees benefits board organization" or "SEBB organization" means a public school district or educational service district or charter school established under chapter 28A.710 RCW that is required to participate in benefit plans provided by the school employees benefits board.

"School year" means school year as defined in RCW 28A.150.203(11).

"SEBB" means the school employees benefits board.

"SEBB benefits" means one or more insurance coverages or other school employee benefits administered by the SEBB program within the HCA.

"SEBB insurance coverage" means any health plan, life insurance, accidental death and dismemberment insurance, or long-term disability insurance administered as a SEBB benefit.

"SEBB program" means the program within the HCA that administers insurance and other benefits for eligible school employees (as described in WAC 182-31-040 or 182-30-130), eligible dependents (as described in WAC 182-31-140), and eligible school board members (as described in WAC 182-31-200).

"Special open enrollment" means a period of time when subscribers may make changes to their health plan enrollment and salary reduction elections outside of the annual open enrollment period when specific life events occur. During the special open enrollment subscribers may change health plans and enroll or remove dependents from coverage. Additionally, school employees may enroll in or waive enrollment (see definition of "waive" in this section). School employees eligible to participate in the salary reduction plan may enroll in or revoke their election under the DCAP, FSA, limited purpose FSA, or the premium payment plan and make a new election. For special open enrollment events related to specific SEBB benefits, see WAC 182-30-090, 182-30-100, 182-31-080, and 182-31-150.

"State registered domestic partner" has the same meaning as defined in RCW 26.60.020(1) and substantially equivalent legal unions from other jurisdictions as defined in RCW 26.60.090.

"Subscriber" means the school employee, continuation coverage enrollee, or school board member who has been determined eligible by the SEBB program, SEBB organization, or employer group, is enrolled in SEBB benefits, and is the individual to whom the SEBB program and contracted vendors will issue all notices, information, requests, and premium bills on behalf of an enrollee.

"Supplemental coverage" means any life insurance or accidental death and dismemberment (AD&D) insurance coverage purchased by the school employee in addition to the coverage provided by the school employees benefits board (SEBB) organization.

"Tobacco products" means any product made with or derived from tobacco that is intended for human consumption, including any component, part, or accessory of a tobacco product. This includes, but is not limited to, cigars, cigarettes, pipe tobacco, chewing tobacco, snuff, and other tobacco products. It does not include e-cigarettes or United States Food and Drug Administration (FDA) approved quit aids.

"Tobacco use" means any use of tobacco products within the past two months. Tobacco use, however, does not include the religious or ceremonial use of tobacco.

"Tribal school" has the same meaning as defined in RCW 28A.715.010.

"Waive" means an eligible school employee affirmatively declining enrollment in SEBB medical because the school employee is enrolled in other employer-based group medical, a TRICARE plan, or medicare Part A and Part B as allowed under WAC 182-31-080. A school employee may waive enrollment in SEBB medical to enroll in PEBB medical only if they are enrolled in PEBB dental and PEBB vision. A school employee who waives enrollment in SEBB medical to enroll in PEBB medical also waives enrollment in SEBB dental and SEBB vision.

"Week" means a seven-day period starting on Sunday and ending on Saturday.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.740. WSR 25-14-083 (Admin #2025-01.02), s 182-31-020, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-31-020, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-31-020, filed 6/21/22, effective 1/1/23*
- *WSR 21-13-117 (Admin #2021-01.04), § 182-31-020, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-31-020, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-31-020, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-31-020, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-31-030** What are the obligations of a school employees benefits board (SEBB) organization in the application of school employee eligibility? {#sec-182-31-030 omnilex-key=us-wa-regs-official--title-182--182-31-030}

(1) All school employees benefits board (SEBB) organizations must carry out all actions, policies, and guidance issued by the SEBB program which are necessary for the operation of benefit plans, education of school employees, claims administration, and appeals process including those described in chapters 182-30, 182-31, and 182-32 WAC. SEBB organizations must:

(a) Use the methods provided by the SEBB program to determine eligibility and enrollment in benefits;

(b) Provide eligibility determination reports with content and in a format designed and communicated by the SEBB program;

(c) Support SEBB program auditing of eligibility and enrollment decisions as needed; and

(d) Carry out corrective action and pay any penalties imposed by the health care authority (HCA) and established by the board when the SEBB organization's eligibility determinations fail to comply with the criteria under these rules.

(2) SEBB organizations must determine school employee eligibility for SEBB benefits and the employer contribution according to the criteria in WAC 182-31-040 and 182-31-050. SEBB organizations must:

(a) Notify newly hired school employees of SEBB program rules and guidance for eligibility and appeal rights;

(b) Inform a school employee in writing whether or not they are eligible for SEBB benefits upon employment. The written notice must include information about the school employee's right to appeal eligibility and enrollment decisions. A school employee eligible for SEBB benefits must have no less than 10 calendar days after the date of notice to elect coverage;

(c) Routinely monitor all school employees work hours to establish eligibility and maintain the employer contribution toward SEBB benefits;

(d) Identify when a previously ineligible school employee becomes eligible or a previously eligible school employee loses eligibility; and

(e) Inform a school employee in writing whether or not they are eligible for SEBB benefits and the employer contribution whenever there is a change in work pattern such that the school employee's eligibility status changes. Whenever this occurs, SEBB organizations must inform the school employee of the right to appeal eligibility and enrollment decisions. A school employee eligible for SEBB benefits must have no less than 10 calendar days after the date of notice to elect coverage.

(3) SEBB organizations must determine school employee's dependents eligibility for SEBB benefits according to the criteria in WAC 182-31-140.

(4) SEBB organizations must assist a school employee in determining whether the school employee or their dependent has experienced an event that creates a special open enrollment as described in WAC 182-30-090, 182-30-100, 182-31-080, or 182-31-150, and inform the school employee of the changes they can make consistent with that event.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-018 (Admin #2023-01), § 182-31-030, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-31-030, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-31-030, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-31-030, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-31-040** How do school employees establish eligibility for the employer contribution toward school employees benefits board (SEBB) benefits and when do SEBB benefits begin? {#sec-182-31-040 omnilex-key=us-wa-regs-official--title-182--182-31-040}

(1) Eligibility shall be determined solely by the criteria that most closely describes the school employee's work circumstance.

(2) All hours worked by an employee in their capacity as a school employee must be included in the calculation of hours for determining eligibility. All hours for which a school employee receives compensation from a school employees benefits board (SEBB) organization during an approved leave (e.g., sick leave, personal leave, bereavement leave) or a paid holiday must be included when determining how many hours a school employee is anticipated to work, or did work, in the school year.

(3) A school employee may establish eligibility for the employer contribution toward SEBB benefits by stacking of hours from multiple positions within one SEBB organization. A school employee may not gain eligibility by stacking of hours from multiple SEBB organizations.

(4) School employee eligibility criteria shall be determined in the following order:

(a) A school employee is eligible for the employer contribution toward SEBB benefits if they are anticipated to work at least 630 hours per school year. The eligibility effective date shall be determined as follows:

(i) If the school employee's first day of work is on or after September 1st but not later than the first day of school for the current school year as established by the SEBB organization, they are eligible for the employer contribution on the first day of work; or

(ii) If the school employee's first day of work is at any other time during the school year, they are eligible for the employer contribution on that day.

(b) A school employee is presumed eligible for the employer contribution at the start of the school year, as described in (a) of this subsection, if they:

(i) Worked at least 630 hours in each of the previous two school years; and

(ii) Are returning to the same type of position (teacher, paraeducator, food service worker, custodian, etc.) or combination of positions with the same SEBB organization.

| Note: | A SEBB organization rebuts this presumption by notifying the school employee, in writing, of the specific reasons why the school employee is not anticipated to work at least 630 hours in the current school year and how to appeal the eligibility determination. |
| --- | --- |

(c) A school employee who is not anticipated to work 630 hours within the school year because of the time of year they are hired but is anticipated to work at least 630 hours the next school year, establishes eligibility for the employer contribution toward SEBB benefits as of their first working day if they are:

(i) A nine to 10 month school employee anticipated to be compensated for at least 17.5 hours a week in six of the last eight weeks counting backwards from the week that contains the last day of school; or

(ii) A 12 month school employee anticipated to be compensated for at least 17.5 hours a week in six of the last eight weeks counting backwards from the week that contains August 31st, the last day of the school year.

(d) A school employee who returns from approved leave without pay will maintain or establish eligibility for the employer contribution toward SEBB benefits if their work schedule, had it been in effect at the start of the school year, would have resulted in the school employee being anticipated to work the minimum hours to meet SEBB eligibility for the employer contribution in the school year. A school employee who regains eligibility under this subsection, establishes eligibility for the employer contribution toward SEBB benefits as of the date they returned from approved leave without pay.

(5) A school employee who is not anticipated to work at least 630 hours in the school year as described in subsection (4)(a) of this section, may later be eligible for SEBB benefits when:

(a) Their work pattern is revised in such a way that they are now anticipated to work 630 hours in the school year. The school employee becomes eligible for the employer contribution toward SEBB benefits on the date their work pattern is revised; or

(b) They actually worked 630 hours in the school year. The school employee becomes eligible for the employer contribution toward SEBB benefits on the date they actually worked 630 hours.

(6) If the school employee is not eligible under subsection (4) or (5) of this section, they may be eligible for SEBB benefits if their SEBB organization is engaging in local negotiations regarding eligibility for school employees as described in WAC 182-30-130.

(7) When SEBB benefits begin:

(a) For a school employee who establishes eligibility under subsection (4)(a)(i) of this section, medical, dental, vision, basic life insurance, basic accidental death and dismemberment (AD&D) insurance, employer-paid long-term disability (LTD) insurance, employee-paid LTD insurance (unless the school employee declines the employee-paid LTD insurance as described in WAC 182-30-080(1)), and if eligible, benefits under the salary reduction plan begin on the first day of work for the new school year. Supplemental life insurance and supplemental AD&D insurance begin on the first day of the month following the date the contracted vendor receives the required form or approves the enrollment.

(b) For a school employee who establishes eligibility under subsection (4)(a)(ii), (c), (d), or (5) of this section, medical, dental, vision, basic life insurance, basic AD&D insurance, employer-paid LTD insurance, employee-paid LTD insurance (unless the school employee declines the employee-paid LTD insurance as described in WAC 182-30-080(1)), and if eligible, benefits under the salary reduction plan begin on the first day of the month following the date the school employee becomes eligible for the employer contribution toward SEBB benefits. Supplemental life insurance and supplemental AD&D insurance begin on the first day of the month following the date the contracted vendor receives the required form or approves the enrollment.

| Exceptions: | (1) When a school employee establishes eligibility for the employer contribution toward SEBB benefits as described under subsection (4)(d) or (5) of this section, at any time in the month of August, SEBB benefits begin on September 1st only if the school employee is also determined to be eligible for the employer contribution toward SEBB benefits for the school year that begins on September 1st. |
| --- | --- |
| | (2) When a school employee who is called to active duty in the uniformed services under Uniformed Services Employment and Reemployment Rights Act (USERRA) loses eligibility for the employer contribution toward SEBB benefits, they regain eligibility for the employer contribution toward SEBB benefits the day they return from active duty. Employer-paid SEBB benefits will begin the first day of the month in which they return from active duty (see WAC 182-30-080(3)). |

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and Policy Resolution SEBB 2022-01. WSR 23-14-021 (Admin #2023-02.03), § 182-31-040, filed 6/23/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions SEBB 2021-11 and 2021-12. WSR 21-13-116 (Admin #2021-01.03), § 182-31-040, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions 2020-01, 2020-02, and 2020-05. WSR 20-16-064 (Admin #2020-01), § 182-31-040, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-31-040, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-31-040, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-31-050** When does eligibility for the employer contribution for school employees benefits board (SEBB) benefits end? {#sec-182-31-050 omnilex-key=us-wa-regs-official--title-182--182-31-050}

(1) The employer contribution toward school employees benefits board (SEBB) benefits ends the last day of the month in which the school year ends. The employer contribution toward SEBB benefits will end earlier than the end of the school year if one of the following occurs:

(a) The SEBB organization terminates the employment relationship. In this case, eligibility for the employer contribution ends the last day of the month in which the employer-initiated termination notice is effective;

(b) The school employee terminates the employment relationship. In this case, eligibility for the employer contribution ends the last day of the month in which the school employee's resignation is effective;

(c) The school employee's work pattern is revised such that the school employee is no longer anticipated to work six hundred thirty hours during the school year. In this case, eligibility for the employer contribution ends as of the last day of the month in which the change is effective;

(d) The school employee who returns from approved leave without pay, who maintained or established eligibility as described in WAC 182-31-040 (4)(d), and who subsequently has a change in work pattern that, had the work pattern been in effect at the start of the school year, would not have resulted in the school employee being anticipated to work the minimum hours to meet SEBB eligibility for the employer contribution in the school year. In this case, eligibility for the employer contribution ends as of the last day of the month in which the change is effective;

(e) The nine to ten month school employee hired late in the year and eligible for the employer contribution as described in WAC 182-31-040 (4)(c)(i), who subsequently has a change in work pattern such that the school employee is no longer eligible under the criteria described in WAC 182-31-040 (4)(c)(i). In this case, eligibility for the employer contribution ends as of the last day of the month in which the change is effective;

(f) The twelve month school employee hired late in the year and eligible for the employer contribution as described in WAC 182-31-040 (4)(c)(ii), who subsequently has a change in work pattern such that the school employee is no longer eligible under the criteria described in WAC 182-31-040 (4)(c)(ii). In this case, eligibility for the employer contribution ends as of the last day of the month in which the change is effective; or

(g) The school employee hired later in the year and eligible for the employer contribution as described in WAC 182-31-040 (4)(c), who is no longer anticipated to work six hundred thirty hours the next school year. In this case, eligibility for the employer contribution ends as of the last day of the month in which the change in the anticipation occurs.

(2) If the SEBB organization deducted the school employee's portion of the premium for SEBB insurance coverage from their pay after the school employee was no longer eligible for the employer contribution, SEBB benefits end the last day of the month for which school employee premiums were deducted to prevent a rescission of SEBB benefits. The SEBB organization must refund any premiums deducted for the school employee's portion of the premium that were deducted in advance of any month's coverage for which the school employee is no longer eligible for the employer contribution.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolution SEBB 2021-01. WSR 21-13-111(Admin #2021-01.01), § 182-31-050, filed 6/21/21, effective 9/1/21. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-31-050, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-31-050, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-31-050, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-31-060** Who is eligible to participate in the salary reduction plan? {#sec-182-31-060 omnilex-key=us-wa-regs-official--title-182--182-31-060}

(1) School employees eligible for the employer contribution toward school employees benefits board (SEBB) benefits are eligible to participate in the premium payment plan under the state's salary reduction plan. School employees eligible for SEBB benefits as described in WAC 182-31-040 may also elect to participate in the FSA, limited purpose FSA, or DCAP programs provided they elect participation within the time frames described in WAC 182-30-100.

(2) School employees of employer groups, as defined in WAC 182-31-020, are not eligible to participate in the state's salary reduction plan.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-31-060, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-31-060, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-31-060, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-31-060, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-31-070** Is dual enrollment in school employees benefits board (SEBB) and public employees benefits board (PEBB) prohibited? {#sec-182-31-070 omnilex-key=us-wa-regs-official--title-182--182-31-070}

WAC 182-31-070

***(Effective until January 1, 2027)***

School employees benefits board (SEBB) medical, dental, and vision coverage is limited to a single enrollment per individual as described in subsections (1) through (5) of this section. Effective January 1, 2022, individuals are limited to a single enrollment in medical, dental, and vision plans in either the SEBB program or public employees benefits board (PEBB) program as described in subsection (6) of this section.

(1) An individual who has more than one source of eligibility for enrollment in SEBB medical, SEBB dental, and SEBB vision coverage (called "dual eligibility") is limited to one enrollment.

(2) An eligible school employee may waive SEBB medical and enroll as a dependent under the SEBB medical plan of their spouse, state registered domestic partner, or parent as described in WAC 182-31-080.

(3) A dependent enrolled in SEBB medical, SEBB dental, or SEBB vision who becomes eligible for SEBB benefits as a school employee must elect to enroll in SEBB benefits as described in WAC 182-30-080(1). This includes making an election to enroll in or waive enrollment in SEBB medical as described in WAC 182-31-080 (1)(a).

(a) If the school employee does not waive enrollment in SEBB medical, the school employee is not eligible to remain enrolled in their spouse's, state registered domestic partner's, or parent's SEBB medical as a dependent. If the school employee's spouse, state registered domestic partner, or parent does not take action to remove the school employee (who is enrolled as a dependent) from their subscriber account, the SEBB program will automatically disenroll the school employee's enrollment as a dependent the last day of the month before the school employee's enrollment in SEBB benefits begins as described in WAC 182-31-040.

| Exception: | An enrolled dependent who becomes newly eligible, at the start of the school year, for SEBB benefits as a school employee could be dual-enrolled in SEBB medical, dental, and vision for one month. This exception is only allowed for the first month the dependent is enrolled as a school employee. |
| --- | --- |

(b) If the school employee elects to waive their enrollment in SEBB medical, the school employee will remain enrolled in SEBB medical under their spouse's, state registered domestic partner's, or parent's SEBB medical as a dependent.

(4) A child who is eligible for SEBB medical, SEBB dental, and SEBB vision under two subscribers may be enrolled under both subscribers but is limited to a single enrollment in SEBB medical, a single enrollment in SEBB dental, and a single enrollment in SEBB vision.

(5) When a school employee is eligible for the employer contribution toward SEBB benefits due to employment in more than one SEBB organization the following provisions apply:

(a) When a school employee is eligible for the employer contribution during a school year under WAC 182-31-040 and 182-30-130 the SEBB organization that has determined the school employee eligible under WAC 182-31-040 must make the employer contribution;

(b) If the school employee is eligible for the employer contribution under WAC 182-31-040 at two different SEBB organizations, the school employee must choose to enroll under only one SEBB organization;

(c) If the school employee is eligible for the employer contribution under WAC 182-30-130 at two different SEBB organizations, the school employee must choose to enroll under only one SEBB organization;

(d) If the school employee loses eligibility under one SEBB organization, they must notify their other SEBB organization no later than 60 days from the date of loss of the first SEBB benefits in order to transfer coverage;

(e) The school employee's elections remain the same when a school employee transfers their enrollment under one SEBB organization to another SEBB organization without a break in SEBB benefits for one month or more, as described in (d) of this subsection.

(6) An individual who has more than one source of eligibility for enrollment in the SEBB and PEBB programs is limited to a single enrollment in medical, dental, and vision plans in either the SEBB or PEBB program. A school employee must elect to enroll in SEBB benefits as described in WAC 182-30-080, waive enrollment as described in WAC 182-31-080, or remove eligible dependents as described in WAC 182-31-150. If the school employee takes no action to resolve the dual enrollment, the SEBB program or the PEBB program will automatically enroll or automatically disenroll the individual as described in (c) through (g) of this subsection.

(a) An eligible school employee may waive enrollment in SEBB medical to enroll in PEBB medical only if they are enrolled in PEBB dental and PEBB vision as described in WAC 182-31-080. A school employee who waives enrollment in SEBB medical to enroll in PEBB medical also waives enrollment in SEBB dental and SEBB vision.

(b) An employee in the PEBB program who waives PEBB medical, PEBB dental, and PEBB vision for SEBB medical must be enrolled in SEBB dental and SEBB vision. If the employee is not already enrolled in SEBB dental and SEBB vision, the SEBB program will automatically enroll the employee in the associated subscriber's SEBB dental and SEBB vision.

(c) If the school employee is enrolled only in SEBB dental and SEBB vision, and is also enrolled in PEBB medical, and no action is taken to resolve their dual enrollment, the school employee will remain in PEBB medical. The SEBB program will automatically disenroll the school employee from SEBB dental and SEBB vision in which they are enrolled. If the school employee is not already enrolled in PEBB dental and PEBB vision, the PEBB program will automatically enroll them in PEBB dental and PEBB vision as described in WAC 182-12-123 (6)(g). The school employee's enrollment in SEBB program life insurance, accidental death and dismemberment (AD&D) insurance, and long-term disability (LTD) insurance will remain.

(d) If the school employee is enrolled in SEBB medical and is also an employee in the PEBB program enrolled in PEBB medical, and the school employee has been enrolled in PEBB medical longer than they have been enrolled in SEBB medical, and no action is taken by the school employee to resolve their dual enrollment, they will remain in PEBB medical. The SEBB program will automatically disenroll the school employee from SEBB medical, SEBB dental, and SEBB vision. The school employee's enrollment in SEBB program life insurance, AD&D insurance, and LTD insurance will remain. If the school employee is not enrolled in medical under either the PEBB or SEBB program but is enrolled in PEBB dental, PEBB vision, SEBB dental, and SEBB vision, the school employee will remain in PEBB benefits. The SEBB program will automatically disenroll the school employee from SEBB dental and SEBB vision.

(e) If the school employee's dependent is enrolled in any SEBB medical, SEBB dental, or SEBB vision plan, and the dependent is also an employee in the PEBB program and enrolled in PEBB medical, and no action is taken by either the school employee or the dependent to resolve the dependent's dual enrollment, the school employee's dependent will remain in PEBB medical. The SEBB program will automatically disenroll the school employee's dependent from SEBB medical, SEBB dental, and SEBB vision in which they are enrolled.

(f) If the school employee's dependent is enrolled in both SEBB medical and PEBB medical as a dependent and has been enrolled in PEBB medical longer than they have been enrolled in SEBB medical, and no action is taken to resolve the dual enrollment, the school employee's dependent will remain in PEBB medical. The SEBB program will automatically disenroll the school employee's dependent from SEBB medical, SEBB dental, and SEBB vision if they are enrolled. If the school employee's dependent who is eligible as a dependent in both the SEBB and PEBB programs is not enrolled in any medical but is enrolled in both a PEBB and SEBB dental plan, PEBB and SEBB vision plan, or any combination of these coverages as a dependent, the dependent will remain in PEBB benefits. The SEBB program will automatically disenroll the dependent from SEBB benefits.

| Exception: | If there is a National Medical Support Notice (NMSN) or a court order in place, enrollment will be in accordance with the NMSN or order. |
| --- | --- |

(g) If the school employee's dependent, who is also an employee in the PEBB program, was automatically disenrolled from PEBB dental and PEBB vision, the SEBB program will automatically enroll the school employee's dependent in SEBB dental and SEBB vision, if they are not already enrolled.

(h) If the school employee who is eligible for the employer contribution toward SEBB benefits was enrolled as a dependent in PEBB medical, PEBB dental, and PEBB vision and is removed by the PEBB subscriber, the school employee will be required to return from waived enrollment as described in WAC 182-31-080 (3)(b).

(i) If the SEBB program automatically disenrolls an individual from SEBB medical, SEBB dental, or SEBB vision to resolve their dual enrollment as described in (d), (e), or (f) of this subsection, but later determines that the school employee did take action to resolve their dual enrollment within the required timelines, the SEBB program will reinstate coverage retroactive to the first of the month in which the individual was disenrolled.

***(Effective January 1, 2027)***

PDF WAC 182-31-070

Is dual enrollment in school employees benefits board (SEBB) and public employees benefits board (PEBB) prohibited?

School employees benefits board (SEBB) medical, dental, and vision coverage is limited to a single enrollment per individual as described in subsections (1) through (5) of this section. Effective January 1, 2022, individuals are limited to a single enrollment in medical, dental, and vision plans in either the SEBB program or public employees benefits board (PEBB) program as described in subsection (6) of this section.

(1) An individual who has more than one source of eligibility for enrollment in SEBB medical, SEBB dental, and SEBB vision coverage (called "dual eligibility") is limited to one enrollment.

(2) An eligible school employee may waive SEBB medical and enroll as a dependent under the SEBB medical plan of their spouse, state registered domestic partner, or parent as described in WAC 182-31-080.

(3) A dependent enrolled in SEBB medical, SEBB dental, or SEBB vision who becomes eligible for SEBB benefits as a school employee must elect to enroll in SEBB benefits as described in WAC 182-30-080(1). This includes making an election to enroll in or waive enrollment in SEBB medical as described in WAC 182-31-080 (1)(a).

(a) If the school employee does not waive enrollment in SEBB medical, the school employee is not eligible to remain enrolled in their spouse's, state registered domestic partner's, or parent's SEBB medical as a dependent. If the school employee's spouse, state registered domestic partner, or parent does not take action to remove the school employee (who is enrolled as a dependent) from their subscriber account, the SEBB program will automatically disenroll the school employee's enrollment as a dependent the last day of the month before the school employee's enrollment in SEBB benefits begins as described in WAC 182-31-040.

| Exception: | An enrolled dependent who becomes newly eligible, at the start of the school year, for SEBB benefits as a school employee could be dual-enrolled in SEBB medical, dental, and vision for one month. This exception is only allowed for the first month the dependent is enrolled as a school employee. |
| --- | --- |

(b) If the school employee elects to waive their enrollment in SEBB medical, the school employee will remain enrolled in SEBB medical under their spouse's, state registered domestic partner's, or parent's SEBB medical as a dependent.

(4) A child who is eligible for SEBB medical, SEBB dental, and SEBB vision under two subscribers may be enrolled under both subscribers but is limited to a single enrollment in SEBB medical, a single enrollment in SEBB dental, and a single enrollment in SEBB vision.

(5) When a school employee is eligible for the employer contribution toward SEBB benefits due to employment in more than one SEBB organization the following provisions apply:

(a) When a school employee is eligible for the employer contribution during a school year under WAC 182-31-040 and 182-30-130 the SEBB organization that has determined the school employee eligible under WAC 182-31-040 must make the employer contribution;

(b) If the school employee is eligible for the employer contribution under WAC 182-31-040 at two different SEBB organizations, the school employee must choose to enroll under only one SEBB organization;

(c) If the school employee is eligible for the employer contribution under WAC 182-30-130 at two different SEBB organizations, the school employee must choose to enroll under only one SEBB organization;

(d) If the school employee loses eligibility under one SEBB organization, they must notify their other SEBB organization no later than 60 days from the date of loss of the first SEBB benefits in order to transfer coverage;

(e) The school employee's elections remain the same when a school employee transfers their enrollment under one SEBB organization to another SEBB organization without a break in SEBB benefits for one month or more, as described in (d) of this subsection.

(6) An individual who has more than one source of eligibility for enrollment in the SEBB and PEBB programs is limited to a single enrollment in medical, dental, and vision plans in either the SEBB or PEBB program. A school employee must elect to enroll in SEBB benefits as described in WAC 182-30-080, waive enrollment as described in WAC 182-31-080, or remove eligible dependents as described in WAC 182-31-150. A school employee may not waive SEBB medical, SEBB dental, and SEBB vision to enroll in PEBB medical with a PEBB participating employer group that offers only medical coverage. If the school employee takes no action to resolve the dual enrollment, the SEBB program or the PEBB program will automatically enroll or automatically disenroll the individual as described in (c) through (g) of this subsection.

(a) An eligible school employee may waive enrollment in SEBB medical to enroll in PEBB medical only if they are enrolled in PEBB dental and PEBB vision as described in WAC 182-31-080. A school employee who waives enrollment in SEBB medical to enroll in PEBB medical also waives enrollment in SEBB dental and SEBB vision.

(b) An employee in the PEBB program who waives PEBB medical, PEBB dental, and PEBB vision for SEBB medical must be enrolled in SEBB dental and SEBB vision. If the employee is not already enrolled in SEBB dental and SEBB vision, the SEBB program will automatically enroll the employee in the associated subscriber's SEBB dental and SEBB vision.

(c) If the school employee is enrolled only in SEBB dental and SEBB vision, and is also enrolled in PEBB medical, and no action is taken to resolve their dual enrollment, the school employee will remain in PEBB medical. The SEBB program will automatically disenroll the school employee from SEBB dental and SEBB vision in which they are enrolled. If the school employee is not already enrolled in PEBB dental and PEBB vision, the PEBB program will automatically enroll them in PEBB dental and PEBB vision as described in WAC 182-12-123 (6)(g). The school employee's enrollment in SEBB program life insurance, accidental death and dismemberment (AD&D) insurance, and long-term disability (LTD) insurance will remain.

(d) If the school employee is enrolled in SEBB medical and is also an employee in the PEBB program enrolled in PEBB medical, and the school employee has been enrolled in PEBB medical longer than they have been enrolled in SEBB medical, and no action is taken by the school employee to resolve their dual enrollment, they will remain in PEBB medical. The SEBB program will automatically disenroll the school employee from SEBB medical, SEBB dental, and SEBB vision. The school employee's enrollment in SEBB program life insurance, AD&D insurance, and LTD insurance will remain. If the school employee is not enrolled in medical under either the PEBB or SEBB program but is enrolled in PEBB dental, PEBB vision, SEBB dental, and SEBB vision, the school employee will remain in PEBB benefits. The SEBB program will automatically disenroll the school employee from SEBB dental and SEBB vision.

(e) If the school employee's dependent is enrolled in any SEBB medical, SEBB dental, or SEBB vision plan, and the dependent is also an employee in the PEBB program and enrolled in PEBB medical, and no action is taken by either the school employee or the dependent to resolve the dependent's dual enrollment, the school employee's dependent will remain in PEBB medical. The SEBB program will automatically disenroll the school employee's dependent from SEBB medical, SEBB dental, and SEBB vision in which they are enrolled.

(f) If the school employee's dependent is enrolled in both SEBB medical and PEBB medical as a dependent and has been enrolled in PEBB medical longer than they have been enrolled in SEBB medical, and no action is taken to resolve the dual enrollment, the school employee's dependent will remain in PEBB medical. The SEBB program will automatically disenroll the school employee's dependent from SEBB medical, SEBB dental, and SEBB vision if they are enrolled. If the school employee's dependent who is eligible as a dependent in both the SEBB and PEBB programs is not enrolled in any medical but is enrolled in both a PEBB and SEBB dental plan, PEBB and SEBB vision plan, or any combination of these coverages as a dependent, the dependent will remain in PEBB benefits. The SEBB program will automatically disenroll the dependent from SEBB benefits.

| Exception: | If there is a National Medical Support Notice (NMSN) or a court order in place, enrollment will be in accordance with the NMSN or order. |
| --- | --- |

(g) If the school employee's dependent, who is also an employee in the PEBB program, was automatically disenrolled from PEBB dental and PEBB vision, the SEBB program will automatically enroll the school employee's dependent in SEBB dental and SEBB vision, if they are not already enrolled.

(h) If the school employee who is eligible for the employer contribution toward SEBB benefits was enrolled as a dependent in PEBB medical, PEBB dental, and PEBB vision and is removed by the PEBB subscriber, the school employee will be required to return from waived enrollment as described in WAC 182-31-080 (3)(b).

(i) If the SEBB program automatically disenrolls an individual from SEBB medical, SEBB dental, or SEBB vision to resolve their dual enrollment as described in (d), (e), or (f) of this subsection, but later determines that the school employee did take action to resolve their dual enrollment within the required timelines, the SEBB program will reinstate coverage retroactive to the first of the month in which the individual was disenrolled.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, Policy Resolutions SEBB 2024-01, 2024-02, 2024-03, 2024-04, and 2024-05. WSR 24-15-108 (Admin #2024-02.01), § 182-31-070, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-31-070, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions SEBB 2021-02, 2021-03, 2021-04, 2021-05, 2021-06, 2021-07, 2021-08, 2021-09, 2021-11. WSR 21-13-115 (Admin #2021-01.02), § 182-31-070, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-31-070, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-31-070, filed 7/1/19, effective 8/1/19.](Effective January 1, 2027) PDF WAC 182-31-070 Is dual enrollment in school employees benefits board (SEBB) and public employees benefits board (PEBB) prohibited? School employees benefits board (SEBB) medical, dental, and vision coverage is limited to a single enrollment per individual as described in subsections (1) through (5) of this section. Effective January 1, 2022, individuals are limited to a single enrollment in medical, dental, and vision plans in either the SEBB program or public employees benefits board (PEBB) program as described in subsection (6) of this section.(1) An individual who has more than one source of eligibility for enrollment in SEBB medical, SEBB dental, and SEBB vision coverage (called "dual eligibility") is limited to one enrollment.(2) An eligible school employee may waive SEBB medical and enroll as a dependent under the SEBB medical plan of their spouse, state registered domestic partner, or parent as described in WAC 182-31-080.(3) A dependent enrolled in SEBB medical, SEBB dental, or SEBB vision who becomes eligible for SEBB benefits as a school employee must elect to enroll in SEBB benefits as described in WAC 182-30-080(1). This includes making an election to enroll in or waive enrollment in SEBB medical as described in WAC 182-31-080 (1)(a).(a) If the school employee does not waive enrollment in SEBB medical, the school employee is not eligible to remain enrolled in their spouse's, state registered domestic partner's, or parent's SEBB medical as a dependent. If the school employee's spouse, state registered domestic partner, or parent does not take action to remove the school employee (who is enrolled as a dependent) from their subscriber account, the SEBB program will automatically disenroll the school employee's enrollment as a dependent the last day of the month before the school employee's enrollment in SEBB benefits begins as described in WAC 182-31-040.Exception:An enrolled dependent who becomes newly eligible, at the start of the school year, for SEBB benefits as a school employee could be dual-enrolled in SEBB medical, dental, and vision for one month. This exception is only allowed for the first month the dependent is enrolled as a school employee.(b) If the school employee elects to waive their enrollment in SEBB medical, the school employee will remain enrolled in SEBB medical under their spouse's, state registered domestic partner's, or parent's SEBB medical as a dependent.(4) A child who is eligible for SEBB medical, SEBB dental, and SEBB vision under two subscribers may be enrolled under both subscribers but is limited to a single enrollment in SEBB medical, a single enrollment in SEBB dental, and a single enrollment in SEBB vision.(5) When a school employee is eligible for the employer contribution toward SEBB benefits due to employment in more than one SEBB organization the following provisions apply:(a) When a school employee is eligible for the employer contribution during a school year under WAC 182-31-040 and 182-30-130 the SEBB organization that has determined the school employee eligible under WAC 182-31-040 must make the employer contribution*
- *(b) If the school employee is eligible for the employer contribution under WAC 182-31-040 at two different SEBB organizations, the school employee must choose to enroll under only one SEBB organization*
- *(c) If the school employee is eligible for the employer contribution under WAC 182-30-130 at two different SEBB organizations, the school employee must choose to enroll under only one SEBB organization*
- *(d) If the school employee loses eligibility under one SEBB organization, they must notify their other SEBB organization no later than 60 days from the date of loss of the first SEBB benefits in order to transfer coverage*
- *(e) The school employee's elections remain the same when a school employee transfers their enrollment under one SEBB organization to another SEBB organization without a break in SEBB benefits for one month or more, as described in (d) of this subsection.(6) An individual who has more than one source of eligibility for enrollment in the SEBB and PEBB programs is limited to a single enrollment in medical, dental, and vision plans in either the SEBB or PEBB program. A school employee must elect to enroll in SEBB benefits as described in WAC 182-30-080, waive enrollment as described in WAC 182-31-080, or remove eligible dependents as described in WAC 182-31-150. A school employee may not waive SEBB medical, SEBB dental, and SEBB vision to enroll in PEBB medical with a PEBB participating employer group that offers only medical coverage. If the school employee takes no action to resolve the dual enrollment, the SEBB program or the PEBB program will automatically enroll or automatically disenroll the individual as described in (c) through (g) of this subsection.(a) An eligible school employee may waive enrollment in SEBB medical to enroll in PEBB medical only if they are enrolled in PEBB dental and PEBB vision as described in WAC 182-31-080. A school employee who waives enrollment in SEBB medical to enroll in PEBB medical also waives enrollment in SEBB dental and SEBB vision.(b) An employee in the PEBB program who waives PEBB medical, PEBB dental, and PEBB vision for SEBB medical must be enrolled in SEBB dental and SEBB vision. If the employee is not already enrolled in SEBB dental and SEBB vision, the SEBB program will automatically enroll the employee in the associated subscriber's SEBB dental and SEBB vision.(c) If the school employee is enrolled only in SEBB dental and SEBB vision, and is also enrolled in PEBB medical, and no action is taken to resolve their dual enrollment, the school employee will remain in PEBB medical. The SEBB program will automatically disenroll the school employee from SEBB dental and SEBB vision in which they are enrolled. If the school employee is not already enrolled in PEBB dental and PEBB vision, the PEBB program will automatically enroll them in PEBB dental and PEBB vision as described in WAC 182-12-123 (6)(g). The school employee's enrollment in SEBB program life insurance, accidental death and dismemberment (AD&D) insurance, and long-term disability (LTD) insurance will remain.(d) If the school employee is enrolled in SEBB medical and is also an employee in the PEBB program enrolled in PEBB medical, and the school employee has been enrolled in PEBB medical longer than they have been enrolled in SEBB medical, and no action is taken by the school employee to resolve their dual enrollment, they will remain in PEBB medical. The SEBB program will automatically disenroll the school employee from SEBB medical, SEBB dental, and SEBB vision. The school employee's enrollment in SEBB program life insurance, AD&D insurance, and LTD insurance will remain. If the school employee is not enrolled in medical under either the PEBB or SEBB program but is enrolled in PEBB dental, PEBB vision, SEBB dental, and SEBB vision, the school employee will remain in PEBB benefits. The SEBB program will automatically disenroll the school employee from SEBB dental and SEBB vision.(e) If the school employee's dependent is enrolled in any SEBB medical, SEBB dental, or SEBB vision plan, and the dependent is also an employee in the PEBB program and enrolled in PEBB medical, and no action is taken by either the school employee or the dependent to resolve the dependent's dual enrollment, the school employee's dependent will remain in PEBB medical. The SEBB program will automatically disenroll the school employee's dependent from SEBB medical, SEBB dental, and SEBB vision in which they are enrolled.(f) If the school employee's dependent is enrolled in both SEBB medical and PEBB medical as a dependent and has been enrolled in PEBB medical longer than they have been enrolled in SEBB medical, and no action is taken to resolve the dual enrollment, the school employee's dependent will remain in PEBB medical. The SEBB program will automatically disenroll the school employee's dependent from SEBB medical, SEBB dental, and SEBB vision if they are enrolled. If the school employee's dependent who is eligible as a dependent in both the SEBB and PEBB programs is not enrolled in any medical but is enrolled in both a PEBB and SEBB dental plan, PEBB and SEBB vision plan, or any combination of these coverages as a dependent, the dependent will remain in PEBB benefits. The SEBB program will automatically disenroll the dependent from SEBB benefits.Exception:If there is a National Medical Support Notice (NMSN) or a court order in place, enrollment will be in accordance with the NMSN or order.(g) If the school employee's dependent, who is also an employee in the PEBB program, was automatically disenrolled from PEBB dental and PEBB vision, the SEBB program will automatically enroll the school employee's dependent in SEBB dental and SEBB vision, if they are not already enrolled.(h) If the school employee who is eligible for the employer contribution toward SEBB benefits was enrolled as a dependent in PEBB medical, PEBB dental, and PEBB vision and is removed by the PEBB subscriber, the school employee will be required to return from waived enrollment as described in WAC 182-31-080 (3)(b).(i) If the SEBB program automatically disenrolls an individual from SEBB medical, SEBB dental, or SEBB vision to resolve their dual enrollment as described in (d), (e), or (f) of this subsection, but later determines that the school employee did take action to resolve their dual enrollment within the required timelines, the SEBB program will reinstate coverage retroactive to the first of the month in which the individual was disenrolled.[Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.740. WSR 26-14-083 (Admin #2026.01), s 182-31-070, filed 6/29/26, effective 1/1/27. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, Policy Resolutions SEBB 2024-01, 2024-02, 2024-03, 2024-04, and 2024-05. WSR 24-15-108 (Admin #2024-02.01), § 182-31-070, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-31-070, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions SEBB 2021-02, 2021-03, 2021-04, 2021-05, 2021-06, 2021-07, 2021-08, 2021-09, 2021-11. WSR 21-13-115 (Admin #2021-01.02), § 182-31-070, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-31-070, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-31-070, filed 7/1/19, effective 8/1/19.*

##### **Wash. Admin. Code § 182-31-080** When may a school employee waive enrollment in school employees benefits board (SEBB) medical and when may they enroll in SEBB medical after having waived enrollment? {#sec-182-31-080 omnilex-key=us-wa-regs-official--title-182--182-31-080}

WAC 182-31-080

***(Effective until January 1, 2027)***

A school employee may waive enrollment in school employees benefits board (SEBB) medical if they are enrolled in other employer-based group medical, a TRICARE plan, or medicare Part A and Part B as described in subsection (1)(a) through (c) of this section. They may not waive enrollment in SEBB medical if they are enrolled in public employees benefits board (PEBB) retiree insurance coverage, and their PEBB retiree insurance coverage will be automatically deferred as described in WAC 182-12-205 (11)(a) or will be auto disenrolled as described in WAC 182-12-262 (2)(d). A school employee who waives enrollment in SEBB medical must enroll in SEBB dental, SEBB vision, basic life insurance, basic accidental death and dismemberment (AD&D) insurance, and employer-paid long-term disability (LTD) insurance (unless the employer group does not participate in these SEBB insurance coverages). For a SEBB organization or employer group that participates in LTD insurance, a school employee will also be enrolled in employee-paid LTD insurance automatically unless the school employee declines their employee-paid LTD insurance as described in WAC 182-30-080.

| Exception: | A school employee may waive their enrollment in SEBB medical to enroll in public employees benefits board (PEBB) medical only if they are enrolled in PEBB dental and PEBB vision. A school employee who waives enrollment in SEBB medical to enroll in PEBB medical also waives enrollment in SEBB dental and SEBB vision. |
| --- | --- |

(1) To waive enrollment in SEBB medical, the school employee must submit the required form to their SEBB organization at one of the following times:

(a) When the school employee becomes eligible: A school employee may waive SEBB medical when they become eligible for SEBB benefits. The school employee must indicate their election to waive enrollment in SEBB medical on the required form and submit the form to their SEBB organization. The SEBB organization must receive the form no later than 31 days after the date the school employee becomes eligible for SEBB benefits (see WAC 182-30-080). SEBB medical will be waived as of the date the school employee becomes eligible for SEBB benefits.

(b) During the annual open enrollment: A school employee may waive SEBB medical during the annual open enrollment. The required form must be received by the school employee's SEBB organization before the end of the annual open enrollment. SEBB medical will be waived beginning January 1st of the following year.

(c) During a special open enrollment: A school employee may waive SEBB medical during a special open enrollment only if they are enrolled in other employer-based group medical, a TRICARE plan, or medicare Part A and Part B as described in subsection (4) of this section. A special open enrollment event must be an event other than a school employee gaining initial eligibility or regaining eligibility for SEBB benefits.

The school employee must submit the required form to their SEBB organization. The SEBB organization must receive the form no later than 60 days after the event that creates the special open enrollment. In addition to the required form, the school employee must provide evidence of the event that creates the special open enrollment to their SEBB organization.

SEBB medical will be waived the last day of the month following the later of the event date or the date the required form is received. If that day is the first of the month, SEBB medical will be waived the last day of the previous month. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, SEBB medical will be waived the last day of the previous month.

(2) If a school employee waives SEBB medical, the school employee may not enroll dependents in SEBB medical.

(3) Once SEBB medical is waived, the school employee is only allowed to enroll in SEBB medical at the following times:

(a) During the annual open enrollment. The required form must be received by the school employee's SEBB organization before the end of the annual open enrollment. SEBB medical will begin January 1st of the following year.

(b) During a special open enrollment. A special open enrollment allows a school employee to revoke their election and make a new election outside of the annual open enrollment. A special open enrollment may be created when one of the events described in subsection (4) of this section occurs.

The school employee must submit the required form to their SEBB organization. The SEBB organization must receive the form no later than 60 days after the event that creates the special open enrollment. In addition to the required form, the school employee must provide evidence of the event that creates the special open enrollment to the SEBB organization.

SEBB medical will begin the first day of the month following the later of the event date or the date the required form is received. If that day is the first of the month, coverage is effective on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, SEBB medical for the school employee will begin on the first day of the month in which the event occurs. SEBB medical for the newly born child, newly adopted child, spouse, or state-registered domestic partner will begin as described in WAC 182-31-150 (3)(a)(iv).

If a school employee who is eligible for the employer contribution toward SEBB benefits was enrolled as a dependent in PEBB medical, PEBB dental, and PEBB vision and is removed by the PEBB subscriber, the health care authority will notify the school employee of their removal from the PEBB subscriber's account and that they have experienced a special enrollment event. The school employee will be required to return from waived enrollment and elect SEBB medical, SEBB dental, and SEBB vision. If the school employee's SEBB organization does not receive the school employee's required forms indicating their medical, dental, and vision elections within 60 days of the school employee losing PEBB medical, PEBB dental, and PEBB vision, they will be defaulted into employee-only SEBB medical, SEBB dental, and SEBB vision as described in WAC 182-30-080 (1)(b)(i) through (iii).

(4) Special open enrollment: Any one of the events in (a) through (k) of this subsection may create a special open enrollment that allows the school employee to enroll in SEBB medical after having waived enrollment. The change in enrollment must be allowable under the Internal Revenue Code (IRC) and Treasury regulations, and correspond to and be consistent with the event that creates the special open enrollment for the school employee, the school employee's dependent, or both.

(a) School employee acquires a new dependent due to:

(i) Marriage or registering a state registered domestic partnership;

(ii) Birth, adoption, or when the school employee has assumed a legal obligation for total or partial support in anticipation of adoption; or

(iii) A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(b) School employee or a school employee's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA);

(c) School employee has a change in employment status that affects the school employee's eligibility for their employer contribution toward their employer-based group medical;

(d) The school employee's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution under their employer-based group medical;

| Note: | As used in (d) of this subsection "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 26 C.F.R. 54.9801-6. |
| --- | --- |

(e) School employee or a school employee's dependent has a change in enrollment under an employer-based group medical plan during its annual open enrollment that does not align with the SEBB program's annual open enrollment;

(f) School employee's dependent has a change in residence from outside of the United States to within the United States, or from within the United States to outside of the United States and that change in residence results in the dependent losing their health insurance;

(g) A court order requires the school employee or any other individual to provide a health plan for an eligible dependent of the school employee (a former spouse or former state registered domestic partner is not an eligible dependent);

(h) School employee or a school employee's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the school employee or a school employee's dependent loses eligibility for coverage under medicaid or CHIP;

| Note: | A school employee may only return from having waived SEBB medical for the events described in (h) of this subsection. A school employee may not waive their SEBB medical for the events described in (h) of this subsection. |
| --- | --- |

(i) School employee or a school employee's dependent becomes eligible for state premium assistance subsidy for SEBB health plan coverage from medicaid or CHIP;

(j) School employee or a school employee's dependent becomes eligible and enrolls in a TRICARE plan, or loses eligibility for a TRICARE plan;

(k) School employee becomes eligible and enrolls in medicare, or loses eligibility for medicare.

***(Effective January 1, 2027)***

PDF WAC 182-31-080

When may a school employee waive enrollment in school employees benefits board (SEBB) medical and when may they enroll in SEBB medical after having waived enrollment?

A school employee may waive enrollment in school employees benefits board (SEBB) medical if they are enrolled in other employer-based group medical, a TRICARE plan, or medicare Part A and Part B as described in subsection (1)(a) through (c) of this section. They may not waive enrollment in SEBB medical if they are enrolled in public employees benefits board (PEBB) retiree insurance coverage, and their PEBB retiree insurance coverage will be automatically deferred as described in WAC 182-12-205 (11)(a) or will be auto disenrolled as described in WAC 182-12-262 (2)(d). A school employee who waives enrollment in SEBB medical must enroll in SEBB dental, SEBB vision, basic life insurance, basic accidental death and dismemberment (AD&D) insurance, and employer-paid long-term disability (LTD) insurance (unless the employer group does not participate in these SEBB insurance coverages). For a SEBB organization or employer group that participates in LTD insurance, a school employee will also be enrolled in employee-paid LTD insurance automatically unless the school employee declines their employee-paid LTD insurance as described in WAC 182-30-080.

| Exception: | A school employee may waive their enrollment in SEBB medical to enroll in public employees benefits board (PEBB) medical only if they are enrolled in PEBB dental and PEBB vision. A school employee who waives enrollment in SEBB medical to enroll in PEBB medical also waives enrollment in SEBB dental and SEBB vision. A school employee may not waive SEBB medical, SEBB dental, and SEBB vision to enroll in PEBB medical with a PEBB participating employer group that offers only medical coverage. |
| --- | --- |

(1) To waive enrollment in SEBB medical, the school employee must submit the required form to their SEBB organization at one of the following times:

(a) When the school employee becomes eligible: A school employee may waive SEBB medical when they become eligible for SEBB benefits. The school employee must indicate their election to waive enrollment in SEBB medical on the required form and submit the form to their SEBB organization. The SEBB organization must receive the form no later than 31 days after the date the school employee becomes eligible for SEBB benefits (see WAC 182-30-080). SEBB medical will be waived as of the date the school employee becomes eligible for SEBB benefits.

(b) During the annual open enrollment: A school employee may waive SEBB medical during the annual open enrollment. The required form must be received by the school employee's SEBB organization before the end of the annual open enrollment. SEBB medical will be waived beginning January 1st of the following year.

(c) During a special open enrollment: A school employee may waive SEBB medical during a special open enrollment only if they are enrolled in other employer-based group medical, a TRICARE plan, or medicare Part A and Part B as described in subsection (4) of this section. A special open enrollment event must be an event other than a school employee gaining initial eligibility or regaining eligibility for SEBB benefits.

The school employee must submit the required form to their SEBB organization. The SEBB organization must receive the form no later than 60 days after the event that creates the special open enrollment. In addition to the required form, the school employee must provide evidence of the event that creates the special open enrollment to their SEBB organization.

SEBB medical will be waived the last day of the month following the later of the event date or the date the required form is received. If that day is the first of the month, SEBB medical will be waived the last day of the previous month. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, SEBB medical will be waived the last day of the month prior to the month in which the birth, adoption, or assuming legal obligation occurred.

(2) If a school employee waives SEBB medical, the school employee may not enroll dependents in SEBB medical.

(3) Once SEBB medical is waived, the school employee is only allowed to enroll in SEBB medical at the following times:

(a) During the annual open enrollment. The required form must be received by the school employee's SEBB organization before the end of the annual open enrollment. SEBB medical will begin January 1st of the following year.

(b) During a special open enrollment. A special open enrollment allows a school employee to revoke their election and make a new election outside of the annual open enrollment. A special open enrollment may be created when one of the events described in subsection (4) of this section occurs.

The school employee must submit the required form to their SEBB organization. The SEBB organization must receive the form no later than 60 days after the event that creates the special open enrollment. In addition to the required form, the school employee must provide evidence of the event that creates the special open enrollment to the SEBB organization.

SEBB medical will begin the first day of the month following the later of the event date or the date the required form is received. If that day is the first of the month, coverage is effective on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, SEBB medical for the school employee will begin on the first day of the month in which the event occurs. SEBB medical for the newly born child, newly adopted child, spouse, or state-registered domestic partner will begin as described in WAC 182-31-150 (3)(a)(iv).

If a school employee who is eligible for the employer contribution toward SEBB benefits was enrolled as a dependent in PEBB medical, PEBB dental, and PEBB vision and is removed by the PEBB subscriber, the health care authority will notify the school employee of their removal from the PEBB subscriber's account and that they have experienced a special enrollment event. The school employee will be required to return from waived enrollment and elect SEBB medical, SEBB dental, and SEBB vision. If the school employee's SEBB organization does not receive the school employee's required forms indicating their medical, dental, and vision elections within 60 days of the school employee losing PEBB medical, PEBB dental, and PEBB vision, they will be defaulted into employee-only SEBB medical, SEBB dental, and SEBB vision as described in WAC 182-30-080 (1)(b)(i) through (iii).

(4) Special open enrollment: Any one of the events in (a) through (k) of this subsection may create a special open enrollment that allows the school employee to enroll in SEBB medical after having waived enrollment. The change in enrollment must be allowable under the Internal Revenue Code (IRC) and Treasury regulations, and correspond to and be consistent with the event that creates the special open enrollment for the school employee, the school employee's dependent, or both.

(a) School employee acquires a new dependent due to:

(i) Marriage or registering a state registered domestic partnership;

(ii) Birth, adoption, or when the school employee has assumed a legal obligation for total or partial support in anticipation of adoption; or

(iii) A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(b) School employee or a school employee's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA);

(c) School employee has a change in employment status that affects the school employee's eligibility for their employer contribution toward their employer-based group medical;

(d) The school employee's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution under their employer-based group medical;

| Note: | As used in (d) of this subsection "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 26 C.F.R. 54.9801-6. |
| --- | --- |

(e) School employee or a school employee's dependent has a change in enrollment under an employer-based group medical plan during its annual open enrollment that does not align with the SEBB program's annual open enrollment;

(f) School employee's dependent has a change in residence from outside of the United States to within the United States, or from within the United States to outside of the United States and that change in residence results in the dependent losing their health insurance;

(g) A court order requires the school employee or any other individual to provide a health plan for an eligible dependent of the school employee (a former spouse or former state registered domestic partner is not an eligible dependent);

(h) School employee or a school employee's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the school employee or a school employee's dependent loses eligibility for coverage under medicaid or CHIP;

| Note: | A school employee may only return from having waived SEBB medical for the events described in (h) of this subsection. A school employee may not waive their SEBB medical for the events described in (h) of this subsection. |
| --- | --- |

(i) School employee or a school employee's dependent becomes eligible for state premium assistance subsidy for SEBB health plan coverage from medicaid or CHIP;

(j) School employee or a school employee's dependent becomes eligible and enrolls in a TRICARE plan, or loses eligibility for a TRICARE plan;

(k) School employee becomes eligible and enrolls in medicare, or loses eligibility for medicare.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.740. WSR 25-14-083 (Admin #2025-01.02), s 182-31-080, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, and Policy Resolution SEBB 2024-01. WSR 24-15-109 (Admin #2024-02.02), § 182-31-080, filed 7/22/24, effective 9/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-018 (Admin #2023-01), § 182-31-080, filed 6/23/23, effective 1/1/24*
- *WSR 22-13-168 (Admin #2022-01), § 182-31-080, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions SEBB 2021-02, 2021-03, 2021-04, 2021-05, 2021-06, 2021-07, 2021-08, 2021-09, 2021-11. WSR 21-13-115 (Admin #2021-01.02), § 182-31-080, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-31-080, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-31-080, filed 7/1/19, effective 8/1/19.](Effective January 1, 2027) PDF WAC 182-31-080 When may a school employee waive enrollment in school employees benefits board (SEBB) medical and when may they enroll in SEBB medical after having waived enrollment? A school employee may waive enrollment in school employees benefits board (SEBB) medical if they are enrolled in other employer-based group medical, a TRICARE plan, or medicare Part A and Part B as described in subsection (1)(a) through (c) of this section. They may not waive enrollment in SEBB medical if they are enrolled in public employees benefits board (PEBB) retiree insurance coverage, and their PEBB retiree insurance coverage will be automatically deferred as described in WAC 182-12-205 (11)(a) or will be auto disenrolled as described in WAC 182-12-262 (2)(d). A school employee who waives enrollment in SEBB medical must enroll in SEBB dental, SEBB vision, basic life insurance, basic accidental death and dismemberment (AD&D) insurance, and employer-paid long-term disability (LTD) insurance (unless the employer group does not participate in these SEBB insurance coverages). For a SEBB organization or employer group that participates in LTD insurance, a school employee will also be enrolled in employee-paid LTD insurance automatically unless the school employee declines their employee-paid LTD insurance as described in WAC 182-30-080.Exception:A school employee may waive their enrollment in SEBB medical to enroll in public employees benefits board (PEBB) medical only if they are enrolled in PEBB dental and PEBB vision. A school employee who waives enrollment in SEBB medical to enroll in PEBB medical also waives enrollment in SEBB dental and SEBB vision. A school employee may not waive SEBB medical, SEBB dental, and SEBB vision to enroll in PEBB medical with a PEBB participating employer group that offers only medical coverage.(1) To waive enrollment in SEBB medical, the school employee must submit the required form to their SEBB organization at one of the following times:(a) When the school employee becomes eligible: A school employee may waive SEBB medical when they become eligible for SEBB benefits. The school employee must indicate their election to waive enrollment in SEBB medical on the required form and submit the form to their SEBB organization. The SEBB organization must receive the form no later than 31 days after the date the school employee becomes eligible for SEBB benefits (see WAC 182-30-080). SEBB medical will be waived as of the date the school employee becomes eligible for SEBB benefits.(b) During the annual open enrollment: A school employee may waive SEBB medical during the annual open enrollment. The required form must be received by the school employee's SEBB organization before the end of the annual open enrollment. SEBB medical will be waived beginning January 1st of the following year.(c) During a special open enrollment: A school employee may waive SEBB medical during a special open enrollment only if they are enrolled in other employer-based group medical, a TRICARE plan, or medicare Part A and Part B as described in subsection (4) of this section. A special open enrollment event must be an event other than a school employee gaining initial eligibility or regaining eligibility for SEBB benefits.The school employee must submit the required form to their SEBB organization. The SEBB organization must receive the form no later than 60 days after the event that creates the special open enrollment. In addition to the required form, the school employee must provide evidence of the event that creates the special open enrollment to their SEBB organization.SEBB medical will be waived the last day of the month following the later of the event date or the date the required form is received. If that day is the first of the month, SEBB medical will be waived the last day of the previous month. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, SEBB medical will be waived the last day of the month prior to the month in which the birth, adoption, or assuming legal obligation occurred.(2) If a school employee waives SEBB medical, the school employee may not enroll dependents in SEBB medical.(3) Once SEBB medical is waived, the school employee is only allowed to enroll in SEBB medical at the following times:(a) During the annual open enrollment. The required form must be received by the school employee's SEBB organization before the end of the annual open enrollment. SEBB medical will begin January 1st of the following year.(b) During a special open enrollment. A special open enrollment allows a school employee to revoke their election and make a new election outside of the annual open enrollment. A special open enrollment may be created when one of the events described in subsection (4) of this section occurs.The school employee must submit the required form to their SEBB organization. The SEBB organization must receive the form no later than 60 days after the event that creates the special open enrollment. In addition to the required form, the school employee must provide evidence of the event that creates the special open enrollment to the SEBB organization.SEBB medical will begin the first day of the month following the later of the event date or the date the required form is received. If that day is the first of the month, coverage is effective on that day. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, SEBB medical for the school employee will begin on the first day of the month in which the event occurs. SEBB medical for the newly born child, newly adopted child, spouse, or state-registered domestic partner will begin as described in WAC 182-31-150 (3)(a)(iv).If a school employee who is eligible for the employer contribution toward SEBB benefits was enrolled as a dependent in PEBB medical, PEBB dental, and PEBB vision and is removed by the PEBB subscriber, the health care authority will notify the school employee of their removal from the PEBB subscriber's account and that they have experienced a special enrollment event. The school employee will be required to return from waived enrollment and elect SEBB medical, SEBB dental, and SEBB vision. If the school employee's SEBB organization does not receive the school employee's required forms indicating their medical, dental, and vision elections within 60 days of the school employee losing PEBB medical, PEBB dental, and PEBB vision, they will be defaulted into employee-only SEBB medical, SEBB dental, and SEBB vision as described in WAC 182-30-080 (1)(b)(i) through (iii).(4) Special open enrollment: Any one of the events in (a) through (k) of this subsection may create a special open enrollment that allows the school employee to enroll in SEBB medical after having waived enrollment. The change in enrollment must be allowable under the Internal Revenue Code (IRC) and Treasury regulations, and correspond to and be consistent with the event that creates the special open enrollment for the school employee, the school employee's dependent, or both.(a) School employee acquires a new dependent due to:(i) Marriage or registering a state registered domestic partnership*
- *(ii) Birth, adoption, or when the school employee has assumed a legal obligation for total or partial support in anticipation of adoption*
- *or(iii) A child becoming eligible as an extended dependent through legal custody or legal guardianship.(b) School employee or a school employee's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA)*
- *(c) School employee has a change in employment status that affects the school employee's eligibility for their employer contribution toward their employer-based group medical*
- *(d) The school employee's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution under their employer-based group medical*
- *Note:As used in (d) of this subsection "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 26 C.F.R. 54.9801-6.(e) School employee or a school employee's dependent has a change in enrollment under an employer-based group medical plan during its annual open enrollment that does not align with the SEBB program's annual open enrollment*
- *(f) School employee's dependent has a change in residence from outside of the United States to within the United States, or from within the United States to outside of the United States and that change in residence results in the dependent losing their health insurance*
- *(g) A court order requires the school employee or any other individual to provide a health plan for an eligible dependent of the school employee (a former spouse or former state registered domestic partner is not an eligible dependent)*
- *(h) School employee or a school employee's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the school employee or a school employee's dependent loses eligibility for coverage under medicaid or CHIP*
- *Note:A school employee may only return from having waived SEBB medical for the events described in (h) of this subsection. A school employee may not waive their SEBB medical for the events described in (h) of this subsection.(i) School employee or a school employee's dependent becomes eligible for state premium assistance subsidy for SEBB health plan coverage from medicaid or CHIP*
- *(j) School employee or a school employee's dependent becomes eligible and enrolls in a TRICARE plan, or loses eligibility for a TRICARE plan*
- *(k) School employee becomes eligible and enrolls in medicare, or loses eligibility for medicare.[Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.740. WSR 26-14-083 (Admin #2026.01), s 182-31-080, filed 6/29/26, effective 1/1/27*
- *WSR 25-14-083 (Admin #2025-01.02), s 182-31-080, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, and Policy Resolution SEBB 2024-01. WSR 24-15-109 (Admin #2024-02.02), § 182-31-080, filed 7/22/24, effective 9/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-018 (Admin #2023-01), § 182-31-080, filed 6/23/23, effective 1/1/24*
- *WSR 22-13-168 (Admin #2022-01), § 182-31-080, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions SEBB 2021-02, 2021-03, 2021-04, 2021-05, 2021-06, 2021-07, 2021-08, 2021-09, 2021-11. WSR 21-13-115 (Admin #2021-01.02), § 182-31-080, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-31-080, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-31-080, filed 7/1/19, effective 8/1/19.*

##### **Wash. Admin. Code § 182-31-090** When is an enrollee eligible to continue school employees benefits board (SEBB) benefits under Consolidated Omnibus Budget Reconciliation Act (COBRA)? {#sec-182-31-090 omnilex-key=us-wa-regs-official--title-182--182-31-090}

(1) A school employee or a school employee's dependent who loses eligibility for the employer contribution toward school employees benefits board (SEBB) benefits and who qualifies for continuation coverage under the federal Consolidated Omnibus Budget Reconciliation Act (COBRA) may continue coverage for all or any combination of SEBB medical, dental, or vision for the maximum number of months allowed under COBRA.

(2) A school employee or a school employee's dependent who loses eligibility for continuation coverage described in WAC 182-31-100 or 182-31-120 but who has not used the maximum number of months allowed under COBRA may continue any combination of SEBB medical, dental, or vision for the remaining difference in months.

(3) A school board member and their dependents who are enrolled in SEBB medical, dental, and vision who lose eligibility when the school board member leaves office or their term ends may continue enrollment in SEBB medical, dental, or vision coverage for the maximum number of months allowed under COBRA.

(4) An enrollee may continue SEBB medical, dental, or vision under COBRA by self-paying the premium and applicable premium surcharges set by the health care authority (HCA):

(a) The election must be received by the SEBB program no later than 60 days from the date the enrollee's SEBB health plan coverage ended or from the postmark date on the election notice sent by the SEBB program, whichever is later;

(b) The first premium payment under COBRA coverage and applicable premium surcharges are due to the HCA no later than 45 days after the election period ends as described in (a) of this subsection, except as described in WAC 182-30-040 (1)(a). Following the enrollee's first premium payment, premiums and applicable premium surcharges must be paid as described in WAC 182-30-040 (1)(c);

(c) COBRA continuation coverage enrollees who voluntarily terminate their COBRA coverage will not be eligible to reenroll in COBRA coverage unless they regain eligibility as described in WAC 182-31-040 or 182-31-200. Those who request to terminate their COBRA coverage must do so in writing. COBRA coverage will end on the last day of the month in which the SEBB program receives the termination request or on the last day of the month specified in the COBRA enrollee's termination request, whichever is later. If the termination request is received on the first day of the month, COBRA coverage will end on the last day of the previous month;

(d) A school employee enrolled in a flexible spending arrangement (FSA) or limited purpose FSA and the school employee's dependents will have an opportunity to continue making contributions to their FSA or limited purpose FSA by electing COBRA if on the date of the qualifying event, as described under 42 U.S.C. Sec. 300bb-3, the school employee's FSA or limited purpose FSA has a greater amount in remaining benefits than remaining contribution payments for the current year. The election must be received by the contracted vendor no later than 60 days from the date the SEBB health plan coverage ended or from the postmark date on the election notice sent by the contracted vendor, whichever is later. The first premium payment under COBRA coverage is due to the contracted vendor no later than 45 days after the election period ends as described above.

(5) A subscriber's state registered domestic partner and the state registered domestic partner's children may continue SEBB medical, dental, or vision on the same terms and conditions as spouses and other eligible dependents under COBRA as described under RCW 26.60.015.

(6) Medical, dental, and vision coverage under COBRA begin on the first day of the month following the day the COBRA enrollee loses eligibility for SEBB health plan coverage as described in WAC 182-31-050, 182-31-100, 182-31-120, 182-31-140, or 182-31-200.

(7) An enrollee's COBRA coverage will terminate the last day of the month prior to the month their medicare coverage begins.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.740. WSR 25-14-083 (Admin #2025-01.02), s 182-31-090, filed 6/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, 2023 c 51 § 3, and Policy Resolution SEBB 2024-06. WSR 24-15-110 (Admin #2024-02.03), § 182-31-090, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-31-090, filed 6/21/22, effective 1/1/23*
- *WSR 21-13-117 (Admin #2021-01.04), § 182-31-090, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-31-090, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-31-090, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-31-090, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-31-093** School employees benefits boards (SEBB) continuation coverage for nonrepresented educational service district (ESD) school employees and their dependents who are not eligible for benefits under the SEBB program as of January 1, 2024, and for dependents who were already on an ESD's or public employees benefits board (PEBB) program's continuation coverage as of December 31, 2023. {#sec-182-31-093 omnilex-key=us-wa-regs-official--title-182--182-31-093}

Nonrepresented educational service district (ESD) school employees and their dependents may gain temporary eligibility for school employees benefits board (SEBB) benefits, on a self-pay basis, if they meet the following criteria:

(1) A nonrepresented ESD school employee and their dependents who are enrolled in medical, dental, or vision under a group plan offered by a SEBB organization on December 31, 2023, who lose eligibility because the school employee is not eligible under WAC 182-30-130 or 182-31-040, may elect to continue existing enrollment in one or more of the following SEBB benefits: Medical, dental, or vision coverage. These benefits will be provided for a maximum of 18 months.

(2) A dependent of a SEBB eligible nonrepresented school employee of an ESD who is enrolled in medical, dental, or vision under a school employee's account on December 31, 2023, who loses eligibility because they are not an eligible dependent under WAC 182-31-140 may continue existing enrollment for a maximum of 36 months.

(3) A dependent of a nonrepresented school employee who is continuing medical, dental, or vision coverage through an ESD on December 31, 2023, may elect to continue existing enrollment to finish out their remaining months, up to the maximum number of months authorized by Consolidated Omnibus Budget Reconciliation Act for a similar event, by enrolling in a medical, dental, or vision plan offered through the SEBB program.

(4) The nonrepresented school employee's or the dependent's election must be received by the SEBB program no later than 60 days after January 1, 2024. If the nonrepresented school employee's or a dependent's monthly premium or applicable premium surcharges remain unpaid for 60 days from the original due date, the nonrepresented school employee's SEBB benefits will be terminated retroactive to the last day of the month for which the monthly premium and applicable premium surcharges were paid as described in WAC 182-30-040 (1)(c).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, Policy Resolutions SEBB 2023-01, 2023-02, and 2023-03. WSR 23-14-019 (Admin #2023-02.01), § 182-31-093, filed 6/23/23, effective 1/1/24.*

##### **Wash. Admin. Code § 182-31-100** What options for continuation coverage are available to school employees and their dependents during certain types of leave or when employment ends due to a layoff? {#sec-182-31-100 omnilex-key=us-wa-regs-official--title-182--182-31-100}

School employees who have established eligibility for school employees benefits board (SEBB) benefits as described in WAC 182-31-040 may continue coverage for themselves and their dependents during certain types of leave or when their employment ends due to a layoff.

(1) School employees who are no longer eligible for the employer contribution toward SEBB benefits due to an event described in (b)(i) through (v) of this subsection may continue coverage by self-paying the premium and applicable premium surcharges set by the health care authority (HCA) from the date eligibility for the employer contribution is lost:

(a) School employees may continue any combination of medical, dental, or vision, and may also continue life insurance and accidental death and dismemberment (AD&D) insurance. If life insurance or AD&D insurance is elected, both basic life and basic AD&D insurance must be continued. School employees who continue basic life insurance and basic AD&D insurance may also continue supplemental life and AD&D insurance;

(b) School employees in the following circumstances who lose their eligibility for the employer contribution toward SEBB benefits qualify to continue coverage under this subsection:

(i) School employees who are on authorized leave without pay;

(ii) School employees who are receiving time-loss benefits under workers' compensation;

(iii) School employees who are called to active duty in the uniformed services as defined under USERRA;

(iv) School employees whose employment ends due to a layoff as defined in WAC 182-31-020; and

(v) School employees who are applying for disability retirement.

(c) The school employee's elections must be received by the SEBB program no later than 60 days from the date the school employee's SEBB health plan coverage ended or from the postmark date on the election notice sent by the SEBB program, whichever is later;

(d) School employees may self-pay for a maximum of 29 months. The school employee's first premium payment and applicable premium surcharges are due no later than 45 days after the election period ends as described in (c) of this subsection, except as described in WAC 182-30-040 (1)(a).

Premiums and applicable premium surcharges associated with continuing SEBB medical, must be made to the HCA as well as premiums associated with continuing SEBB dental and vision insurance coverage. Premiums associated with continuing life insurance coverage or AD&D insurance coverage must be made to the contracted vendor. Following the school employee's first premium payment, the school employee must pay the premium amounts for SEBB insurance coverage and applicable premium surcharges as premiums become due; and

(e) If the school employee's monthly premium or applicable premium surcharges remain unpaid for 60 days from the original due date, the school employee's SEBB insurance coverage will be terminated retroactive to the last day of the month for which the monthly premium and applicable premium surcharges were paid as described in WAC 182-30-040 (1)(c).

(2) The number of months that school employees self-pay the premium while eligible as described in subsection (1) of this section will count toward the total months of continuation coverage allowed under the federal Consolidated Omnibus Budget Reconciliation Act (COBRA). School employees who are no longer eligible for continuation coverage as described in subsection (1) of this section but who have not used the maximum number of months allowed under COBRA coverage may continue medical, dental, vision, or any combination of them for the remaining difference in months by self-paying the premium and applicable premium surcharges as described in WAC 182-31-090.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-31-100, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-31-100, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-31-100, filed 7/1/19, effective 8/1/19.*

##### **Wash. Admin. Code § 182-31-110** What options are available if a school employee is approved for the federal Family and Medical Leave Act (FMLA) or the paid family and medical leave program? {#sec-182-31-110 omnilex-key=us-wa-regs-official--title-182--182-31-110}

(1) A school employee on approved leave under the federal Family and Medical Leave Act (FMLA) may continue to receive the employer contribution toward school employees benefits board (SEBB) benefits in accordance with the federal FMLA. The school employee may also continue current supplemental life, supplemental accidental death and dismemberment (AD&D), and employee-paid long-term disability (LTD) insurance. The school employee's SEBB organization is responsible for determining if the school employee is eligible for leave under FMLA and the duration of such leave.

(2) A school employee on approved leave under the paid family and medical leave program under chapter 50A.05 RCW may continue to receive the employer contribution toward SEBB benefits in accordance with RCW 50A.35.020. The school employee may also continue current supplemental life, supplemental AD&D, and employee-paid LTD insurance. The employment security department is responsible for determining if the school employee is eligible for the paid family and medical leave program.

(3) If a school employee exhausts the period of leave approved under FMLA or paid family and medical leave, SEBB benefits may be continued by self-paying the premium and applicable premium surcharges set by the health care authority (HCA), with no contribution from the SEBB organization, as described in WAC 182-31-100(1).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions SEBB 2021-11 and 2021-12. WSR 21-13-116 (Admin #2021-01.03), § 182-31-110, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-31-110, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-31-110, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-31-110, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-31-120** What options for continuation coverage are available to school employees during their appeal of a grievance? {#sec-182-31-120 omnilex-key=us-wa-regs-official--title-182--182-31-120}

(1) A school employee awaiting the hearing outcome of a grievance action before any of the following may continue their school employees benefits board (SEBB) insurance coverage by self-paying the premium and applicable premium surcharges set by the health care authority (HCA), with no contribution from the SEBB organization, on the same terms as a school employee who is granted leave as described in WAC 182-31-100(1):

(a) An arbitrator;

(b) A grievance or appeals committee established under a collective bargaining agreement for union represented employees; or

(c) A court.

(2) The school employee must pay premium amounts and applicable premium surcharges associated with SEBB insurance coverage as premiums and applicable premium surcharges become due. If the monthly premium or applicable premium surcharges remain unpaid for sixty days from the original due date, SEBB insurance coverage will be terminated retroactive to the last day of the month for which the monthly premium and applicable premium surcharges were paid as described in WAC 182-30-040 (1)(c).

(3) If the dismissal is upheld, all SEBB insurance coverage will terminate at the end of the month in which the decision is entered, or the date to which premiums have been paid, whichever is later, with the exception described in subsection (4) of this section.

(4) If the dismissal is upheld and the school employee is eligible under the federal Consolidated Omnibus Budget Reconciliation Act (COBRA), the school employee may continue SEBB medical, dental, vision, or any combination of them for the remaining months available under COBRA. See WAC 182-31-090 for information on COBRA. The number of months the school employee self-paid premiums during the appeal will count toward the total number of months allowed under COBRA.

(5) If the arbitrator, committee, or court sustains the school employee in the appeal and directs reinstatement of SEBB organization paid SEBB insurance coverage retroactively, the SEBB organization must forward to HCA the full employer contribution for the period directed by the arbitrator, committee, or court and collect from the school employee the school employee's share of premiums due, if any.

(a) When the employer contribution is reinstated, HCA will refund premiums and applicable premium surcharges the school employee paid only if the school employee retroactively pays their employee contribution amounts for SEBB benefits. In the alternative, at the request of the school employee, HCA may deduct the school employee's contribution amount for SEBB benefits from the refund of premiums and applicable premium surcharges self-paid by the school employee during the appeal period.

(b) All supplemental life insurance, supplemental accidental death and dismemberment (AD&D) insurance, and employee-paid long-term disability (LTD) insurance that was in force at the time of dismissal shall be reinstated retroactively only if the school employee makes retroactive payment of premium for any such supplemental coverage and employee-paid LTD insurance that was not continued by self-payment during the appeal process. If the school employee chooses not to pay the retroactive premium, evidence of insurability will be required to enroll in such supplemental coverage and employee-paid LTD insurance.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions SEBB 2021-11 and 2021-12. WSR 21-13-116 (Admin #2021-01.03), § 182-31-120, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-31-120, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-31-120, filed 7/1/19, effective 8/1/19.*

##### **Wash. Admin. Code § 182-31-130** What options for continuation coverage are available to dependents who cease to meet the eligibility criteria as described in WAC 182-31-140 or 182-30-130? {#sec-182-31-130 omnilex-key=us-wa-regs-official--title-182--182-31-130}

If eligible, dependents may continue health plan enrollment under one of the continuation coverage options in subsection (1) or (2) of this section by self-paying the premiums and applicable premium surcharges set by the health care authority (HCA), with no contribution from the school employees benefits board (SEBB) organization, following their loss of eligibility under the subscriber's health plan coverage. The dependent's first premium payment and applicable premium surcharges are due no later than 45 days after the dependent's election period ends as described in WAC 182-31-090 or 182-12-265, whichever applies, except as described in WAC 182-08-180 (1)(a). Premiums and applicable premium surcharges associated with continuing SEBB medical, must be made to the HCA as well as premiums associated with continuing SEBB dental or SEBB vision insurance coverage. Following the dependent's first premium payment, the dependent must pay premium and applicable premium surcharges as they become due. If the monthly premium or applicable premium surcharges remain unpaid for 60 days from the original due date, SEBB insurance coverage will be terminated retroactive to the last day of the month for which the monthly premium and applicable premium surcharges were paid as described in WAC 182-30-040 (1)(c). The SEBB program must receive the required forms as outlined in the SEBB initial notice of COBRA and continuation coverage rights. Options for continuing health plan enrollment are based on the reason that eligibility was lost.

(1) Dependents who lose eligibility due to the death of a school employee may be eligible to continue health plan enrollment as described in WAC 182-12-265; or

(2) Dependents who lose eligibility because they no longer meet the eligibility criteria as described in WAC 182-31-140 are eligible to continue SEBB medical, dental, or vision under provisions of the federal Consolidated Omnibus Budget Reconciliation Act (COBRA). See WAC 182-31-090 for more information on COBRA.

(3) A subscriber's state registered domestic partner and the state registered domestic partner's children may continue SEBB medical, dental, or vision on the same terms and conditions as spouses and other eligible dependents under COBRA as described under RCW 26.60.015.

(4) A dependent of a school board member who is enrolled in medical, dental, and vision who loses eligibility because they are not an eligible dependent under the SEBB program may enroll in medical, dental, or vision for a maximum of 36 months on a self-pay basis.

(5) No continuation coverage will be offered unless the SEBB program is notified through hand delivery or United States Postal Service mail of the qualifying event as outlined in the SEBB initial notice of COBRA and continuation coverage rights.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, and Policy Resolution SEBB 2024-07. WSR 24-15-111 (Admin #2024-02.04), § 182-31-130, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-31-130, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-31-130, filed 7/1/19, effective 8/1/19.*

##### **Wash. Admin. Code § 182-31-135** Where may school employee survivors go for additional coverage options? {#sec-182-31-135 omnilex-key=us-wa-regs-official--title-182--182-31-135}

A school employee's spouse, state registered domestic partner, or child who loses eligibility for the employer contribution toward school employees benefits board (SEBB) benefits due to the death of an eligible school employee may be eligible to enroll in or defer enrollment as a survivor under public employees benefits board (PEBB) retiree insurance coverage as described in WAC 182-12-265 rather than enrolling in continuation coverage.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-31-135, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-31-135, filed 7/1/19, effective 8/1/19.*

##### **Wash. Admin. Code § 182-31-140** Who are eligible dependents? {#sec-182-31-140 omnilex-key=us-wa-regs-official--title-182--182-31-140}

To be enrolled in SEBB health plan coverage, a dependent must be eligible under this section and the subscriber must comply with enrollment procedures outlined in WAC 182-31-150.

The school employees benefits board (SEBB) program verifies the eligibility of all dependents and will request documents from subscribers that provide evidence of a dependent's eligibility. The SEBB program reserves the right to review a dependent's eligibility at any time. The SEBB program will remove a subscriber's enrolled dependents from health plan coverage if the SEBB program is unable to verify a dependent's eligibility. A dependent will not be enrolled in SEBB health plan coverage if the SEBB program or the SEBB organization is unable to verify the dependent's eligibility within the SEBB program enrollment timelines.

The subscriber must provide notice, in writing, when their dependent is not eligible under this section as described in WAC 182-31-150 (2)(a).

The following are eligible as dependents:

(1) Legal spouse. A former spouse is not an eligible dependent upon finalization of a divorce or annulment, even if a court order requires the subscriber to provide health insurance for the former spouse;

(2) State registered domestic partner. A former state registered domestic partner is not an eligible dependent upon dissolution or termination of a partnership, even if a court order requires the subscriber to provide health insurance for the former partner;

(3) Children. Children are eligible through the last day of the month in which their twenty-sixth birthday occurred except as described in (f) of this subsection. Children are defined as the subscriber's:

(a) Children based on establishment of a parent-child relationship as described in RCW 26.26A.100, except when parental rights have been terminated;

(b) Children of the subscriber's spouse, based on the spouse's establishment of a parent-child relationship, except when parental rights have been terminated. The stepchild's relationship to the subscriber (and eligibility as a dependent) ends on the same date the marriage with the spouse ends through divorce, annulment, dissolution, termination, or death;

(c) Children of the subscriber's state registered domestic partner, based on the state registered domestic partner's establishment of a parent-child relationship, except when parental rights have been terminated. The child's relationship to the subscriber (and eligibility as a dependent) ends on the same date the subscriber's legal relationship with the state registered domestic partner ends through divorce, annulment, dissolution, termination, or death;

(d) Children for whom the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption of the child;

(e) Children specified in a court order or divorce decree for whom the subscriber has a legal obligation to provide support or health care coverage;

(f) Children of any age with a developmental or physical disability that renders the child incapable of self-sustaining employment and chiefly dependent upon the subscriber for support and maintenance provided such condition occurs before the age of twenty-six:

(i) The subscriber must provide proof of the disability and dependency within sixty days of the child's attainment of age twenty-six;

(ii) The subscriber must notify the SEBB program, in writing, when the child is no longer eligible under this subsection as described in WAC 182-31-150 (2)(a);

(iii) A child with a developmental or physical disability who becomes self-supporting is not eligible under this subsection as of the last day of the month in which they become capable of self-support;

(iv) A child with a developmental or physical disability age twenty-six and older who becomes capable of self-support does not regain eligibility if they later become incapable of self-support; and

(v) The SEBB program with input from the applicable contracted vendor will periodically verify the eligibility of a dependent child with a disability beginning at age twenty-six, but no more frequently than annually after the two-year period following the child's twenty-sixth birthday. Verification will require renewed proof of disability and dependence from the subscriber.

(g) Extended dependent in the legal custody or legal guardianship of the subscriber, the subscriber's spouse, or the subscriber's state registered domestic partner. The legal responsibility is demonstrated by a valid court order and the child's official residence with the custodian or guardian. Extended dependent child does not include a foster child unless the subscriber, the subscriber's spouse, or the subscriber's state registered domestic partner has assumed a legal obligation for total or partial support in anticipation of adoption.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-31-140, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-31-140, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-31-140, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-31-150** When may subscribers enroll or remove eligible dependents? {#sec-182-31-150 omnilex-key=us-wa-regs-official--title-182--182-31-150}

WAC 182-31-150

***(Effective until January 1, 2027)***

(1) Enrolling dependents in school employees benefits board (SEBB) health plan coverage, supplemental dependent life insurance, and accidental death and dismemberment (AD&D) insurance. A dependent must be enrolled in the same health plan coverage as the subscriber, and the subscriber must be enrolled in health plan coverage to enroll their dependent in health plan coverage. A dependent with more than one source of eligibility for enrollment in the public employees benefits board (PEBB) and SEBB programs is limited to a single enrollment in medical, dental, and vision plans in either the PEBB or SEBB program. Subscribers must satisfy the enrollment requirements as described in subsection (4) of this section and may enroll eligible dependents at the following times:

(a) When the subscriber becomes eligible and enrolls in SEBB benefits. If eligibility is verified the dependent's effective date will be as follows:

(i) SEBB health plan coverage will be the same as the subscriber's effective date;

(ii) Supplemental dependent life insurance or AD&D insurance, if elected, will be effective the first day of the month following the date the contracted vendor receives the required form or approves the enrollment. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage is effective.

(b) During the annual open enrollment. SEBB health plan coverage begins January 1st of the following year;

(c) During special open enrollment. Subscribers may enroll dependents during a special open enrollment as described in subsection (3) of this section;

(d) When a National Medical Support Notice (NMSN) requires a subscriber to cover a dependent child in health plan coverage as described in WAC 182-31-160; or

(e) Any time during the calendar year for supplemental dependent life insurance or AD&D insurance by submitting the required form to the contracted vendor for approval. Evidence of insurability may be required for supplemental dependent life insurance but will not be required for supplemental AD&D insurance. Supplemental dependent life insurance or AD&D insurance will be effective the first day of the month following the date the contracted vendor receives the required form or approves the enrollment. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage is effective.

(2) Removing dependents from SEBB health plan coverage or supplemental dependent life insurance or AD&D insurance.

(a) A dependent's eligibility for enrollment in SEBB health plan coverage or supplemental dependent life insurance or AD&D insurance ends the last day of the month the dependent meets the eligibility criteria as described in WAC 182-31-140. Subscribers must provide notice when a dependent is no longer eligible due to divorce, annulment, dissolution, or qualifying event of dependent ceasing to be eligible as a dependent child as described in WAC 182-31-140(3). For supplemental dependent life insurance or AD&D insurance, subscribers must notify the contracted vendor on the required form, in writing, or by telephone when a dependent is no longer eligible. Contact information for the contracted vendor may be found at hca.wa.gov/sebb-employee-contact-plan. For SEBB health plan coverage, the notice must be received within 60 days of the last day of the month the dependent loses eligibility. School employees must notify their SEBB organization when a dependent is no longer eligible for SEBB health plan coverage, except as required under WAC 182-31-140 (3)(f)(ii). All other subscribers must notify the SEBB program. Consequences for not submitting notice within the required 60 days include, but are not limited to:

(i) The dependent may lose eligibility to continue SEBB medical, dental, or vision under one of the continuation coverage options described in WAC 182-31-130;

(ii) The subscriber may be billed for claims paid by the health plan for services that were rendered after the dependent lost eligibility as described in WAC 182-31-130;

(iii) The subscriber may not be able to recover subscriber-paid insurance premiums for dependents that lost their eligibility; and

(iv) The subscriber may be responsible for premiums paid by the state for the dependent's health plan coverage after the dependent lost eligibility.

(b) School employees have the opportunity to remove eligible dependents:

(i) During the annual open enrollment. The dependent will be removed from SEBB health plan coverage the last day of December;

(ii) During a special open enrollment as described in subsections (3) and (4)(f) of this section;

(iii) When a NMSN requires a spouse, former spouse, or other individual to provide health plan coverage for a dependent who is already enrolled in SEBB coverage, and that health plan coverage is in fact provided as described in WAC 182-31-160(2); or

(iv) Any time during the calendar year from supplemental dependent life insurance or AD&D insurance by submitting a request to the contracted vendor on the required form, in writing, or by telephone. Contact information for the contracted vendor may be found at hca.wa.gov/sebb-employee-contact-plan.

(c) Enrollees with SEBB continuation coverage as described in WAC 182-31-090 and 182-31-100, or a school board member as described in WAC 182-31-200 may remove dependents from their SEBB health plan coverage outside of the annual open enrollment or a special open enrollment by providing written notice to the SEBB program. The dependent will be removed from the subscriber's SEBB health plan coverage prospectively. SEBB health plan coverage will end on the last day of the month in which the written notice is received by the SEBB program or on the last day of the month specified in the subscriber's written notice, whichever is later. If the written notice is received on the first day of the month, SEBB health plan coverage will end on the last day of the previous month. SEBB continuation coverage enrollees may remove dependents from supplemental dependent life insurance or AD&D insurance any time during the calendar year by submitting a request to the contracted vendor on the required form, in writing, or by telephone. Contact information for the contracted vendor may be found at hca.wa.gov/sebb-employee-contact-plan.

(3) Special open enrollment.

(a) Subscribers may enroll or remove their eligible dependents outside of the annual open enrollment if a special open enrollment event occurs. The change in enrollment must be allowable under the Internal Revenue Code and Treasury regulations, and correspond to and be consistent with the event that creates the special open enrollment for the subscriber, the subscriber's dependents, or both.

(i) SEBB health plan coverage will begin the first of the month following the later of the event date or the date the required form is received. If that day is the first of the month, the change in enrollment begins on that day.

(ii) SEBB health plan coverage for an extended dependent or a dependent with a disability will begin the first day of the month following the later of the event date or eligibility certification.

(iii) The dependent will be removed from the subscriber's SEBB health plan coverage the last day of the month following the later of the event date or the date the required form and proof of the event is received. If that day is the first of the month, the change in enrollment will be made the last day of the previous month.

(iv) If the special open enrollment is due to the birth or adoption of a child, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption of a child, SEBB health plan coverage will begin or end as follows:

• For the newly born child, SEBB health plan coverage will begin the date of birth;

• For a newly adopted child, SEBB health plan coverage will begin on the date of placement or the date a legal obligation is assumed in anticipation of adoption, whichever is earlier;

• For a spouse or state registered domestic partner of a subscriber, SEBB health plan coverage will begin the first day of the month in which the event occurs. The spouse or state registered domestic partner will be removed from SEBB health plan coverage the last day of the month in which the event occurred.

(v) Supplemental dependent life insurance or AD&D insurance will begin the first day of the month following the date the contracted vendor receives the required form or approves the enrollment. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage is effective.

(b) The events described in this subsection (3)(b)(i) of this section create a special open enrollment to enroll eligible dependents in supplemental dependent life insurance or AD&D insurance. Any one of the following events may create a special open enrollment to enroll or remove eligible dependents from SEBB health plan coverage:

(i) Subscriber acquires a new dependent due to:

• Marriage or registering a state registered domestic partnership;

• Birth, adoption, or when a subscriber has assumed a legal obligation for total or partial support in anticipation of adoption; or

• A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(ii) Subscriber or a subscriber's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA);

(iii) Subscriber has a change in employment status that affects the subscriber's eligibility for their employer contribution toward their employer-based group health plan;

(iv) The subscriber's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution under their employer-based group health plan;

| Note: | As used in (iv) of this subsection "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 54.9801-6. |
| --- | --- |

(v) Subscriber or a subscriber's dependent has a change in enrollment under an employer-based group health plan during its annual open enrollment that does not align with the SEBB program's annual open enrollment;

(vi) Subscriber's dependent has a change in residence from outside of the United States to within the United States, or from within the United States to outside of the United States and that change in residence results in the dependent losing their health insurance;

(vii) A court order requires the subscriber or any other individual to provide insurance coverage for an eligible dependent of the subscriber (a former spouse or former state registered domestic partner is not an eligible dependent);

(viii) Subscriber or a subscriber's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the subscriber or a subscriber's dependent loses eligibility for coverage under medicaid or CHIP;

(ix) Subscriber or a subscriber's dependent becomes eligible for state premium assistance subsidy for SEBB health plan coverage from medicaid or CHIP;

(x) Subscriber's dependent enrolls in medicare, or loses eligibility for medicare.

(4) Enrollment requirements. A subscriber must submit the required forms within the time frames described in this subsection. For SEBB health plan coverage, a school employee must submit the required forms to their SEBB organization, any other subscriber must submit the required forms to the SEBB program. In addition to the required forms indicating dependent enrollment, the subscriber must provide the required documents as evidence of the dependent's eligibility; or as evidence of the event that created the special open enrollment. All required forms and documents must be received within the required time frames. A school employee enrolling a dependent in supplemental dependent life insurance or AD&D insurance must submit the required form to the contracted vendor for approval within the required time frames.

| Note: | When enrolling a state registered domestic partner or a state registered domestic partner's child, a subscriber must certify that the state registered domestic partner or state registered domestic partner's child is a tax dependent on the required form; otherwise, the SEBB program will assume the state registered domestic partner or state registered domestic partner's child is not a tax dependent. |
| --- | --- |

(a) If a subscriber wants to enroll their eligible dependents in SEBB health plan coverage when the subscriber becomes eligible to enroll in SEBB benefits, the subscriber must include the dependent's enrollment information on the required forms and submit them within the required time frame as described in WAC 182-30-060, 182-30-080, or 182-31-200. If a school employee enrolls a dependent in supplemental dependent life insurance or AD&D insurance, the required form must be submitted within the required time frame described in WAC 182-30-080.

(b) If a subscriber wants to enroll eligible dependents in SEBB health plan coverage during the SEBB annual open enrollment period, the required forms must be received no later than the last day of the annual open enrollment.

(c) If a subscriber wants to enroll newly eligible dependents, the required forms must be received no later than 60 days after the dependent becomes eligible. A school employee enrolling a dependent in supplemental dependent life insurance or AD&D insurance must submit the required form to the contracted vendor for approval. A school employee may enroll a dependent in supplemental dependent life insurance up to the guaranteed issue coverage amount without evidence of insurability if the required form is submitted to the contracted vendor as required. Evidence of insurability will be required for supplemental dependent life insurance over the guaranteed issue coverage amount. Evidence of insurability is not required for supplemental AD&D insurance.

(d) If a subscriber wants to enroll a newborn or child whom the subscriber has adopted or has assumed a legal obligation for total or partial support in anticipation of adoption in SEBB health plan coverage, the subscriber should notify the SEBB program by submitting the required forms as soon as possible to ensure timely payment of claims. If adding the child increases the premium, the required forms must be received no later than 60 days after the date of the birth, adoption, or the date the legal obligation is assumed for total or partial support in anticipation of adoption. A school employee enrolling a dependent in supplemental dependent life insurance or AD&D insurance must submit the required form to the contracted vendor for approval no later than 60 days after the date of the birth, adoption, or the date the legal obligation is assumed for total or partial support in anticipation of adoption. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage can become effective.

(e) If the subscriber wants to enroll a child age 26 or older as a child with a disability in SEBB health plan coverage, the required forms must be received no later than 60 days after the child reaches age 26 or within the relevant time frame described in (a), (b), and (f) of this subsection. To recertify an enrolled child with a disability, the required forms must be received by the SEBB program or the contracted vendor by the child's scheduled SEBB health plan coverage termination date.

(f) If the subscriber wants to change a dependent's enrollment status in SEBB health plan coverage during a special open enrollment, the required forms must be received no later than 60 days after the event that creates the special open enrollment.

(g) A school employee may enroll a dependent in supplemental dependent life insurance or AD&D insurance at any time during the calendar year by submitting the required form to the contracted vendor for approval. Evidence of insurability may be required for supplemental dependent life insurance but will not be required for supplemental AD&D insurance.

***(Effective January 1, 2027)***

PDF WAC 182-31-150

When may subscribers enroll or remove eligible dependents?

(1) Enrolling dependents in school employees benefits board (SEBB) health plan coverage, supplemental dependent life insurance, and accidental death and dismemberment (AD&D) insurance. A dependent must be enrolled in the same health plan coverage as the subscriber, and the subscriber must be enrolled in health plan coverage to enroll their dependent in health plan coverage. A dependent with more than one source of eligibility for enrollment in the public employees benefits board (PEBB) and SEBB programs is limited to a single enrollment in medical, dental, and vision plans in either the PEBB or SEBB program. Subscribers must satisfy the enrollment requirements as described in subsection (4) of this section and may enroll eligible dependents at the following times:

(a) When the subscriber becomes eligible and enrolls in SEBB benefits. If eligibility is verified the dependent's effective date will be as follows:

(i) SEBB health plan coverage will be the same as the subscriber's effective date;

(ii) Supplemental dependent life insurance or AD&D insurance, if elected, will be effective the first day of the month following the date the contracted vendor receives the required form or approves the enrollment. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage is effective.

(b) During the annual open enrollment. SEBB health plan coverage begins January 1st of the following year;

(c) During special open enrollment. Subscribers may enroll dependents during a special open enrollment as described in subsection (3) of this section;

(d) When a National Medical Support Notice (NMSN) requires a subscriber to cover a dependent child in health plan coverage as described in WAC 182-31-160; or

(e) Any time during the calendar year for supplemental dependent life insurance or AD&D insurance by submitting the required form to the contracted vendor for approval. Evidence of insurability may be required for supplemental dependent life insurance but will not be required for supplemental AD&D insurance. Supplemental dependent life insurance or AD&D insurance will be effective the first day of the month following the date the contracted vendor receives the required form or approves the enrollment. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage is effective.

(2) Removing dependents from SEBB health plan coverage or supplemental dependent life insurance or AD&D insurance.

(a) A dependent's eligibility for enrollment in SEBB health plan coverage or supplemental dependent life insurance or AD&D insurance ends the last day of the month the dependent meets the eligibility criteria as described in WAC 182-31-140. Subscribers must provide notice when a dependent is no longer eligible due to divorce, annulment, dissolution, or qualifying event of dependent ceasing to be eligible as a dependent child as described in WAC 182-31-140(3). For supplemental dependent life insurance or AD&D insurance, subscribers must notify the contracted vendor on the required form, in writing, or by telephone when a dependent is no longer eligible. Contact information for the contracted vendor may be found at hca.wa.gov/sebb-employee-contact-plan. For SEBB health plan coverage, the notice must be received within 60 days of the last day of the month the dependent loses eligibility. School employees must notify their SEBB organization when a dependent is no longer eligible for SEBB health plan coverage, except as required under WAC 182-31-140 (3)(f)(ii). All other subscribers must notify the SEBB program. Consequences for not submitting notice within the required 60 days include, but are not limited to:

(i) The dependent may lose eligibility to continue SEBB medical, dental, or vision under one of the continuation coverage options described in WAC 182-31-130;

(ii) The subscriber may be billed for claims paid by the health plan for services that were rendered after the dependent lost eligibility as described in WAC 182-31-130;

(iii) The subscriber may not be able to recover subscriber-paid insurance premiums for dependents that lost their eligibility; and

(iv) The subscriber may be responsible for premiums paid by the state for the dependent's health plan coverage after the dependent lost eligibility.

(b) School employees have the opportunity to remove eligible dependents:

(i) During the annual open enrollment. The dependent will be removed from SEBB health plan coverage the last day of December;

(ii) During a special open enrollment as described in subsections (3) and (4)(f) of this section;

(iii) When a NMSN requires a spouse, former spouse, or other individual to provide health plan coverage for a dependent who is already enrolled in SEBB coverage, and that health plan coverage is in fact provided as described in WAC 182-31-160(2); or

(iv) Any time during the calendar year from supplemental dependent life insurance or AD&D insurance by submitting a request to the contracted vendor on the required form, in writing, or by telephone. Contact information for the contracted vendor may be found at hca.wa.gov/sebb-employee-contact-plan.

(c) Enrollees with SEBB continuation coverage as described in WAC 182-31-090 and 182-31-100, or a school board member as described in WAC 182-31-200 may remove dependents from their SEBB health plan coverage outside of the annual open enrollment or a special open enrollment by providing written notice to the SEBB program. The dependent will be removed from the subscriber's SEBB health plan coverage prospectively. SEBB health plan coverage will end on the last day of the month in which the written notice is received by the SEBB program or on the last day of the month specified in the subscriber's written notice, whichever is later. If the written notice is received on the first day of the month, SEBB health plan coverage will end on the last day of the previous month. SEBB continuation coverage enrollees may remove dependents from supplemental dependent life insurance or AD&D insurance any time during the calendar year by submitting a request to the contracted vendor on the required form, in writing, or by telephone. Contact information for the contracted vendor may be found at hca.wa.gov/sebb-employee-contact-plan.

(3) Special open enrollment.

(a) Subscribers may enroll or remove their eligible dependents outside of the annual open enrollment if a special open enrollment event occurs. The change in enrollment must be allowable under the Internal Revenue Code and Treasury regulations, and correspond to and be consistent with the event that creates the special open enrollment for the subscriber, the subscriber's dependents, or both.

(i) SEBB health plan coverage will begin the first of the month following the later of the event date or the date the required form is received. If that day is the first of the month, the change in enrollment begins on that day.

| Note: | As used in (a)(i) of this subsection, "the date the required form is received" may determine the effective date of coverage before proof of the event is received. |
| --- | --- |

(ii) SEBB health plan coverage for an extended dependent or a dependent with a disability will begin the first day of the month following the later of the event date or eligibility certification.

(iii) The dependent will be removed from the subscriber's SEBB health plan coverage the last day of the month following the later of the event date or the date the required form and proof of the event is received. If that day is the first of the month, the change in enrollment will be made the last day of the previous month.

(iv) If the special open enrollment is due to the birth or adoption of a child, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption of a child, SEBB health plan coverage will begin or end as follows:

• For the newly born child, SEBB health plan coverage will begin the date of birth;

• For a newly adopted child, SEBB health plan coverage will begin on the date of placement or the date a legal obligation is assumed in anticipation of adoption, whichever is earlier;

• For a spouse or state registered domestic partner of a subscriber, SEBB health plan coverage will begin the first day of the month in which the event occurs. The spouse or state registered domestic partner will be removed from SEBB health plan coverage the last day of the month in which the event occurred.

(v) Supplemental dependent life insurance or AD&D insurance will begin the first day of the month following the date the contracted vendor receives the required form or approves the enrollment. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage is effective.

(b) The events described in this subsection (3)(b)(i) of this section create a special open enrollment to enroll eligible dependents in supplemental dependent life insurance or AD&D insurance. Any one of the following events may create a special open enrollment to enroll or remove eligible dependents from SEBB health plan coverage:

(i) Subscriber acquires a new dependent due to:

• Marriage or registering a state registered domestic partnership;

• Birth, adoption, or when a subscriber has assumed a legal obligation for total or partial support in anticipation of adoption; or

• A child becoming eligible as an extended dependent through legal custody or legal guardianship.

(ii) Subscriber or a subscriber's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA);

(iii) Subscriber has a change in employment status that affects the subscriber's eligibility for their employer contribution toward their employer-based group health plan;

(iv) The subscriber's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution under their employer-based group health plan;

| Note: | As used in (iv) of this subsection "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 54.9801-6. |
| --- | --- |

(v) Subscriber or a subscriber's dependent has a change in enrollment under an employer-based group health plan during its annual open enrollment that does not align with the SEBB program's annual open enrollment;

(vi) Subscriber's dependent has a change in residence from outside of the United States to within the United States, or from within the United States to outside of the United States and that change in residence results in the dependent losing their health insurance;

(vii) A court order requires the subscriber or any other individual to provide insurance coverage for an eligible dependent of the subscriber (a former spouse or former state registered domestic partner is not an eligible dependent);

(viii) Subscriber or a subscriber's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the subscriber or a subscriber's dependent loses eligibility for coverage under medicaid or CHIP;

(ix) Subscriber or a subscriber's dependent becomes eligible for state premium assistance subsidy for SEBB health plan coverage from medicaid or CHIP;

(x) Subscriber's dependent enrolls in medicare, or loses eligibility for medicare;

(xi) Subscriber or a subscriber's dependent becomes eligible and enrolls in a TRICARE plan or loses eligibility for a TRICARE plan.

(4) Enrollment requirements. A subscriber must submit the required forms within the time frames described in this subsection. For SEBB health plan coverage, a school employee must submit the required forms to their SEBB organization, any other subscriber must submit the required forms to the SEBB program. In addition to the required forms indicating dependent enrollment, the subscriber must provide the required documents as evidence of the dependent's eligibility; or as evidence of the event that created the special open enrollment. All required forms and documents must be received within the required time frames. A school employee enrolling a dependent in supplemental dependent life insurance or AD&D insurance must submit the required form to the contracted vendor for approval within the required time frames.

| Note: | When enrolling a state registered domestic partner or a state registered domestic partner's child, a subscriber must certify that the state registered domestic partner or state registered domestic partner's child is a tax dependent on the required form; otherwise, the SEBB program will assume the state registered domestic partner or state registered domestic partner's child is not a tax dependent. |
| --- | --- |

(a) If a subscriber wants to enroll their eligible dependents in SEBB health plan coverage when the subscriber becomes eligible to enroll in SEBB benefits, the subscriber must include the dependent's enrollment information on the required forms and submit them within the required time frame as described in WAC 182-30-060, 182-30-080, or 182-31-200. If a school employee enrolls a dependent in supplemental dependent life insurance or AD&D insurance, the required form must be submitted within the required time frame described in WAC 182-30-080.

(b) If a subscriber wants to enroll eligible dependents in SEBB health plan coverage during the SEBB annual open enrollment period, the required forms must be received no later than the last day of the annual open enrollment.

(c) If a subscriber wants to enroll newly eligible dependents, the required forms must be received no later than 60 days after the dependent becomes eligible. A school employee enrolling a dependent in supplemental dependent life insurance or AD&D insurance must submit the required form to the contracted vendor for approval. A school employee may enroll a dependent in supplemental dependent life insurance up to the guaranteed issue coverage amount without evidence of insurability if the required form is submitted to the contracted vendor as required. Evidence of insurability will be required for supplemental dependent life insurance over the guaranteed issue coverage amount. Evidence of insurability is not required for supplemental AD&D insurance.

(d) If a subscriber wants to enroll a newborn or child whom the subscriber has adopted or has assumed a legal obligation for total or partial support in anticipation of adoption in SEBB health plan coverage, the subscriber should notify the SEBB program by submitting the required forms as soon as possible to ensure timely payment of claims. If adding the child increases the premium, the required forms must be received no later than 60 days after the date of the birth, adoption, or the date the legal obligation is assumed for total or partial support in anticipation of adoption. A school employee enrolling a dependent in supplemental dependent life insurance or AD&D insurance must submit the required form to the contracted vendor for approval no later than 60 days after the date of the birth, adoption, or the date the legal obligation is assumed for total or partial support in anticipation of adoption. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage can become effective.

(e) If the subscriber wants to enroll a child age 26 or older as a child with a disability in SEBB health plan coverage, the required forms must be received no later than 60 days after the child reaches age 26 or within the relevant time frame described in (a), (b), and (f) of this subsection. To recertify an enrolled child with a disability, the required forms must be received by the SEBB program or the contracted vendor by the child's scheduled SEBB health plan coverage termination date.

(f) If the subscriber wants to change a dependent's enrollment status in SEBB health plan coverage during a special open enrollment, the required forms must be received no later than 60 days after the event that creates the special open enrollment.

(g) A school employee may enroll a dependent in supplemental dependent life insurance or AD&D insurance at any time during the calendar year by submitting the required form to the contracted vendor for approval. Evidence of insurability may be required for supplemental dependent life insurance but will not be required for supplemental AD&D insurance.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-31-150, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-31-150, filed 6/21/22, effective 1/1/23*
- *WSR 21-13-117 (Admin #2021-01.04), § 182-31-150, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-31-150, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-31-150, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-31-150, filed 12/14/18, effective 1/14/19.](Effective January 1, 2027) PDF WAC 182-31-150 When may subscribers enroll or remove eligible dependents? (1) Enrolling dependents in school employees benefits board (SEBB) health plan coverage, supplemental dependent life insurance, and accidental death and dismemberment (AD&D) insurance. A dependent must be enrolled in the same health plan coverage as the subscriber, and the subscriber must be enrolled in health plan coverage to enroll their dependent in health plan coverage. A dependent with more than one source of eligibility for enrollment in the public employees benefits board (PEBB) and SEBB programs is limited to a single enrollment in medical, dental, and vision plans in either the PEBB or SEBB program. Subscribers must satisfy the enrollment requirements as described in subsection (4) of this section and may enroll eligible dependents at the following times:(a) When the subscriber becomes eligible and enrolls in SEBB benefits. If eligibility is verified the dependent's effective date will be as follows:(i) SEBB health plan coverage will be the same as the subscriber's effective date*
- *(ii) Supplemental dependent life insurance or AD&D insurance, if elected, will be effective the first day of the month following the date the contracted vendor receives the required form or approves the enrollment. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage is effective.(b) During the annual open enrollment. SEBB health plan coverage begins January 1st of the following year*
- *(c) During special open enrollment. Subscribers may enroll dependents during a special open enrollment as described in subsection (3) of this section*
- *(d) When a National Medical Support Notice (NMSN) requires a subscriber to cover a dependent child in health plan coverage as described in WAC 182-31-160*
- *or(e) Any time during the calendar year for supplemental dependent life insurance or AD&D insurance by submitting the required form to the contracted vendor for approval. Evidence of insurability may be required for supplemental dependent life insurance but will not be required for supplemental AD&D insurance. Supplemental dependent life insurance or AD&D insurance will be effective the first day of the month following the date the contracted vendor receives the required form or approves the enrollment. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage is effective.(2) Removing dependents from SEBB health plan coverage or supplemental dependent life insurance or AD&D insurance.(a) A dependent's eligibility for enrollment in SEBB health plan coverage or supplemental dependent life insurance or AD&D insurance ends the last day of the month the dependent meets the eligibility criteria as described in WAC 182-31-140. Subscribers must provide notice when a dependent is no longer eligible due to divorce, annulment, dissolution, or qualifying event of dependent ceasing to be eligible as a dependent child as described in WAC 182-31-140(3). For supplemental dependent life insurance or AD&D insurance, subscribers must notify the contracted vendor on the required form, in writing, or by telephone when a dependent is no longer eligible. Contact information for the contracted vendor may be found at hca.wa.gov/sebb-employee-contact-plan. For SEBB health plan coverage, the notice must be received within 60 days of the last day of the month the dependent loses eligibility. School employees must notify their SEBB organization when a dependent is no longer eligible for SEBB health plan coverage, except as required under WAC 182-31-140 (3)(f)(ii). All other subscribers must notify the SEBB program. Consequences for not submitting notice within the required 60 days include, but are not limited to:(i) The dependent may lose eligibility to continue SEBB medical, dental, or vision under one of the continuation coverage options described in WAC 182-31-130*
- *(ii) The subscriber may be billed for claims paid by the health plan for services that were rendered after the dependent lost eligibility as described in WAC 182-31-130*
- *(iii) The subscriber may not be able to recover subscriber-paid insurance premiums for dependents that lost their eligibility*
- *and(iv) The subscriber may be responsible for premiums paid by the state for the dependent's health plan coverage after the dependent lost eligibility.(b) School employees have the opportunity to remove eligible dependents:(i) During the annual open enrollment. The dependent will be removed from SEBB health plan coverage the last day of December*
- *(ii) During a special open enrollment as described in subsections (3) and (4)(f) of this section*
- *(iii) When a NMSN requires a spouse, former spouse, or other individual to provide health plan coverage for a dependent who is already enrolled in SEBB coverage, and that health plan coverage is in fact provided as described in WAC 182-31-160(2)*
- *or(iv) Any time during the calendar year from supplemental dependent life insurance or AD&D insurance by submitting a request to the contracted vendor on the required form, in writing, or by telephone. Contact information for the contracted vendor may be found at hca.wa.gov/sebb-employee-contact-plan.(c) Enrollees with SEBB continuation coverage as described in WAC 182-31-090 and 182-31-100, or a school board member as described in WAC 182-31-200 may remove dependents from their SEBB health plan coverage outside of the annual open enrollment or a special open enrollment by providing written notice to the SEBB program. The dependent will be removed from the subscriber's SEBB health plan coverage prospectively. SEBB health plan coverage will end on the last day of the month in which the written notice is received by the SEBB program or on the last day of the month specified in the subscriber's written notice, whichever is later. If the written notice is received on the first day of the month, SEBB health plan coverage will end on the last day of the previous month. SEBB continuation coverage enrollees may remove dependents from supplemental dependent life insurance or AD&D insurance any time during the calendar year by submitting a request to the contracted vendor on the required form, in writing, or by telephone. Contact information for the contracted vendor may be found at hca.wa.gov/sebb-employee-contact-plan.(3) Special open enrollment.(a) Subscribers may enroll or remove their eligible dependents outside of the annual open enrollment if a special open enrollment event occurs. The change in enrollment must be allowable under the Internal Revenue Code and Treasury regulations, and correspond to and be consistent with the event that creates the special open enrollment for the subscriber, the subscriber's dependents, or both.(i) SEBB health plan coverage will begin the first of the month following the later of the event date or the date the required form is received. If that day is the first of the month, the change in enrollment begins on that day.Note:As used in (a)(i) of this subsection, "the date the required form is received" may determine the effective date of coverage before proof of the event is received.(ii) SEBB health plan coverage for an extended dependent or a dependent with a disability will begin the first day of the month following the later of the event date or eligibility certification.(iii) The dependent will be removed from the subscriber's SEBB health plan coverage the last day of the month following the later of the event date or the date the required form and proof of the event is received. If that day is the first of the month, the change in enrollment will be made the last day of the previous month.(iv) If the special open enrollment is due to the birth or adoption of a child, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption of a child, SEBB health plan coverage will begin or end as follows:• For the newly born child, SEBB health plan coverage will begin the date of birth*
- *• For a newly adopted child, SEBB health plan coverage will begin on the date of placement or the date a legal obligation is assumed in anticipation of adoption, whichever is earlier*
- *• For a spouse or state registered domestic partner of a subscriber, SEBB health plan coverage will begin the first day of the month in which the event occurs. The spouse or state registered domestic partner will be removed from SEBB health plan coverage the last day of the month in which the event occurred.(v) Supplemental dependent life insurance or AD&D insurance will begin the first day of the month following the date the contracted vendor receives the required form or approves the enrollment. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage is effective.(b) The events described in this subsection (3)(b)(i) of this section create a special open enrollment to enroll eligible dependents in supplemental dependent life insurance or AD&D insurance. Any one of the following events may create a special open enrollment to enroll or remove eligible dependents from SEBB health plan coverage:(i) Subscriber acquires a new dependent due to:• Marriage or registering a state registered domestic partnership*
- *• Birth, adoption, or when a subscriber has assumed a legal obligation for total or partial support in anticipation of adoption*
- *or• A child becoming eligible as an extended dependent through legal custody or legal guardianship.(ii) Subscriber or a subscriber's dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA)*
- *(iii) Subscriber has a change in employment status that affects the subscriber's eligibility for their employer contribution toward their employer-based group health plan*
- *(iv) The subscriber's dependent has a change in their own employment status that affects their eligibility or their dependent's eligibility for the employer contribution under their employer-based group health plan*
- *Note:As used in (iv) of this subsection "employer contribution" means contributions made by the dependent's current or former employer toward health coverage as described in Treasury Regulation 54.9801-6.(v) Subscriber or a subscriber's dependent has a change in enrollment under an employer-based group health plan during its annual open enrollment that does not align with the SEBB program's annual open enrollment*
- *(vi) Subscriber's dependent has a change in residence from outside of the United States to within the United States, or from within the United States to outside of the United States and that change in residence results in the dependent losing their health insurance*
- *(vii) A court order requires the subscriber or any other individual to provide insurance coverage for an eligible dependent of the subscriber (a former spouse or former state registered domestic partner is not an eligible dependent)*
- *(viii) Subscriber or a subscriber's dependent enrolls in coverage under medicaid or a state children's health insurance program (CHIP), or the subscriber or a subscriber's dependent loses eligibility for coverage under medicaid or CHIP*
- *(ix) Subscriber or a subscriber's dependent becomes eligible for state premium assistance subsidy for SEBB health plan coverage from medicaid or CHIP*
- *(x) Subscriber's dependent enrolls in medicare, or loses eligibility for medicare*
- *(xi) Subscriber or a subscriber's dependent becomes eligible and enrolls in a TRICARE plan or loses eligibility for a TRICARE plan.(4) Enrollment requirements. A subscriber must submit the required forms within the time frames described in this subsection. For SEBB health plan coverage, a school employee must submit the required forms to their SEBB organization, any other subscriber must submit the required forms to the SEBB program. In addition to the required forms indicating dependent enrollment, the subscriber must provide the required documents as evidence of the dependent's eligibility*
- *or as evidence of the event that created the special open enrollment. All required forms and documents must be received within the required time frames. A school employee enrolling a dependent in supplemental dependent life insurance or AD&D insurance must submit the required form to the contracted vendor for approval within the required time frames.Note:When enrolling a state registered domestic partner or a state registered domestic partner's child, a subscriber must certify that the state registered domestic partner or state registered domestic partner's child is a tax dependent on the required form*
- *otherwise, the SEBB program will assume the state registered domestic partner or state registered domestic partner's child is not a tax dependent.(a) If a subscriber wants to enroll their eligible dependents in SEBB health plan coverage when the subscriber becomes eligible to enroll in SEBB benefits, the subscriber must include the dependent's enrollment information on the required forms and submit them within the required time frame as described in WAC 182-30-060, 182-30-080, or 182-31-200. If a school employee enrolls a dependent in supplemental dependent life insurance or AD&D insurance, the required form must be submitted within the required time frame described in WAC 182-30-080.(b) If a subscriber wants to enroll eligible dependents in SEBB health plan coverage during the SEBB annual open enrollment period, the required forms must be received no later than the last day of the annual open enrollment.(c) If a subscriber wants to enroll newly eligible dependents, the required forms must be received no later than 60 days after the dependent becomes eligible. A school employee enrolling a dependent in supplemental dependent life insurance or AD&D insurance must submit the required form to the contracted vendor for approval. A school employee may enroll a dependent in supplemental dependent life insurance up to the guaranteed issue coverage amount without evidence of insurability if the required form is submitted to the contracted vendor as required. Evidence of insurability will be required for supplemental dependent life insurance over the guaranteed issue coverage amount. Evidence of insurability is not required for supplemental AD&D insurance.(d) If a subscriber wants to enroll a newborn or child whom the subscriber has adopted or has assumed a legal obligation for total or partial support in anticipation of adoption in SEBB health plan coverage, the subscriber should notify the SEBB program by submitting the required forms as soon as possible to ensure timely payment of claims. If adding the child increases the premium, the required forms must be received no later than 60 days after the date of the birth, adoption, or the date the legal obligation is assumed for total or partial support in anticipation of adoption. A school employee enrolling a dependent in supplemental dependent life insurance or AD&D insurance must submit the required form to the contracted vendor for approval no later than 60 days after the date of the birth, adoption, or the date the legal obligation is assumed for total or partial support in anticipation of adoption. A newly born child must be at least 14 days old before supplemental dependent life insurance or AD&D insurance coverage can become effective.(e) If the subscriber wants to enroll a child age 26 or older as a child with a disability in SEBB health plan coverage, the required forms must be received no later than 60 days after the child reaches age 26 or within the relevant time frame described in (a), (b), and (f) of this subsection. To recertify an enrolled child with a disability, the required forms must be received by the SEBB program or the contracted vendor by the child's scheduled SEBB health plan coverage termination date.(f) If the subscriber wants to change a dependent's enrollment status in SEBB health plan coverage during a special open enrollment, the required forms must be received no later than 60 days after the event that creates the special open enrollment.(g) A school employee may enroll a dependent in supplemental dependent life insurance or AD&D insurance at any time during the calendar year by submitting the required form to the contracted vendor for approval. Evidence of insurability may be required for supplemental dependent life insurance but will not be required for supplemental AD&D insurance.[Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.740. WSR 26-14-083 (Admin #2026.01), s 182-31-150, filed 6/29/26, effective 1/1/27. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-31-150, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-31-150, filed 6/21/22, effective 1/1/23*
- *WSR 21-13-117 (Admin #2021-01.04), § 182-31-150, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-31-150, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-31-150, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-31-150, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-31-160** National Medical Support Notice (NMSN). {#sec-182-31-160 omnilex-key=us-wa-regs-official--title-182--182-31-160}

(1) When a National Medical Support Notice (NMSN) requires a subscriber to provide health plan coverage for a dependent child the following provisions apply:

(a) The subscriber may enroll their dependent child and request changes to their health plan coverage as described under (c) of this subsection. School employees submit the required forms to their school employees benefits board (SEBB) organization. All other subscribers submit the required forms to the SEBB program;

(b) If the subscriber fails to request enrollment or health plan coverage changes as directed by the NMSN, the SEBB organization or the SEBB program may make enrollment or health plan coverage changes according to (c) of this subsection upon request of:

(i) The child's other parent; or

(ii) Child support enforcement program.

(c) Changes to health plan coverage or enrollment are allowed as directed by the NMSN:

(i) The dependent will be enrolled under the subscriber's health plan coverage as directed by the NMSN;

(ii) A school employee who has waived SEBB medical as described in WAC 182-31-080 will be enrolled in medical as directed by the NMSN, in order to enroll the dependent;

(iii) The subscriber's selected health plan will be changed if directed by the NMSN;

(iv) If the dependent is already enrolled under another SEBB subscriber, the dependent will be removed from the other health plan coverage and enrolled as directed by the NMSN;

(v) If the dependent is enrolled in both public employees benefits board medical and SEBB medical as a dependent as described in WAC 182-31-070 (6)(f) and there is a NMSN in place, enrollment will be in accordance with the NMSN; or

(vi) If the subscriber is eligible for and elects Consolidated Omnibus Budget Reconciliation Act (COBRA) or other continuation coverage, the NMSN will be enforced and the dependent must be covered in accordance with the NMSN.

(d) Changes to health plan coverage or enrollment as described in (c)(i) through (iii) of this subsection will begin the first day of the month following receipt by the SEBB organization or the SEBB program of the NMSN. If the NMSN is received on the first day of the month, the change to health plan coverage or enrollment begins on that day. A dependent will be removed from the subscriber's health plan coverage as described in (c)(iv) of this subsection the last day of the month the NMSN is received. If that day is the first of the month, the change in enrollment will be made the last day of the previous month.

(2) When a NMSN requires a spouse, former spouse, or other individual to provide health plan coverage for a dependent who is already enrolled in SEBB coverage, and that health plan coverage is in fact provided, the dependent may be removed from the subscriber's SEBB health plan coverage prospectively.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-31-160, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160 and Policy resolutions SEBB 2021-02, 2021-03, 2021-04, 2021-05, 2021-06, 2021-07, 2021-08, 2021-09, 2021-11. WSR 21-13-115 (Admin #2021-01.02), § 182-31-160, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-31-160, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-31-160, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-31-160, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-31-190** School employees benefits board (SEBB) wellness incentive program eligibility and procedural requirements. {#sec-182-31-190 omnilex-key=us-wa-regs-official--title-182--182-31-190}

The board annually determines the design of the SEBB wellness incentive program.

(1) All subscribers are eligible to participate in the SEBB wellness incentive program.

(2) Effective January 1, 2020, to receive the SEBB wellness incentive of a reduction to the subscriber's medical plan deductible or a deposit to the subscriber's health savings account for the following plan year, eligible subscribers must complete SEBB wellness incentive program requirements during the current plan year by the following deadline:

(a) For subscribers continuing enrollment in SEBB medical and subscribers enrolling in SEBB medical with an effective date in January through September, the deadline is November 30th; or

(b) For subscribers enrolling in SEBB medical with an effective date in October through December, the deadline is December 31st.

(3) Subscribers who do not complete the requirements according to subsection (2) of this section within the time frame described are not eligible to receive a SEBB wellness incentive the following plan year.

| Note: | All eligible subscribers can earn a wellness incentive. Subscribers who cannot complete the wellness incentive program requirements may be able to earn the same incentive by different means. The contracted vendor will work with enrollees (and their physician, if they wish) to define an individual wellness program that provides the opportunity to qualify for the same incentive in light of the enrollee's health status. |
| --- | --- |

(4) A SEBB wellness incentive will be provided only if:

(a) For the wellness incentive described in subsection (2) of this section the subscriber is still eligible to participate in the SEBB wellness incentive program, and is enrolled in a SEBB medical plan in the year the incentive applies;

(b) The funding rate provided by the legislature is designed to provide a SEBB wellness incentive program or a SEBB wellness incentive, or both; or

(c) Specific appropriations are provided for wellness incentives.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-31-190, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-31-190, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-31-190, filed 7/1/19, effective 8/1/19.*

##### **Wash. Admin. Code § 182-31-200** School board members participation requirements. {#sec-182-31-200 omnilex-key=us-wa-regs-official--title-182--182-31-200}

WAC 182-31-200

This section applies to school board members as defined in WAC 182-31-020. A school board member may enroll in health plans offered by the school employees benefits board (SEBB) by self-paying the premium and applicable premium surcharges set by the health care authority (HCA). A school board member must enroll in SEBB medical, SEBB dental, and SEBB vision.

(1) Effective May 14, 2026, a school board member may enroll in SEBB medical, SEBB dental, and SEBB vision during the following times:

(a) Upon being elected or appointed as a school board member. The required forms must be received by the SEBB program no later than 60 days from the beginning of their elected or appointed term;

(b) During the annual open enrollment; or

(c) Following the loss of other coverage under a group health plan or through health insurance coverage as defined by the Health Insurance Portability and Accountability Act (HIPAA). The required forms must be received by the SEBB program no later than 60 days after the date of the loss of other coverage.

(2) A school board member may elect to enroll in SEBB health plan coverage by submitting the required forms along with the first premium payment and applicable premium surcharges to the SEBB program. The first premium payment and applicable premium surcharges must be received no later than 45 days after the 60-day election period ends or the last day of the annual open enrollment.

(a) If the required forms are received no later than 60 days from the beginning of their elected or appointed term, the school board member's SEBB health plan coverage will begin the first day of the month following the day the SEBB program receives the required forms;

(b) If the required forms are received no later than the last day of the annual open enrollment, the school board member's SEBB health plan coverage will begin January 1st of the following year; or

(c) If the required forms are received no later than 60 days after the date of loss of other coverage under a group health plan or through health insurance coverage as defined by HIPAA, the school board member's SEBB health plan coverage will begin the first day of the month following the later of the date of loss of other coverage or the date the SEBB program receives the required forms.

(3) If the school board member elects to enroll a dependent in SEBB health plan coverage, the dependent will be enrolled in the same SEBB medical, SEBB dental, and SEBB vision plans as the school board member.

(4) A school board member may participate in SEBB health plan coverage for the duration of their elected term as a school board member as long as:

(a) Premiums and applicable premium surcharges continue to be paid as described in WAC 182-30-040; and

(b) May renew their participation at the start of each subsequent term as a school board member. If a school board member is reelected for a new term consecutive from their previous term, the school board member will not be required to make new elections.

(5) If a school board member is terminated due to no longer paying the premium and applicable premium surcharges as described in WAC 182-30-040 (1)(c) or requests to voluntarily terminate their enrollment in SEBB health plan coverage prior to the end of their elected term, they are no longer eligible under this section to participate in SEBB health plan coverage for the remainder of their elected term. Those who request to voluntarily terminate their SEBB health plan coverage must do so in writing. SEBB health plan coverage will end on the last day of the month in which the SEBB program receives the termination request or on the last day of the month specified in the school board member's termination request, whichever is later. If the termination request is received on the first day of the month, SEBB health plan coverage will end on the last day of the previous month.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, and Resolution SEBB 2026-01. WSR 26-16-017 (Admin #2026.02), s 182-31-200, filed 7/24/26, effective 9/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-31-200, filed 7/22/24, effective 1/1/25.*

## **Chapter 182-32** Appeals practices and procedures. {#struct-chapter-182-32}

##### **Wash. Admin. Code § 182-32-010** Purpose. {#sec-182-32-010 omnilex-key=us-wa-regs-official--title-182--182-32-010}

This chapter describes the general rules and procedures that apply to the health care authority's brief adjudicative proceedings and formal administrative hearings for the school employees benefits board program.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-010, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-010, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-020** Definitions. {#sec-182-32-020 omnilex-key=us-wa-regs-official--title-182--182-32-020}

The following definitions apply throughout this chapter unless the context clearly indicates another meaning:

"Accidental death and dismemberment insurance" or "AD&D" means basic accidental death and dismemberment (AD&D) insurance paid for by the SEBB organization, as well as supplemental accidental death and dismemberment insurance offered to and paid for by school employees for themselves and their dependents.

"Appellant" means a person who requests a brief adjudicative proceeding with the SEBB appeals unit about the action of the SEBB organization, employer group, the HCA, or its contracted vendor.

"Authority" or "HCA" means the Washington state health care authority.

"Board" means the school employees benefits board established under provisions of RCW 41.05.740.

"Brief adjudicative proceeding" means the process described in RCW 34.05.482 through 34.05.494 and in WAC 182-32-2000 through 182-32-2160.

"Business days" means all days except Saturdays, Sundays, and all state legal holidays as set forth in RCW 1.16.050.

"Calendar days" or "days" means all days including Saturdays, Sundays, and all state legal holidays as set forth in RCW 1.16.050.

"Continuance" means a change in the date or time of when a brief adjudicative proceeding or formal administrative hearing will occur.

"Contracted vendor" means any person, persons, or entity under contract or agreement with the HCA to provide goods or services for the provision or administration of SEBB benefits. The term "contracted vendor" includes subcontractors of the HCA and subcontractors of any person, persons, or entity under contract or agreement with the HCA that provide goods or services for the provision or administration of SEBB benefits.

"Denial" or "denial notice" means an action by, or communication from, a school employees benefits board (SEBB) organization, employer group, contracted vendor, or the SEBB program that aggrieves a subscriber, a dependent, or an applicant, with regard to SEBB benefits including, but not limited to, actions or communications expressly designated as a "denial," "denial notice," or "cancellation notice."

"Dependent" means a person who meets eligibility requirements in WAC 182-31-140.

"Dependent care assistance program" or "DCAP" means a benefit plan whereby school employees may pay for certain employment related dependent care with pretax dollars as provided in the salary reduction plan under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 129 or other sections of the Internal Revenue Code.

"Director" means the director of the authority.

"Dispositive motion" is a motion made to a presiding officer, reviewing officer, or hearing officer to decide a claim or case in favor of the moving party without further proceedings.

"Documents" means papers, letters, writings, electronic mail, electronic files, or other printed or written items.

"Employer-based group medical" means group medical related to a current employment relationship. It does not include medical coverage available to retired employees, individual market medical coverage or government-sponsored programs such as medicare or medicaid.

"Employer group" means an employee organization representing school employees and a tribal school as defined in RCW 28A.715.010, obtaining school employee benefits through a contractual agreement with the authority to participate in benefit plans developed by the school employees benefits board as described in WAC 182-30-215.

"Enrollee" means a person who meets all eligibility requirements defined in chapter 182-31 WAC or WAC 182-30-130, who is enrolled in SEBB benefits, and for whom applicable premium payments have been made.

"File" or "filing" means the act of delivering documents to the office of the presiding officer, reviewing officer, or hearing officer. A document is considered filed when it is received by the authority or its designee. A document may be filed by one or more of the following:

• Personal delivery to the authority at Cherry Street Plaza, 626 8th Avenue S.E., Olympia, Washington 98501;

• First class, registered, or certified mail to the authority to the following mailing address:

Health Care Authority

Attn: SEBB Appeals Unit

P.O. Box 45504

Olympia, WA 98504-5504;

• Fax: 360-763-4709; or

• Submission online through the designated submission portal.

The identified methods are the exclusive methods for a document to be filed, and submission of documents by any other fashion to the authority shall not constitute filing unless agreed to in advance by the authority.

"Final order" means an order that is the final health care authority decision.

"Flexible spending arrangement" or "FSA" means a benefit plan whereby eligible school employees may reduce their salary before taxes to pay for medical expenses not reimbursed by insurance as provided in the salary reduction plan established under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"Formal administrative hearing" means a proceeding before a hearing officer that gives an appellant an opportunity for an evidentiary hearing as described in RCW 34.05.413 through 34.05.476 and WAC 182-32-3000 through 182-32-3200.

"HCA hearing representative" means a person who is authorized to represent the SEBB program in a formal administrative hearing. The person may be an assistant attorney general or authorized HCA employee.

"Health plan" means a plan offering medical, vision, dental, or any combination of these coverages, developed by the board and provided by a contracted vendor or self-insured plans administered by the HCA.

"Hearing officer" means an impartial decision maker who presides at a formal administrative hearing, and is:

• A director-designated HCA employee; or

• When the director has designated the office of administrative hearings (OAH) as a hearing body, an administrative law judge employed by the OAH.

"Life insurance" means any basic life insurance paid for by the SEBB organization, as well as supplemental life insurance or supplemental dependent life insurance offered to and paid for by school employees for themselves and their dependents.

"Limited purpose flexible spending arrangement" or "limited purpose FSA" means a benefit plan whereby eligible school employees may reduce their salary before taxes to pay for dental and vision expenses not reimbursed by insurance as provided in the salary reduction plan established under chapter 41.05 RCW pursuant to 26 U.S.C Sec. 125 or other sections of the Internal Revenue Code.

"Long-term disability insurance" or "LTD insurance" means employer-paid long-term disability insurance and employee-paid long-term disability insurance offered by the SEBB program.

"PEBB" means the public employees benefits board.

"Prehearing conference" means a proceeding scheduled and conducted by a hearing officer to address issues in preparation for a formal administrative hearing.

"Premium payment plan" means a benefit plan whereby school employees may pay their share of group health plan premiums with pretax dollars as provided in the salary reduction plan under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"Premium surcharge" means a payment required from a subscriber, in addition to the subscriber's medical premium contribution, due to an enrollee's tobacco use or an enrolled subscriber's spouse or state registered domestic partner choosing not to enroll in their employer-based group medical when:

• The spouse's or state registered domestic partner's share of the medical premiums is less than 95 percent of the additional cost an employee would be required to pay to enroll a spouse or state registered domestic partner in the public employees benefits board (PEBB) Uniform Medical Plan (UMP) Classic; and

• The benefits have an actuarial value of at least 95 percent of the actuarial value of PEBB UMP Classic benefits.

"Presiding officer" means an impartial decision maker who conducts a brief adjudicative proceeding and is a director-designated HCA employee.

"Reviewing officer or officers" means one or more delegates from the director that consider appeals relating to the administration of SEBB benefits by the SEBB program.

"Salary reduction plan" means a benefit plan whereby school employees may agree to a reduction of salary on a pretax basis to participate in the dependent care assistance program, flexible spending arrangement, limited purpose flexible spending arrangement, or premium payment plan offered pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.

"School board member" means the board of directors of a school district as governed by chapter 28A.343 RCW or the board of directors of an educational service district as governed by chapter 28A.310 RCW.

"School employee" means all employees of school districts and charter schools established under chapter 28A.710 RCW; represented employees of educational service districts; effective January 1, 2024, all employees of educational service districts; and effective January 1, 2024, pursuant to a contractual agreement with the authority, "school employee" may also include (a) employees of employee organizations representing school employees, at the option of each such employee organization; and (b) employees of a tribal school as defined in RCW 28A.715.010, if the governing body of the tribal school seeks and receives the approval of the authority to provide any of its insurance programs by contracts with the authority, as provided in RCW 41.05.021 (1)(f) and (g).

"School employees benefits board organization" or "SEBB organization" means a public school district or educational service district or charter school established under chapter 28A.710 RCW that is required to participate in benefit plans provided by the school employees benefit board.

"SEBB" means the school employees benefits board.

"SEBB benefits" means one or more insurance coverages or other employee benefits administered by the SEBB program within the HCA.

"SEBB insurance coverage" means any health plan, life insurance, accidental death and dismemberment insurance, or long-term disability insurance administered as a SEBB benefit.

"SEBB program" means the program within the HCA that administers insurance and other benefits for eligible school employees (as described in WAC 182-31-040 or 182-30-130), eligible dependents (as described in WAC 182-31-140), and eligible school board members (as described in WAC 182-31-200).

"State registered domestic partner," has the same meaning as defined in RCW 26.60.020(1) and substantially equivalent legal unions from other jurisdictions as defined in RCW 26.60.090.

"Subscriber" means the school employee, continuation coverage enrollee, or school board member who has been determined eligible by the SEBB program, SEBB organization, or employer group, is enrolled in SEBB benefits, and is the individual to whom the SEBB program and contracted vendors will issue all notices, information, requests, and premium bills on behalf of an enrollee.

"Tobacco products" means any product made with or derived from tobacco that is intended for human consumption, including any component, part, or accessory of a tobacco product. This includes, but is not limited to, cigars, cigarettes, pipe tobacco, chewing tobacco, snuff, and other tobacco products. It does not include e-cigarettes or United States Food and Drug Administration (FDA) approved quit aids.

"Tobacco use" means any use of tobacco products within the past two months. Tobacco use, however, does not include the religious or ceremonial use of tobacco.

"Tribal school" has the same meaning as defined in RCW 28A.715.010.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-32-020, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-32-020, filed 6/21/22, effective 1/1/23*
- *WSR 21-13-117 (Admin #2021-01.04), § 182-32-020, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-020, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-020, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-020, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-055** Mailing address changes. {#sec-182-32-055 omnilex-key=us-wa-regs-official--title-182--182-32-055}

(1) During the appeal process, if the appellant's mailing address changes, the appellant must notify the school employees benefits board (SEBB) appeals unit as soon as possible.

(2) If the appellant does not notify the SEBB appeals unit of a change in the appellant's mailing address and the SEBB appeals unit continues to serve notices and other important documents to the appellant's last known mailing address, the documents will be deemed served on the appellant.

(3) This requirement to provide notice of an address change is in addition to WAC 182-30-075 that require a subscriber to update their address with the SEBB appeals unit.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-055, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-058** Service or serve. {#sec-182-32-058 omnilex-key=us-wa-regs-official--title-182--182-32-058}

(1) When the rules in this chapter or in other school employees benefits board (SEBB) program rules or statutes require a party to serve copies of documents on other parties, a party must send copies of the documents to all other parties or their representatives as described in this chapter. In this section, requirements for service or delivery by a party apply also when service is required by the presiding officer or reviewing officer or officers, or hearing officer.

(2) Unless otherwise stated in applicable law, documents may be sent only as identified in this chapter to accomplish service. A party may serve someone by:

(a) Personal service (hand delivery);

(b) First class, registered, or certified mail sent via the United States Postal Service or Washington state consolidated mail services;

(c) Fax;

(d) Commercial delivery service; or

(e) Legal messenger service.

(3) A party must serve all other parties or their representatives whenever the party files a motion, pleading, brief, or other document with the presiding officer, reviewing officer or officers, or hearing officer's office, or when required by law.

(4) Unless otherwise stated in applicable law, service is complete when:

(a) Personal service is made;

(b) Mail is properly stamped, addressed, and deposited in the United States Postal Service;

(c) Mail is properly addressed, and deposited in the Washington state consolidated mail services;

(d) Fax produces proof of transmission;

(e) A parcel is delivered to a commercial delivery service with charges prepaid; or

(f) A parcel is delivered to a legal messenger service with charges prepaid.

(5) A party may prove service by providing any of the following:

(a) A signed affidavit of mailing or certificate of service;

(b) The certified mail receipt signed by the person who received the parcel;

(c) A signed receipt from the person who accepted the commercial delivery service or legal messenger service parcel;

(d) Proof of fax transmission.

(6) Service cannot be made by electronic mail unless mutually agreed to in advance and in writing by the parties.

(7) If the document is a subpoena, follow the compliance procedure as described in WAC 182-32-3130.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-32-058, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-058, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-058, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-064** Applicable rules and laws. {#sec-182-32-064 omnilex-key=us-wa-regs-official--title-182--182-32-064}

(1) A school employees benefits board (SEBB) organization or employer group must apply SEBB program rules adopted in the Washington Administrative Code (WAC) and follow instructions from the authority.

(2) A presiding officer, reviewing officer or officers, or hearing officer must first apply the applicable SEBB program rules adopted in the WAC. If no SEBB program rule applies, the presiding officer, reviewing officer or officers, or hearing officer must decide the issue according to the best legal authority and reasoning available, including federal and Washington state constitutions, statutes, regulations, significant decisions indexed as described in WAC 182-32-130, and court decisions.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-32-064, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-32-064, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-064, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-064, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-066** Burden of proof, standard of proof, and presumptions. {#sec-182-32-066 omnilex-key=us-wa-regs-official--title-182--182-32-066}

(1) The burden of proof is a party's responsibility to provide evidence regarding disputed facts and persuade the presiding officer, reviewing officer or officers, or hearing officer that a position is correct based on the standard of proof. Unless stated otherwise in rules or law, the appellant has the burden of proof in a brief adjudicative proceeding or formal administrative hearing.

(2) Standard of proof refers to the amount of evidence needed to prove a party's position. Unless stated otherwise in rules or law, the standard of proof in a brief adjudicative proceeding or formal administrative hearing is a preponderance of the evidence, meaning that something is more likely to be true than not.

(3) Public officers and school employees benefits board (SEBB) organizations are presumed to have properly performed their duties and acted as described in the law, unless preponderance of the evidence to the contrary is presented. A party challenging this presumption bears the burden of proof.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-32-066, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-066, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-066, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-066, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-120** Computation of time. {#sec-182-32-120 omnilex-key=us-wa-regs-official--title-182--182-32-120}

(1) In computing any period of time prescribed by this chapter, the day of the event from which the time begins to run is not included. (For example, if an initial order is served on Friday and the party has twenty-one days to request a review, start counting the days with Saturday.)

(2) As provided in subsection (3) of this section, the last day of the period so computed is included unless it is a Saturday, Sunday, or legal holiday as defined in RCW 1.16.050, in which case the period extends to the next business day.

(3) When the period of time prescribed or allowed is ten days or less, intermediate Saturdays, Sundays and state legal holidays must be excluded in the computation.

(4) The deadline is 5:00 p.m. on the last day of the computed period.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-120, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-120, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-120, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-130** Index of significant decisions. {#sec-182-32-130 omnilex-key=us-wa-regs-official--title-182--182-32-130}

(1) A final order may be relied upon, used, or cited as precedent by a party only if the final order has been indexed in the authority's index of significant decisions in accordance with RCW 34.05.473 (1)(b).

(2) An index of significant decisions is available to the public on the health care authority's (HCA) website. As decisions are indexed they will be available on the website.

(3) A final order published in the index of significant decisions may be removed from the index when:

(a) A published decision entered by the court of appeals or the supreme court reverses an indexed final order; or

(b) HCA determines that the indexed final order is no longer precedential due to changes in statute, rule, or policy.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-130, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-130, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-130, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-2000** Brief adjudicative proceedings. {#sec-182-32-2000 omnilex-key=us-wa-regs-official--title-182--182-32-2000}

Pursuant to RCW 34.05.482, the authority may use brief adjudicative proceedings for issues identified in this chapter when doing so would not violate law, or when protection of the public interest does not require the authority to give notice and an opportunity to participate to persons other than the parties, or the issue and interests involved in the controversy do not warrant use of the procedures of RCW 34.05.413 through 34.05.476 which govern formal administrative hearings.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-32-2000, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-2000, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-2000, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-2005** Record—Brief adjudicative proceeding. {#sec-182-32-2005 omnilex-key=us-wa-regs-official--title-182--182-32-2005}

The record in a brief adjudicative proceeding consists of any documents regarding the matter, considered or prepared by the presiding officer for the brief adjudicative proceeding or by the reviewing officer or officers for any review. The authority's record does not have to constitute the exclusive basis for agency action, unless otherwise required by law.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-32-2005, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-2005, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-2010** Appealing a decision regarding school employees benefits board (SEBB) eligibility, enrollment, premium payments, premium surcharges, a wellness incentive, or the administration of benefits. {#sec-182-32-2010 omnilex-key=us-wa-regs-official--title-182--182-32-2010}

(1) Any current or former school employee of a school employees benefits board (SEBB) organization or their dependent aggrieved by a decision made by the SEBB organization with regard to SEBB eligibility, enrollment, or premium surcharges may appeal that decision to the SEBB organization by the process described in WAC 182-32-2020.

| Note: | Eligibility decisions address whether a subscriber or a subscriber's dependent is entitled to SEBB benefits, as described in SEBB rules and policies. Enrollment decisions address the application for SEBB benefits as described in SEBB rules and policies including, but not limited to, the submission of proper documentation and meeting enrollment deadlines. |
| --- | --- |

(2) Any current or former school employee of an employer group or their dependent who is aggrieved by a decision made by the employer group with regard to SEBB eligibility, enrollment, or premium surcharges may appeal that decision to the employer group through the process established by the employer group.

| Exception: | Any current or former school employee of an employer group aggrieved by a decision regarding life insurance, long-term disability (LTD) insurance, eligibility to participate in the SEBB wellness incentive program, or eligibility to receive a SEBB wellness incentive may appeal that decision to the SEBB appeals unit by the process described in WAC 182-32-2030. |
| --- | --- |

(3) Any subscriber or dependent aggrieved by a decision made by the SEBB program with regard to SEBB eligibility, enrollment, premium payments, premium surcharges, eligibility to participate in the SEBB wellness incentive program, or eligibility to receive the SEBB wellness incentive, may appeal that decision to the SEBB appeals unit by the process described in WAC 182-32-2030.

(4) Any enrollee aggrieved by a decision regarding the administration of SEBB medical, dental, and vision, life insurance, accidental death and dismemberment (AD&D) insurance, or long-term disability insurance, may appeal that decision by following the appeal provisions of those plans, with the exception of:

(a) Enrollment decisions;

(b) Premium payment decisions other than life insurance or AD&D insurance premium payment decisions; and

(c) Eligibility decisions.

(5) Any SEBB enrollee aggrieved by a decision regarding the administration of SEBB property and casualty insurance may appeal that decision by following the appeal provisions of those plans.

(6) Any school employee aggrieved by a decision regarding the administration of a benefit offered under the salary reduction plan may appeal that decision by the process described in WAC 182-32-2050.

(7) Any subscriber aggrieved by a decision made by the SEBB wellness incentive program contracted vendor regarding the completion of the SEBB wellness incentive program requirements, or a request for a reasonable alternative to a wellness incentive program requirement, may appeal that decision by the process described in WAC 182-32-2040.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-32-2010, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-13-117 (Admin #2021-01.04), § 182-32-2010, filed 6/21/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-2010, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-2010, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-2010, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-2020** Appealing a decision made by a school employees benefits board (SEBB) organization about eligibility, premium surcharges, or enrollment in benefits. {#sec-182-32-2020 omnilex-key=us-wa-regs-official--title-182--182-32-2020}

(1) An eligibility, premium surcharges, or enrollment decision made by a school employees benefits board (SEBB) organization may be appealed by submitting a written request for administrative review to the SEBB organization. The SEBB organization must receive the request for administrative review no later than thirty days after the date of the denial notice. The contents of the request for administrative review are to be provided as described in WAC 182-32-2070.

(a) Upon receiving the request for administrative review, the SEBB organization must perform a complete review of the denial by one or more staff who did not take part in the decision resulting in the denial.

(b) The SEBB organization must render a written decision within thirty days of receiving the written request for administrative review. The written decision must be sent to the school employee or school employee's dependent who submitted the request for administrative review and must include a description of the appeal rights. The SEBB organization must also send a copy of the SEBB organization's written decision to the SEBB organization's administrator (or designee) and to the SEBB appeals unit. If the SEBB organization fails to render a written decision within thirty days of receiving the written request for administrative review, the request for administrative review may be considered denied as of the thirty-first day and the original underlying SEBB organization decision may be appealed to the SEBB appeals unit by following the process in this section.

(c) The SEBB organization may reverse eligibility, premium surcharges, or enrollment decisions as permitted by WAC 182-30-060.

(2) Any current or former school employee or school employee's dependent who disagrees with the SEBB organization's decision in response to a written request for administrative review, as described in subsection (1) of this section, may request a brief adjudicative proceeding to be conducted by the authority by submitting a written request to the SEBB appeals unit.

(a) The SEBB appeals unit must receive the request for a brief adjudicative proceeding no later than thirty days after the date of the SEBB organization's written decision on the request for administrative review. If the SEBB organization fails to render a written decision within thirty days of receiving a written request for administrative review, the SEBB appeals unit must receive the request for a brief adjudicative proceeding no later than thirty days after the date the request for administrative review was deemed denied. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-32-2070.

(i) The SEBB appeals unit must notify the appellant in writing when the request for a brief adjudicative proceeding has been received.

(ii) Once the SEBB appeals unit receives a request for a brief adjudicative proceeding, the SEBB appeals unit will send a request for documentation and information to the applicable SEBB organization. The SEBB organization will then have two business days to respond to the request and provide the requested documentation and information. The SEBB organization will also send a copy of the documentation and information to the appellant.

(iii) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.

(b) If a school employee fails to timely request a brief adjudicative proceeding, the SEBB organization's prior written decision becomes the authority's final order without further action.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-2020, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-2020, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-2020, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-2030** Appealing a school employees benefits board (SEBB) program decision regarding eligibility, enrollment, premium payments, premium surcharges, a SEBB wellness incentive, or certain decisions made by an employer group. {#sec-182-32-2030 omnilex-key=us-wa-regs-official--title-182--182-32-2030}

(1) A decision made by the school employees benefits board (SEBB) program regarding eligibility, enrollment, premium payments, premium surcharges, or a SEBB wellness incentive may be appealed by submitting a request to the SEBB appeals unit for a brief adjudicative proceeding to be conducted by the authority.

(2) A decision made by an employer group regarding life insurance, LTD insurance, eligibility to participate in the SEBB wellness incentive program, or eligibility to receive a SEBB wellness incentive, may be appealed by submitting a request to the SEBB appeals unit for a brief adjudicative proceeding to be conducted by the authority.

(3) The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-32-2070.

(4) The request for a brief adjudicative proceeding from a current or former school employee or school employee's dependent must be received by the SEBB appeals unit no later than 30 days after the date of the denial notice.

(5) The request for a brief adjudicative proceeding from a continuation coverage enrollee, school board member, or their dependent must be received by the SEBB appeals unit no later than 60 days after the date of the denial notice.

(6) The SEBB appeals unit must notify the appellant in writing when the request for a brief adjudicative proceeding has been received.

(7) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.

(8) Failing to timely request a brief adjudicative proceeding will result in the prior SEBB program decision becoming the authority's final order without further action.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-32-2030, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-2030, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-2030, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-2030, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-2040** How can a subscriber appeal a decision regarding the administration of wellness incentive program requirements? {#sec-182-32-2040 omnilex-key=us-wa-regs-official--title-182--182-32-2040}

(1) Any subscriber aggrieved by a decision made by the school employees benefits board (SEBB) wellness incentive program contracted vendor regarding the completion of the wellness incentive program requirements, or request for a reasonable alternative to a wellness incentive program requirement, may appeal that decision to the SEBB program.

(2) Any subscriber who disagrees with a decision in response to an appeal filed with the SEBB program may appeal the decision by submitting a request for a brief adjudicative proceeding to the SEBB appeals unit.

(a) The request for a brief adjudicative proceeding from a current or former school employee must be received by the SEBB appeals unit no later than 30 days after the date of the denial notice. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-32-2070.

(b) The request for a brief adjudicative proceeding from a continuation coverage enrollee or school board member must be received by the SEBB appeals unit no later than 60 days after the date of the denial notice. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-32-2070.

(3) The SEBB appeals unit must notify the appellant in writing when the request for a brief adjudicative proceeding has been received.

(4) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.

(5) If a subscriber fails to timely request a brief adjudicative proceeding, the decision of the SEBB wellness incentive program contracted vendor becomes the authority's final order without further action.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-12-050 (Admin #2025.01.01), s 182-32-2040, filed 5/29/25, effective 7/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-32-2040, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-2040, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-2040, filed 7/1/19, effective 8/1/19.*

##### **Wash. Admin. Code § 182-32-2050** How can a school employee appeal a decision regarding the administration of benefits offered under the salary reduction plan? {#sec-182-32-2050 omnilex-key=us-wa-regs-official--title-182--182-32-2050}

(1) Any school employee who disagrees with a decision that denies eligibility for, or enrollment in, a benefit offered under the salary reduction plan may appeal that decision by submitting a written request for administrative review to their school employees benefits board (SEBB) organization. The SEBB organization must receive the written request for administrative review no later than 30 days after the date of the decision resulting in denial. The contents of the written request for administrative review are to be provided as described in WAC 182-32-2070.

(a) Upon receiving the written request for administrative review, the SEBB organization must perform a complete review of the denial by one or more staff who did not take part in the decision resulting in the denial.

(b) The SEBB organization must render a written decision within 30 days of receiving the written request for administrative review. The written decision must be sent to the school employee who submitted the written request for review and must include a description of appeal rights. The SEBB organization must also send a copy of the SEBB organization's written decision to the SEBB organization's administrator (or designee) and to the SEBB appeals unit. If the SEBB organization fails to render a written decision within 30 days of receiving the written request for administrative review, the request for administrative review may be considered denied as of the 31st day and the original underlying SEBB organization decision may be appealed to the SEBB appeals unit by following the process in this section.

(2) Any school employee who disagrees with the SEBB organization's decision in response to a written request for administrative review, as described in this section, may request a brief adjudicative proceeding to be conducted by the authority by submitting a written request to the SEBB appeals unit.

(a) The SEBB appeals unit must receive the request for a brief adjudicative proceeding no later than 30 days after the date of the SEBB organization's written decision on the request for administrative review. If a SEBB organization fails to render a written decision within 30 days of receiving a written request for administrative review, the SEBB appeals unit must receive the request for a brief adjudicative proceeding no later than 30 days after the date the request for administrative review was deemed denied. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-32-2070.

(i) The SEBB appeals unit must notify the appellant in writing when the request for a brief adjudicative proceeding has been received.

(ii) Once the SEBB appeals unit receives a request for a brief adjudicative proceeding, the SEBB appeals unit will send a request for documentation and information to the applicable SEBB organization. The SEBB organization will then have two business days to respond to the request and provide the documentation and information requested. The SEBB organization will also send a copy of the documentation and information to the school employee.

(iii) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.

(b) If a school employee fails to timely request a brief adjudicative proceeding, the SEBB organization's prior written decision becomes the authority's final order without further action.

(3) Any school employee aggrieved by a decision regarding a claim for benefits under the flexible spending arrangement or limited purpose flexible spending arrangement (FSA) or dependent care assistance program (DCAP) offered under the salary reduction plan may appeal that decision to the authority's contracted vendor by following the appeal process of that contracted vendor.

(a) Any school employee who disagrees with a decision in response to an appeal filed with the contracted vendor that administers the FSA, limited purpose FSA, and DCAP under the salary reduction plan may request a brief adjudicative proceeding by submitting a written request to the SEBB appeals unit. The SEBB appeals unit must receive the request for a brief adjudicative proceeding no later than 30 days after the date of the contracted vendor's appeal decision. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-32-2070.

(i) The SEBB appeals unit must notify the appellant in writing when the request for a brief adjudicative proceeding has been received.

(ii) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.

(b) If a school employee fails to timely request a brief adjudicative proceeding, the contracted vendor's prior written decision becomes the authority's final order without further action.

(4) Any school employee aggrieved by a decision regarding the administration of the premium payment plan offered under the salary reduction plan may request a brief adjudicative proceeding to be conducted by the authority by submitting a written request to the SEBB appeals unit for a brief adjudicative proceeding.

(a) The SEBB appeals unit must receive the request for a brief adjudicative proceeding no later than 30 days after the date of the denial notice by the SEBB program. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.

(i) The SEBB appeals unit must notify the appellant in writing when the notice of appeal has been received.

(ii) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.

(b) If a school employee fails to timely request a brief adjudicative proceeding, the SEBB program's prior written decision becomes the authority's final order without further action.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-32-2050, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-32-2050, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-2050, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-2050, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-2050, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-2060** How can an entity or organization appeal a decision of the health care authority to deny an employer group application? {#sec-182-32-2060 omnilex-key=us-wa-regs-official--title-182--182-32-2060}

(1) An entity or organization whose employer group application to participate in school employees benefits board (SEBB) insurance coverage is denied by the authority may appeal the decision by submitting a request for a brief adjudicative proceeding to the SEBB appeals unit.

(2) The SEBB appeals unit must receive the request for a brief adjudicative proceeding no later than 30 days after the date of the denial notice. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-32-2070.

(3) The SEBB appeals unit must notify the appellant in writing when the request for a brief adjudicative proceeding has been received.

(4) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.

(5) Failing to timely request a brief adjudicative proceeding will result in the prior SEBB program decision becoming the authority's final order without further action.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-32-2060, filed 7/22/24, effective 1/1/25.*

##### **Wash. Admin. Code § 182-32-2070** What should a written request for administrative review and a request for brief adjudicative proceeding contain? {#sec-182-32-2070 omnilex-key=us-wa-regs-official--title-182--182-32-2070}

(1) A written request for administrative review of the school employees benefits board (SEBB) organization's or employer group's decision and a request for brief adjudicative proceeding should contain the following:

(a) The name and mailing address of the party requesting an administrative review or the brief adjudicative proceeding;

(b) The name and mailing address of the appealing party's representative, if any;

(c) Documentation, or reference to documentation, of decisions previously rendered through the appeal process, if any;

(d) A statement identifying the specific portion of the decision being appealed and clarifying what is believed to be unlawful or in error;

(e) A statement of facts in support of the appealing party's position;

(f) Any information or documentation that the appealing party would like considered;

(g) The type of relief sought;

(h) The signature of the appealing party or the appealing party's representative; and

(i) A statement that describes the appealing party or the appealing party's representative has read the notice of request for an appeal and believes the contents to be true and correct.

(2) Failing to provide documentation, or reference to documentation, of decisions previously rendered through the appeal process as described in subsection (1)(c) of this section, may result in rejection of the item being appealed.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-12-050 (Admin #2025.01.01), s 182-32-2070, filed 5/29/25, effective 7/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-32-2070, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-2070, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-2080** Who can appeal or represent a party in a brief adjudicative proceeding? {#sec-182-32-2080 omnilex-key=us-wa-regs-official--title-182--182-32-2080}

(1) The appellant may act as their own representative or may choose to be represented by another person, except that employees of the health care authority (HCA) or HCA's authorized agents may not represent an appellant, unless approved by a presiding officer or reviewing officer.

(2) If the appellant is represented by a person who is not an attorney admitted to practice in Washington state, the representative must provide the presiding officer and other parties with the representative's name, address, and telephone number. In cases involving confidential information, the nonattorney representative must provide the school employees benefits board (SEBB) appeals unit and other parties with a signed, written consent permitting release to the nonattorney representative of the appellant's health information protected by state or federal law.

(3) An attorney admitted to practice law in Washington state representing the appellant must file a written notice of appearance containing the attorney's name, address, and telephone number with the presiding officer's office and serve all parties with the notice. In cases involving confidential information, the attorney must provide the SEBB appeals unit and other parties with a signed, written consent permitting release to the attorney of the appellant's health information protected by state or federal law. If the appellant's attorney representative no longer represents the appellant, then the attorney must file a written notice of withdrawal of representation with the presiding officer or reviewing officer or officer's office and serve all parties with the notice.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-32-2080, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-2080, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-2080, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-2085** Continuances. {#sec-182-32-2085 omnilex-key=us-wa-regs-official--title-182--182-32-2085}

The presiding officer, reviewing officer or officers may grant, in their sole discretion, a request for a continuance on motion of the appellant, the authority, or on their own. The continuance may be up to 30 calendar days.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-32-2085, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-2085, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-2085, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-2085, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-2090** Initial order. {#sec-182-32-2090 omnilex-key=us-wa-regs-official--title-182--182-32-2090}

Unless a continuance has been granted, the presiding officer will render a written initial order that addresses the issue or issues raised by the appellant in their appeal within 10 days after the presiding officer receives the contents of the request for a brief adjudicative proceeding. The presiding officer must serve a copy of the initial order on all parties and the initial order must contain information on how the appellant may request review of the initial order.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-12-050 (Admin #2025.01.01), s 182-32-2090, filed 5/29/25, effective 7/1/25. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-2090, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-2090, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-2100** How to request a review of an initial order resulting from a brief adjudicative proceeding. {#sec-182-32-2100 omnilex-key=us-wa-regs-official--title-182--182-32-2100}

(1) Both the appellant and the authority may request review of an initial order. An appellant who has received an initial order upholding a school employees benefits board (SEBB) organization decision, employer group decision, SEBB program decision, or a decision made by a SEBB program contracted vendor, may request review of the initial order by the authority. The appellant may request review of the initial order by filing a written request or making an oral request with the SEBB appeals unit within 21 days after service of the initial order. The written or oral request for review of the initial order must be made by using the contact information included in the initial order. If the appellant fails to request review of the initial order within 21 days, the initial order becomes the authority's final order without further action.

(2) Upon timely request by the appellant, a review of an initial order will be performed by one or more reviewing officers designated by the director of the authority.

(3) If the appellant has not requested review, the authority may review an order resulting from a brief adjudicative proceeding on its own, and without notice to the parties, but it may not take action on review less favorable to any party than the initial order without giving that party notice and an opportunity to explain that party's view of the matter.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-32-2100, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-32-2100, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-2100, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-2100, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-2100, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-2105** Withdrawing the request for a brief adjudicative proceeding or review of an initial order. {#sec-182-32-2105 omnilex-key=us-wa-regs-official--title-182--182-32-2105}

(1) The appellant may withdraw the request for a brief adjudicative proceeding or review of an initial order for any reason, and at any time, by contacting the school employees benefits board (SEBB) appeals unit. The SEBB appeals unit will present the withdrawal request to the presiding officer or reviewing officer or officers.

(2) The request for withdrawal must be made in writing.

(3) After a withdrawal request is received, the presiding officer or reviewing officer or officers must enter and serve a written order dismissing the brief adjudicative proceeding or review of an initial order.

(4) If an appellant withdraws a request for a brief adjudicative proceeding or review of an initial order, the appellant may not reinstate the request for a brief adjudicative proceeding or review of an initial order unless time remains on their original appeal period.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-32-2105, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-2105, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-2105, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-2110** Final order. {#sec-182-32-2110 omnilex-key=us-wa-regs-official--title-182--182-32-2110}

(1) A final order issued by the reviewing officer or officers will be in writing and include a brief statement of the reasons for the decision.

(2) The final order must be served within 20 days of the date of the initial order or of the date the request for review of the initial order was received by the SEBB appeals unit, whichever is later.

(3) The final order will include a notice that reconsideration and judicial review may be available.

(4) A request for review of the initial order is deemed denied if the authority does not issue a final order within 20 days after the request for review of the initial order is filed.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-32-2110, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-2110, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-2110, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-2120** Request for reconsideration. {#sec-182-32-2120 omnilex-key=us-wa-regs-official--title-182--182-32-2120}

(1) A request for reconsideration asks the reviewing officer or officers to reconsider the final order because the party believes the reviewing officer or officers made a mistake of law, mistake of fact, or clerical error.

(2) A request for reconsideration must state in writing why the party wants the final order to be reconsidered.

(3) Requests for reconsideration must be filed with the reviewing officer or officers who entered the final order.

(4) If a party files a request for reconsideration:

(a) The reviewing officer or officers must receive the request for reconsideration on or before the tenth business day after the service date of the final order;

(b) The party filing the request must send copies of the request to all other parties; and

(c) Within five business days of receiving a request for reconsideration, the reviewing officer or officers must serve to all parties a notice that provides the date the request for reconsideration was received.

(5) The other parties may respond to the request for reconsideration. The response must state in writing why the final order should stand. Responses are optional. If a party chooses not to respond, that party will not be prejudiced because of that choice.

(a) Responses to a request for reconsideration must be received by the reviewing officer or officers no later than seven business days after the service date of the reviewing officer or officers' notice as described in subsection (4)(c) of this section, or the response will not be considered.

(b) Service of responses to a request for reconsideration must be made to all parties.

(6) If a party needs more time to file a request for reconsideration or respond to a request for reconsideration, the reviewing officer or officers may extend the required time frame if the party makes a written request providing a good reason for the request within the required time frame.

(7) Unless the request for reconsideration is denied as untimely filed under subsection (4)(a) of this section, the same reviewing officer or officers who entered the final order, if reasonably available, will also consider the request as well as any responses received.

(8) The decision on the request for reconsideration must be in the form of a written order denying the request, granting the request in whole or in part and issuing a new written final order, or granting the request and setting the matter for further hearing.

(9) If the reviewing officer or officers do not send an order on the request for reconsideration within 20 calendar days of the date of the notice described in subsection (4)(c) of this section, the request is deemed denied.

(10) If any party files a request for reconsideration of the final order, the reconsideration process must be completed before any judicial review may be requested. However, the filing of a request for reconsideration is not required before requesting judicial review.

(11) An order denying a request for reconsideration is not subject to judicial review.

(12) No evidence may be offered in support of a motion for reconsideration, except newly discovered evidence that is material for the party moving for reconsideration and that the party could not with reasonable diligence have discovered and produced prior to the final order being issued.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-32-2120, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-2120, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-2120, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-2120, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-2130** Judicial review of final order. {#sec-182-32-2130 omnilex-key=us-wa-regs-official--title-182--182-32-2130}

(1) Judicial review is the process of appealing a final order to a court.

(2) The appellant may appeal a final order by filing a written petition for judicial review that meets the requirements of RCW 34.05.510 through 34.05.598. Neither the school employees benefits board (SEBB) program nor a SEBB organization or employer group may request judicial review.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-32-2130, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-2130, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-2130, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-2135** Petitions for judicial review—Service on the authority. {#sec-182-32-2135 omnilex-key=us-wa-regs-official--title-182--182-32-2135}

Delivery pursuant to RCW 34.05.542(4) shall be deemed to have been made when a copy of the petition for judicial review has been received by the school employees benefits board (SEBB) appeals unit at Cherry Street Plaza, 626 8th Avenue S.E., Olympia, WA 98501 or received by mail at the SEBB appeals unit, P.O. Box 45504, Olympia, WA 98504-5504.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-32-2135, filed 6/21/22, effective 1/1/23.*

##### **Wash. Admin. Code § 182-32-2140** Presiding officer—Designation and authority. {#sec-182-32-2140 omnilex-key=us-wa-regs-official--title-182--182-32-2140}

The designation of a presiding officer must be consistent with the requirements of RCW 34.05.485 and the presiding officer must not have personally participated in the decision made by the school employees benefits board (SEBB) organization, employer group, or SEBB program.

(1) The presiding officer will decide the issue based on the information provided by the parties during the presiding officer's review of the appeal.

(2) A presiding officer is limited to those powers granted by the state constitution, statutes, rules, or applicable case law.

(3) A presiding officer may not decide that a rule is invalid or unenforceable.

(4) In addition to the record, the presiding officer may employ the authority's expertise as a basis for the decision.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-32-2140, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-2140, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-2140, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-2150** Reviewing officer or officers—Designation and authority. {#sec-182-32-2150 omnilex-key=us-wa-regs-official--title-182--182-32-2150}

(1) The designation of a reviewing officer or officers must be consistent with the requirements of RCW 34.05.491 and the reviewing officer or officers must not have personally participated in the decision made by the school employees benefits board (SEBB) organization, employer group, or SEBB program.

(2) The reviewing officer or officers must review the initial order and the record to determine if the initial order was correctly decided and make any inquiries necessary to ascertain whether the proceeding must be converted to a formal administrative hearing.

(3) The reviewing officer or officers will issue a final order that will either:

(a) Affirm the initial order in whole or in part; or

(b) Reverse the initial order in whole or in part; or

(c) Remand to the presiding officer in whole or in part.

(4) A reviewing officer or officers are limited to those powers granted by the state constitution, statutes, rules, or applicable case law.

(5) A reviewing officer or officers may not decide that a rule is invalid or unenforceable.

(6) In addition to the record, the reviewing officer or officers may employ the authority's expertise as a basis for the decision.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-32-2150, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-32-2150, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-2150, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-2150, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-2150, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-2160** Conversion of a brief adjudicative proceeding to a formal administrative hearing. {#sec-182-32-2160 omnilex-key=us-wa-regs-official--title-182--182-32-2160}

(1) The presiding officer or the reviewing officer or officers, in their sole discretion, may convert a brief adjudicative proceeding to a formal administrative hearing at any time before the final order is issued on motion by:

(a) The appellant;

(b) The representative of the appellant;

(c) The authority; or

(d) The presiding officer or reviewing officer or officers.

(2) The presiding officer or reviewing officer or officers must convert the brief adjudicative proceeding to a formal administrative hearing when it is found that the use of the brief adjudicative proceeding violates any provision of law, when the protection of the public interest requires the authority to give notice and an opportunity to participate to persons other than the parties, or when the issues and interests involved in the controversy warrant the use of the procedures of RCW 34.05.413 through 34.05.476 that govern formal administrative hearings.

(3) When a brief adjudicative proceeding is converted to a formal administrative hearing, the director designates a hearing officer to conduct the formal administrative hearing upon notice to the appellant and the authority.

(4) When a brief adjudicative proceeding is converted to a formal administrative hearing, WAC 182-32-010 through 182-32-130 and WAC 182-32-3000 through 182-32-3200 apply to the formal administrative hearing.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-32-2160, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-2160, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-2160, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-2160, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-3000** Formal administrative hearings. {#sec-182-32-3000 omnilex-key=us-wa-regs-official--title-182--182-32-3000}

(1) When a brief adjudicative proceeding is converted to a formal administrative hearing consistent with WAC 182-32-2160, the director designates a hearing officer to conduct the formal administrative hearing.

(2) Formal administrative hearings are conducted consistent with the Administrative Procedure Act, RCW 34.05.413 through 34-05-476.

(3) Part III describes the general rules and procedures that apply to school employees benefits board (SEBB) benefits formal administrative hearings.

(a) Part III supplements the Administrative Procedure Act (APA), chapter 34.05 RCW, and the model rules of procedure in chapter 10-08 WAC. The model rules of procedure adopted by the chief administrative law judge pursuant to RCW 34.05.250, as now or hereafter amended, are hereby adopted for use by the authority in school employees benefits board (SEBB) benefits formal administrative hearings. Other procedural rules adopted in chapters 182-30, 182-31, and 182-32 WAC are supplementary to the model rules of procedure.

(b) In the case of a conflict between the model rules of procedure and Part III, the procedural rules adopted in Part III must govern.

(c) If there is a conflict between Part III and specific SEBB program rules, the specific SEBB program rules prevail. SEBB program rules are found in chapters 182-30 and 182-31 WAC.

(d) Nothing in Part III is intended to affect the constitutional rights of any person or to limit or change additional requirements imposed by statute or other rule. Other laws or rules determine if a hearing right exists, including the APA and program rules or laws.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-3000, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-3000, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-3000, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-3005** Record—Formal administrative hearings. {#sec-182-32-3005 omnilex-key=us-wa-regs-official--title-182--182-32-3005}

The record in a formal administrative hearing consists of the official documentation of the hearing process. The record includes, but is not limited to, recordings or transcripts, admitted exhibits, decisions, briefs, notices, orders, and other filed documents.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-3005, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-3010** Requirements to appear and represent a party in the formal administrative hearing process. {#sec-182-32-3010 omnilex-key=us-wa-regs-official--title-182--182-32-3010}

(1) All parties must provide the hearing officer and all other parties with their name, address, and telephone number.

(2) The appellant may act as their own representative or have another person represent them, except that employees of the health care authority (HCA) or HCA's authorized agents may not represent an appellant, unless approved by a hearing officer.

(3) If the appellant is represented by a person who is not an attorney admitted to practice in Washington state, the representative must provide the hearing officer and all other parties with the representative's name, address, and telephone number. In cases involving confidential information, the nonattorney representative must provide the HCA hearing representative with a signed, written consent permitting release to the nonattorney representative of health information protected by state or federal law.

(4) An attorney admitted to practice law in Washington state, who wishes to represent the appellant, must file a written notice of appearance containing the attorney's name, address, and telephone number with the hearing officer's office and serve all parties with the notice. In cases involving confidential information, the attorney representative must provide the HCA hearing representative with a signed, written consent permitting release to the attorney representative of the appellant's health information protected by state or federal law. If the appellant's attorney representative no longer represents the appellant, then the attorney must file a written notice of withdrawal of representation with the hearing officer's office and serve all parties with the notice.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-3010, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-3010, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-3015** Hearing officers—Assignment, motions of prejudice, and disqualification. {#sec-182-32-3015 omnilex-key=us-wa-regs-official--title-182--182-32-3015}

(1) Assignment: A hearing officer will be assigned at least five business days before a hearing. A party may ask which hearing officer is assigned to a hearing by contacting the hearing officer's office listed on the notice of hearing. If requested by a party, the hearing officer's office must send the name of the assigned hearing officer to all parties, by electronic mail or in writing, at least five business days before the scheduled hearing date.

(2) Motion of prejudice: Any party requesting a different hearing officer may file a written motion of prejudice against the hearing officer assigned to the matter before the hearing officer rules on a discretionary issue in the case, admits evidence, or takes testimony.

(a) A motion of prejudice must include a declaration stating that a party does not believe the hearing officer can hear the case fairly. Service of copies of the motion must also be made to all parties listed on the notice of hearing.

(b) Any party's first motion of prejudice will be automatically granted. Any subsequent motion of prejudice made by a party may be granted or denied at the discretion of the hearing officer no later than seven days after receiving the motion.

(c) A party may make an oral motion of prejudice at the beginning of a hearing before the hearing officer rules on a discretionary issue in the matter, admits evidence, or takes testimony if:

(i) The hearing officer was not assigned at least five business days before the date of the hearing; or

(ii) The hearing officer was changed within five business days of the date of the hearing.

(3) Disqualification: A hearing officer may be disqualified from presiding over a hearing for bias, prejudice, conflict of interest, or ex parte contact with a party to the hearing.

(a) Any party may file a petition to disqualify a hearing officer as described in RCW 34.05.425. A petition to disqualify must be in writing and service promptly made to all parties and the hearing officer upon discovering facts of possible grounds for disqualification.

(b) The hearing officer whose disqualification is requested will determine whether to grant or deny the petition in a written order, stating facts and reasons for the determination. The hearing officer must serve the order no later than seven days after receiving the petition for disqualification.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-3015, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-3015, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-3030** Authority of the hearing officer. {#sec-182-32-3030 omnilex-key=us-wa-regs-official--title-182--182-32-3030}

(1) A hearing officer must hear and decide the issues based on the evidence and oral or written arguments presented during a formal administrative hearing and admitted into the record.

(2) A hearing officer has no inherent or common law powers, and is limited to those powers granted by the state constitution, statutes, or rules.

(3) A hearing officer may not decide that a rule is invalid or unenforceable. If the validity of a rule is raised during a formal administrative hearing, the hearing officer may allow argument only to preserve the record for judicial review.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-3030, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-3030, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-3080** Time requirements for service of notices made by the hearing officer. {#sec-182-32-3080 omnilex-key=us-wa-regs-official--title-182--182-32-3080}

(1) The hearing officer or their designee must serve a notice of a formal administrative hearing to all parties and their representatives at least twenty-one calendar days before the hearing date. The parties may agree to, but the hearing officer cannot impose, a shorter notice period.

(2) If a prehearing conference or dispositive motion hearing is scheduled, the hearing officer must serve a notice of the prehearing conference or dispositive motion hearing to the parties and their representatives at least seven business days before the date of the prehearing conference or dispositive motion hearing except:

(a) The hearing officer may change any scheduled formal administrative hearing into a prehearing conference or dispositive motion hearing and provide less than seven business days' notice of the prehearing conference or dispositive motion hearing; and

(b) The hearing officer may give less than seven business days' notice if the only purpose of the prehearing conference is to consider whether to grant a continuance.

(3) The hearing officer must reschedule a formal administrative hearing if necessary to comply with the notice requirements in Part III of this chapter.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-3080, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-3080, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-3090** Formal administrative hearing location. {#sec-182-32-3090 omnilex-key=us-wa-regs-official--title-182--182-32-3090}

(1) A hearing officer must be present at all hearings. Hearings may be held either in person or telephonically.

(a) A telephonic hearing is where all parties and the hearing officer are present by telephone.

(b) An in-person hearing is where the appellant appears face-to-face with the hearing officer. The other parties can choose to appear either in person or by telephone, but cannot be ordered to appear in person.

(2) Whether a hearing is held in person or telephonically, the parties have the right to see all documents, hear all testimony, and question all witnesses.

(3) If a hearing is originally scheduled to be held in-person, the appellant may ask the hearing officer to change the in-person hearing to a telephonic hearing. Once a telephonic hearing begins, the hearing officer may stop, reschedule, and change the telephonic hearing to an in-person hearing if any party makes such a request.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-3090, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-3100** Rescheduling and continuances for formal administrative hearings. {#sec-182-32-3100 omnilex-key=us-wa-regs-official--title-182--182-32-3100}

(1) Any party may request the hearing officer to reschedule a formal administrative hearing if a rule requires notice of a hearing and the amount of notice required was not provided.

(a) The hearing officer must reschedule the formal administrative hearing under circumstances identified in this chapter if requested by any party.

(b) The parties may agree to shorten the amount of notice required by any rule.

(2) Any party may request a continuance of a formal administrative hearing either orally or in writing.

(a) In each formal administrative hearing, the hearing officer must grant each party's first request for a continuance. The continuance may be up to thirty calendar days.

(b) The hearing officer may grant each party up to one additional continuance of up to thirty calendar days because of extraordinary circumstances.

(c) After granting a continuance, the hearing officer or their designee must serve an order of continuance on the parties no later than fourteen days before the new formal administrative hearing date. All orders of continuance must provide a new deadline for filing documents with the hearing officer. The new filing deadline can be no less than ten calendar days prior to the new formal administrative hearing date. If the continuance is granted pursuant to (b) of this subsection, then the order of continuance must also include findings of fact that state with specificity the extraordinary circumstances for which the hearing officer granted the continuance.

(3) Regardless of whether a party has been granted a continuance as described in subsection (2)(b) of this section, the hearing officer must grant a continuance if a new material issue is raised during the formal administrative hearing and a party requests a continuance.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-3100, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-3100, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-3100, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-3110** Prehearing conferences. {#sec-182-32-3110 omnilex-key=us-wa-regs-official--title-182--182-32-3110}

(1) A prehearing conference is a formal proceeding conducted on the record by a hearing officer to prepare for a formal administrative hearing.

(a) The hearing officer must record a prehearing conference using audio recording equipment.

(b) The hearing officer may conduct a prehearing conference in person, by telephone conference call, or in any other manner acceptable to the parties.

(2) Any party can request a prehearing conference. The hearing officer must grant each party's first request for a prehearing conference if it is filed with the hearing officer at least seven business days before the next scheduled hearing date. The hearing officer may grant requests for additional prehearing conferences.

(3) The appellant must attend or participate in any scheduled prehearing conference. If the appellant does not attend or participate in a scheduled prehearing conference, the hearing officer will enter an order of default dismissing the matter.

(4) During a prehearing conference the parties and the hearing officer may:

(a) Identify the issue or issues to be decided;

(b) Agree to the date, time, and place of any requested or necessary hearing or hearings;

(c) Identify accommodation and safety issues; or

(d) Establish a schedule for:

(i) The exchange and filing of briefs;

(ii) Providing a list of proposed witnesses;

(iii) Providing exhibit lists; and

(iv) Providing proposed exhibits before the hearing.

(5) After the prehearing conference ends, the hearing officer must enter a written order that recites the action taken at the prehearing conference, a case schedule outlining hearing dates and deadlines for exchanging witness lists and exhibits, and any other agreements reached by the parties.

(6) The hearing officer must serve the prehearing order to the parties at least fourteen calendar days before the next scheduled hearing.

(7) A party may object to the prehearing order by filing an objection with the hearing officer in writing no later than ten days after the service date of the order. The hearing officer must serve a written ruling on the objection.

(8) If no objection is made to the prehearing order, the order determines how the case will be conducted by the hearing officer, including whether a hearing will be in person or held by telephone conference, unless the hearing officer enters an amended prehearing conference order.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-3110, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-3120** Dispositive motions. {#sec-182-32-3120 omnilex-key=us-wa-regs-official--title-182--182-32-3120}

(1) A dispositive motion could dispose of one or all the issues in a formal administrative hearing, such as a motion to dismiss or motion for summary judgment.

(2) To request a dispositive motion hearing a party must file a written dispositive motion with the hearing officer and serve a copy of the motion to all other parties. The hearing officer may also set a dispositive motion hearing, and request briefing from the parties, to address any possible dispositive issues the hearing officer believes must be addressed before the hearing.

(3) The deadline to file a timely dispositive motion must be ten calendar days before the scheduled hearing.

(4) Upon receiving a dispositive motion, a hearing officer:

(a) Must convert the scheduled hearing to a dispositive motion hearing when:

(i) The dispositive motion is timely filed with the hearing officer at least ten calendar days before the date of the hearing; and

(ii) The party filing the dispositive motion has not previously filed a dispositive motion.

(b) May schedule a dispositive motion hearing in all instances other than described in (a) of this subsection.

(5) The hearing officer may conduct the dispositive motion hearing in person or by telephone conference. For dispositive motion hearings scheduled to be held in person, the health care authority (HCA) hearing representative may choose to attend and participate in person or by telephone conference call.

(6) The party requesting the dispositive motion hearing must attend and participate in the dispositive motion hearing in person or by telephone. If the party requesting the motion hearing does not attend and participate in the dispositive motion hearing, the hearing officer will enter an order dismissing the dispositive motion.

(7) During a dispositive motion hearing, the hearing officer can only consider the filed dispositive motions, any response to the motions, evidence submitted to support or oppose the motions, and argument on the motions. Prior to rescheduling any necessary hearings, the hearing officer must serve a written order on the dispositive motions.

(8) The hearing officer must serve the written order on the dispositive motions to all parties no later than eighteen calendar days after the dispositive motion hearing is held. Orders on dispositive motions are subject to motions for reconsideration or petitions for judicial review as described in WAC 182-32-3180 and 182-32-3200.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-3120, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-3120, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-3120, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-3130** Subpoenas. {#sec-182-32-3130 omnilex-key=us-wa-regs-official--title-182--182-32-3130}

(1) Hearing officers, the health care authority (HCA) hearing representative, and attorneys for the parties may prepare subpoenas as described in Washington state civil rule 45, unless otherwise prohibited by law. Any party may request the hearing officer prepare a subpoena on their behalf.

(2) The hearing officer may schedule a prehearing conference to decide whether to issue a subpoena.

(3) If a party requests the hearing officer prepare a subpoena on its behalf, the party is responsible for:

(a) Service of the subpoena; and

(b) Any costs associated with:

(i) Compliance with the subpoena; and

(ii) Witness fees as described in RCW 34.05.446(7).

(4) Service of a subpoena must be made by a person who is at least eighteen years old and not a party to the hearing. Service of the subpoena is complete when the person serving the subpoena:

(a) Gives the person or entity named in the subpoena a copy of the subpoena; or

(b) Leaves a copy of the subpoena with a person over the age of eighteen at the residence or place of business of the person or entity named in the subpoena.

(5) To prove service of a subpoena on a witness, the person serving the subpoena must file with the hearing officer's office a signed, written, and dated statement that includes:

(a) The name of the person to whom service of the subpoena occurred;

(b) The date of the service of the subpoena occurred;

(c) The address where the service of the subpoena occurred; and

(d) The name, age, and address of the person who provided service of the subpoena.

(6) A person or entity subject to or affected by the subpoena may request the hearing officer quash (set aside) or change a subpoena request at any time before the deadline given in the subpoena.

(7) A hearing officer may quash (set aside) or change a subpoena if it is unreasonable.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-3130, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-3130, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-3140** Orders of dismissal—Reinstating a formal administrative hearing after an order of dismissal. {#sec-182-32-3140 omnilex-key=us-wa-regs-official--title-182--182-32-3140}

(1) An order of dismissal is an order from the hearing officer ending the matter. The order is entered because the party who made the appeal withdrew from the proceeding, the appellant is no longer aggrieved, the hearing officer granted a dispositive motion dismissing the matter, or the hearing officer entered an order of default because the party who made the appeal failed to attend or refused to participate in a prehearing conference or the formal administrative hearing.

(2) The order of dismissal becomes a final order if no party files a request to vacate the order as described in subsections (3) through (7) of this section.

(3) If the hearing officer enters and serves an order dismissing the formal administrative hearing, the appellant may file a written request to vacate (set aside) the order of dismissal. Upon receipt of a request to vacate an order of dismissal, the hearing officer must schedule and serve notice of a prehearing conference as described in WAC 182-32-3080. At the prehearing conference, the party asking that the order of dismissal be vacated has the burden to show good cause according to subsection (8) of this section for an order of dismissal to be vacated and the matter to be reinstated.

(4) The request to vacate an order of dismissal must be filed with the hearing officer and the other parties. The party requesting that an order of dismissal be vacated should specify in the request with good cause why the order of dismissal should be vacated.

(5) The request to vacate an order of dismissal must be filed with the hearing officer no later than twenty-one calendar days after the date the order of dismissal was entered. If no request is received within that deadline, the dismissal order becomes the health care authority's final decision without further action.

(6) If the hearing officer finds good cause, as described in subsection (8) of this section, for the order of dismissal to be vacated, the hearing officer must enter and serve a written order to the parties setting forth the findings of fact, conclusions of law, and the reinstatement of the matter.

(7) If the order of dismissal is vacated, the hearing officer will conduct a formal administrative hearing at which the parties may present argument and evidence about issues raised in the original appeal. The formal administrative hearing may occur immediately following the prehearing conference on the request to vacate only if agreed to by the parties and the hearing officer, otherwise a formal administrative hearing date must be scheduled by the hearing officer.

(8) Good cause is a substantial reason or legal justification for failing to appear, act, or respond to an action using the provisions of superior court civil rule 60 as a guideline. This good cause exception does not apply to any other chapter in Title 182 WAC except WAC 182-16-3140(8).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-3140, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-3140, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-3140, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-3160** Withdrawing a formal administrative hearing. {#sec-182-32-3160 omnilex-key=us-wa-regs-official--title-182--182-32-3160}

(1) The appellant may withdraw a formal administrative hearing for any reason, and at any time, by contacting the health care authority (HCA) hearing representative who will coordinate the withdrawal with the hearing officer.

(2) The request for withdrawal must generally be made in writing. An oral withdrawal by the appellant is permitted during a formal administrative hearing when both the hearing officer and HCA hearing representative are present.

(3) After a withdrawal request is received, the hearing officer must cancel any scheduled hearings and enter and serve a written order dismissing the case.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-3160, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-3170** Office of administrative hearings—Initial or final order—Required information. {#sec-182-32-3170 omnilex-key=us-wa-regs-official--title-182--182-32-3170}

(1) Initial order: When the office of administrative hearings is holding a formal administrative hearing on behalf of the authority, the hearing officer must render a written initial order that addresses the issue or issues raised by the appellant in their appeal. The hearing officer must serve a copy of the initial order on all parties and the initial order must contain information on how the appellant may request review of the initial order.

(2) Final order: The final order will only be issued by the authority. After the reviewing officer or officers receives a request for review, the reviewing officer or officers has 20 calendar days to enter and serve a final order to all parties unless the reviewing officer serves notice allowing more time.

(3) In the written final order, the hearing officer must:

(a) Identify the order as a final order of the school employees benefits board (SEBB) program;

(b) List the name and docket number of the case and the names of all parties and representatives;

(c) Enter findings of fact used to resolve the dispute based on the evidence admitted in the record;

(d) Explain why evidence is, or is not, credible when describing the weight given to evidence related to disputed facts;

(e) State the law that applies to the dispute;

(f) Apply the law to the facts of the case in the conclusions of law;

(g) Discuss the reasons for the decision based on the facts and the law;

(h) State the result and remedy ordered; and

(i) Include any other information required by law or program rules.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-32-3170, filed 6/21/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-3170, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-3170, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-3175** How to request a review of an initial order by the office of administrative hearings. {#sec-182-32-3175 omnilex-key=us-wa-regs-official--title-182--182-32-3175}

(1) Both the appellant and the authority may request review of an initial order. An appellant who has received an initial order upholding a school employees benefits board (SEBB) organization or employer group decision, a SEBB program decision, or a decision made by a SEBB program contracted vendor, may request review of the initial order by filing a written request or making an oral request with the SEBB appeals unit within 20 days after service of the initial order. The written or oral request for review of the initial order must be made by using the contact information included in the initial order. If such review is requested, the hearing officer or their designee from the authority, shall issue a final order in accordance with WAC 182-32-3030. If the appellant fails to request review of the initial order within 20 days, the initial order becomes the authority's final order without further action.

(2) Upon timely request by the appellant, a review of an initial order will be performed by one or more reviewing officers designated by the director of the authority.

(3) If the appellant has not requested review of the initial order, the authority may review an initial order issued by the office of administrative hearings on its own, and without notice to the parties, but it may not take action on review less favorable to any party than the initial order without giving that party notice and an opportunity to explain that party's view of the matter.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.740, 2023 c 13 § 2, and 2023 c 51 § 3. WSR 24-15-107 (Admin #2024-01), § 182-32-3175, filed 7/22/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-32-3175, filed 6/21/22, effective 1/1/23.*

##### **Wash. Admin. Code § 182-32-3180** Request for reconsideration and response—Process. {#sec-182-32-3180 omnilex-key=us-wa-regs-official--title-182--182-32-3180}

(1) A request for reconsideration asks the hearing officer to reconsider the final order because the party believes the hearing officer made a mistake of law, mistake of fact, or clerical error.

(2) A request for reconsideration must state in writing why the party wants the final order to be reconsidered.

(3) Requests for reconsideration must be filed with the hearing officer who entered the final order.

(4) If a party files a request for reconsideration:

(a) The hearing officer must receive the request for reconsideration on or before the tenth business day after the service date of the final order;

(b) The party filing the request must serve copies of the request on all other parties on the same day the request is served on the hearing officer; and

(c) Within five business days of receiving a request for reconsideration, the hearing officer must serve to all parties a notice that provides the date the request for reconsideration was received.

(5) The other parties may respond to the request for reconsideration. The response must state in writing why the final order should stand. Responses are optional. If a party chooses not to respond, that party will not be prejudiced because of that choice.

(a) Responses to a request for reconsideration must be received by the hearing officer no later than seven business days after the service date of the hearing officer's notice as described in subsection (4)(c) of this section, or the response will not be considered.

(b) Service of responses to a request for reconsideration must be made to all parties.

(6) If a party needs more time to file a request for reconsideration or respond to a request for reconsideration, the hearing officer may extend the required time frame if the party makes a written request providing a good reason for the request within the required time frame.

(7) No evidence may be offered in support of a motion for reconsideration, except newly discovered evidence that is material for the party moving for reconsideration and that the party could not with reasonable diligence have discovered and produced prior to the final order being issued.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-3180, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-3180, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-3180, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-3190** Decisions on requests for reconsideration. {#sec-182-32-3190 omnilex-key=us-wa-regs-official--title-182--182-32-3190}

(1) Unless the request for reconsideration is denied as untimely filed under WAC 182-32-3180, the same hearing officer who entered the final order, if reasonably available, will also decide the request as well as any responses received.

(2) The decision on the request for reconsideration must be in the form of a written order denying or granting the request in whole or in part and if the request is granted issuing a new written final order.

(3) If the hearing officer does not send an order on the request for reconsideration within twenty calendar days of the date of the notice described in WAC 182-32-3180 (4)(c), the request is deemed denied.

(4) If any party files a request for reconsideration of the final order, the reconsideration process must be completed before any judicial review may be requested. However, the filing of a request for reconsideration is not required before requesting judicial review.

(5) An order denying a request for reconsideration is not subject to judicial review.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 231. WSR 20-16-067 (Admin #2020-04), § 182-32-3190, filed 7/28/20, effective 8/28/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-3190, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-3190, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-3200** Judicial review of final order. {#sec-182-32-3200 omnilex-key=us-wa-regs-official--title-182--182-32-3200}

(1) Judicial review is the process of appealing a final order to a court.

(2) The appellant may appeal a final order by filing a written petition for judicial review that meets the requirements of RCW 34.05.510 through 34.05.598. The school employees benefits board (SEBB) program may not request judicial review.

(3) The appellant should consult RCW 34.05.510 through 34.05.598 for further details and requirements of the judicial review process.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 13, 2018 c 260, and SEBB policy resolutions. WSR 19-14-093 (Admin #2019-01), § 182-32-3200, filed 7/1/19, effective 8/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and SEBB policy resolutions. WSR 19-01-055 (Admin #2018-01), § 182-32-3200, filed 12/14/18, effective 1/14/19.*

##### **Wash. Admin. Code § 182-32-3210** Petitions for judicial review—Service on the authority. {#sec-182-32-3210 omnilex-key=us-wa-regs-official--title-182--182-32-3210}

Delivery pursuant to RCW 34.05.542(4) shall be deemed to have been made when a copy of the petition for judicial review has been received by the school employees benefits board (SEBB) appeals unit at Cherry Street Plaza, 626 8th Avenue S.E., Olympia, WA 98501 or received by mail at the SEBB appeals unit, P.O. Box 45504, Olympia, WA 98504-5504.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-168 (Admin #2022-01), § 182-32-3210, filed 6/21/22, effective 1/1/23.*

## **Chapter 182-40** PEBB/SEBB reimbursement methodology requirements. {#struct-chapter-182-40}

##### **Wash. Admin. Code § 182-40-0100** Purpose. {#sec-182-40-0100 omnilex-key=us-wa-regs-official--title-182--182-40-0100}

***(Effective January 1, 2027)***

The rules in this chapter are effective January 1, 2027, and implement the requirements and limitations in RCW 41.05.028.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.028. WSR 25-24-066, s 182-40-0100, filed 12/1/25, effective 1/1/27.*

##### **Wash. Admin. Code § 182-40-0200** Definitions. {#sec-182-40-0200 omnilex-key=us-wa-regs-official--title-182--182-40-0200}

***(Effective January 1, 2027)***

The following definitions and those found in chapter 41.05 RCW apply to this chapter. If a definition in this chapter conflicts with a definition in chapter 41.05 RCW, the definition in chapter 41.05 RCW prevails:

"Authority" - See RCW 41.05.011.

"Allowed amount" means the maximum portion of a billed charge a contractor will pay, including any applicable enrollee cost-sharing responsibility, for a covered health care service.

"Benchmark reimbursement" means the applicable payment standard against which a contractor's allowed amounts paid to providers and facilities are assessed for compliance measurement.

"Benchmark weight" means a numerical assignment of required resources to provide care for a specific medicare diagnosis-related group (DRG) relative to average resources across all DRGs.

"Centers for Medicare and Medicaid Services" or "CMS" - See WAC 182-500-0020.

"Compliance measurement" means the authority's review of contractor-submitted data for each plan year to determine compliance under this chapter.

"Contractor" means a health carrier that provides medical insurance offered to public employees and their covered dependents under chapter 41.05 RCW, or a third-party administrator contracted by the authority to provide medical coverage to public employees under chapter 41.05 RCW.

"Diagnosis-related group" or "DRG" - See WAC 182-550-1050.

"Hospital" means a hospital licensed under chapter 70.41 RCW and located in Washington state that receives payment for services provided to enrollees in the public employees' benefits board (PEBB) program, as defined in WAC 182-08-015, or enrollees in the school employees' benefits board (SEBB) program, as defined in WAC 182-30-020.

"Percent of medicare" means the percent of the equivalent amount of medicare or other reimbursement benchmarking as determined by the reimbursement benchmarking methodology in WAC 182-40-0600.

"Plan year" means the 12-month period beginning on January 1st of each year and ending on December 31st of the same year.

"Premium" means all sums charged, received, or deposited by a health carrier as consideration for a health plan or the continuance of a health plan. Any assessment or any "membership," "policy," "contract," "service," or similar fee or charge made by a health carrier in consideration for a health plan is deemed part of the premium. "Premium" does not include amounts paid as enrollee point-of-service cost-sharing.

"Public employee" - See RCW 41.05.011.

"Ratio of costs-to-charges" or "RCC" - See WAC 182-550-1050.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.028. WSR 25-24-066, s 182-40-0200, filed 12/1/25, effective 1/1/27.*

##### **Wash. Admin. Code § 182-40-0300** Hospital reimbursement requirements. {#sec-182-40-0300 omnilex-key=us-wa-regs-official--title-182--182-40-0300}

***(Effective January 1, 2027)***

(1) In-network hospitals. The maximum reimbursement paid to an in-network hospital for inpatient and outpatient hospital services, including contractor payments and any applicable member cost-sharing, must be the lesser of:

(a) The billed charges;

(b) The contractor's contracted rate with a hospital; or

(c) One of the following:

(i) For hospitals not primarily engaged in the care and treatment of children located in King or Pierce counties, 200 percent of what medicare would have reimbursed that hospital for the same or similar service; or

(ii) For a hospital primarily engaged in the care and treatment of children and located in either of the following:

(A) King County - 150 percent of the hospital-specific medicaid inpatient ratio of costs-to-charges (RCC) published by the authority; or

(B) Pierce County - 190 percent of the hospital-specific medicaid inpatient RCC published by the authority.

(2) Out-of-network hospitals. The maximum reimbursement amount paid by a contractor, including any applicable enrollee cost-sharing responsibility, to an in-state, out-of-network hospital for inpatient and outpatient hospital services must be the lesser of:

(a) The billed charges; or

(b) One of the following:

(i) For hospitals not primarily engaged in the care and treatment of children located in King or Pierce counties, 185 percent of what medicare would have reimbursed that hospital for the same or similar service; or

(ii) For a hospital primarily engaged in the care and treatment of children located in either of the following:

(A) King County - 135 percent of the hospital-specific medicaid inpatient RCC published by the authority; or

(B) Pierce County - 175 percent of the hospital-specific medicaid inpatient RCC published by the authority.

(3) Contractor reimbursement for services provided by rural hospitals certified by the Centers for Medicare and Medicaid Services (CMS) as critical access hospitals may not be less than 101 percent of allowable costs as defined by CMS for the purpose of medicare cost reporting.

(4) By September 1st of every calendar year, the authority notifies contractors of the published medicaid RCC that applies to reimbursements under subsections (1) and (2) of this section for the following plan year.

(5) A contractor must determine any applicable member cost-sharing based on the reimbursement amount authorized to be paid to hospitals for claims under this section.

(6) If the authority determines a contractor has provided payments that exceed the maximum reimbursement established in subsections (1) and (2) of this section, or is less than the minimum reimbursement established in subsection (3) of this section, the authority will send the contractor a written notice of noncompliance according to WAC 182-40-1400.

(7) The authority determines compliance under this section separately for contractor payments made under the public employees' benefits board program and school employees' benefits board program established under chapter 41.05 RCW.

(8) Annual premiums established by a contractor must take into account projected changes in reimbursement for hospital services anticipated to result from the application of reimbursement caps applied in subsections (1) and (2) of this section.

(9) For purposes of this section:

(a) Reimbursement for inpatient and outpatient services does not include charges for professional services; and

(b) "The contractor's contracted rate" means the allowed amount established by the contractor to each in-network hospital for each inpatient and outpatient service in effect when the service was provided.

(10) Except for subsection (3) of this section, this section does not apply to:

(a) Rural hospitals certified by CMS as sole community hospitals or critical access hospitals, except for hospitals owned or operated by a health system that owns or operates more than two acute care hospitals licensed under chapter 70.41 RCW;

(b) Hospitals located on an island operating within a public hospital district in Skagit County; or

(c) Hospitals that:

(i) Are not currently designated as a critical access hospital;

(ii) Do not meet current federal eligibility requirements for designation as a critical access hospital;

(iii) Have combined medicaid and medicare inpatient days greater than 60 percent of all hospital inpatient days; and

(iv) Are located on the land of a federally recognized Indian tribe.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.028. WSR 25-24-066, s 182-40-0300, filed 12/1/25, effective 1/1/27.*

##### **Wash. Admin. Code § 182-40-0400** Primary care and behavioral health reimbursement requirements. {#sec-182-40-0400 omnilex-key=us-wa-regs-official--title-182--182-40-0400}

***(Effective January 1, 2027)***

(1) Reimbursement for in-network primary care and in-network nonfacility-based behavioral health services may not be less than 150 percent of the total amount medicare would have reimbursed for the same or similar service, inclusive of contractor payments and any member cost-sharing.

(2) If the authority determines a contractor's payments, inclusive of contractor payments and any member cost-sharing, are less than the minimum reimbursement established in subsection (1) of this section, the authority will send the contractor a written notice of noncompliance according to WAC 182-40-1400.

(3) The authority determines compliance under this section separately for contractor payments made under the public employees' benefits board program and school employees' benefits board program established under chapter 41.05 RCW.

(4) The authority will publish a list of service codes, provider licensure types, and sites of service to which the reimbursement provisions in this section are applicable no later than January 31st of the year preceding the plan year for which the reimbursement requirements are applicable.

(5) For the purposes of this section, reimbursement for primary care and behavioral health services does not include charges for facility-based services.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.028. WSR 25-24-066, s 182-40-0400, filed 12/1/25, effective 1/1/27.*

##### **Wash. Admin. Code § 182-40-0500** Reimbursement using a payment methodology other than fee-for-service. {#sec-182-40-0500 omnilex-key=us-wa-regs-official--title-182--182-40-0500}

***(Effective January 1, 2027)***

A contractor may reimburse a provider or hospital using a payment methodology other than fee-for-service as long as:

(1) The payments incentivize higher quality or improved outcomes including, but not limited to:

(a) Value-based payments;

(b) Capitation payments;

(c) Bundled payments;

(d) Integrated care payments consistent with the requirements in RCW 74.09.758; and

(e) Shared savings payments; and

(2) The contractor complies with the reimbursement requirements in WAC 182-40-0300 and 182-40-0400.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.028. WSR 25-24-066, s 182-40-0500, filed 12/1/25, effective 1/1/27.*

##### **Wash. Admin. Code § 182-40-0600** Reimbursement benchmarking. {#sec-182-40-0600 omnilex-key=us-wa-regs-official--title-182--182-40-0600}

***(Effective January 1, 2027)***

(1) Except for hospitals primarily engaged in the care and treatment of children in King or Pierce counties, for the purpose of calculating any payment thresholds set in this chapter:

(a) The authority calculates the amount of benchmark reimbursement for a service as the amount that would have been paid if the Centers for Medicare and Medicaid Services reimbursed a claim under the medicare program, including applicable post claim settlements, except for:

(i) Services for which there is no published medicare rate or payment methodology; or

(ii) Services with a published medicare reimbursement rate or payment methodology with a low volume of medicare experience.

(b) For inpatient services with a low volume of medicare experience, the authority determines the relative benchmark weight for enrollees in the public employees' benefits board program and school employees' benefits board program, established under chapter 41.05 RCW, by using medicare or elements from publicly available fee schedules.

(c) For primary care and behavioral health services where there is no published medicare rate or payment methodology, the authority will exclude these services from the compliance determination.

(d) For outpatient services where there is no published medicare rate or payment methodology, the authority projects the benchmark amount using the facility's average medicare discount off billed charges for services where there is a medicare fee schedule rate or payment methodology.

(2) For hospitals primarily engaged in the care and treatment of children in King and Pierce counties, the authority calculates the amount of benchmark reimbursement for services using the hospital-specific published medicaid inpatient ratio of cost to charges as determined by the authority.

(3) For rural hospitals certified by the Centers for Medicare and Medicaid Services as critical access hospitals, the authority calculates the amount of benchmark reimbursement for a service using allowable cost reporting in the hospital's medicare cost report.

(4) The authority annually publishes a compliance guide by January 31st of the year preceding the plan year for which the reimbursement requirements are applicable that includes the following:

(a) Payment thresholds;

(b) A list of hospitals subject to the provisions of WAC 182-40-0300; and

(c) The underlying reimbursement benchmarking methodology used in the annual compliance measurement.

(5) The authority develops, maintains, and has final approval authority over the published compliance guide. The compliance guide is located on the authority's website. The authority uses the compliance guide for the purposes of calculating any payment thresholds set in this chapter.

(6) At any time during the year, the authority may make changes to the compliance guide. The authority will provide contractors the opportunity to comment on substantive changes to the compliance guide 30 days before the change is finalized for that plan year.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.028. WSR 25-24-066, s 182-40-0600, filed 12/1/25, effective 1/1/27.*

##### **Wash. Admin. Code § 182-40-0700** Reporting requirements. {#sec-182-40-0700 omnilex-key=us-wa-regs-official--title-182--182-40-0700}

***(Effective January 1, 2027)***

(1) Contractors must provide the authority with the following in the form and manner prescribed by the authority:

(a) Cost and quality of care information; and

(b) Data on all claims and encounters.

(2) Except for hospitals primarily engaged in the care and treatment of children in King and Pierce counties, providers and hospitals submitting any claims to a public employees' benefits board program and school employees' benefits board program health plan must include all the current year modifiers required by the Centers for Medicare and Medicaid Services. This ensures all rebates, incentives, or adjustments that would have applied if the services were reimbursed by medicare apply.

(3) Contractors may not enter into an agreement with a provider, hospital, or third party that would restrict the contractor from providing this information or data.

(4) If a contractor reimburses a hospital or provider on a nonfee-for-service basis or provides payment in addition to a fee-for-service arrangement, the contractor must report to the authority such alternative payment methods and amounts paid in a format determined by the authority, by no later than July 1st of each year for the preceding plan year.

(5) When the authority determines that a contractor failed to meet the requirements in this section, the authority provides the contractor with a written notice of noncompliance and assesses a fine for each failure according to WAC 182-40-1500.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.028. WSR 25-24-066, s 182-40-0700, filed 12/1/25, effective 1/1/27.*

##### **Wash. Admin. Code § 182-40-0800** Annual compliance measurement. {#sec-182-40-0800 omnilex-key=us-wa-regs-official--title-182--182-40-0800}

***(Effective January 1, 2027)***

(1) The authority conducts an annual measurement as described in WAC 182-40-0300 and 182-40-0400 following the end of a plan year to ensure compliance with this chapter. Failure to comply with the reimbursement requirements in this chapter will result in a written notice of noncompliance as identified in WAC 182-40-1400.

(2) The authority may request additional information or documentation from the contractor.

(a) If the authority sends a written request for additional information or documentation, the contractor has 28 calendar days upon receipt of the request to:

(i) Provide the requested information or documentation; or

(ii) Request additional time to complete the request.

(b) The authority grants additional time on a case-by-case basis, but the request must be received before the expiration of the original 28 calendar days to avoid a fine.

(3) When the authority determines that a contractor has failed to meet the requirements in this section, the authority will provide the contractor with a written notice of noncompliance and may assess a fine for each failure according to WAC 182-40-1400.

(4) The authority deposits any amounts collected from the contractor due to overpayments into the public employees' and retirees' insurance accounts or school employees' insurance account established under chapter 41.05 RCW, as applicable.

(5) The authority uses amounts deposited to offset health care costs for the public employees' benefits board and school employees' benefits board program health plan offerings in future plan years.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.028. WSR 25-24-066, s 182-40-0800, filed 12/1/25, effective 1/1/27.*

##### **Wash. Admin. Code § 182-40-0900** Hospital overpayments. {#sec-182-40-0900 omnilex-key=us-wa-regs-official--title-182--182-40-0900}

***(Effective January 1, 2027)***

(1) When the authority determines a contractor has reimbursed a hospital an amount in excess of the payment threshold for any plan year, as specified in WAC 182-40-0300, it is an overpayment. When the authority identifies an overpayment, the authority provides to the contractor written notice of noncompliance and assessment of the overpayment owed by the contractor.

(2) When the authority determines a contractor failed to meet the requirements under WAC 182-40-0300 for consecutive plan years due to making overpayments, the authority may also assess a fine according to WAC 182-40-1400.

(3) The authority may also require the contractor to create a corrective action plan or demonstrate corrective action. See WAC 182-40-1200.

(4) Nothing in this chapter prevents a contractor from seeking to recoup overpayments from hospitals.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.028. WSR 25-24-066, s 182-40-0900, filed 12/1/25, effective 1/1/27.*

##### **Wash. Admin. Code § 182-40-1000** Primary care, behavioral health, and critical access hospital underpayments. {#sec-182-40-1000 omnilex-key=us-wa-regs-official--title-182--182-40-1000}

***(Effective January 1, 2027)***

(1) When the authority determines a contractor reimbursed primary care, behavioral health providers, or critical access hospitals below the required payment threshold for any plan year, as specified in WAC 182-40-0300 and 182-40-0400, the authority provides written notice of noncompliance to the contractor.

(2) When the authority determines a contractor failed to meet the requirements under WAC 182-40-0300 and 182-40-0400 for consecutive plan years due to making underpayments, the authority may also assess a fine according to WAC 182-40-1400.

(3) The authority may also require the contractor to create a corrective action plan or demonstrate corrective action. See WAC 182-40-1200.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.028. WSR 25-24-066, s 182-40-1000, filed 12/1/25, effective 1/1/27.*

##### **Wash. Admin. Code § 182-40-1100** Contractor responsibility for ensuring reimbursement to providers and provider networks. {#sec-182-40-1100 omnilex-key=us-wa-regs-official--title-182--182-40-1100}

***(Effective January 1, 2027)***

Contractors are responsible for ensuring any reimbursements to providers and provider networks comply with reimbursement requirements established in WAC 182-40-0300 and 182-40-0400. This includes provider reimbursements resulting from arrangements with any person or organization the contractor uses to develop its provider network. For example, arrangements include, but are not limited to, rental provider networks, subcontracted business partners, subcontracted provider networks, contracted vendor networks, reciprocal claims pricing arrangements, health care benefit managers as defined in RCW 48.200.020, etc.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.028. WSR 25-24-066, s 182-40-1100, filed 12/1/25, effective 1/1/27.*

##### **Wash. Admin. Code § 182-40-1200** Corrective action plan. {#sec-182-40-1200 omnilex-key=us-wa-regs-official--title-182--182-40-1200}

***(Effective January 1, 2027)***

(1) In addition to any action described in this chapter, the authority may require the contractor to create and comply with a corrective action plan and demonstrate corrective action. A copy of the corrective action plan must be provided to the authority within the time period specified by the authority in its request.

(2) Submission and implementation of a correction plan does not guarantee a contractor's future compliance with the requirements in this chapter.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.028. WSR 25-24-066, s 182-40-1200, filed 12/1/25, effective 1/1/27.*

##### **Wash. Admin. Code § 182-40-1300** Hospital balance billing. {#sec-182-40-1300 omnilex-key=us-wa-regs-official--title-182--182-40-1300}

***(Effective January 1, 2027)***

(1) An in-state, out-of-network hospital that is reimbursed in accordance with WAC 182-40-0300(2) may not charge to or collect from the patient, for a service covered by the patient's health plan, or a person who is financially responsible for the patient, an amount in addition to the reimbursement paid by the contractor under WAC 182-40-0300(2) other than cost-sharing amounts authorized by the terms of the public employees' benefits board or school employees' benefits board health plan.

(2) The hospital is prohibited from obtaining a patient's waiver of their rights to protection under this section.

(3) Cost-sharing amounts applied under this section for services rendered by a hospital that are covered by a fully insured contractor under an alternate access delivery request (AADR) approved by the office of the insurance commissioner under WAC 284-170-210 must comply with the terms of the AADR.

(4) When the authority receives or identifies information indicating that an out-of-network hospital may have violated subsection (1) of this section, the following actions apply:

(a) The authority conducts a balance billing review and provides notice to the hospital and any impacted contractor of the balance billing review.

(i) The notice may require the hospital to provide records and additional information or documentation relevant and necessary for the authority to evaluate and validate that the hospital received only those funds to which it was entitled under this chapter.

(ii) The hospital has 30 calendar days upon receipt of the notice to:

(A) Provide the requested information or documentation; or

(B) Request additional time to complete the request.

(iii) The authority grants additional time on a case-by-case basis, but the request must be received before the expiration of the original 30 calendar days to avoid a fine.

(b) Once a balance billing review begins:

(i) The hospital must retain all original records and supportive materials sent to the authority until the authority sends the balance billing determination notice to the hospital and all issues are resolved; and

(ii) Unless instructed to do so by the authority, the hospital must not adjust or rebill a claim or encounter within the scope of the balance billing activity until the authority has concluded the balance billing determination review.

(c) After the balance billing review, the authority provides a balance billing determination notice to the hospital and impacted health contractor.

(i) If the authority finds that the hospital has not balance billed, the authority issues a notice that the review is closed.

(ii) If the authority finds that the hospital has balance billed:

(A) The authority notifies the hospital it must reimburse the enrollee, if it has collected excess funds, within 30 calendar days from receipt of the balance billing determination notice and provide to the authority proof of payment, if any is owed, to the enrollee; and

(B) The authority may assess a fine on the hospital for balance billing according to WAC 182-40-1400, whether or not the member actually paid the amount inappropriately billed.

(iii) If the hospital has not repaid the enrollee any amount owed within 30 calendar days of the hospital's receipt of the balance billing determination notice from the authority, the authority may assess an additional fine according to WAC 182-40-1400.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.028. WSR 25-24-066, s 182-40-1300, filed 12/1/25, effective 1/1/27.*

##### **Wash. Admin. Code § 182-40-1400** Written notice of noncompliance, overpayments, and fines. {#sec-182-40-1400 omnilex-key=us-wa-regs-official--title-182--182-40-1400}

***(Effective January 1, 2027)***

(1) When the authority determines that a contractor or hospital failed to comply with a requirement in this chapter, the authority provides written notice of noncompliance to the contractor or hospital explaining the nature of the violation.

(2) The authority may assess overpayments or fines against the contractor or hospital as follows:

(a) Consecutive plan years of hospital overpayments. For two or more years of consecutive noncompliance, the authority may fine a contractor up to 500 percent of the overpayment amount for the impacted plan years, in addition to collecting the overpayments from the contractor.

(b) Consecutive plan years of primary care or behavioral health underpayments. For two or more years of consecutive noncompliance, the authority may fine a contractor up to 500 percent of the underpayment amount for the impacted plan years.

(c) The authority considers the following factors when determining the amount of the fine that will be assessed for consecutive plan years of hospital overpayments or primary care and behavioral health underpayments:

(i) The number of facilities or providers over or underpaid;

(ii) The duration of underpayments or overpayments;

(iii) The volume of over or underpayments; and

(iv) The types of contract or payment terms that led to over or underpayment.

(d) Hospital balance billing. If the authority finds a hospital to be in violation of WAC 182-40-1300, the authority may assess a fine on that hospital in an amount not to exceed $10,000 per violation. In assessing a fine, the authority considers mitigating circumstances, such as the nature of claims and the circumstances under which these claims were presented to the authority, the degree of culpability, any history of prior offenses, the frequency of violations (i.e., whether the issue represents a pattern or is an isolated incident), and other factors as necessary.

(e) Reporting penalties. For failure to meet the requirements in WAC 182-40-0700, the authority may assess the following fines:

| Number of failures | Fine assessed |
| --- | --- |
| First | $10,000 |
| Second | $25,000 |
| Third | $50,000 |
| Fourth and subsequent incidents | $100,000 |

(f) Untimely responses to an authority request. If the authority determines that a contractor has failed to fully and timely respond to the authority's request for information or documentation, the authority may impose an immediate fine for each failure to comply with the requirements of this section as follows:

| Number of failures | Fine assessed |
| --- | --- |
| First | $10,000 |
| Second | $25,000 |
| Third | $50,000 |
| Fourth and subsequent incidents | $100,000 |

(g) Fines under this section are cumulative.

(3) The authority must receive payment of any assessed fine within 28 calendar days of the date the party received the written notice of noncompliance assessing a fine.

(4) Notices are sent either electronically or in another manner that provides proof of receipt.

(5) Contractors and hospitals may appeal a notice of noncompliance, overpayment, or fine in accordance with WAC 182-40-1500.

(6) Payment of fines or overpayments is stayed through the administrative process only if a contractor or hospital timely files an appeal under this section.

(7) The authority may impose a one percent interest charge for each month fines are unpaid after the due date.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.028. WSR 25-24-066, s 182-40-1400, filed 12/1/25, effective 1/1/27.*

##### **Wash. Admin. Code § 182-40-1500** Appeal of notice of noncompliance. {#sec-182-40-1500 omnilex-key=us-wa-regs-official--title-182--182-40-1500}

***(Effective January 1, 2027)***

(1) A contractor or hospital may appeal a written notice of noncompliance by timely filing an appeal, and the authority will schedule an administrative hearing.

(2) To file an appeal, the contractor or hospital must send a written request to the authority.

(a) The authority must receive the written request within 28 calendar days of the date the contractor or hospital received the notice of noncompliance.

(b) The written request to appeal must be sent to the address listed on the notice in a manner that provides proof of receipt.

(c) The written request to appeal must provide a copy of the notice of noncompliance being disputed.

(3) The authority conducts hearings and appeals under the Administrative Procedure Act, chapter 34.05 RCW, and the administrative hearing rules in chapter 182-526 WAC.

(4) Under WAC 182-526-0025, the authority, in its sole discretion, may conduct the administrative hearing or may transfer the hearing to the office of administrative hearings (OAH).

(a) If the authority conducts the administrative hearing, it issues the final agency decision.

(b) If OAH conducts the administrative hearing, it issues an initial order with instructions on how either party can request review with the authority's board of appeals.

(5) If the final order upholds the notice of noncompliance, the contractor or hospital must pay the fine within 28 calendar days of the issuance date of the final order.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.028. WSR 25-24-066, s 182-40-1500, filed 12/1/25, effective 1/1/27.*

## **Chapter 182-50** Prescription drug programs. {#struct-chapter-182-50}

##### **Wash. Admin. Code § 182-50-001** Authority and purpose. {#sec-182-50-001 omnilex-key=us-wa-regs-official--title-182--182-50-001}

RCW 41.05.021 (1)(b)(iii) and 70.14.050 authorize the director to establish an independent Washington state pharmacy and therapeutics committee within the health care authority to evaluate available evidence of the relative safety, efficacy and the effectiveness of prescription drugs within a class of prescription drugs, in the development of an evidence-based prescription drug program for participating state purchased health care programs. This section requires the director to adopt rules governing practitioner endorsement and use of the Washington preferred drug list developed as part of the prescription drug program.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 69.41.190. WSR 16-16-083, § 182-50-001, filed 7/29/16, effective 8/29/16. Statutory Authority: RCW 41.05.160*
- *2004 1st sp.s. c 29 § 10. WSR 04-06-021 (Order 03-02), § 182-50-001, filed 2/23/04, effective 3/25/04.*

##### **Wash. Admin. Code § 182-50-005** Definitions. {#sec-182-50-005 omnilex-key=us-wa-regs-official--title-182--182-50-005}

When used in this chapter:

(1) "Appointing authority" means the following people acting jointly: The director of the health care authority and the director of the department of labor and industries.

(2) "Committee" means the independent Washington state pharmacy and therapeutics committee created by RCW 41.05.021 (1)(b)(iii) and 70.14.050. At the election of the health care authority, the committee may serve as the drug use review board provided for in WAC 182-530-4000.

(3) "Drug" means the term as it is defined in RCW 69.41.010.

(4) "Endorsing practitioner" means a practitioner who has notified the health care authority that he or she agrees to allow therapeutic interchange.

(5) "Practitioner" means a health care provider, except a veterinarian, as defined at RCW 18.64.011.

(6) "Preferred drug" means a drug selected by the appointing authority for inclusion in the Washington preferred drug list used by applicable state agencies for state purchased health care programs.

(7) "Prescription" has the meaning set forth in RCW 18.64.011.

(8) "Refill" means the continuation of therapy with the same drug, including the renewal of a previous prescription or adjustments in dosage.

(9) "State purchased health care" has the meaning set forth in RCW 41.05.011.

(10) "Therapeutic interchange" means to dispense a preferred drug in place of a prescribed nonpreferred drug within the same therapeutic class listed on the Washington preferred drug list.

(11) "Washington preferred drug list" or "WPDL" means the list of drugs selected by the appointing authority to be used by applicable state agencies as the basis for the purchase of drugs in state purchased health care programs.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 69.41.190. WSR 16-16-083, § 182-50-005, filed 7/29/16, effective 8/29/16. Statutory Authority: RCW 41.05.160 and 69.41.180. WSR 07-19-031 (Order 07-03), § 182-50-005, filed 9/12/07, effective 10/13/07. Statutory Authority: RCW 41.05.160*
- *2004 1st sp.s. c 29 § 10. WSR 04-06-021 (Order 03-02), § 182-50-005, filed 2/23/04, effective 3/25/04.*

##### **Wash. Admin. Code § 182-50-010** Purpose of the pharmacy and therapeutics committee. {#sec-182-50-010 omnilex-key=us-wa-regs-official--title-182--182-50-010}

The purpose of the committee is to evaluate the available evidence of the relative safety, efficacy, and effectiveness of prescription drugs within a class of prescription drugs and make recommendations to the appointing authority for its deliberation in the development of the Washington preferred drug list established in RCW 70.14.050.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 69.41.190. WSR 16-16-083, § 182-50-010, filed 7/29/16, effective 8/29/16. Statutory Authority: RCW 41.05.160*
- *2004 1st sp.s. c 29 § 10. WSR 04-06-021 (Order 03-02), § 182-50-010, filed 2/23/04, effective 3/25/04.*

##### **Wash. Admin. Code § 182-50-015** Open Public Meetings Act and Administrative Procedure Act; exception as technical review committee. {#sec-182-50-015 omnilex-key=us-wa-regs-official--title-182--182-50-015}

(1) Meetings of the pharmacy and therapeutics committee comply with the provisions of the Open Public Meetings Act, chapter 42.30 RCW, and are subject to the provisions of the Administrative Procedure Act, chapter 34.05 RCW, as applicable.

(2) The pharmacy and therapeutics committee constitutes a technical review committee created to facilitate the development, acquisition, or implementation of the Washington preferred drug list, for the purposes of state purchased health care under RCW 41.05.026, and may hold an executive session in accordance with chapter 42.30 RCW during any regular or special meeting to discuss information submitted in accordance with RCW 41.05.026.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 69.41.190. WSR 16-16-083, § 182-50-015, filed 7/29/16, effective 8/29/16. Statutory Authority: RCW 41.05.160*
- *2004 1st sp.s. c 29 § 10. WSR 04-06-021 (Order 03-02), § 182-50-015, filed 2/23/04, effective 3/25/04.*

##### **Wash. Admin. Code § 182-50-025** Membership and qualifications of pharmacy and therapeutics committee. {#sec-182-50-025 omnilex-key=us-wa-regs-official--title-182--182-50-025}

(1) The committee consists of no fewer than ten members appointed by the appointing authority.

(2) The appointing authority has the sole right to appoint committee members and may terminate appointment of any member at any time during the term.

(3) The appointing authority makes appointments to the committee from a pool of interested applicants. Interested people are provided an opportunity to submit applications to the appointing authority.

(4) Members enter into an agreement with the health care authority at the time of their appointment to the committee and act in accordance with all of its terms and conditions. Failure to do so may result in termination of the appointment.

(5) The membership composition at all times is consistent with applicable federal requirements for its drug utilization review board under the federal Social Security Act, Title 19 Sec. 1927 and the requirements of the health care authority. Pharmacists and physicians each represent at least thirty-one percent, but no more than fifty-one percent of committee membership respectively.

(6) Members must be actively practicing in their clinical area of expertise throughout the entire term of their appointments.

(7) Members must have knowledge and expertise in one or more of the following:

(a) Clinically appropriate prescribing of covered outpatient drugs;

(b) Clinically appropriate dispensing and monitoring of covered outpatient drugs;

(c) Drug use review;

(d) Medical quality assurance;

(e) Disease state management; or

(f) Evidence-based medicine.

(8) Members of the committee must not be employed by a pharmaceutical manufacturer, a pharmacy benefits management company, or by any state agency administering state purchased health care programs during their terms and must not have been so employed for eighteen months prior to their appointment.

(9) A member must not have a substantial financial conflict of interest including any interest in any pharmaceutical company, including the holding of stock options or the receipt of honoraria or consultant moneys. The appointing authority in its sole discretion may disqualify any potential member if it determines that a substantial conflict of interest exists.

(10) As part of the application process, prospective committee members must complete a conflict of interest disclosure form, provided by the appointing authority, and after appointment, annually by July 1st of each year. Members must keep their disclosure statements current and provide updated information whenever circumstances change.

(11) Committee members must agree to keep all proprietary information confidential.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 69.41.190. WSR 16-16-083, § 182-50-025, filed 7/29/16, effective 8/29/16. Statutory Authority: RCW 41.05.160*
- *2004 1st sp.s. c 29 § 10. WSR 04-06-021 (Order 03-02), § 182-50-025, filed 2/23/04, effective 3/25/04.*

##### **Wash. Admin. Code § 182-50-030** Period of appointment. {#sec-182-50-030 omnilex-key=us-wa-regs-official--title-182--182-50-030}

(1) Members are appointed to a term of three years and serve until a successor is appointed. A member may be reappointed for up to two additional three-year terms for a total of nine years.

(2) Committee members serve staggered three-year terms. Of the initial appointees, in order to provide for staggered terms, some members may be appointed initially for less than three years. If the initial appointment is for less than 24 months, that period of time is not counted toward the limitation of years of appointment described in subsection (1) of this section.

(3) Vacancies on the committee will be filled for the balance of the unexpired term from nominee lists for the appropriate committee category as provided under WAC 182-50-025.

(4) Members of the committee are compensated for participation in the work of the committee in accordance with a personal services contract executed after appointment and prior to commencement of activities related to the work of the committee.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-16-022, § 182-50-030, filed 7/26/24, effective 8/26/24. Statutory Authority: RCW 41.05.021, 41.05.160, and 69.41.190. WSR 16-16-083, § 182-50-030, filed 7/29/16, effective 8/29/16. Statutory Authority: RCW 41.05.160*
- *2004 1st sp.s. c 29 § 10. WSR 04-06-021 (Order 03-02), § 182-50-030, filed 2/23/04, effective 3/25/04.*

##### **Wash. Admin. Code § 182-50-035** Duties. {#sec-182-50-035 omnilex-key=us-wa-regs-official--title-182--182-50-035}

Committee members:

(1) Select a chair and a vice chair from among the committee membership.

(2) Meet at least quarterly and may meet at other times at the discretion of the chair.

(3) Adopt a plan of operation that sets forth the policies and procedures established by the committee to develop an evidence-based prescription drug program as authorized by state law for approval by the appointing authority.

(4) Operate according to the plan of operation as approved by the appointing authority.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 69.41.190. WSR 16-16-083, § 182-50-035, filed 7/29/16, effective 8/29/16. Statutory Authority: RCW 41.05.160*
- *2004 1st sp.s. c 29 § 10. WSR 04-06-021 (Order 03-02), § 182-50-035, filed 2/23/04, effective 3/25/04.*

##### **Wash. Admin. Code § 182-50-200** Endorsing practitioner therapeutic interchange program; effect of practitioner's endorsing status; dispense as written instructions. {#sec-182-50-200 omnilex-key=us-wa-regs-official--title-182--182-50-200}

(1) When filling prescriptions for participating state purchased health care programs, pharmacists must make a therapeutic interchange if the prescription is prescribed by an endorsing practitioner except:

(a) If the endorsing practitioner indicates "dispense as written" on the nonpreferred prescription;

(b) If the prescription is a refill of an antipsychotic, antidepressant, antiepileptic, chemotherapy, antiretroviral, immunosuppressive drug, or an immunomodulator/antiviral treatment for hepatitis C; or

(c) If the pharmacy and therapeutics committee has determined that therapeutic interchange is not clinically appropriate for a specific drug or drug class on the Washington preferred drug list.

(2) When a therapeutic interchange is made, the pharmacist must notify the endorsing practitioner of the specific drug and dose dispensed.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 69.41.190. WSR 16-16-083, § 182-50-200, filed 7/29/16, effective 8/29/16. Statutory Authority: RCW 41.05.160 and 69.41.180. WSR 07-19-031 (Order 07-03), § 182-50-200, filed 9/12/07, effective 10/13/07. Statutory Authority: RCW 41.05.160*
- *2004 1st sp.s. c 29 § 10. WSR 04-06-021 (Order 03-02), § 182-50-200, filed 2/23/04, effective 3/25/04.*

## **Chapter 182-51** Drug price transparency program. {#struct-chapter-182-51}

##### **Wash. Admin. Code § 182-51-0050** Authority and purpose. {#sec-182-51-0050 omnilex-key=us-wa-regs-official--title-182--182-51-0050}

(1) Under the authority of chapter 43.71C RCW, this chapter implements the Washington drug price transparency program.

(2) The purpose of the Washington drug price transparency program is to improve transparency relating to the cost and price of prescription drugs to provide accountability to the state for rising drug costs and a consumer's ability to afford prescription drugs.

(3) The authority publishes a data submission guide to the authority's website, detailing the data elements to report as required by chapter 43.71C RCW, and how to submit the data.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 43.71C.110. WSR 22-17-075, § 182-51-0050, filed 8/16/22, effective 9/16/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 334. WSR 20-19-079, § 182-51-0050, filed 9/15/20, effective 10/16/20.*

##### **Wash. Admin. Code § 182-51-0100** Definitions. {#sec-182-51-0100 omnilex-key=us-wa-regs-official--title-182--182-51-0100}

For the purposes of this chapter:

(1) "Authority" means the health care authority.

(2) "Calendar days" means the same as in WAC 182-526-0010.

(3) "Calendar year" means the period from January 1st to December 31st of each year.

(4) "Confidential information" means information collected by the authority according to RCW 43.71C.020 through 43.71C.080, which is not subject to public disclosure under chapter 42.56 RCW and must be held confidential by all data recipients, according to WAC 182-51-0900.

(5) "Course of treatment" means the duration of the actual administration of a drug to treat a condition.

(6) "Covered drug" means any prescription drug that:

(a) A covered manufacturer intends to introduce to market at a wholesale acquisition cost of $10,000 or more for a course of treatment lasting less than one month or a 30-day supply, whichever period is longer; or

(b) Meets all of the following:

(i) Has been introduced to market;

(ii) Is manufactured by a covered manufacturer; and

(iii) Has a wholesale acquisition cost of more than $100 for a course of treatment lasting less than one month or a 30-day supply, and, taking into account only price increases that take effect on or after October 1, 2019, the manufacturer increases the wholesale acquisition cost such that:

(A) The new wholesale acquisition cost is 20 percent higher than the wholesale acquisition cost on the same day of the month, 12 months before the date of the proposed increase; or

(B) The new wholesale acquisition cost is 50 percent higher than the wholesale acquisition cost on the same day of the month, 36 months before the date of the proposed increase.

(7) "Covered manufacturer" means a person, corporation or other entity engaged in the manufacture of prescription drugs sold in or into Washington state. "Covered manufacturer" does not include a private label distributor or retail pharmacy that sells a drug under the retail pharmacy's store label, or a prescription drug repackager.

(8) "Data" means all data provided to the authority under RCW 43.71C.020 through 43.71C.080 and any analysis prepared by the authority.

(9) "Data recipient" means an individual or entity authorized to receive data under RCW 43.71C.100.

(10) "Data submission guide" means the document that identifies the data required under chapter 43.71C RCW, and provides instructions for submitting this data to the authority, including guidance on required format for reporting, for each reporting entity.

(11) "Food and drug administration (FDA) approval date" means the deadline for the FDA to review applications for new drugs or new biologics after the new drug application or biologic application is accepted by the FDA as complete in accordance with the Prescription Drug User Fee Act of 1992 (106 Stat. 4491; P.L. 102-571).

(12) "Health plan," "health carrier," and "carrier" mean the same as in RCW 48.43.005.

(13) "Introduced to market" or "introduce to market" means to make available for purchase in Washington state.

(14) "Pharmacy benefit manager" means the same as defined in RCW 48.200.020.

(15) "Pharmacy services administrative organization" means an entity that:

(a) Contracts with a pharmacy to act as the pharmacy's agent with respect to matters involving a pharmacy benefit manager, third-party payor, or other entities, including negotiating, executing, or administering contracts with the pharmacy benefit manager, third-party payor, or other entities; and

(b) Provides administrative services to pharmacies.

(16) "Pipeline drug" means a drug or biologic product, not yet approved by the Food and Drug Administration, for which a manufacturer intends to seek initial approval from the Food and Drug Administration under an original new drug application under 21 U.S.C. Sec. 355(b) or under a biologics license application under 42 U.S.C. Sec. 262.

(17) "Prescription drug" means a drug regulated under chapter 69.41 or 69.50 RCW that is prescribed for outpatient use and distributed in a retail setting, including generic, brand name, specialty drugs, and biological products.

(18) "Private label distributor" means a firm that does not participate in the manufacture or processing of a drug but instead markets and distributes under its own trade name, and labels a drug product made by someone else.

(19) "Public domain" means information that is available to the general public, whether through internet search, Freedom of Information Act request, or through purchase or subscription, and includes information submitted to or reviewed by the Food and Drug Administration, information contained in financial statements, and information published or otherwise made available through drug information resources. "Public domain" does not include trade secrets as defined by RCW 19.108.010 and information protected by copyright law.

(20) "Qualifying price increase" means a price increase described in subsection (6)(b) of this section.

(21) "Rebate" means negotiated price concessions, discounts, however characterized, that accrue directly or indirectly to a reporting entity in connection with utilization of prescription drugs by reporting entity members including, but not limited to, rebates, administrative fees, market share rebates, price protection rebates, performance-based price concessions, volume-related rebates, other credits, and any other negotiated price concessions or discounts that are reasonably anticipated to be passed through to a reporting entity during a coverage year, and any other form of price concession prearranged with a covered manufacturer, dispensing pharmacy, pharmacy benefit manager, rebate aggregator, group purchasing organization, or other party which are paid to a reporting entity and are directly attributable to the utilization of certain drugs by reporting entity members.

(22) "Reporting entity" means carriers, covered manufacturers, health carriers, health plans, pharmacy benefit managers, and pharmacy services administrative organizations, which are required to or voluntarily submit data according to chapter 43.71C RCW.

(23) "Wholesale acquisition cost" means, with respect to a prescription drug, the manufacturer's list price for the drug to wholesalers or direct purchasers in the United States, excluding any discounts, rebates, or reductions in price, for the most recent month for which the information is available, as reported in wholesale acquisition cost guides or other publications containing prescription drug prices.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 43.71C.110. WSR 22-17-075, § 182-51-0100, filed 8/16/22, effective 9/16/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-18-046, § 182-51-0100, filed 8/25/21, effective 9/25/21. Statutory Authority: RCW 41.05.021, 41.05.160, 43.71C.010, 43.71C.050, 43.71C.100, and 43.71C.110. WSR 21-10-008, § 182-51-0100, filed 4/22/21, effective 5/23/21. Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 334. WSR 20-19-079, § 182-51-0100, filed 9/15/20, effective 10/16/20.*

##### **Wash. Admin. Code § 182-51-0200** Reporting entity registration. {#sec-182-51-0200 omnilex-key=us-wa-regs-official--title-182--182-51-0200}

(1) A reporting entity must register with the authority and provide the required contact information as defined in the applicable data submission guide. Reregistration is required only if the contact information previously provided has changed.

(2) It is the responsibility of the reporting entity to maintain current and accurate contact information with the authority.

(3) Failure to register and provide or maintain accurate contact information with the authority may result in a reporting entity's inability to submit required data in compliance with this chapter.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 43.71C.110. WSR 22-17-075, § 182-51-0200, filed 8/16/22, effective 9/16/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 334. WSR 20-19-079, § 182-51-0200, filed 9/15/20, effective 10/16/20.*

##### **Wash. Admin. Code § 182-51-0300** Health carriers—Cost utilization data reporting. {#sec-182-51-0300 omnilex-key=us-wa-regs-official--title-182--182-51-0300}

(1) No later than October 16, 2020, a health carrier must submit to the authority the prescription drug cost and utilization data for calendar years 2018 and 2019, for each health plan it offered in Washington state in calendar years 2018 and 2019, following the guidelines set in the authority's applicable data submission guide.

(2) Beginning October 1, 2021, and no later than October 1st annually thereafter, a health carrier must submit to the authority the prescription drug cost and utilization data for the previous calendar year for each health plan it offered in Washington state, following the guidelines set in the authority's applicable data submission guide.

(3) A carrier may voluntarily submit the data described in subsection (1) of this section for other health plans it administers such as employer-sponsored, self-funded health plans; Taft-Hartley trust health plans; worker's compensation plans; medicare Part D plans; medicare advantage plans; or medicaid managed care plans.

(4) The authority may assess fines for not complying with the requirements in this section. See WAC 182-51-1100.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 43.71C.110. WSR 22-17-075, § 182-51-0300, filed 8/16/22, effective 9/16/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 334. WSR 20-19-079, § 182-51-0300, filed 9/15/20, effective 10/16/20.*

##### **Wash. Admin. Code § 182-51-0400** Pharmacy benefit managers—Data reporting. {#sec-182-51-0400 omnilex-key=us-wa-regs-official--title-182--182-51-0400}

(1) No later than March 1st of each year, a pharmacy benefit manager must submit to the authority all data specified in RCW 43.71C.030, following the guidelines set in the authority's applicable data submission guide.

(2) The authority may examine or audit a pharmacy benefit manager's financial records to ensure the information submitted under this section is accurate. Information the authority acquires in an examination of financial records according to this subsection is treated as proprietary and confidential. The information collected according to this subsection is not subject to public disclosure under chapter 42.56 RCW.

(3) A pharmacy benefit manager may voluntarily submit the data described in subsection (1) of this section for other health plans it administers such as employer-sponsored, self-funded health plans; Taft-Hartley trust health plans; worker's compensation plans; medicare Part D plans; medicare advantage plans; or medicaid managed care plans.

(4) The information submitted according to this section is not subject to public disclosure under chapter 42.56 RCW.

(5) The agency may assess fines for not complying with the requirements in this section. See WAC 182-51-1100.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 43.71C.110. WSR 22-17-075, § 182-51-0400, filed 8/16/22, effective 9/16/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 334. WSR 20-19-079, § 182-51-0400, filed 9/15/20, effective 10/16/20.*

##### **Wash. Admin. Code § 182-51-0500** Pharmacy benefit managers—Compliance. {#sec-182-51-0500 omnilex-key=us-wa-regs-official--title-182--182-51-0500}

(1) No later than March 1st of each year, each pharmacy benefit manager must file with the authority an attestation in the format required by the authority for the preceding calendar year, stating that the pharmacy benefit manager is in compliance with this chapter.

(2) A pharmacy benefit manager must not cause or knowingly permit the use of any advertisement, promotion, solicitation, representation, proposal, or offer that is untrue, deceptive, or misleading.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 334. WSR 20-19-079, § 182-51-0500, filed 9/15/20, effective 10/16/20.*

##### **Wash. Admin. Code § 182-51-0600** Manufacturers—Data and price reporting. {#sec-182-51-0600 omnilex-key=us-wa-regs-official--title-182--182-51-0600}

(1) On or before December 31, 2020, a covered manufacturer must submit to the authority all data specified in RCW 43.71C.050 and 43.71C.070, following the guidelines set in the authority's applicable data submission guide for each new covered drug introduced to market, or a covered drug that had a qualifying price increase between and including October 1, 2019, and October 15, 2020.

(2) Beginning October 16, 2020, a covered manufacturer must submit to the authority all data specified in RCW 43.71C.050 and 43.71C.070, following the guidelines set in the authority's applicable data submission guide, for each covered drug as follows:

(a) Sixty days in advance of a qualifying price increase for a covered drug already introduced to market; or

(b) Within 30 days of a new covered drug introduced to market.

(3) For any drug approved under section 505(j) of the federal Food, Drug, and Cosmetic Act as it existed on August 18, 2020, or a biosimilar approved under section 351(k) of the federal Public Health Service Act as it existed on August 18, 2020, if submitting data in accordance with subsection (2)(a) of this section is not possible 60 days before the price increase, that submission must be made as soon as known but no later than the date of the price increase.

(4) The information submitted according to this section is not subject to public disclosure under chapter 42.56 RCW.

(5) The authority may assess fines for not complying with the requirements in this section. See WAC 182-51-1100.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 43.71C.110. WSR 22-17-075, § 182-51-0600, filed 8/16/22, effective 9/16/22. Statutory Authority: RCW 41.05.021, 41.05.160, 43.71C.010, 43.71C.050, 43.71C.100, and 43.71C.110. WSR 21-10-008, § 182-51-0600, filed 4/22/21, effective 5/23/21. Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 334. WSR 20-19-079, § 182-51-0600, filed 9/15/20, effective 10/16/20.*

##### **Wash. Admin. Code § 182-51-0700** Manufacturers—Notice of new drug applications and biologic license applications. {#sec-182-51-0700 omnilex-key=us-wa-regs-official--title-182--182-51-0700}

(1) On or before December 31, 2020, a manufacturer must submit to the authority all data specified in RCW 43.71C.060(1), following the guidelines set in the authority's applicable data submission guide for all new drug applications or biologic license applications for pipeline drugs submitted on or after October 1, 2019, through October 15, 2020, for which the manufacturer has received an FDA approval date.

(2) Beginning October 16, 2020, a manufacturer must submit to the authority all data specified in RCW 43.71C.060(1), following the guidelines set in the authority's applicable data submission guide for all new drug applications or biologic license applications for pipeline drugs submitted on or after October 16, 2020, within sixty calendar days of the manufacturer receiving the FDA approval date.

(3) The authority considers fifty thousand dollars per biennium to be a significant impact on state expenditures. Reporting entities may anticipate a request for additional information per RCW 43.71C.060(3) from the authority for products expected to exceed fifty thousand dollars per biennium. To improve efficiency in reporting, manufacturers who submit a new drug application or a biologics license application for a pipeline drug or a biologics license application for a biological product that is expected to cost the state more than fifty thousand dollars per biennium may submit the data elements in RCW 43.71C.060(3) at the same time they submit the notice of the new drug application.

(4) A manufacturer may limit the information reported according to this section to information that is in the public domain or publicly reported.

(5) The agency may assess fines for not complying with the requirements in this section. See WAC 182-51-1100.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 334. WSR 20-19-079, § 182-51-0700, filed 9/15/20, effective 10/16/20.*

##### **Wash. Admin. Code § 182-51-0800** Pharmacy services administrative organizations—Data reporting. {#sec-182-51-0800 omnilex-key=us-wa-regs-official--title-182--182-51-0800}

(1) No later than October 16, 2020, and October 1st of each year thereafter, a pharmacy services administrative organization representing a pharmacy or pharmacy chain in Washington state must submit to the authority the data specified in RCW 43.71C.080 following the guidelines set in the authority's applicable data submission guide.

(2) Any pharmacy services administrative organization whose revenue is generated from flat service fees not connected to drug prices or volume, and paid by the pharmacy, is exempt from reporting, subject to audit by the authority. These organizations must petition the authority for exemption from the reporting requirements according to the frequency listed and the formatting guidelines in the authority's applicable data submission guide.

(3) The authority may assess fines for not complying with the requirements in this section. See WAC 182-51-1100.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 334. WSR 20-19-079, § 182-51-0800, filed 9/15/20, effective 10/16/20.*

##### **Wash. Admin. Code § 182-51-0900** Data confidentiality. {#sec-182-51-0900 omnilex-key=us-wa-regs-official--title-182--182-51-0900}

(1) For the purpose of reviewing drug prices and conducting affordability reviews, the following boards may access all data collected under RCW 43.71C.020 through 43.71C.080 and any analysis prepared by the authority:

(a) The prescription drug affordability board, as established in chapter 70.405 RCW; and

(b) The health care cost transparency board, as established in chapter 70.390 RCW.

(2) The authority provides data only after the data recipient, as defined by this chapter, has signed a nondisclosure agreement. The authority may prohibit access to or use of the data by a data recipient who violates the nondisclosure agreement.

(3) Data recipients must keep data confidential by:

(a) Accessing, using, and disclosing information only in accordance with this section and consistent with applicable statutes, regulations, and policies;

(b) Having a public policy purpose to access and use the confidential information according to chapter 43.71C RCW;

(c) Protecting all confidential information against unauthorized use, access, disclosure, or loss by employing reasonable security measures, including physically securing any computers, documents, or other media containing confidential information and viewing confidential information only on secure workstations in nonpublic areas;

(d) Destroying all confidential information when it is no longer needed to perform authorized activities; and

(e) Adhering to the confidentiality requirements in this section after the data recipient is no longer an authorized data recipient under RCW 43.71C.100.

(4) Data recipients must not:

(a) Disclose any confidential information, as defined by WAC 182-51-0100, or otherwise publicly release the confidential information;

(b) Use or disclose any confidential information for any commercial or personal purpose, or any other purpose that is not authorized in chapter 43.17C RCW;

(c) Attempt to identify people who are the subject of the confidential information;

(d) Discuss confidential information in public spaces in a manner in which unauthorized individuals could overhear;

(e) Discuss confidential information with unauthorized individuals, including spouses, domestic partners, family members, or friends;

(f) Have any conflicts of interests under the ethics in public service act that would prevent the data recipient from accessing or using confidential information; and

(g) Share information received according to this chapter with any person who is not authorized to receive confidential information as specified by this chapter.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 70.390.050, and 2024 c 80 s 2 (2)(a). WSR 25-03-038, s 182-51-0900, filed 1/8/25, effective 2/8/25. Statutory Authority: RCW 41.05.021, 41.05.160, 43.71C.010, 43.71C.050, 43.71C.100, and 43.71C.110. WSR 21-10-008, § 182-51-0900, filed 4/22/21, effective 5/23/21. Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 334. WSR 20-19-079, § 182-51-0900, filed 9/15/20, effective 10/16/20.*

##### **Wash. Admin. Code § 182-51-1000** Data submission guides. {#sec-182-51-1000 omnilex-key=us-wa-regs-official--title-182--182-51-1000}

(1) All data and data files must be submitted to the authority in accordance with the requirements in this chapter and the respective data submission guide for the respective reporting period. Data submission guides are located on the authority's website.

(2) The authority develops data submission guides and has final approval authority over them. The authority provides reporting entities the opportunity to comment on changes to data requirements in the applicable data submission guide, at least thirty days before the effective date of the change.

(3) At its discretion, the authority may grant reporting entities an extension to comply with any changes the authority makes to the data submission guides. Reporting entities must request extensions in accordance with WAC 182-51-1200.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 334. WSR 20-19-079, § 182-51-1000, filed 9/15/20, effective 10/16/20.*

##### **Wash. Admin. Code § 182-51-1100** Authority to assess fines. {#sec-182-51-1100 omnilex-key=us-wa-regs-official--title-182--182-51-1100}

(1) RCW 43.71C.090 allows the authority to assess a fine of up to one thousand dollars per day for failure to comply with the requirements of RCW 43.71C.020 through 43.71C.080 and the requirements of this chapter. See WAC 182-51-1300 for fines for failing to comply with reporting requirements and WAC 182-51-1400 for the amount of fines based on culpability.

(2) The authority may grant an extension of time to a reporting requirement deadline under WAC 182-51-1200.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 334. WSR 20-19-079, § 182-51-1100, filed 9/15/20, effective 10/16/20.*

##### **Wash. Admin. Code § 182-51-1200** Extension of deadlines. {#sec-182-51-1200 omnilex-key=us-wa-regs-official--title-182--182-51-1200}

(1) The authority may grant:

(a) An extension of time to a reporting requirement deadline; or

(b) Permission to correct a previously submitted and accepted report.

(2) Extensions.

(a) A reporting entity may request an extension of time for submitting a report or the resubmission of a report due to extenuating circumstances affecting the reporting entity's ability to submit the data by the deadline.

(b) The request for an extension must contain a detailed explanation as to the reason the reporting entity is unable to meet the reporting requirements for that period.

(c) A reporting entity must submit a request for an extension to the authority at least 30 calendar days before the applicable reporting deadline unless the requestor is unable to meet this deadline due to circumstances beyond the reporting entity's control. If unable to meet this deadline, the reporting entity must notify the authority in writing as soon as the reporting entity determines that an extension is necessary.

(d) The authority may approve a request for an extension for a period of time based on the specific circumstances or other extenuating circumstances. The authority provides written notification of the approval or denial to the requestor within 15 calendar days from when the authority receives the request from the reporting entity. If the authority does not approve a request for an extension, the written notification includes the reason for the denial.

(e) A reporting entity may not appeal the authority's decision to deny an extension.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 43.71C.110. WSR 22-17-075, § 182-51-1200, filed 8/16/22, effective 9/16/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 334. WSR 20-19-079, § 182-51-1200, filed 9/15/20, effective 10/16/20.*

##### **Wash. Admin. Code § 182-51-1300** Fines for failure to comply with reporting requirements. {#sec-182-51-1300 omnilex-key=us-wa-regs-official--title-182--182-51-1300}

(1) The authority may assess fines for failure to comply with the general reporting requirements of this chapter including, but not limited to, failing to report data or reporting erroneous or inaccurate data.

(2) Unless the authority has approved an extension or has received a request to correct previously submitted data, the authority may assess a fine for failure to comply with general reporting requirements contained in chapter 43.71C RCW and this chapter including, but not limited to, the following:

(a) Failure to timely submit required data files; or

(b) Failure to accurately submit all data elements.

(3) Unless the authority has approved an extension or has received a request to correct previously submitted data, the authority may assess fines for failure to comply with data file requirements outlined in the applicable data submission guide in effect for the required reporting period including, but not limited to, the following:

(a) Submitting a data file in an unapproved layout;

(b) Submitting a data element in an unapproved format;

(c) Submitting a data element with unapproved coding;

(d) Failing to submit a required data element;

(e) Failing to comply with the approved data submission schedule; or

(f) Transmitting data files using an unapproved process.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 334. WSR 20-19-079, § 182-51-1300, filed 9/15/20, effective 10/16/20.*

##### **Wash. Admin. Code § 182-51-1400** Amount of fines based on culpability. {#sec-182-51-1400 omnilex-key=us-wa-regs-official--title-182--182-51-1400}

(1) In determining the amount of any fine, the authority considers the level of culpability associated with the violation. The levels of culpability, in the order of least severe to most severe, are as follows:

(a) Did not know. The reporting entity did not know and by exercising reasonable diligence, could not have known the violation had occurred.

(b) Reasonable cause. The reporting entity knew, or by exercising diligence should have known, that the violation had taken place, but the reporting entity did not act with willful neglect.

(c) Willful neglect - Corrected. The violation was due to the reporting entity's intentional failure or reckless indifference, and the violation was corrected within thirty calendar days from the date the reporting entity knew or with reasonable diligence should have known of the violation.

(d) Willful neglect - Uncorrected. The violation was due to the reporting entity's intentional failure or reckless indifference, and the violation was not corrected within thirty calendar days from the date the reporting entity knew or with reasonable diligence should have known of the violation.

(2) The fine ranges for each level of culpability and the daily cap for violations of a similar nature are as follows:

| Culpability category | Fines per violation, per day |
| --- | --- |
| Did not know | $250 |
| Reasonable cause | $500 |
| Willful neglect - Corrected | $750 |
| Willful neglect - Not corrected | $1,000 |

(3) Fines begin to accrue on the first day after the reporting deadline. For those reporting entities granted an extension by the authority, fines begin to accrue on the first day after the extended due date.

(4) Fines continue to accrue daily until the reporting entity comes into compliance, settles through an informal dispute resolution conference under WAC 182-51-1700, or files a formal appeal under WAC 182-51-1800.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 334. WSR 20-19-079, § 182-51-1400, filed 9/15/20, effective 10/16/20.*

##### **Wash. Admin. Code § 182-51-1500** Preliminary notice of violation and fine(s). {#sec-182-51-1500 omnilex-key=us-wa-regs-official--title-182--182-51-1500}

(1) Upon failing to comply with a reporting requirement in this chapter, the authority first issues a warning notice to a reporting entity. The authority sends the warning notice to the reporting entity's last known email or physical address. The warning notice describes the failure to comply with the requirements of this chapter and gives the reporting entity thirty days to become compliant or request an extension of time to report the required data according to WAC 182-51-1200(2).

(2) When a reporting entity fails to comply with reporting requirement(s) after receiving a warning notice, the authority may assess a fine(s) as established in WAC 182-51-1400. The authority mails a preliminary notice of violation and fine(s) to the reporting entity's last known address by certified mail, return receipt requested.

(3) The preliminary notice of violation and fine(s) includes the following information:

(a) The specific reasons and criteria that support the imposition of the assessed fine(s);

(b) The legal authority that supports the imposition of a fine or fines;

(c) The amount of the fine(s) as of the date of the preliminary notice of violation and fine(s);

(d) Notice that fines will continue to accrue at the assessed daily rate, per WAC 182-51-1400, until the reporting entity either complies with the reporting requirements or settles through an informal dispute resolution conference; and

(e) An explanation of the reporting entity's right to request an informal dispute resolution conference under WAC 182-51-1700.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 334. WSR 20-19-079, § 182-51-1500, filed 9/15/20, effective 10/16/20.*

##### **Wash. Admin. Code § 182-51-1600** Process to appeal determination of a violation and assessed fines. {#sec-182-51-1600 omnilex-key=us-wa-regs-official--title-182--182-51-1600}

(1) Each reporting entity to whom the authority issues a preliminary notice of a violation and fine(s) may request an informal dispute resolution conference under WAC 182-51-1700.

(2) If the reporting entity requests an informal dispute resolution conference under WAC 182-51-1700, the reporting entity must complete the informal dispute resolution process before requesting an administrative hearing.

(3) In lieu of an informal dispute resolution conference, the reporting entity may request a formal appeal under WAC 182-51-1800 in writing, in a manner that provides proof of receipt, within 28 calendar days after receipt of the preliminary notice of violation and fine(s). Upon receipt of the reporting entity's request, the authority issues a final notice of violation and fine(s) with an explanation of the reporting entity's administrative hearing rights under WAC 182-51-1800.

(4) If the reporting entity does not request an informal dispute resolution conference or formal appeal within 28 calendar days after receipt of the preliminary notice of violation and fine(s), the authority issues a final notice of violation with an explanation of the reporting entity's administrative hearing rights under WAC 182-51-1800.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 43.71C.110. WSR 22-17-075, § 182-51-1600, filed 8/16/22, effective 9/16/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 334. WSR 20-19-079, § 182-51-1600, filed 9/15/20, effective 10/16/20.*

##### **Wash. Admin. Code § 182-51-1700** Informal dispute resolution prior to a hearing. {#sec-182-51-1700 omnilex-key=us-wa-regs-official--title-182--182-51-1700}

(1) A reporting entity may informally dispute the authority's preliminary determination of a violation under this chapter.

(2) A reporting entity must submit a request for an informal dispute resolution conference to the authority in writing, in a manner that provides proof of receipt, within twenty-eight calendar days after receipt of the preliminary notice of violation and fine(s).

(3) Requests should specify:

(a) The name of the reporting entity requesting the informal dispute resolution conference and the reporting entity's, or representative's, mailing address, telephone number, and email address (if available);

(b) The items, facts, or conclusions in the preliminary notice of violation being contested; and

(c) The basis for contesting the authority's action, including any mitigating factors upon which the reporting entity relies and the outcome the reporting entity is seeking.

(4) If the agency grants the reporting entity's request for a dispute resolution conference, the conference occurs within sixty calendar days of the date the reporting entity received the authority's written acceptance of the request for a dispute resolution conference.

(5) The reporting entity must notify the authority of who will attend the dispute resolution conference on the reporting entity's behalf at least five business days before the conference.

(6) The authority may terminate the dispute resolution process at any time.

(7) Upon completion or termination of the informal dispute resolution process, the authority will issue a final notice of violation and fine(s).

(8) Nothing in this chapter prevents settlement discussions between the parties. All settlement discussions are informal and without prejudice to the rights of the participants in the discussions.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 334. WSR 20-19-079, § 182-51-1700, filed 9/15/20, effective 10/16/20.*

##### **Wash. Admin. Code § 182-51-1800** Administrative hearing (formal appeal) right. {#sec-182-51-1800 omnilex-key=us-wa-regs-official--title-182--182-51-1800}

A reporting entity has a right to an administrative hearing (formal appeal), and any resulting appeals process available under chapters 34.05 RCW and 182-526 WAC, if the authority assesses a final notice of violation and fine(s) against the reporting entity under any section of chapter 43.71C RCW and this chapter. See WAC 182-526-0203.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 43.71C.110, and 2019 c 334. WSR 21-11-039, § 182-51-1800, filed 5/12/21, effective 6/12/21. Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 334. WSR 20-19-079, § 182-51-1800, filed 9/15/20, effective 10/16/20.*

## **Chapter 182-52** Prescription drug affordability board. {#struct-chapter-182-52}

##### **Wash. Admin. Code § 182-52-0005** Prescription drug affordability board—Purpose. {#sec-182-52-0005 omnilex-key=us-wa-regs-official--title-182--182-52-0005}

The prescription drug affordability board conducts reviews of drug prices, performs drug affordability reviews, and sets upper payment limits for prescription drugs.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, chapter 70.405 RCW, and 2022 c 153. WSR 24-02-078, § 182-52-0005, filed 1/2/24, effective 6/10/24.*

##### **Wash. Admin. Code § 182-52-0010** Prescription drug affordability board—Definitions. {#sec-182-52-0010 omnilex-key=us-wa-regs-official--title-182--182-52-0010}

The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.

"Authority" means the health care authority, as defined in WAC 182-02-045.

"Biological product" has the same meaning as in 42 U.S.C. Sec. 262 (i)(1).

"Biologics" means biological products and biosimilars.

"Biosimilar" has the same meaning as in 42 U.S.C. Sec. 262 (i)(2).

"Board" means the prescription drug affordability board.

"Brand name drug" means specific legend drug products that are sold by a manufacturer under certain trademarks or patents.

"Confidential information" means:

(a) Specific information collected by the authority that is not publicly available for the purposes of this chapter; or

(b) Proprietary data provided by any entity in accordance with this chapter that is not subject to public disclosure.

"Conflict of interest" means an association, including a financial or personal association, that has the potential to bias or appear to bias an individual's decisions in board matters or activities.

"Data recipient" means an individual or entity authorized to receive data under chapter 70.405 RCW.

"Drug" means a substance:

(a) Recognized as drugs in the official United States Pharmacopeia, official Homeopathic Pharmacopoeia of the United States, or official national formulary, or any supplement to any of them;

(b) Intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease in human beings;

(c) Other than food, minerals, or vitamins intended to affect the structure of any function of the body of human beings; and

(d) Intended for use as a component of any article specified in (a), (b), or (c) of this definition.

"Excess costs" means costs of appropriate utilization of a prescription drug that exceed the therapeutic benefit relative to other alternative treatments; or, costs of appropriate utilization of a prescription drug that are not sustainable to public and private health care systems over a 10-year time frame.

"Generic drug" has the same meaning as in RCW 69.48.020.

"Health carrier" or "carrier" has the same meaning as in RCW 48.43.005.

"Legend drug" means brand drug, generic drug, or biological product which is required by state law or regulation of the pharmacy quality assurance commission to be dispensed on prescription only or are restricted to use by practitioners only.

"Manufacturer" means a person, corporation, or other entity engaged in the manufacture of prescription drugs sold in or into Washington state. "Manufacturer" does not include a private label distributor or retail pharmacy that sells a drug under the retail pharmacy's store, or a prescription drug repackager.

"Out-of-pocket costs" means the amount of money the patient, another person on behalf of the patient, or entity on behalf of the patient paid to the pharmacy each time a prescription is filled, excluding the amount paid by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered drugs plus all costs for drugs that are not covered.

"Prescription drug" means a drug regulated under chapter 69.41 or 69.50 RCW, including generic drugs, brand name drugs, specialty drugs, and biological products.

"Publicly available" means information that is available to the general public, whether through internet search, Freedom of Information Act request or similar request, or through purchase or subscription, and includes information submitted to or reviewed by the Food and Drug Administration, information contained in financial statements, and information published or otherwise made available through drug information resources. "Publicly available" does not include trade secrets as defined by RCW 19.108.010 and information protected by copyright law. Publicly available information includes:

(a) Drug name;

(b) Drug class;

(c) Price and pricing;

(d) Course of treatment;

(e) Manufacturer name;

(f) Price increase over time;

(g) Competitors; and

(h) Competitor price and pricing.

"Rebate" means negotiated price concessions, discounts, however characterized, that accrue directly or indirectly to an entity in connection with utilization of prescription drugs including, but not limited to, rebates, administrative fees, market share rebates, price protection rebates, performance-based price concessions, volume-related rebates, other credits, and any other negotiated price concessions or discounts that are reasonably anticipated to be passed through to an entity during a coverage year, and any other form of price concession prearranged with a manufacturer, dispensing pharmacy, pharmacy benefit manager, rebate aggregator, group purchasing organization, or other party which are paid to an entity and are directly attributable to the utilization of certain drugs.

"Therapeutic alternative" means a drug product that may contain a different chemical or biological structure than the drug prescribed and can be expected to have a similar therapeutic effect and adverse reaction profile when administered to individuals in a therapeutically equivalent dose.

"Therapeutic equivalent" means a drug product of the identical base or salt as the specific drug product prescribed with essentially the same efficacy and toxicity when administered to an individual in the same dosage regimen.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, chapter 70.405 RCW, and 2022 c 153. WSR 24-02-078, § 182-52-0010, filed 1/2/24, effective 6/10/24.*

##### **Wash. Admin. Code § 182-52-0015** Prescription drug affordability board—Board members. {#sec-182-52-0015 omnilex-key=us-wa-regs-official--title-182--182-52-0015}

(1) The prescription drug affordability board has five governor-appointed members with expertise in health care economics or clinical medicine. Once appointed, board members serve a five-year term.

(2) The governor may reappoint board members for additional terms.

(3) Board members cannot be an employee of, a board member of, or a consultant to any of the following:

(a) Prescription drug manufacturer;

(b) Pharmacy benefit manager;

(c) Health carrier;

(d) Prescription drug wholesale distributor; or

(e) Trade association related to (a) through (d) of this subsection.

(4) Board members can be replaced or removed under the following circumstances including, but not limited to:

(a) Failure to participate;

(b) Unprofessional/unethical behavior; or

(c) Conflict of interest.

(5) If a board member violates subsection (3) or (4) of this section or other board established policies, the member may be removed from the board.

(6) Following appointment, board members must submit a conflict of interest disclosure form provided by the authority. The conflict of interest disclosure form must be submitted on an annual basis by July 1st of each year while the member is active with the board. Board members must keep their disclosure statements current and provide updated information within 30 calendar days whenever circumstances change.

(7) Board members must recuse themselves from any board activity in which they have a conflict of interest or the appearance of a conflict of interest, whether or not it is disclosed in the conflict of interest disclosure form.

(8) Following appointment and prior to participating in board activities, board members must enter into a personal services contract with the authority to be compensated for participation in the work of the board.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, chapter 70.405 RCW, and 2022 c 153. WSR 24-02-078, § 182-52-0015, filed 1/2/24, effective 6/10/24.*

##### **Wash. Admin. Code § 182-52-0020** Prescription drug affordability board—Procedures. {#sec-182-52-0020 omnilex-key=us-wa-regs-official--title-182--182-52-0020}

(1) The board determines by member vote who will be the board chair and vice chair.

(2) The board chair remains as the chair for the duration of their term unless there are violations as stated in WAC 182-52-0015(4).

(3) The board chair may choose to step down from their chair responsibilities and can continue to be an active board member.

(4) In the absence of the board chair, the vice chair acts in their place for that meeting.

(5) If board member vacancies exist, business continues as necessary with the remaining board members, as long as a quorum exists.

(6) A simple majority of the board's membership constitutes a quorum for the purpose of conducting business. If only three board members are present for a vote, the vote must be unanimous in order to pass.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, chapter 70.405 RCW, and 2022 c 153. WSR 24-02-078, § 182-52-0020, filed 1/2/24, effective 6/10/24.*

##### **Wash. Admin. Code § 182-52-0025** Prescription drug affordability board—Meetings. {#sec-182-52-0025 omnilex-key=us-wa-regs-official--title-182--182-52-0025}

(1) The board meets at least once annually, and additionally as defined by board policy.

(2) All board meetings must be open and public, except that the board may hold executive sessions to the extent permitted by chapter 42.30 RCW.

(a) Before convening an executive session, the board chair must publicly announce the purpose for excluding the public from the executive session.

(b) The board chair must announce the executive session place, date, and time.

(c) The executive session may be extended or have the date and time changed by announcement from the board chair.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, chapter 70.405 RCW, and 2022 c 153. WSR 24-02-078, § 182-52-0025, filed 1/2/24, effective 6/10/24.*

##### **Wash. Admin. Code § 182-52-0030** Prescription drug affordability board—Advisory groups—Purpose, participation, application process, and operations. {#sec-182-52-0030 omnilex-key=us-wa-regs-official--title-182--182-52-0030}

(1) The prescription drug affordability board advisory groups provide stakeholder input to the board regarding the affordability of prescription drugs.

(2) Utilizing administrative support from the authority, the board will establish advisory groups consisting of relevant stakeholders and subject matter experts for each drug selected for a drug affordability review conducted by the board.

(a) Advisory groups will consist of patients and patient advocates for the condition treated by the drug and one representative of the prescription drug industry. Additional group members, as selected by the board may include, but are not limited to, relevant stakeholders and experts in the following subject matters:

(i) The pharmaceutical business model;

(ii) Supply chain business model;

(iii) The practice of medicine or clinical training;

(iv) Health care consumer or patient perspectives;

(v) Health care cost trends and drivers;

(vi) Clinical and health services research;

(vii) The state's health care marketplace; or

(viii) Health care provider who specializes in treating the condition for the drug being reviewed.

(b) To the extent possible, advisory group members will have experience serving underserved communities and reflect the diversity of the state with regard to race, ethnicity, immigration status, income, wealth, disability, age, gender identity, sexual orientation, and geography.

(3) Advisory group members are chosen by the authority. Once members complete the conflict of interest form, they serve on the advisory group(s) through conclusion of the current affordability review. The authority may remove or replace advisory group members for, among other reasons:

(a) Failure to participate;

(b) Unprofessional/unethical behavior; or

(c) Conflict of interest.

(4) Advisory group members cannot be an employee of, a board member of, or a consultant to any of the following:

(a) Prescription drug manufacturer (with the exception that one representative from the prescription drug industry can serve on an advisory group and may be an employee, consultant, or board member of a prescription drug manufacturer or related trade association and will not be deemed to have a conflict of interest, see subsection (2) of this section);

(b) Pharmacy benefit manager;

(c) Health carrier;

(d) Prescription drug wholesale distributor; or

(e) Trade association related to (a) through (d) of this subsection.

(5) If an advisory group member violates any of subsection (4) of this section, the member may be removed from the advisory group(s).

(6) To become a member of advisory groups, the authority will establish an application process to be maintained and posted on the authority's website.

(7) Advisory groups meet on a frequency as determined necessary by the board.

(8) Participation in advisory groups is voluntary. Members of the advisory groups are not compensated.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, chapter 70.405 RCW, and 2022 c 153. WSR 24-02-078, § 182-52-0030, filed 1/2/24, effective 6/10/24.*

##### **Wash. Admin. Code § 182-52-0035** Prescription drug affordability board—Review of drug prices. {#sec-182-52-0035 omnilex-key=us-wa-regs-official--title-182--182-52-0035}

(1) By June 30th of each year, using data considered relevant by the board, the board must identify legend drugs and biologics that:

(a) Have been on the market for at least seven years;

(b) Are dispensed at a retail, specialty, or mail-order pharmacy; and

(c) Are not designated by the FDA under 21 U.S.C. Sec. 360bb as a drug solely for the treatment of a rare disease or condition.

(2) The legend drugs and biologics must meet the following thresholds:

(a) Brand name drugs and biologic products that must have:

(i) A wholesale acquisition cost of $60,000 or more per year or course of treatment lasting less than 12 months; or

(ii) A wholesale acquisition cost increase of 15 percent or more in any 12-month period or for a course of treatment lasting less than 12 months, or a 50 percent cumulative increase during any 36-month period.

(b) A biosimilar product with an initial wholesale acquisition cost that is less than 15 percent lower than the wholesale acquisition cost of the reference biological product, on the date the biosimilar becomes available on the market; and

(c) Generic drugs with a wholesale acquisition cost of $100 or more, for a 30-day supply or course of treatment less than 30 days, that has an increase in price of 200 percent or more in the preceding 12 months.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, chapter 70.405 RCW, and 2022 c 153. WSR 24-02-078, § 182-52-0035, filed 1/2/24, effective 6/10/24.*

##### **Wash. Admin. Code § 182-52-0040** Prescription drug affordability board—Affordability review requirements. {#sec-182-52-0040 omnilex-key=us-wa-regs-official--title-182--182-52-0040}

(1) The board may choose to conduct an affordability review of up to 24 legend drugs or biologics per year and consider the following:

(a) The class of the prescription drug and whether any therapeutically equivalent prescription drugs are available for sale;

(b) Input from relevant advisory groups as listed in this chapter; and

(c) The out-of-pocket cost for the drug.

(2) For drugs chosen for the affordability review, the board must determine whether the drug has led or will lead to excess costs to patients. Additionally, the board will determine whether a drug has led to or will lead to excess costs as defined in RCW 70.405.010. The board may examine publicly available and confidential information from the prescription drug manufacturer and other sources.

(3) The board, or the authority as directed by the board, may request information from the manufacturer. The requested information must be sent to the authority in the form and manner as published by the authority within 30 calendar days of the date on the request.

(4) The authority may assess a fine against a manufacturer for each failure to comply with a request for information from the board or the authority on behalf of the board. See WAC 182-52-0075 for information on notification of violation and fine(s).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, chapter 70.405 RCW, and 2022 c 153. WSR 24-02-078, § 182-52-0040, filed 1/2/24, effective 6/10/24.*

##### **Wash. Admin. Code § 182-52-0045** Prescription drug affordability board—Drug publication and conducting affordability reviews. {#sec-182-52-0045 omnilex-key=us-wa-regs-official--title-182--182-52-0045}

Drugs selected for an affordability review are published on the board's website before initiating the affordability review.

(1) When conducting an affordability review, the board will consider:

(a) The relevant factors contributing to the price paid for the prescription drug, including the wholesale acquisition cost, discounts, rebates, and other price concessions;

(b) The average out-of-pocket cost for the drug;

(c) The effect of the price on consumers' access to the drug in the state;

(d) Orphan drug status;

(e) The dollar value and accessibility of patient assistance programs offered by the manufacturer for the drug;

(f) The price and availability of therapeutic alternatives;

(g) Input from:

(i) Patients affected by the condition or disease treated by the drug; and

(ii) Individuals with medical or scientific expertise related to the condition or disease treated by the drug;

(h) Any other information the drug manufacturer or other relevant entity chooses to provide; and

(i) The impact of pharmacy benefit manager policies on the price consumers pay for the drug.

(2) In performing an affordability review of a drug the board may consider the following factors:

(a) Life-cycle management;

(b) The average cost of the drug in the state;

(c) Market competition and context;

(d) Projected revenue;

(e) Off-label usage of the drug; and

(f) Any additional factors identified by the board.

(3) All information collected by the board or the authority under this section is not subject to public disclosure under chapter 42.56 RCW.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, chapter 70.405 RCW, and 2022 c 153. WSR 24-02-078, § 182-52-0045, filed 1/2/24, effective 6/10/24.*

##### **Wash. Admin. Code § 182-52-0050** Prescription drug affordability board—Data and confidentiality. {#sec-182-52-0050 omnilex-key=us-wa-regs-official--title-182--182-52-0050}

(1) For the purpose of reviewing drug prices and conducting affordability reviews, the board (as established in chapter 70.405 RCW) and the health care cost transparency board (established in chapter 70.390 RCW) may share data with each other and access all data collected under RCW 43.71C.020 through 43.71C.080 and any analysis prepared by the authority.

(2) Advisory group members may not access or review any confidential information.

(3) The information collected by the board pursuant to RCW 70.405.040 is not subject to public disclosure under chapter 42.56 RCW.

(4) The authority provides data only after the data recipient, as defined by this chapter, has signed a nondisclosure agreement. The authority may prohibit access to or use of the data by a data recipient who violates the nondisclosure agreement.

(5) Data recipients must keep data confidential by:

(a) Accessing, using, and disclosing information only in accordance with this section and consistent with applicable statutes, regulations, and policies;

(b) Having a public policy purpose to access and use the confidential information according to chapter 70.405 RCW;

(c) Protecting all confidential information against unauthorized use, access, disclosure, or loss by employing reasonable security measures in alignment with the agency information system security plan, including physically securing any computers, documents, or other media containing confidential information and viewing confidential information only on secure workstations in nonpublic areas;

(d) Destroying all confidential information according to document retention requirements;

(e) Adhering to the confidentiality requirements in this section after the data recipient is no longer an authorized data recipient under chapter 70.405 RCW; and

(f) Acknowledging that the data recipient may be responsible for liability arising from misuse of the data.

(6) Data recipients must not:

(a) Disclose any confidential information, as defined by WAC 182-52-0010, or otherwise publicly release the confidential information;

(b) Use or disclose any confidential information for any commercial or personal purpose, or any other purpose that is not authorized in chapter 70.405 RCW;

(c) Attempt to identify people who are the subject of the confidential information;

(d) Discuss confidential information in public spaces in a manner in which unauthorized individuals could overhear;

(e) Discuss confidential information with unauthorized individuals, including spouses, domestic partners, family members, or friends;

(f) Have any conflicts of interests under the Ethics in Public Service Act that would prevent the data recipient from accessing or using confidential information; and

(g) Share information received according to this chapter with any person who is not authorized to receive confidential information as specified by this chapter.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 70.390.050, 42.30.250, 2024 c 80 s 2 (2)(a), and 2024 c 171 s 1(1). WSR 24-23-011, s 182-52-0050, filed 11/8/24, effective 12/8/24. Statutory Authority: RCW 41.05.021, 41.05.160, chapter 70.405 RCW, and 2022 c 153. WSR 24-02-078, § 182-52-0050, filed 1/2/24, effective 6/10/24.*

##### **Wash. Admin. Code § 182-52-0055** Prescription drug affordability board—Authorization to assess fines. {#sec-182-52-0055 omnilex-key=us-wa-regs-official--title-182--182-52-0055}

(1) RCW 70.405.040 allows the authority to assess a fine(s) against a manufacturer for failure to comply with the requirements of this chapter. See WAC 182-52-0065 for fine(s) for failing to comply with information request(s) and WAC 182-52-0070 for the amount of the fine(s) based on culpability.

(2) The authority may grant an extension of time to an information request deadline under WAC 182-52-0060.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, chapter 70.405 RCW, and 2022 c 153. WSR 24-02-078, § 182-52-0055, filed 1/2/24, effective 6/10/24.*

##### **Wash. Admin. Code § 182-52-0060** Prescription drug affordability board—Extension of deadlines. {#sec-182-52-0060 omnilex-key=us-wa-regs-official--title-182--182-52-0060}

(1) The authority may grant:

(a) An extension of time for an information request submission deadline; or

(b) Permission to correct a previously submitted and accepted request.

(2) Extensions:

(a) The manufacturer or subcontractor may request an extension of time for an information request submission deadline or the resubmission of a request due to circumstances beyond their control affecting the manufacturer's or subcontractor's ability to submit the information by the deadline.

(b) The request for an extension must contain a detailed explanation as to the reason the manufacturer or subcontractor is unable to meet the information request deadline.

(c) The manufacturer or subcontractor must submit a request for an extension to the authority at least 10 calendar days before the applicable deadline unless the manufacturer or subcontractor is unable to meet this deadline due to circumstances beyond their control. If unable to meet the deadline, the manufacturer or subcontractor must notify the authority in writing as soon as the manufacturer or subcontractor determines that an extension is necessary.

(d) The authority may approve an extension on a case-by-case basis based on the specific circumstances or other circumstances beyond the control of the manufacturer. The authority provides written notification of an approval or denial to the manufacturer or subcontractor within 15 calendar days from the date the authority receives the request from the manufacturer or subcontractor. If the authority does not approve a request for an extension, the written notification includes the reason for the denial. Only the authority can approve or deny a request for an extension.

(e) The manufacturer or subcontractor may not appeal the authority's decision to deny an extension.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, chapter 70.405 RCW, and 2022 c 153. WSR 24-02-078, § 182-52-0060, filed 1/2/24, effective 6/10/24.*

##### **Wash. Admin. Code § 182-52-0065** Prescription drug affordability board—Fine(s) for failure to comply with information request(s). {#sec-182-52-0065 omnilex-key=us-wa-regs-official--title-182--182-52-0065}

(1) The authority may assess a fine of up to $100,000 against a manufacturer for each failure to comply with a request for information from the board or the authority as directed by the board.

(2) The assessment of a fine under this section is subject to review under the Administrative Procedure Act, chapter 34.05 RCW.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, chapter 70.405 RCW, and 2022 c 153. WSR 24-02-078, § 182-52-0065, filed 1/2/24, effective 6/10/24.*

##### **Wash. Admin. Code § 182-52-0070** Prescription drug affordability board—Amount of fine(s) based on culpability. {#sec-182-52-0070 omnilex-key=us-wa-regs-official--title-182--182-52-0070}

(1) In determining the amount of any fine, the authority considers the level of culpability associated with the violation. The levels of culpability, in the order of least severe to most severe, are as follows:

(a) Did not know. The manufacturer did not know (and, by exercising reasonable diligence, could not have known) the violation had occurred.

(b) Reasonable cause. The manufacturer knew, or by exercising reasonable diligence should have known, that the violation had taken place, but the manufacturer did not act with willful neglect.

(c) Willful neglect – Corrected. The violation was due to the manufacturer's intentional failure or reckless indifference, and the violation was corrected within 30 calendar days from the date the manufacturer knew or with reasonable diligence should have known of the violation.

(d) Willful neglect – Uncorrected. The violation was due to the manufacturer's intentional failure or reckless indifference, and the violation was not corrected within 30 calendar days from the date the manufacturer knew or with reasonable diligence should have known of the violation.

(2) Culpability and fines.

| Culpability Category | Fines Per Violation |
| --- | --- |
| Did not know | $25,000 |
| Reasonable cause | $50,000 |
| Willful neglect – Corrected | $75,000 |
| Willful neglect – Uncorrected | $100,000 |

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, chapter 70.405 RCW, and 2022 c 153. WSR 24-02-078, § 182-52-0070, filed 1/2/24, effective 6/10/24.*

##### **Wash. Admin. Code § 182-52-0075** Prescription drug affordability board—Advisory notice, notice of violation, and fine(s). {#sec-182-52-0075 omnilex-key=us-wa-regs-official--title-182--182-52-0075}

(1) The authority will issue an advisory notice to the manufacturer for the initial request for information directing the manufacturer to comply within 30 calendar days of the request or request an extension of time to provide the required information, in accordance with WAC 182-52-0060.

(2) If the manufacturer fails to comply with the initial request for information within 30 calendar days, the authority may assess a fine(s). The authority will mail a preliminary notice of violation to the manufacturer's last known address in a manner that provides proof of receipt by the manufacturer.

(3) The preliminary notice of violation and fine(s) will include the following information:

(a) The specific reasons and criteria that support the imposition of the assessed fine(s);

(b) The legal authority that supports the imposition of a fine(s);

(c) The amount of the fine(s); and

(d) An explanation of the manufacturer's right to request an informal dispute resolution conference.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, chapter 70.405 RCW, and 2022 c 153. WSR 24-02-078, § 182-52-0075, filed 1/2/24, effective 6/10/24.*

##### **Wash. Admin. Code § 182-52-0080** Prescription drug affordability board—Appeal determination of a violation and assessed fine(s). {#sec-182-52-0080 omnilex-key=us-wa-regs-official--title-182--182-52-0080}

(1) Each manufacturer to whom the authority issues a preliminary notice of violation and fine(s) may request an informal dispute resolution conference. If the manufacturer does request an informal dispute resolution conference, then the manufacturer must complete the process before requesting an administrative hearing.

(2) In lieu of an informal dispute resolution conference, the manufacturer may request an administrative hearing, under WAC 182-52-0090, in writing, in a manner that provides proof of receipt by the authority, within 28 calendar days after receipt of the notice of violation and fine(s). Upon receipt of the manufacturer's request for administrative hearing, the authority will issue a final notice of violation and fine(s) with an explanation of the manufacturer's administrative hearing rights (See WAC 182-52-0090).

(3) If the manufacturer does not request an informal dispute resolution conference or administrative hearing within 28 calendar days after receipt of the preliminary notice of violation and fine(s), the authority issues a final notice of violation with an explanation of the manufacturer's administrative hearing rights (See WAC 182-52-0090).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, chapter 70.405 RCW, and 2022 c 153. WSR 24-02-078, § 182-52-0080, filed 1/2/24, effective 6/10/24.*

##### **Wash. Admin. Code § 182-52-0085** Prescription drug affordability board—Informal dispute resolution process prior to an administrative hearing. {#sec-182-52-0085 omnilex-key=us-wa-regs-official--title-182--182-52-0085}

(1) The manufacturer may informally dispute the authority's determination of a violation under this chapter.

(2) The manufacturer must submit a request for an informal dispute resolution conference to the authority in writing, in a manner that provides proof of receipt by the authority, within 28 calendar days after receipt of the notice violation and fine(s).

(3) Requests must specify:

(a) The name of the manufacturer requesting the informal dispute resolution conference and the manufacturer's, or representative's, mailing address, telephone number, and email address (if available);

(b) The items, facts, or conclusions in the notice of violation being contested; and

(c) The basis for contesting the authority's action, including any mitigating factors upon which the manufacturer relies and the outcome the manufacturer is seeking.

(4) The conference occurs within 60 calendar days of the date the manufacturer received the authority's written acceptance of the request for a dispute resolution conference.

(5) The manufacturer must notify the authority of who will attend the dispute resolution conference on the manufacturer's behalf at least five business days before the conference.

(6) The authority may terminate the dispute resolution process at any time and will provide the manufacturer with the reason for the termination.

(7) Upon completion or termination of the informal dispute resolution process, the authority will issue a final notice of violation and fine(s).

(8) Nothing in this chapter prevents settlement discussions between the parties. All settlement discussions are informal and without prejudice to the rights of the participants in the discussions.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, chapter 70.405 RCW, and 2022 c 153. WSR 24-02-078, § 182-52-0085, filed 1/2/24, effective 6/10/24.*

##### **Wash. Admin. Code § 182-52-0090** Prescription drug affordability board—Administrative hearing rights. {#sec-182-52-0090 omnilex-key=us-wa-regs-official--title-182--182-52-0090}

A manufacturer has a right to an administrative hearing under chapters 34.05 RCW and 182-526 WAC, if the authority assesses a notice of violation and fine(s) against the manufacturer.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, chapter 70.405 RCW, and 2022 c 153. WSR 24-02-078, § 182-52-0090, filed 1/2/24, effective 6/10/24.*

##### **Wash. Admin. Code § 182-52-0095** Prescription drug affordability board—Upper payment limits—Public comment. {#sec-182-52-0095 omnilex-key=us-wa-regs-official--title-182--182-52-0095}

The board must allow 30 calendar days for the submission of public comment before setting an upper payment limit. Prior to the 30-day comment period, the authority will notify the public of both the beginning and ending dates that written comment will be accepted.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 70.390.050, 42.30.250, 2024 c 80 s 2 (2)(a), and 2024 c 171 s 1(1). WSR 24-23-011, s 182-52-0095, filed 11/8/24, effective 12/8/24.*

## **Chapter 182-55** Health technology assessment program. {#struct-chapter-182-55}

##### **Wash. Admin. Code § 182-55-005** Authority and purpose. {#sec-182-55-005 omnilex-key=us-wa-regs-official--title-182--182-55-005}

Under RCW 70.14.080 through 70.14.140, the director of the Washington state health care authority provides administrative support for, and adopts rules to govern the health technology clinical committee and a health technology assessment program within the health care authority. The health technology assessment program will:

(1) Contract with an evidence-based technology assessment center to produce health technology assessments;

(2) Administratively support the independent health technology clinical committee; and

(3) Maintain a centralized, internet-based communication tool.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-18-023, § 182-55-005, filed 8/26/16, effective 9/26/16. Statutory Authority: RCW 41.05.013, 41.05.160, and 70.14.090. WSR 06-23-083 (Order 06-10), § 182-55-005, filed 11/13/06, effective 12/14/06.*

##### **Wash. Admin. Code § 182-55-010** Definitions. {#sec-182-55-010 omnilex-key=us-wa-regs-official--title-182--182-55-010}

When used in this chapter:

(1) "Advisory group" as defined in RCW 70.14.080 means a group established under RCW 70.14.110 (2)(c).

(2) "Centralized, internet-based communication tool" means the health care authority's health technology assessment program internet web pages established under RCW 70.14.130(1).

(3) "Committee" as defined in RCW 70.14.080 means the health technology clinical committee established under RCW 70.14.090.

(4) "Coverage determination" as defined in RCW 70.14.080 means a determination of the circumstances, if any, under which a health technology will be included as a covered benefit in a state purchased health care program.

(5) "Decisions made under the federal medicare program" means national coverage determinations issued by the Centers for Medicare and Medicaid Services stating whether and to what extent medicare covers specific services, procedures, or technologies.

(6) "Director" means the director of the Washington state health care authority under chapter 41.05 RCW.

(7) "Health technology" as defined in RCW 70.14.080 means medical and surgical devices and procedures, medical equipment, and diagnostic tests. Health technologies do not include prescription drugs governed by RCW 70.14.050.

(8) "Health technology assessment" means a report produced by a contracted, evidence-based, technology assessment center or other appropriate entity, as provided for in RCW 70.14.100(4), based on a systematic review of evidence of a technology's safety, efficacy, and cost-effectiveness.

(9) "Participating agency" as defined in RCW 70.14.080 means the department of social and health services, the state health care authority, and the department of labor and industries.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-18-023, § 182-55-010, filed 8/26/16, effective 9/26/16. Statutory Authority: RCW 41.05.013, 41.05.160, and 70.14.090. WSR 06-23-083 (Order 06-10), § 182-55-010, filed 11/13/06, effective 12/14/06.*

##### **Wash. Admin. Code § 182-55-015** Committee purpose. {#sec-182-55-015 omnilex-key=us-wa-regs-official--title-182--182-55-015}

The purpose of the committee is to make coverage determinations for the participating agencies as described under RCW 70.14.110.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-18-023, § 182-55-015, filed 8/26/16, effective 9/26/16. Statutory Authority: RCW 41.05.013, 41.05.160, and 70.14.090. WSR 06-23-083 (Order 06-10), § 182-55-015, filed 11/13/06, effective 12/14/06.*

##### **Wash. Admin. Code § 182-55-020** Committee selection. {#sec-182-55-020 omnilex-key=us-wa-regs-official--title-182--182-55-020}

(1) The director, in consultation with the participating state agencies, appoints vacant committee positions from a pool of interested applicants. Interested persons are provided an opportunity to submit applications to the director for consideration.

(2) When appointing committee members, the director considers, in addition to the membership requirements imposed by RCW 70.14.090, other relevant information, including:

(a) Practitioner specialty or type and use of health technologies, especially in relation to current committee member specialty or types;

(b) Practice location and community knowledge;

(c) Length of practice experience;

(d) Knowledge of and experience with evidence-based medicine, including formal additional training in fields relevant to evidence-based medicine;

(e) Medical quality assurance experience; and

(f) Health technology assessment review experience.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-18-023, § 182-55-020, filed 8/26/16, effective 9/26/16. Statutory Authority: RCW 41.05.013, 41.05.160, and 70.14.090. WSR 06-23-083 (Order 06-10), § 182-55-020, filed 11/13/06, effective 12/14/06.*

##### **Wash. Admin. Code § 182-55-025** Committee member requirements and committee member terms. {#sec-182-55-025 omnilex-key=us-wa-regs-official--title-182--182-55-025}

(1) As a continuing condition of appointment, committee members must:

(a) Not have a substantial financial conflict of interest, such as an interest in a health technology company, including the holding of stock options, or the receipt of honoraria, or consultant moneys;

(b) Complete a conflict of interest disclosure form, update the form annually, and keep disclosure statements current;

(c) Abide by confidentiality requirements and keep all personal medical information and proprietary information confidential; and

(d) Not use information gained from committee membership outside of committee responsibilities, unless the information is publicly available.

(2) The director has the sole discretion to terminate a committee member's appointment if the director determines that the committee member has violated a condition of appointment.

(3) Committee members serve staggered three-year terms. To provide for staggered terms, committee members may be appointed initially for less than three years.

(4) A committee member may be appointed for a total of nine years of committee service, but an initial appointment of less than twenty-four months is not included in the nine-year limitation.

(5) A committee member may serve until that member's successor is appointed, notwithstanding the limits on service in subsection (3) of this section.

(6) Mid-term vacancies on the committee are filled for the remainder of the unexpired three-year term.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-18-023, § 182-55-025, filed 8/26/16, effective 9/26/16. Statutory Authority: RCW 41.05.013, 41.05.160, and 70.14.090. WSR 06-23-083 (Order 06-10), § 182-55-025, filed 11/13/06, effective 12/14/06.*

##### **Wash. Admin. Code § 182-55-026** Committee governance. {#sec-182-55-026 omnilex-key=us-wa-regs-official--title-182--182-55-026}

(1) The committee may establish bylaws, within applicable statutory and regulatory requirements, to govern the orderly resolution of the committee's purposes. Proposed bylaw amendments are published on the centralized, internet-based communication tool at least fourteen calendar days before adoption by the committee. Before adoption, the committee gives an opportunity at an open public meeting for public comment on proposed bylaw amendments. Committee bylaws shall be published on the centralized, internet-based communication tool.

(2) The director appoints a committee chair.

(3) The committee chair:

(a) Selects a vice chair from among the committee membership;

(b) Presents bylaws, or amendments to the bylaws, to the committee for review and ratification; and

(c) Operates the committee according to the bylaws and committee member agreements.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-18-023, § 182-55-026, filed 8/26/16, effective 9/26/16.*

##### **Wash. Admin. Code § 182-55-030** Committee coverage determination process. {#sec-182-55-030 omnilex-key=us-wa-regs-official--title-182--182-55-030}

(1) In making a coverage determination, committee members shall review and consider evidence regarding the safety, efficacy, and cost-effectiveness of the technology as set forth in the health technology assessment. The committee also considers other information it deems relevant, including other information provided by the director, reports or testimony from an advisory group, and submissions or comments from the public.

(2) The committee shall give the greatest weight to the evidence determined, based on objective factors, to be the most valid and reliable, considering the nature and source of the evidence, the empirical characteristic of the studies or trials upon which the evidence is based, and the consistency of the outcome with comparable studies. The committee also considers additional evidentiary valuation factors such as recency, relevance, and bias.

(3) The committee also considers any unique impacts the health technology has on specific populations based on factors like sex, age, ethnicity, race, or disability, as identified in the health technology assessment.

(4) The committee provides an opportunity for public comment after the health technology assessment is published on the centralized, internet-based communication tool and before the committee's final coverage determination decision.

(5) After the committee makes a final coverage determination, the health technology assessment program publishes it on the centralized, internet-based communication tool and submits a notice in the Washington State Register.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-18-023, § 182-55-030, filed 8/26/16, effective 9/26/16. Statutory Authority: RCW 41.05.013, 41.05.160, and 70.14.090. WSR 06-23-083 (Order 06-10), § 182-55-030, filed 11/13/06, effective 12/14/06.*

##### **Wash. Admin. Code § 182-55-035** Committee coverage determination. {#sec-182-55-035 omnilex-key=us-wa-regs-official--title-182--182-55-035}

The committee shall:

(1) Determine the conditions, if any, under which the health technology will be included as a covered benefit in health care programs of participating agencies by deciding that:

(a) Coverage is allowed without special conditions because the evidence is sufficient to conclude that the health technology is safe, efficacious, and cost-effective for all indicated conditions; or

(b) Coverage is allowed with special conditions because the evidence is sufficient to conclude that the health technology is safe, efficacious, and cost-effective in only certain situations; or

(c) Coverage is not allowed because either the evidence is insufficient to conclude that the health technology is safe, efficacious, and cost-effective or the evidence is sufficient to conclude that the health technology is unsafe, inefficacious, or not cost-effective.

(2) Identify whether the coverage determination is consistent with decisions made under the federal medicare program and expert treatment guidelines.

(3) For decisions that are inconsistent with either decisions made under the federal medicare program or expert treatment guidelines, including those from specialty physician and patient advocacy organizations, specify the substantial evidence regarding the safety, efficacy, and cost-effectiveness of the technology that supports the contrary determination.

(4) For covered health technologies, specify criteria for participating agencies to use when deciding whether the health technology is medically necessary or proper and necessary treatment.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-18-023, § 182-55-035, filed 8/26/16, effective 9/26/16. Statutory Authority: RCW 41.05.013, 41.05.160, and 70.14.090. WSR 06-23-083 (Order 06-10), § 182-55-035, filed 11/13/06, effective 12/14/06.*

##### **Wash. Admin. Code § 182-55-040** Health care authority's implementation of final coverage determinations. {#sec-182-55-040 omnilex-key=us-wa-regs-official--title-182--182-55-040}

This section applies to all final coverage determinations made after August 1, 2016.

(1) The health care authority reviews the final coverage determination for conflicts identified in RCW 70.14.120 (1)(a) and (b).

(2) The health care authority reviews whether the health technology review process meets the requirements in this subsection before compliance by the health care authority's state-purchased health care programs. The review includes whether the:

(a) Notification of the health technology selected for review was made on the centralized, internet-based communication tool as required by RCW 70.14.130 (1)(a);

(b) Health technology assessment provided to the committee met the requirements in RCW 70.14.100(4) and WAC 182-55-055;

(c) Health technology assessment was published on the centralized, internet-based communication tool at least fourteen calendar days before the committee's consideration of the health technology assessment;

(d) Health technology assessment was considered by the committee in an open and transparent process, as required by RCW 70.14.110 (2)(a);

(e) Committee provided an opportunity for public comment prior to the committee's final coverage determination decision;

(f) Committee acknowledged public comment timely received after publication of the committee's draft coverage determination and before the committee's final coverage determination decision;

(g) Committee's final coverage determination specifies the reason or reasons for a decision that is inconsistent with the identified decisions made under the federal medicare program and expert treatment guidelines, including those from specialty physician and patient advocacy organizations, for the reviewed health technology; and

(h) Committee meetings complied with the requirements of the Open Public Meetings Act as required by RCW 70.14.090(3).

(3) After the health care authority completes its reviews under subsections (1) and (2) of this section, it establishes an implementation date for each of the health care authority's state-purchased health care programs and publishes the implementation dates on the health care authority's website.

(4) The health care authority's implementation of a final coverage determination can be reviewed as other agency action under RCW 34.05.570(4). A petition for review must be filed in superior court and comply with all statutory requirements for judicial review of other agency action required in chapter 34.05 RCW.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-18-023, § 182-55-040, filed 8/26/16, effective 9/26/16. Statutory Authority: RCW 41.05.013, 41.05.160, and 70.14.090. WSR 06-23-083 (Order 06-10), § 182-55-040, filed 11/13/06, effective 12/14/06.*

##### **Wash. Admin. Code § 182-55-041** Judicial review of final coverage determination. {#sec-182-55-041 omnilex-key=us-wa-regs-official--title-182--182-55-041}

Nothing in this chapter limits the superior court's inherent authority to review health technology clinical committee determinations to the extent of assuring the decisions are not arbitrary, capricious, or contrary to law.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-18-023, § 182-55-041, filed 8/26/16, effective 9/26/16.*

##### **Wash. Admin. Code § 182-55-045** Advisory group. {#sec-182-55-045 omnilex-key=us-wa-regs-official--title-182--182-55-045}

(1) The committee chair, upon an affirmative vote of the committee members, may establish ad hoc temporary advisory groups under RCW 70.14.110 (2)(c). At the time an ad hoc temporary advisory group is formed, the committee must state the ad hoc temporary advisory group's objective and questions to address. Notice of the formation of an ad hoc temporary advisory group, and information about how to participate, shall be posted on the centralized, internet-based communication tool.

(2) The committee chair, or designee, may appoint or remove an advisory group member. An ad hoc temporary advisory group must include at least three members. The advisory group will generally include at least one enrollee, client, or patient. The advisory group must have:

(a) Two or more experts or specialists within the field relevant to the health technology, preferably with demonstrated experience in the use, evaluation, or research of the health technology;

(b) At least one expert who is a proponent or advocate of the health technology; and

(c) At least one expert who is an opponent or critic of the health technology.

(3) Each advisory group member must:

(a) Not have a substantial financial conflict of interest, such as an interest in a health technology company, including the holding of stock options, or the receipt of honoraria, or consultant moneys;

(b) Complete an advisory group member agreement, including a conflict of interest disclosure form, and keep disclosure statements current;

(c) Abide by confidentiality requirements and keep all personal medical information and proprietary information confidential; and

(d) Not utilize information gained as a result of advisory group membership outside of advisory group responsibilities, unless such information is publicly available.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-18-023, § 182-55-045, filed 8/26/16, effective 9/26/16. Statutory Authority: RCW 41.05.013, 41.05.160, and 70.14.090. WSR 06-23-083 (Order 06-10), § 182-55-045, filed 11/13/06, effective 12/14/06.*

##### **Wash. Admin. Code § 182-55-050** Health technology selection. {#sec-182-55-050 omnilex-key=us-wa-regs-official--title-182--182-55-050}

(1) The director, in consultation with participating agencies and the committee, selects health technologies to be reviewed or rereviewed by the committee.

(2) The director or committee may also consider petitions requesting initial review of a health technology from interested parties. To suggest a topic for initial review, interested parties must use the petition form made available on the centralized, internet-based communication tool. The health technology assessment program will provide copies of the petition to the director, committee members, and participating agencies.

(a) Petitions are considered by the director, in consultation with participating agencies and the committee.

(b) Only after the director has declined to grant the petition can a petition be considered for selection by the committee, as described in RCW 70.14.100(3).

(c) If a health technology is selected by the committee, the health technology is referred to the director for assignment to the next available contract for a health technology assessment review as described in RCW 70.14.100(4).

(3) Interested parties may submit a petition for the rereview of a health technology. Interested parties must use the petition form available on the centralized, internet-based communication tool and may submit to the health technology assessment program evidence that has since become available that could change the previous coverage determination. The health technology assessment program will provide copies of the petition to the director, committee members, and participating agencies.

(a) Petitions are considered by the director, in consultation with participating agencies and the committee.

(b) Only after the director has declined to grant the petition can a petition be reviewed by the committee, as described in RCW 70.14.100(3).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-18-023, § 182-55-050, filed 8/26/16, effective 9/26/16. Statutory Authority: RCW 41.05.013, 41.05.160, and 70.14.090. WSR 06-23-083 (Order 06-10), § 182-55-050, filed 11/13/06, effective 12/14/06.*

##### **Wash. Admin. Code § 182-55-055** Health technology assessment. {#sec-182-55-055 omnilex-key=us-wa-regs-official--title-182--182-55-055}

(1) Upon providing notice on the centralized, internet-based communication tool required by RCW 70.14.100 (1)(b) that the health technology has been selected for review, the director shall post an invitation for interested parties to submit information relevant to the health technology for consideration by the evidence-based technology assessment center. The information must be submitted to the director or designee within thirty calendar days from the date of the notice.

(2) Upon notice of the health technology selected for review, the director or designee shall request participating agencies to provide information relevant to the health technology, including data on safety, health outcome, and cost. The relevant information must be submitted to the director or designee within thirty calendar days from the date of the notice.

(3) Upon notice of the health technology selected for review, the director or designee shall identify relevant decisions made under the federal medicare program and expert treatment guidelines, including those from specialty physician and patient advocacy organizations, and any referenced information used as the basis for such determinations or guidelines.

(4) The director shall provide all information gathered under subsections (1), (2), and (3) of this section to the evidence-based technology assessment center and shall post such information, along with the key questions for review, on the centralized, internet-based communication tool.

(5) Upon completion of the health technology assessment by the evidence-based technology assessment center, the director shall publish a copy of the health technology assessment on the centralized, internet-based communication tool and provide the committee with:

(a) A copy of the health technology assessment;

(b) A copy of decisions made under the federal medicare program related to the health technology being reviewed and accompanying information describing the basis for the decision;

(c) Information as to whether expert treatment guidelines exist, including those from specialty physician organizations and patient advocacy organizations, and describing the basis for the guidelines.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-18-023, § 182-55-055, filed 8/26/16, effective 9/26/16. Statutory Authority: RCW 41.05.013, 41.05.160, and 70.14.090. WSR 06-23-083 (Order 06-10), § 182-55-055, filed 11/13/06, effective 12/14/06.*

## **Chapter 182-60** Patient decision aids. {#struct-chapter-182-60}

##### **Wash. Admin. Code § 182-60-005** Authority and purpose. {#sec-182-60-005 omnilex-key=us-wa-regs-official--title-182--182-60-005}

Under RCW 7.70.060(4), the agency's medical director is authorized to independently assess and certify patient decision aids.

**History**
- *Statutory Authority: RCW 7.70.060 and 2012 c 101. WSR 12-24-052, § 182-60-005, filed 11/30/12, effective 1/1/13.*

##### **Wash. Admin. Code § 182-60-010** Definitions. {#sec-182-60-010 omnilex-key=us-wa-regs-official--title-182--182-60-010}

When used in this chapter:

(1) "Agency" means the Washington state health care authority (HCA), created pursuant to chapter 41.05 RCW.

(2) "Certification fee" means a fee assessed by the agency to an individual or organization applicant requesting certification or recertification of a patient decision aid not already certified by an organization located in the United States or Canada and recognized by the agency's medical director.

(3) "Certified patient decision aid" means a patient decision aid, as defined in this section, for any medical condition or procedure, including abortion as defined in RCW 9.02.170, that:

(a) Is certified by one or more national certifying organizations recognized by the agency's medical director; or

(b) Has been evaluated based on the International Patient Decision Aid Standards (IPDAS) by an organization located in the United States or Canada and has current scores satisfactory to the agency's medical director in each of the following categories: Content criteria, development process criteria, and effectiveness criteria; or

(c) Is independently assessed and certified by the agency's medical director based on the International Patient Decision Aid Standards developed by the IPDAS Collaboration if a current evaluation is not available from an organization located in the United States or Canada.

(4) "National certifying organization" means a group, entity, or organization in the United States or Canada that is recognized by the agency's medical director to certify patient decision aids under this chapter.

(5) "Patient decision aid" means a written, audio-visual, or online tool that provides a balanced presentation of the condition and test or treatment options, benefits, and harms including, if appropriate, a discussion of the limits of scientific knowledge about outcomes, for any medical condition or procedure.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-17-039, § 182-60-010, filed 8/9/17, effective 9/9/17. Statutory Authority: RCW 7.70.060 and 2012 c 101. WSR 12-24-052, § 182-60-010, filed 11/30/12, effective 1/1/13.*

##### **Wash. Admin. Code § 182-60-020** National certifying organizations. {#sec-182-60-020 omnilex-key=us-wa-regs-official--title-182--182-60-020}

The agency's medical director:

(1) Maintains a list of recognized national certifying organizations so that individuals or organizations seeking certification may identify organizations recognized by the agency's medical director.

(2) Considers organizations recommended by applicants for inclusion in the list.

(3) Updates the list as needed.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-17-039, § 182-60-020, filed 8/9/17, effective 9/9/17. Statutory Authority: RCW 7.70.060 and 2012 c 101. WSR 12-24-052, § 182-60-020, filed 11/30/12, effective 1/1/13.*

##### **Wash. Admin. Code § 182-60-025** Agency review process and certification. {#sec-182-60-025 omnilex-key=us-wa-regs-official--title-182--182-60-025}

(1) When independently reviewing decision aids under RCW 7.70.060 (4)(a)(ii), the agency's medical director uses agency certification criteria, which are based on criteria developed by the International Patient Decision Aid Standards (IPDAS) Collaboration, for evaluation of a patient decision aid.

(2) The agency's medical director may certify a patient decision aid if it is reviewed by a national certifying organization and has current scores satisfactory to the agency's medical director in each of the following categories: Content criteria, development process criteria, and effectiveness criteria.

(3) An applicant requesting review and certification must provide written documentation of the basis for certification as provided in subsection (1) of this section, using the application materials developed by the agency.

(4) The agency's medical director may contract for an assessment of the patient decision aid.

(a) The contract will:

(i) Be with an evidence-based organization or other appropriate entity; and

(ii) Require an assessment to evaluate the patient decision aid based on the agency's IPDAS-based certification criteria using information provided by the applicant and the agency's medical director.

(b) The agency's medical director may use the results of the assessment in whole or part as the basis for a certification determination.

(5) The agency's medical director may establish minimum scores in each of the following areas: Content criteria, development process criteria, and effectiveness criteria.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-17-039, § 182-60-025, filed 8/9/17, effective 9/9/17. Statutory Authority: RCW 7.70.060 and 2012 c 101. WSR 12-24-052, § 182-60-025, filed 11/30/12, effective 1/1/13.*

##### **Wash. Admin. Code § 182-60-027** Patient decision aid review advisory panel. {#sec-182-60-027 omnilex-key=us-wa-regs-official--title-182--182-60-027}

(1) The agency's medical director has the authority to establish one or more expert advisory panels to review patient decision aids using established criteria under WAC 182-60-025.

(2) The panel may include the following as necessary:

(a) Practicing physicians or other relevant licensed health professionals;

(b) Health literacy and numeracy experts;

(c) Experts in shared decision making;

(d) Legal experts; and

(e) Patient representatives.

(3) The agency's medical director may contract with an evidence-based practice center or other appropriate expert to review and advise on the validity or presentation of evidence, other elements of the decision aid, or on developing and updating policies or practices.

(4) Advisory review panel members must meet conflict of interest and disclosure requirements. Each advisory panel member must:

(a) Complete an advisory panel member agreement, including a conflict of interest disclosure form, and keep disclosure statements current;

(b) Abide by confidentiality requirements and keep all proprietary information confidential; and

(c) Not use information gained as a result of advisory panel membership outside of advisory panel responsibilities, unless the information is publicly available.

(5) The agency's medical director makes the final determination on certification.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-18-053, § 182-60-027, filed 8/26/21, effective 9/26/21*
- *WSR 17-17-039, § 182-60-027, filed 8/9/17, effective 9/9/17.*

##### **Wash. Admin. Code § 182-60-030** Certification fees. {#sec-182-60-030 omnilex-key=us-wa-regs-official--title-182--182-60-030}

The agency charges one or more fees to an applicant to defray the costs of assessments, certifications, recertifications, and any opportunities to remedy deficiencies in the application, according to this chapter.

(1) Fees are based on the reasonable projected or actual cost of the certification program.

(2) Except as otherwise provided in this chapter, a certification fee applies to each review of a patient decision aid. An opportunity to remedy deficiencies as described in WAC 182-60-045 may require an additional fee.

(3) The agency may, at its discretion, waive or otherwise reduce applicable fees for patient decision aids publicly available at no cost.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-17-039, § 182-60-030, filed 8/9/17, effective 9/9/17. Statutory Authority: RCW 7.70.060 and 2012 c 101. WSR 12-24-052, § 182-60-030, filed 11/30/12, effective 1/1/13.*

##### **Wash. Admin. Code § 182-60-035** Patient decision aid topic selection. {#sec-182-60-035 omnilex-key=us-wa-regs-official--title-182--182-60-035}

(1) The agency may, at the medical director's discretion, give preference to certification of patient decision aids identified as priority topics for shared decision making by the Healthier Washington Initiative, the Robert Bree collaborative, or other topics that are important to state health care purchasing or policy objectives.

(2) Periodically throughout the year, the agency may issue a request for submission of specific patient decision aid topics that address state priorities.

(3) The agency may review additional decision aids that do not reflect the topics requested in its solicitation but may decline or defer review based on resource limitations or priorities for review.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-17-039, § 182-60-035, filed 8/9/17, effective 9/9/17.*

##### **Wash. Admin. Code § 182-60-040** Agency medical director certification. {#sec-182-60-040 omnilex-key=us-wa-regs-official--title-182--182-60-040}

(1) Decisions.

(a) The agency's medical director, with input as determined necessary by an advisory review team, or contracted experts, or both, makes a written determination to:

(i) Certify the decision aid;

(ii) Notify the developer of areas of deficiency and provide an opportunity to remedy deficiencies as described in WAC 182-60-045; or

(iii) Decline to certify the decision aid.

(b) Upon certification, the agency adds the decision aid to a list of certified products posted on the agency website.

(c) Certification determinations are final and not subject to appeal.

(2) Certification period. For patient decision aids certified on January 1, 2021, and after, a certification under this chapter is valid for five years from the date of the written certification determination, except in the case of withdrawal or suspension under subsection (4) of this section.

(3) Recertification.

(a) The developer may request recertification by taking the following steps six months before the current certification expires:

(i) Request recertification;

(ii) Submit any needed updates or modifications using HCA 82-328 form; and

(iii) Pay the required certification fee.

(b) The agency's medical director may limit review to the updated elements of the application and the decision aid, together with associated evidence and may make the determinations described in subsection (1) of this section.

(c) For patient decision aids certified on January 1, 2021, and after, recertification is effective for five years from the date of the written recertification determination.

(4) Withdrawal or suspension of certification.

(a) Developers must notify the agency's medical director when they become aware of information that may materially change the content of an approved decision aid or supporting application materials on file.

(b) The agency's medical director may withdraw or suspend a certification:

(i) On the medical director's own initiative, if information becomes available that may materially change the decision aid's content or supporting application materials; or

(ii) In response to developer notification under (a) of this subsection.

(c) Within ten business days of the agency's withdrawal or suspension of a certification, the agency sends notification to the developer's address on file.

(d) The developer must submit its updated application materials to the agency's medical director within the time frame specified in the agency's notice. The agency charges the developer reasonable costs associated with the recertification.

(e) The agency's medical director may limit review to the updated elements of the decision aid and may make the determinations described in subsection (1) of this section.

(f) If a developer fails to submit updated application materials within the time frame in (d) of this subsection, the agency withdraws the certification.

(g) The agency posts withdrawal, suspension, and recertification decisions on the agency's website.

(5) Effect of certification determination.

(a) Certification under this chapter provides the basis for heightened legal protections under RCW 7.70.065; and

(b) A certified patient decision aid used as part of a shared decision-making process may also be a requirement or preference in contract or arrangements for state-purchased health care.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-18-053, § 182-60-040, filed 8/26/21, effective 9/26/21*
- *WSR 17-17-039, § 182-60-040, filed 8/9/17, effective 9/9/17.*

##### **Wash. Admin. Code § 182-60-045** Opportunity to remedy deficiencies. {#sec-182-60-045 omnilex-key=us-wa-regs-official--title-182--182-60-045}

(1) The agency's medical director may suspend the certification or recertification process if the medical director determines there are deficiencies in an application, including the decision aid and supporting materials.

(2) The agency provides the developer with a written notice of deficiencies and gives an opportunity to provide additional information or materials. The developer must pay any additional fees related to the review of additional information.

(3) The developer must submit any additional materials within sixty calendar days of the date on the written notice.

(4) The medical director makes a final decision to certify or to decline to certify the decision aid within sixty calendar days of receipt of the developer's materials.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-17-039, § 182-60-045, filed 8/9/17, effective 9/9/17.*

##### **Wash. Admin. Code § 182-60-050** Public notices. {#sec-182-60-050 omnilex-key=us-wa-regs-official--title-182--182-60-050}

The agency posts the following information on its website:

(1) Priority certification topics and the timeline for application and consideration of submitted decision aids;

(2) Certification forms and criteria;

(3) A complete listing of certified decision aids and certification effective dates; and

(4) All notifications of certification expirations, withdrawals, and suspensions.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-17-039, § 182-60-050, filed 8/9/17, effective 9/9/17.*

## **Chapter 182-70** All payer health care claims database. {#struct-chapter-182-70}

##### **Wash. Admin. Code § 182-70-010** Purpose. {#sec-182-70-010 omnilex-key=us-wa-regs-official--title-182--182-70-010}

WAC 182-70-010

(1) Chapter 43.371 RCW establishes the framework for the creation and administration of a statewide all-payer health care claims database.

(2) RCW 43.371.020 directs the health care authority to establish a statewide all-payer health care claims database to support transparent public reporting of health care information. The authority may act as the lead organization or select a lead organization to coordinate and manage the database. The lead organization must also contract with a data vendor to perform data collection, processing, aggregation, extracts, and analytics.

(3) RCW 43.371.070 mandates that the director of the health care authority adopt rules necessary to implement chapter 43.371 RCW. In addition, RCW 43.371.010 and 43.371.050 direct the adoption of specific rules by the director.

(4) The purpose of this chapter is to implement chapter 43.371 RCW, to facilitate the creation and administration of the Washington statewide all-payer health care claims database.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 43.371.070, and 2025 c 305. WSR 26-11-002, s 182-70-010, filed 5/7/26, effective 7/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 43.371.020. WSR 20-08-059, § 182-70-010, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-010, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 16-04-068, § 82-75-010, filed 1/29/16, effective 2/29/16.*

##### **Wash. Admin. Code § 182-70-020** Definitions required by chapter 43.371 RCW. {#sec-182-70-020 omnilex-key=us-wa-regs-official--title-182--182-70-020}

The following definitions apply throughout this chapter unless the context clearly indicates another meaning.

"Allowed amount" means the maximum dollar amount contractually agreed to for an eligible health care service covered under the terms of an insurance policy, health benefits plan or state labor and industries program.

"Billed amount" means the dollar amount charged for a health care service rendered.

"Claim file" means a data set composed of health care service level remittance information for all nondenied adjudicated claims under the terms of an insurance policy, health benefits plan or state labor and industries program including, but not limited to, covered medical services files, pharmacy files and dental files.

"Covered medical services file" means a data set composed of service level remittance information for all nondenied adjudicated claims for Washington covered persons that are authorized under the terms of an insurance policy, health benefits plan or state labor and industries program including, but not limited to, member demographics, provider information, charge and payment information including facility fees, clinical diagnosis codes and procedure codes.

"Data file" means a data set composed of member or provider information including, but not limited to, member eligibility and enrollment data and provider data with necessary identifiers.

"Dental claims file" means a data set composed of service level remittance information for all nondenied adjudicated claims for dental services for Washington covered persons including, but not limited to, member demographics, provider information, charge and payment information including facility fees, and current dental terminology codes as defined by the American Dental Association.

"Member eligibility and enrollment data file" means a data set containing data about Washington covered persons who receive health care coverage from a payer for one or more days of coverage during the reporting period including, but not limited to, subscriber and member identifiers, member demographics, plan type, benefit codes, and enrollment start and end dates.

"Paid amount" means the dollar amount paid for a health care service rendered under the terms of an insurance policy, health benefits plan or state labor and industries program for covered services, excluding member copayments, coinsurance, deductibles and other sources of third-party payment. This dollar amount includes incentive payments that are captured in the claims financial fields in the WA-APCD Data Submission Guide; such incentive payments include, but are not limited to, withholds, shared savings payments, case or episode payments, and pay-for-performance amounts. For capitated services the fee-for-service equivalent is to be reported as the paid amount.

"Pharmacy claims file" means a data set containing service level remittance information for all nondenied adjudicated claims for pharmacy services for Washington covered persons including, but not limited to, enrolled member demographics, provider information, charge and payment information including dispensing fees, and national drug codes.

"Provider data with necessary identifiers" means a data file containing information about health care providers that submitted claims for providing health care services, equipment or supplies, to subscribers or members and such other data as required by the data submission guide.

**History**
- *WSR 19-24-090, recodified as § 182-70-020, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.050(6) and chapter 43.371 RCW. WSR 17-22-121, § 82-75-020, filed 10/31/17, effective 12/1/17. Statutory Authority: Chapter 43.371 RCW. WSR 16-04-068, § 82-75-020, filed 1/29/16, effective 2/29/16.*

##### **Wash. Admin. Code § 182-70-030** Additional definitions authorized by chapter 43.371 RCW. {#sec-182-70-030 omnilex-key=us-wa-regs-official--title-182--182-70-030}

WAC 182-70-030

The following additional definitions apply throughout this chapter unless the context clearly indicates another meaning.

"Authority" means the Washington state health care authority.

"Capitation payment" means a payment model where providers receive a payment on a per "covered person" basis, for specified calendar periods, for the coverage of specified health care services regardless of whether the patient obtains care. Capitation payments include, but are not limited to, global capitation arrangements that cover a comprehensive set of health care services, partial capitation arrangements for subsets of services, and care management payments.

"Claim" means a request or demand on a carrier, third-party administrator, or the state labor and industries program for payment of a benefit.

"Claimant" means a person who files a workers compensation claim with the Washington state department of labor and industries.

"Coinsurance" means the percentage or amount an enrolled member pays towards the cost of a covered service.

"Copayment" means the fixed dollar amount a member pays to a health care provider at the time a covered service is provided or the full cost of a service when that is less than the fixed dollar amount.

"Data management plan" or "DMP" means a formal document that outlines how a data requestor will handle the WA-APCD data to ensure privacy and security both during and after the project.

"Data policy committee" or "DPC" is the advisory committee required by RCW 43.371.020 (5)(h) to provide advice related to data policy development.

"Data release committee" or "DRC" is the advisory committee required by RCW 43.371.020 (5)(h) to establish a data release process and to provide advice regarding formal data release requests.

"Data submission guide" means the document that contains data submission requirements including, but not limited to, required fields, file layouts, file components, edit specifications, instructions and other technical specifications.

"Data use agreement" or "DUA" means the legally binding document signed by either the lead organization and the data requestor, or the authority and the data requestor, or the authority and a Washington state agency, that defines the terms and conditions under which access to and use of the WA-APCD data is authorized, how the data will be secured and protected, and how the data will be destroyed at the end of the agreement term.

"Days" means calendar days.

"Deductible" means the total dollar amount an enrolled member pays on an incurred claim toward the cost of specified covered services designated by the policy or plan over an established period of time before the carrier or third-party administrator makes any payments under an insurance policy or health benefit plan.

"Director" means the director of the health care authority.

"Fee-for-service equivalent" means the amount that would have been paid by the payer for a specified service if the service had not been capitated or paid under an alternative payment formula like treatment episodes, or the fee amount reflected in the payer's internal fee schedule(s) for services that are not paid on a fee-for-service basis.

"Fee-for-service payment" means a payment model where providers receive a negotiated or payer-specified rate for a specific health care service provided to a patient.

"Health benefits plan" or "health plan" has the same meaning as in RCW 48.43.005.

"Health care" means care, services, or supplies related to the prevention, cure or treatment of illness, injury or disease of an individual, which includes medical, pharmaceutical or dental care. Health care includes, but is not limited to:

(a) Preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, service, assessment, or procedure with respect to the physical or mental condition, or functional status, of an individual or that affects the structure or function of the body; and

(b) Sale or dispensing of a drug, device, equipment, or other item in accordance with a prescription.

"Lead organization" means the entity selected by the health care authority to coordinate and manage the database as provided in chapter 43.371 RCW.

"Malicious intent" means the person acted willfully or intentionally to cause harm, without legal justification.

"Member" means a person covered by a health plan including an enrollee, subscriber, policyholder, beneficiary of a group plan, or individual covered by any other health plan.

"Person" means an individual; group of individuals however organized; public or private corporation, including profit and nonprofit corporations; a partnership; joint venture; public and private institution of higher education; a state, local, and federal agency; and a local or tribal government.

"PHI" means protected health information as defined in the Health Insurance Portability and Accountability Act (HIPAA). Incorporating this definition from HIPAA, does not, in any manner, intend or incorporate any other HIPAA rule not otherwise applicable to the WA-APCD.

"Subscriber" means the insured individual who pays the premium or whose employment makes him or her eligible for coverage under an insurance policy or member of a health benefit plan.

"WA-APCD" means the statewide all payer health care claims database authorized in chapter 43.371 RCW.

"WA-APCD program director" means the individual designated by the authority as responsible for the oversight and management of the operations of the statewide all payer health care claims database authorized in chapter 43.371 RCW.

"Washington covered person" means any eligible member and all covered dependents where the covered person is a Washington state resident, or the state of Washington has primary jurisdiction, and whose laws, rules and regulations govern the members' and dependents' insurance policy or health benefit plan.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 43.371.070, and 2025 c 305. WSR 26-11-002, s 182-70-030, filed 5/7/26, effective 7/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 43.371.020. WSR 20-08-059, § 182-70-030, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-030, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.010(3) and 43.371.070. WSR 19-05-054, § 82-75-030, filed 2/15/19, effective 3/18/19*
- *WSR 18-19-056, § 82-75-030, filed 9/15/18, effective 10/16/18. Statutory Authority: RCW 43.371.070 (1)(h). WSR 18-15-002, § 82-75-030, filed 7/5/18, effective 8/5/18. Statutory Authority: RCW 43.371.050(6) and chapter 43.371 RCW. WSR 17-22-121, § 82-75-030, filed 10/31/17, effective 12/1/17. Statutory Authority: Chapter 43.371 RCW. WSR 17-08-079, § 82-75-030, filed 4/4/17, effective 5/5/17*
- *WSR 16-22-062, § 82-75-030, filed 11/1/16, effective 12/2/16*
- *WSR 16-04-068, § 82-75-030, filed 1/29/16, effective 2/29/16.*

##### **Wash. Admin. Code § 182-70-040** Registration requirements. {#sec-182-70-040 omnilex-key=us-wa-regs-official--title-182--182-70-040}

(1) Washington covered persons threshold for data suppliers. Any carrier, third-party administrator, public program, or other potential data supplier identified in RCW 43.371.030 with 1000 or more Washington covered persons, as defined in WAC 182-70-030, as of December 31st of the previous calendar year must submit data in accordance with this chapter.

(a) For the purposes of determining whether a potential data supplier is subject to the requirements of this chapter, potential data suppliers must aggregate the number of Washington covered persons for all companies at the group code level, as defined by the National Association of Insurance Commissioners.

(b) Potential data suppliers that offer any combination of medical, dental, or pharmaceutical benefits under separate or combined plans must count all Washington covered persons, regardless of the comprehensiveness of the plan, toward the 1000 Washington covered persons threshold.

(2) Initial registration. Each data supplier required to submit health care data pursuant to chapter 43.371 RCW must register within thirty days of notification from the lead organization.

(3) Annual registration. Each data supplier required to submit health care data pursuant to chapter 43.371 RCW must register by December 31st of each year after the initial registration. If the data supplier initially registers September 1st or later, then the data supplier must file its annual registration by December 31st of the year following the year of the initial registration.

(4) Each data supplier newly required to submit health care data under chapter 43.371 RCW, either by a change in law or loss of qualified exemption, must register with the lead organization within thirty days of being required to submit data.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-18-057, § 182-70-040, filed 8/26/21, effective 9/26/21. WSR 19-24-090, recodified as § 182-70-040, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 16-04-068, § 82-75-040, filed 1/29/16, effective 2/29/16.*

##### **Wash. Admin. Code § 182-70-050** Data submission schedule. {#sec-182-70-050 omnilex-key=us-wa-regs-official--title-182--182-70-050}

(1) Data suppliers shall submit the required health care data in accordance with the schedule provided in this section.

(2) Test file.

(a) At least sixty calendar days prior to the data suppliers' first required submission, the lead organization will notify the data supplier in writing regarding the obligation to file. The lead organization will schedule time to work with the data supplier to establish a schedule for when the data supplier shall submit the initial test files.

(b) No more than ninety calendar days after notification of changes in requirements in the data submission guide, the data supplier shall submit initial test files. This deadline may be extended by the lead organization when it determines that additional time will be needed in order for the change to be implemented.

(3) Submission file. Data and claim files shall be submitted to the WA-APCD on a quarterly basis. On or before April 30th, July 31st, October 31st and January 31st of each year, data and claim files shall be submitted for all nondenied adjudicated claims paid in the preceding three months.

(4) Resubmission file. Failure to conform to the requirements of this chapter or the data submission guide shall result in the rejection of the applicable data and claim files. The lead organization shall notify the data supplier when data and claim files are rejected. All rejected files must be resubmitted in the appropriate, corrected format within fifteen business days of notification unless a written request for an extension is received by the lead organization before the expiration of this fifteen business day period.

(5) Claims run-out file. If health care coverage is terminated for a Washington covered person, the data supplier shall submit data for a six month period following the health care coverage termination date.

(6) Replacement file.

(a) A data supplier may replace a complete data file, claim file or both data and claim file submission. Requests must be made to the lead organization with a detailed explanation as to why the replacement is needed. The lead organization shall make a recommendation to the authority as to whether to approve or deny the request. The approval recommendation shall also state whether the approval is for the entire period requested or for a period less than requested.

(b) The authority shall approve or deny the request and provide written notification to the requestor within thirty calendar days of receipt of the request. The authority decision on the request for a replacement file will be provided in writing. If the authority does not approve the complete request for a replacement file, the written notification will include the reason for the denial or approval of the shorter period of time.

(c) Requests may not be made more than one year after the end of the month in which the file was submitted unless the data supplier can establish exceptional circumstances for the replacement. The lead organization may recommend approval and the authority may approve a request for more than one year for exceptional circumstances. The authority shall approve or deny the request using the process set forth in (b) of this subsection.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-050, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-050, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 16-04-068, § 82-75-050, filed 1/29/16, effective 2/29/16.*

##### **Wash. Admin. Code § 182-70-060** Historical data submission. {#sec-182-70-060 omnilex-key=us-wa-regs-official--title-182--182-70-060}

(1) The purpose of collecting historical data into the WA-APCD is to permit the systematic analysis of the health care delivery system including evaluation of the effectiveness of the Patient Protection and Affordable Care Act signed into law on March 23, 2010.

(2) The lead organization will provide written notification to the data suppliers when the WA-APCD is ready to accept the submission of historical data. Data suppliers shall submit the historical data within sixty days of notification. Requests for an extension of time to submit historical data shall be made in accordance with WAC 182-70-080(3).

(3) "Historical data" means covered medical services claim files, pharmacy claim files, dental claim files, member eligibility and enrollment data files, and provider data files with necessary identifiers for the period January 1, 2013, through December 31, 2016, or through the end of the quarter immediately prior to the first regular quarterly submission due in accordance with the data submission schedule.

(4) The authority may grant an exception to this section and approve the filing of historical data for a period less than the period specified in subsection (3) of this section. Requests for an exception under this subsection shall be made to the lead organization within fifteen calendar days of being notified in accordance with subsection (2) of this section. The lead organization shall make a recommendation to the authority as to whether to approve or deny the request. The authority may approve the request for good cause.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-060, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-060, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 17-05-024, § 82-75-060, filed 2/7/17, effective 3/10/17*
- *WSR 16-04-068, § 82-75-060, filed 1/29/16, effective 2/29/16.*

##### **Wash. Admin. Code § 182-70-070** Data submission guide. {#sec-182-70-070 omnilex-key=us-wa-regs-official--title-182--182-70-070}

(1) Data files and claim files shall be submitted to the WA-APCD in accordance with the requirements set forth in this chapter and the data submission guide.

(2) The lead organization shall develop the data submission guide with input from stakeholders. The lead organization shall develop a process to allow for stakeholder review and comment on drafts of the data submission guide and all subsequent changes to the guide. The authority shall have final approval authority over the data submission guide and all subsequent changes.

(3) The lead organization shall notify data suppliers before changes to the data submission guide are final. Notification shall occur no less than one hundred twenty calendar days prior to the effective date of any change.

(4) Upon good cause shown, data suppliers may be granted an extension to comply with any changes to the data submission guide. Requests for extensions or exceptions shall be made in accordance with WAC 182-70-080.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-070, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-070, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 16-04-068, § 82-75-070, filed 1/29/16, effective 2/29/16.*

##### **Wash. Admin. Code § 182-70-080** Waivers and extensions. {#sec-182-70-080 omnilex-key=us-wa-regs-official--title-182--182-70-080}

(1) The authority may grant a waiver of reporting requirements or an extension of time to a reporting requirement deadline based on extenuating circumstances.

(2) Waivers.

(a) A data supplier may request a waiver from submission for a period of time due to extenuating circumstances affecting the data supplier's ability to comply with the reporting requirement for that period.

(b) The request shall be for no more than one reporting year and shall contain a detailed explanation as to the reason the data supplier is unable to meet the reporting requirements.

(c) A request for a waiver must be submitted to the lead organization at least sixty calendar days prior to the applicable reporting deadline. The lead organization shall make a recommendation to the authority as to whether to approve or deny the request. The approval recommendation shall also state whether the approval is for the entire period requested or for a period less than requested.

(d) The authority may approve a request for extenuating circumstances. Approval may be for a time period shorter than requested. The authority shall approve or deny the request and provide written notification to the requester within thirty calendar days of receipt of the request. The authority decision on the request for a waiver will be provided in writing. If the authority does not approve a request for a waiver, the written notification will include the reason for the denial.

(3) Extensions.

(a) A data supplier may request an extension of time for submitting a quarterly report or the resubmission of a report due to extenuating circumstances affecting the data supplier's ability to submit the data by the deadline.

(b) The request shall be for no more than one reporting quarter and shall contain a detailed explanation as to the reason the data supplier is unable to meet the reporting requirements for that quarter.

(c) A request for an extension must be submitted to the lead organization at least thirty calendar days prior to the applicable reporting deadline unless the requestor is unable to meet this deadline due to circumstances beyond the data supplier's control. If unable to meet this deadline, the data supplier shall notify the lead organization in writing as soon as the data supplier determines that an extension is necessary.

(d) The lead organization shall make a recommendation to the authority as to whether to approve or deny the request. The approval recommendation shall also state whether the approval is for the entire period requested or for a period less than requested.

(e) The authority may approve a request for extenuating circumstances. The authority shall approve or deny the request and provide written notification to the requestor within fifteen calendar days from when the lead organization receives the request from the data supplier. The authority decision on the request for an extension will be provided in writing. If the authority does not approve a request for an extension, the written notification will include the reason for the denial.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-080, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-080, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 16-04-068, § 82-75-080, filed 1/29/16, effective 2/29/16.*

##### **Wash. Admin. Code § 182-70-090** Penalties for failure to comply with reporting requirements. {#sec-182-70-090 omnilex-key=us-wa-regs-official--title-182--182-70-090}

(1) The authority may assess fines for failure to comply with the requirements of this chapter including, but not limited to:

(a) General reporting requirements.

(b) Health care claim files and data files requirements.

(c) Health care claim files and data files submission requirements.

The authority will not assess fines when the data supplier is working in good faith with the lead organization to comply with the reporting requirements.

(2) Unless the authority has approved a waiver or extension, the authority may assess a fine for failure to comply with general reporting requirements including, but not limited to, the following occurrences:

(a) Failure to submit health care claim files or data files for a required line of business; and

(b) Submitting health information for an excluded line of business.

(3) Unless the authority has approved a waiver or extension, the authority may assess a fine for failure to comply with health care claim file or data file requirements including, but not limited to, the following occurrences:

(a) Submitting a health care claim or data file in an unapproved layout;

(b) Submitting a data element in an unapproved format;

(c) Submitting a data element with unapproved coding; and

(d) Failure to submit a required data element.

(4) Unless the authority has approved a waiver or extension, the authority may assess a fine for failure to comply with health care claim file or data file submission requirements including, but not limited to, the following occurrences:

(a) Failure to comply with WAC 182-70-050 (Data submission schedule);

(b) Rejection of a health care claim or data file by the data vendor that is not corrected by the data supplier; and

(c) Transmitting health care claim or data files using an unapproved process.

(5) Upon the failure to comply with a reporting requirement in this chapter, the authority shall first issue a warning notice to a data supplier. The warning notice shall set forth the nature of the failure to comply and offer to provide assistance to the data supplier to correct the failure.

(6) A data supplier that fails to comply with the same reporting requirement in this chapter for which it previously received a warning notice, may be assessed a penalty of two hundred fifty dollars per day, not to exceed a maximum of twenty-five thousand dollars per occurrence. Each failure to comply with a reporting requirement for a reporting period is considered a separate occurrence.

(7) For good cause shown, the authority may suspend in whole or in part any fine assessed in accordance with this section.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-090, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-090, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 16-04-068, § 82-75-090, filed 1/29/16, effective 2/29/16.*

##### **Wash. Admin. Code § 182-70-100** Administrative review. {#sec-182-70-100 omnilex-key=us-wa-regs-official--title-182--182-70-100}

(1) Data suppliers may request an administrative review of an authority decision to deny a request for an extension or waiver, or an assessment of a fine.

(2) A request for an administrative review may be initiated by a written petition filed with the authority within thirty calendar days after notice of the denial or assessment of a fine. The petition shall include the following information:

(a) Data supplier's name, address, telephone number, email address and contact person.

(b) Information about the subject of the appeal including remedy requested.

(c) A detailed explanation as to the issue or area of dispute, and why the dispute should be decided in the data supplier's favor.

(3) The petition and all materials submitted will be reviewed by the director or director's designee. The reviewing official may request additional information or a conference with the data supplier. A decision from the reviewing official shall be provided in writing to the data supplier no later than thirty calendar days after receipt of the petition. A denial of the petition will include the reasons for the denial.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-100, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-100, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 16-04-068, § 82-75-100, filed 1/29/16, effective 2/29/16.*

##### **Wash. Admin. Code § 182-70-110** Appeals. {#sec-182-70-110 omnilex-key=us-wa-regs-official--title-182--182-70-110}

A data supplier may request an appeal of a denial of its administrative review conducted in accordance with WAC 182-70-100. See WAC 182-526-0205.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 43.71C.110, and 2019 c 334. WSR 21-11-039, § 182-70-110, filed 5/12/21, effective 6/12/21. Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-110, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-110, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 16-04-068, § 82-75-110, filed 1/29/16, effective 2/29/16.*

##### **Wash. Admin. Code § 182-70-200** General data request and release procedures. {#sec-182-70-200 omnilex-key=us-wa-regs-official--title-182--182-70-200}

(1) The lead organization must adopt clear policies and procedures for data requests and data release. At a minimum, the lead organization, in coordination with the data vendor, must develop procedures for making a request for data, how data requests will be reviewed, how decisions will be made on whether to grant or disapprove release of the requested data, and data release processes. The policies and procedures must be approved by the authority.

(2) The lead organization should help data requestors identify the best ways to describe and tailor the data request, understand the privacy and security requirements, and understand the limitations on use and data products derived from the data released.

(3) The lead organization must maintain a log of all requests and action taken on each request. The log must include at a minimum the following information: Name of requestor, data requested, purpose of the request, whether the request was approved or denied, if approved the date and data released, and if denied the date and reason for the denial. The lead organization shall post the log on the WA-APCD website that the lead organization is required to maintain.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-200, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-200, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 16-22-062, § 82-75-200, filed 11/1/16, effective 12/2/16.*

##### **Wash. Admin. Code § 182-70-210** Procedures for data requests. {#sec-182-70-210 omnilex-key=us-wa-regs-official--title-182--182-70-210}

(1) The lead organization must use an application process for data requests.

(2) In addition to the requirements in RCW 43.371.050(1), at a minimum, the application must require the following information:

(a) Detailed information about the project for which the data is being requested including, but not limited to:

(i) Purpose of the project and data being requested, and level of detail for the data requested.

(ii) Methodology for data analysis and timeline for the project.

(iii) If applicable, copy of an Institutional Review Board (IRB) protocol and approval or Exempt Determination and application for the IRB exemption for the project review. Researchers must use an IRB that has been registered with the United States Department of Health and Human Services Office of Human Research Protections. The IRB may however be located outside the state of Washington.

(iv) Staffing qualifications and resumes.

(v) Information on third-party organizations or individuals who may have access to the requested data as part of the project for which the data is requested. The information provided must include the same information required by the requestor, as applicable. Data cannot be shared with third parties except as approved in a data request.

(b) Information regarding whether the requestor has, within the three years prior to the data request date, violated a data use agreement, nondisclosure agreement or confidentiality agreement. Such information must include, but not be limited to, the facts surrounding the violation or data breach, the cause of the violation or data breach, and all steps taken to correct the violation or data breach and prevent a reoccurrence.

(c) Information regarding whether the requestor has, within the five years prior to the data request date, been subject to a state or federal regulatory action related to a data breach and has been found in violation and assessed a penalty, been a party to a criminal or civil action relating to a data breach and found guilty or liable for that breach, or had to take action to notify individuals due to a data breach for data maintained by the data requestor or for which the data requestor was responsible for maintaining in a secure environment.

(d) Submittal of the project's data management plan (DMP), which DMP must include the information required in WAC 182-70-220.

(e) Require all recipients of protected health information (PHI) to provide an attestation from an authorized individual that the recipient of the requested data has data privacy and security policies and procedures in place on the date of the request and will maintain these policies and procedures for the project period, these policies and procedures comply with Washington state laws and rules, and meet the standards and guidelines required by the Washington state office of chief information officer. Data recipients must also attest that recipients will provide copies of the data privacy and security policies and procedures upon request by the lead organization.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-210, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-210, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 16-22-062, § 82-75-210, filed 11/1/16, effective 12/2/16.*

##### **Wash. Admin. Code § 182-70-220** Data management plan. {#sec-182-70-220 omnilex-key=us-wa-regs-official--title-182--182-70-220}

(1)(a) The lead organization must require data requestors to submit data management plans with the data request application. Data management plans must comply with the Washington state office of chief security officer standards.

(b) Additional organizations that are involved in using the data in the data requestors' projects must also provide the information required in the data management plan for their organizations.

(2) Data management plans must provide detailed information including, but not limited to, the following:

(a) Physical possession and storage of the data files, including details about the third-party vendor and personnel handling the data; the facilities, hardware and software that will secure the data; and the physical, administrative and technical safeguards in place to ensure the privacy and security of the released data.

(b) Data sharing, electronic transmission and distribution, including the data requestor's policies and procedures for sharing, transmitting, distributing and tracking data files; physical removal and transport of data files; staff restriction to data access; and use of technical safeguards for data access (e.g., protocols for passwords, log-on/log-off, session time out and encryption for data in motion and at rest).

(c) Data reporting and publication, including who will have the main responsibility for notifying the lead organization of any suspected incidents where the security and privacy of the released data may have been compromised; how DMPs are reviewed and approved by the data requestor; and whether the DMPs will be subjected to periodic updates during the DUA period for the released data.

(d) Completion of project tasks and data destruction, including the data requestor's process to complete the certificate of destruction form and the policies and procedures to:

(i) Dispose of WA-APCD data files upon completion of its project.

(ii) Protect the WA-APCD data files when staff members of project teams (as well as collaborating organizations) terminate their participation in projects. This may include staff exit interviews and immediate termination of data access.

(iii) Inform the lead organization of project staffing changes, including when individual staff members' participation in projects is terminated, voluntarily or involuntarily, within twenty-one calendar days of the staffing change.

(iv) Ensure that the WA-APCD data and any derivatives or parts thereof are not used following the completion of the project.

**History**
- *WSR 19-24-090, recodified as § 182-70-220, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 16-22-062, § 82-75-220, filed 11/1/16, effective 12/2/16.*

##### **Wash. Admin. Code § 182-70-230** Review of data requests. {#sec-182-70-230 omnilex-key=us-wa-regs-official--title-182--182-70-230}

WAC 182-70-230

(1) The lead organization must establish a transparent process for the review of data requests, which includes a process for public review for specific requests. The process must include a timeline for processing requests, and notification procedures to keep the requestor updated on the progress of the review. The process must also include the ability for the public to comment on requests that include the release of protected health information. The authority has final approval over the process and criteria used for review of data requests and all subsequent changes.

(2) The lead organization must post on the WA-APCD website all requests that include the release of protected health information and the schedule for the receipt of public comment on the request. The time frame for public comment should not be less than 14 calendar days. The lead organization must post the final decision for the request within seven days after the decision is made.

(3) The lead organization has the responsibility to convene the DRC when needed to review data requests and make a recommendation to the lead organization as to whether to approve or deny a data request. The lead organization must establish an annual meeting schedule for DRC and post the schedule on the website. The DRC must review requests for identifiable data and provide a recommendation regarding data release. The lead organization may request the DRC to review other data requests. The review must include a technical review of the data management plan by an expert on the DRC, staff from the office of chief information officer, or other technical expert. The DRC may recommend that the requestor provide additional information before a final decision can be rendered, approve the data release in whole or in part, or deny the release. For researchers who are required in RCW 43.371.050 (4)(a) to have IRB approval, the DRC may recommend provisional approval subject to the receipt of an IRB approval letter and protocol and submittal of a copy of the IRB letter to the lead organization.

(4) The lead organization may only deny a data request based on a reason set forth in WAC 182-70-280.

(5) The lead organization must notify the requestor of the final decision. The notification should include the process available for review or appeal of the decision.

(6) The lead organization must post all data requests and final decisions on the WA-APCD website maintained by the lead organization.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 43.371.070, and 2025 c 305. WSR 26-11-002, s 182-70-230, filed 5/7/26, effective 7/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 43.371.020. WSR 20-08-059, § 182-70-230, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-230, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 16-22-062, § 82-75-230, filed 11/1/16, effective 12/2/16.*

##### **Wash. Admin. Code § 182-70-240** Data release. {#sec-182-70-240 omnilex-key=us-wa-regs-official--title-182--182-70-240}

(1) Upon approval of a request for data, the lead organization must provide notice to the requestor. The notice must include the following:

(a) The data use agreement (DUA). The DUA will include a confidentiality statement to which the requesting organization or individual must adhere.

(b) The confidentiality agreement that requestors and all other individuals who will have access to the released data, whether an employee of the requestor, subcontractor or other contractor or third-party vendor including data storage or other information technology vendor, who will have access to or responsibility for the data must sign. At a minimum, the confidentiality agreement developed for recipients must meet the requirements of RCW 43.371.050 (4)(a).

(c) Requestors must comply with the requirements for data release in WAC 182-70-500 through 182-70-520.

(2) A person with authority to bind the requesting organization must sign the DUA; or in the case of an individual requesting data, the individual must sign the DUA.

(3) All employees or other persons who will be allowed access to the data must sign a confidentiality agreement.

(4) No data may be released until the lead organization receives a signed copy of the DUA from the data requestor and signed copies of the confidentiality agreement.

(5) The lead organization must maintain a record of all signed agreements and retain the documents for at least six years after the termination of the agreements.

(6) Data fees, if applicable, must be paid in full to the lead organization. Itemized data fees assessed for each data request are subject to public disclosure and should be included in the approval that is posted on the WA-APCD website.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-240, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-240, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.050(6) and chapter 43.371 RCW. WSR 17-22-121, § 82-75-240, filed 10/31/17, effective 12/1/17. Statutory Authority: Chapter 43.371 RCW. WSR 16-22-062, § 82-75-240, filed 11/1/16, effective 12/2/16.*

##### **Wash. Admin. Code § 182-70-250** Data use agreement. {#sec-182-70-250 omnilex-key=us-wa-regs-official--title-182--182-70-250}

(1) The lead organization must develop a standard data use agreement. The authority must approve the final form of the DUA, and all substantial changes to the form.

(2) At a minimum, the DUA shall include the following provisions:

(a) A start date and end date. The end date must be no longer than the length of the project for which the data is requested. The DUA may provide for the ability to extend the end date of the agreement upon good cause shown.

(b) The application for data should be incorporated into the DUA and attached as an exhibit to the agreement. There should be an affirmative provision that data provided for one project cannot be used for any other project or purpose.

(c) Data can be used only for the purposes described in the request. The data recipient agrees not to use, disclose, market, release, show, sell, rent, lease, loan or otherwise grant access to the data files specified except as expressly permitted by the DUA, confidentiality agreement if any and the approval letter.

(d) With respect to analysis and displays of data, the data recipient must agree to abide by Washington state law and rules, and standards and guidelines provided by the lead organization.

(e) A requirement for completion of an attestation by an officer or otherwise authorized individual of the data requestor that the data requestor will adhere to the WA-APCD's rules and lead organization policies regarding the publication or presentation to anyone who is not an authorized user of the data.

(f) A requirement that all requestor employees and all other individuals who access the data will sign a confidentiality agreement prior to data release. The confidentiality requirements should be set out in the DUA and include the consequences for failure to comply with the agreement.

(g) A requirement that any new employee who joins the organization or project after the data requestor has received the data and who will have access to the data must sign a confidentiality agreement prior and passed required privacy and security training prior to accessing the data.

(3) The authority or lead organization may audit compliance with data use agreements and confidentiality agreements. The requestor must comply and assist, if requested, in any audit of these agreements.

(4) Breach of a data use agreement or confidentiality agreement may result in immediate termination of the data use agreement. The data requestor must immediately destroy all WA-APCD data in its possession upon termination of the data use agreement. Termination of the data use agreement is in addition to any other penalty or regulatory action taken or that may be taken as a result of the breach.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-250, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-250, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 16-22-062, § 82-75-250, filed 11/1/16, effective 12/2/16.*

##### **Wash. Admin. Code § 182-70-260** Confidentiality agreement. {#sec-182-70-260 omnilex-key=us-wa-regs-official--title-182--182-70-260}

(1) The lead organization must develop a standard confidentiality agreement, as required, before data may be released. The authority must approve the final form for confidentiality agreement, and all substantial changes to the form.

(2) The confidentiality agreement must be signed by all requestor employees and other third parties who may have access to the data.

(3) In addition to other penalties or regulatory actions that may be taken, including denial of future data requests, breach of a confidentiality agreement may result in immediate termination of the agreement. If an individual breaches the confidentiality agreement, the lead organization must review the circumstances and determine if the requestor's agreement should be terminated or only the agreement with the individual who caused the breach should be terminated. When an agreement is terminated for breach of the confidentiality agreement, the data requestor or individual whose agreement is terminated must immediately destroy all WA-APCD data in his or her possession and provide an attestation of the destruction to the lead organization within seven business days. Attestation of destruction should be in the form as prescribed by the lead organization. Failure to destroy data or provide attestation of the destruction may result in other penalties or regulatory actions.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-260, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-260, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 16-22-062, § 82-75-260, filed 11/1/16, effective 12/2/16.*

##### **Wash. Admin. Code § 182-70-270** Data procedures at the end of the project. {#sec-182-70-270 omnilex-key=us-wa-regs-official--title-182--182-70-270}

(1) Upon the end of the project or the termination of the data use agreement, the data recipient shall destroy all WA-APCD data. The data recipient must provide to the lead organization an attestation that the data has been destroyed according to the required standards set forth in the DUA. The attestation shall account for all copies of the data being used by the requestor, its employees, subcontractors, and any other person provided access to the data. Attestation of destruction should be in the form as prescribed by the lead organization.

(2) The attestation of data destruction must be provided within ten business days from the end of the project or termination of the DUA or confidentiality agreement, whichever is sooner.

(3) Failure to destroy data or provide attestation of the destruction may result in other penalties or regulatory actions.

**History**
- *WSR 19-24-090, recodified as § 182-70-270, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 16-22-062, § 82-75-270, filed 11/1/16, effective 12/2/16.*

##### **Wash. Admin. Code § 182-70-280** Reasons to decline a request for data. {#sec-182-70-280 omnilex-key=us-wa-regs-official--title-182--182-70-280}

The lead organization may decline a request for data for any of the following reasons:

(1) The requestor has violated a data use agreement, nondisclosure agreement or confidentiality agreement within three years of the date of request.

(2) Any person, other than the requestor, who will have access to the data has violated a data use agreement, nondisclosure agreement or confidentiality agreement within three years of the date of request.

(3) The requestor or any person other than the requestor, who will have access to the data, within the five years prior to the data request date, been subject to a state or federal regulatory action related to a data breach and has been found in violation and assessed a penalty, been a party to a criminal or civil action relating to a data breach and found guilty or liable for that breach, or had to take action to notify individuals due to a data breach for data maintained by the data requestor or for which the data requestor was responsible for maintaining in a secure environment.

(4) The proposed privacy and security protections in the data management plan on the date the data is requested are not sufficient to meet Washington state standards. The protections must be in place on the date the data is requested. For out-of-state requestors, meeting the standards in the state where the requestor or data recipient is located is not acceptable if those standards do not meet those required in Washington state.

(5) The information provided is incomplete or not sufficient to approve the data request.

(6) The proposed purpose for accessing the data is not allowable under WA-APCD statutes, rules or policies, or other state or federal statutes, rules, regulations or federal agency policy or standards for example the Department of Justice Statements of Antitrust Enforcement Policy in Health Care.

(7) The proposed use of the requested data is for an unacceptable commercial use or purpose. An unacceptable commercial use or purpose includes, but is not limited to:

(a) A requestor using data to identify patients using a particular product or drug to develop a marketing campaign to directly contact those patients; or

(b) A requestor using data to directly contact patients for fund-raising purposes; or

(c) A requestor intends to contact an individual whose data is released; or

(d) Sells, gives, shares or intends to sell, give or share released data with another entity or individual not included in the original application for the data and for which approval was given.

**History**
- *WSR 19-24-090, recodified as § 182-70-280, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 16-22-062, § 82-75-280, filed 11/1/16, effective 12/2/16.*

##### **Wash. Admin. Code § 182-70-290** Process to review a declined data request. {#sec-182-70-290 omnilex-key=us-wa-regs-official--title-182--182-70-290}

(1) A data requestor may request an administrative review of the lead organization's decision to deny a request for data.

(2) A request for an administrative review may be initiated by a written petition filed with the authority and also provided to the lead organization within thirty calendar days after notice of the denial. The petition shall include the following information:

(a) Data requestor's name, address, telephone number, email address and contact person.

(b) Information about the subject of the review including remedy requested.

(c) A detailed explanation as to the issue or area of dispute, and why the dispute should be decided in the data requestor's favor.

(3) The petition and all materials submitted will be reviewed by the director or director's designee. The reviewing official may request additional information or a conference with the data requestor. A decision from the reviewing official shall be provided in writing to the data requestor no later than thirty calendar days after receipt of the petition. A denial of the petition will include the reasons for the denial.

(4) The authority will post the petition and final decision on the authority website. The lead organization will provide a link to the petition and decision from its WA-APCD website.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-290, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-290, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 16-22-062, § 82-75-290, filed 11/1/16, effective 12/2/16.*

##### **Wash. Admin. Code § 182-70-300** Process to appeal of final denial of data request. {#sec-182-70-300 omnilex-key=us-wa-regs-official--title-182--182-70-300}

(1) A data requestor may appeal the denial of its administrative review conducted in accordance with WAC 182-70-290.

(2) Request for an appeal must be submitted in writing to the authority within fifteen calendar days after receipt of written notification of denial of its administrative review, with a copy provided to the lead organization.

(3) The lead organization must provide notice and a copy of the appeal request to affected data suppliers within five days of being served. Data suppliers may seek to intervene in an appeal by submitting a petition to intervene to the office of administrative hearings, and serving the petition to intervene on the authority, lead organization and requestor within five days of being notified of the appeal.

(4) Within ten business days of receipt of a written notice of appeal, the authority will transmit the request to the office of administrative hearings (OAH).

(a) Scheduling. OAH will assign an administrative law judge (ALJ) to handle the appeal. The ALJ will notify parties of the time when any additional documents or arguments must be submitted. If a party fails to comply with a scheduling letter or established timelines, the ALJ may decline to consider arguments or documents submitted after the scheduled timelines. A status conference in complex cases may be scheduled to provide for the orderly resolution of the case and to narrow issues and arguments for hearing.

(b) Hearings. Hearings may be by telephone or in-person. The ALJ may decide the case without a hearing if legal or factual issues are not in dispute, the appellant does not request a hearing, or the appellant fails to appear at a scheduled hearing or otherwise fails to respond to inquiries. The ALJ will notify the appellant by mail whether a hearing will be held, whether the hearing will be in-person or by telephone, the location of any in-person hearing, and the date and time for any hearing in the case. The date and time for a hearing may be continued at the ALJ's discretion. Other authority employees may attend a hearing, and the ALJ will notify the appellant when other authority employees are attending. The appellant may appear in person or may be represented by an attorney.

(c) Decisions. The decision of the ALJ shall be considered a final decision. A petition for review of the final decision may be filed in the superior court. If no appeal is filed within the time period set by RCW 34.05.542, the decision is conclusive and binding on all parties. The appeal must be filed within thirty days from service of the final decision.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-300, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-75-300, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 16-22-062, § 82-75-300, filed 11/1/16, effective 12/2/16.*

##### **Wash. Admin. Code § 182-70-400** Privacy and security. {#sec-182-70-400 omnilex-key=us-wa-regs-official--title-182--182-70-400}

(1) RCW 43.371.070 (1)(d) authorizes the director of the health care authority to adopt rules providing procedures for ensuring that all data received from data suppliers are securely collected and stored in compliance with applicable state and federal law.

(2) RCW 43.371.070 (1)(e) authorizes the director of the health care authority to adopt rules providing procedures for ensuring compliance with state and federal privacy laws.

(3) WAC 182-70-410 through 182-70-470 provide the procedures required in subsections (1) and (2) of this section.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-400, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-400, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 17-08-079, § 82-75-400, filed 4/4/17, effective 5/5/17.*

##### **Wash. Admin. Code § 182-70-410** Requirements for data vendor. {#sec-182-70-410 omnilex-key=us-wa-regs-official--title-182--182-70-410}

(1) The data vendor must enter into an agreement with the lead organization that contains the following requirements:

(a) A provision that the data vendor is responsible for ensuring compliance of all aspects of WA-APCD operations with all applicable federal and state laws, and the state's security standards established by the office of the chief information officer;

(b) Provisions that the data vendor is required to keep logs and documentation on activities conducted pursuant to the security plan consistent with the state records retention requirements, which the authority can request to verify that the security protocols are being followed;

(c) A provision that requires a detailed security process, which should include, but is not limited to, details regarding security risk assessments and corrective actions plans when deficiencies are discovered;

(d) Provisions that require secure file transfer for all receipt and transmission of health care claims data; and

(e) Provisions for encryption of data both in motion and at rest using latest industry standard methods and tools for encryption, consistent with the standards of the office of the chief information officer.

(2) The data vendor must enter into a legally binding data use and confidentiality agreement with the lead organization. The agreement must include provisions that restrict the access and use of data in the WA-APCD to that necessary for the operation and administration of the database as authorized by chapter 43.371 RCW.

(3)(a) The data vendor must annually engage the services of an independent third-party security auditor to conduct a security audit to verify that the infrastructure, environment and operations of the WA-APCD are in compliance with federal and state laws, Washington state information technology security standards, and the contract with the lead organization. The data vendor must prepare a plan to correct any deficiency found in the annual security audit.

(b) The data vendor must submit its latest HITRUST common security framework (CSF) report and the latest statement on standards for attestation engagements (SSAE) No. 16 service organization control 2 (SOC 2) Type II audit report covering the data vendor's third-party data center, to the authority within thirty calendar days of receiving the final report. The data vendor must develop and implement an appropriate corrective action plan, including remediation timelines, when necessary, and provide the corrective action plan to the authority or the office of the state chief information security officer upon request.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-410, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-410, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 17-08-079, § 82-75-410, filed 4/4/17, effective 5/5/17.*

##### **Wash. Admin. Code § 182-70-420** Data submission. {#sec-182-70-420 omnilex-key=us-wa-regs-official--title-182--182-70-420}

(1) All data suppliers must submit data to the WA-APCD using a secure transfer protocol and transmission approach approved by the office of the state chief information security officer.

(2) All data suppliers must encrypt data using the latest industry standard methods and tools for encryption consistent with the data vendor's requirements for data encryption as required in WAC 182-70-410.

(3) The data vendor must provide a unique set of login credentials for each individual acting on behalf of or at the direction of an active data supplier.

(4) The data vendor must ensure that the data supplier can only use strong passwords consistent with the state standards when securely submitting data or accessing the secure site.

(5) The data vendor must automatically reject and properly dispose of any files from data suppliers that are not properly encrypted.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-420, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-420, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 17-08-079, § 82-75-420, filed 4/4/17, effective 5/5/17.*

##### **Wash. Admin. Code § 182-70-430** WA-APCD infrastructure. {#sec-182-70-430 omnilex-key=us-wa-regs-official--title-182--182-70-430}

(1) The data vendor must limit access to the secure site. Personnel allowed access must be based on the principle of least privilege and have an articulable need to know or access the site.

(2) The data vendor must conduct annual penetration testing and have specific requirements around the timing of penetration and security testing of infrastructure used to host the WA-APCD by the outside firm. The results of penetration and security testing must be documented and the data vendor must provide the summary results, along with a corrective action plan and remediation timelines, to the authority and the office of the state chief information security officer within thirty calendar days of receipt of the results.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-430, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-430, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 17-08-079, § 82-75-430, filed 4/4/17, effective 5/5/17.*

##### **Wash. Admin. Code § 182-70-440** Accountability. {#sec-182-70-440 omnilex-key=us-wa-regs-official--title-182--182-70-440}

(1) The data vendor must submit an annual report to the lead organization, the authority, and the office of the state chief information security office that includes the following information:

(a) Summary results of its independent security assessment; and

(b) Summary of its penetration testing and vulnerability assessment results.

(2) The data vendor, upon reasonable notice, must allow access and inspections by staff of the office of the state chief information security officer to ensure compliance with state standards.

(3) The data vendor, upon reasonable notice, must allow on-site inspections by the authority to ensure compliance with laws, rules and contract terms and conditions.

(4) The data vendor must have data retention and destruction policies that are no less stringent than that required by federal standards, including the most current version of NIST Special Publication 800-88, Guidelines for Media Sanitization.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-440, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-440, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 17-08-079, § 82-75-440, filed 4/4/17, effective 5/5/17.*

##### **Wash. Admin. Code § 182-70-450** Data vendor and lead organization compliance with privacy and security requirements. {#sec-182-70-450 omnilex-key=us-wa-regs-official--title-182--182-70-450}

WAC 182-70-450

(1) To ensure compliance with privacy and security requirements, the data vendor must immediately report to the authority and the office of the state chief information security officer any data breach of the WA-APCD or knowledge that a data recipient is not complying with confidentiality requirements in accordance with health care authority-approved data breach notification procedures. The data vendor may not unilaterally disclose any information related to a breach of the WA-APCD without written permission from the authority and the state chief information security officer.

(2) Upon receiving approval from the authority and the state chief information security officer, the data vendor must notify the data supplier if the data it supplied has been the subject of a data breach for which the reporting requirements in subsection (1) of this section apply. The data vendor is responsible for complying with the applicable notification provisions in state and federal law.

(3) To ensure compliance with privacy and security requirements, the lead organization must:

(a) Conduct follow-up with data recipients of PHI on a schedule developed by the lead organization;

(b) Request data recipients share any manuscripts, reports, or products with lead organization and the authority;

(c)(i) Require data recipients to complete a project completion form, attesting that the project has terminated and data have been destroyed in accordance with the data use agreement;

(ii) Require the data recipient to provide the written verification that the data has been destroyed in a manner no less stringent than is required in WAC 182-70-440(4).

(d) Track all requests and research projects and follow up with the data recipient when the research or project is expected to be completed; and

(e) Follow up and require written verification that data is destroyed.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 43.371.070, and 2025 c 305. WSR 26-11-002, s 182-70-450, filed 5/7/26, effective 7/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 43.371.020. WSR 20-08-059, § 182-70-450, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-450, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 17-08-079, § 82-75-450, filed 4/4/17, effective 5/5/17.*

##### **Wash. Admin. Code § 182-70-460** Additional requirements. {#sec-182-70-460 omnilex-key=us-wa-regs-official--title-182--182-70-460}

(1) The data vendor will ensure access to the WA-APCD data is strictly controlled and limited to authorized staff with appropriate training, clearance, background checks, and confidentiality agreements.

(2) All data vendor employees who are provided access to data submitted to the WA-APCD must attend security and privacy training before actual access to data is allowed. The training will cover the relevant privacy and security requirements in state and federal law.

**History**
- *WSR 19-24-090, recodified as § 182-70-460, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 17-08-079, § 82-75-460, filed 4/4/17, effective 5/5/17.*

##### **Wash. Admin. Code § 182-70-470** State oversight of compliance with privacy and security requirements. {#sec-182-70-470 omnilex-key=us-wa-regs-official--title-182--182-70-470}

In order to ensure compliance with privacy and security requirements and procedures, the authority or the office of chief information officer or both may request from the lead organization any or all of the following:

(1) Audit logs pertaining to accessing the WA-APCD data;

(2) Completion of a security design review as required by Washington state IT security standards;

(3) Documentation of compliance with OCIO security policy (OCIO policy 141.10 Securing information technology assets standards);

(4) All data use agreements.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-470, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-470, filed 12/3/19, effective 1/1/20. Statutory Authority: Chapter 43.371 RCW. WSR 17-08-079, § 82-75-470, filed 4/4/17, effective 5/5/17.*

##### **Wash. Admin. Code § 182-70-500** Additional definitions related to the format for the calculation and display of data. {#sec-182-70-500 omnilex-key=us-wa-regs-official--title-182--182-70-500}

WAC 182-70-500

The following additional definitions apply throughout this chapter unless the context clearly indicates another meaning. These definitions are related to the rules regarding the format for the calculation and display of data.

(1) "Aggregate data" means data collected from individual-level records that are maintained in a form that does not permit the identification of individual records.

(2) "Arithmetic mean" means the sum of a set of values, divided by the number of values in the set.

(3) "Average" means the arithmetic mean.

(4) "Cell size suppression" means a method used to report data that restricts or suppresses disclosure of subsets of data to protect the identity and privacy of data subjects and to avoid the risk of identification of individuals or providers in small population groups.

(5) "Median" means the middle value of a list of values where the values have been sorted in size order. If the list has an even number of values, the median is the arithmetic mean of the two middle values.

(6) "Outlier" means an observation that is well outside of the expected range of values in a study or experiment, and which is often discarded from the data set.

(7) "Proportion" means a comparative relation between things or magnitudes as to size, quantity, number, or ratio.

(8) "Range" is the largest value in the set of numbers minus the smallest value in the set. Often, a range is expressed to denote a particular span, e.g., 25th to 75th percentile range. Note that as a statistical term, the range is a single number, not a range of numbers.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 43.371.070, and 2025 c 305. WSR 26-11-002, s 182-70-500, filed 5/7/26, effective 7/1/26. WSR 19-24-090, recodified as § 182-70-500, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.050(6) and chapter 43.371 RCW. WSR 17-22-121, § 82-75-500, filed 10/31/17, effective 12/1/17.*

##### **Wash. Admin. Code § 182-70-520** Elements to safeguard the use of data. {#sec-182-70-520 omnilex-key=us-wa-regs-official--title-182--182-70-520}

WAC 182-70-520

All reports, analytics or other information drawn from the WA-APCD that an approved WA-APCD data recipient under WAC 182-70-250 shares with any third party must comply with the following restrictions and best practices to protect patient privacy and ensure data integrity.

(1) Aggregate health care and cost data may be made available for public use.

(2) Absolute or relative allowed cost, utilization, or outcome information must be communicated in ways that mitigate the potential to mislead data users including, but not limited to:

(a) Use of median cost or utilization rates to mitigate the impact of outlier cases;

(b) Reporting of cost variation statistics, such as ranges, confidence intervals, or standard deviations, to illustrate the typical distribution around a point estimate;

(c) Application of categorization, stratification or risk-adjustment techniques to enable like-comparisons of patient populations;

(d) Minimum case volume rules and/or reporting of volume alerts to inform users to the underlying sample size and potential instability; and

(e) Compliance with cell size suppression rules for proportions, rates, and aggregates, ensuring no percentages, ratios, or derivations reveal suppressed cells.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 43.371.070, and 2025 c 305. WSR 26-11-002, s 182-70-520, filed 5/7/26, effective 7/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 43.371.020. WSR 20-08-059, § 182-70-520, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-520, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.050(6) and chapter 43.371 RCW. WSR 17-22-121, § 82-75-520, filed 10/31/17, effective 12/1/17.*

##### **Wash. Admin. Code § 182-70-550** Requirement for fee schedules and processes. {#sec-182-70-550 omnilex-key=us-wa-regs-official--title-182--182-70-550}

(1) RCW 43.371.020 (5)(g) requires the lead organization to develop a plan for the financial sustainability of the database, and charge fees for reports and data files to fund the database.

(2) The authority must approve any fee established by the lead organization.

(3) RCW 43.371.070 requires the authority to establish by rule, procedures for the lead organization to establish these statutorily required fees.

(4) The process to develop, review and approve fee schedules will be open and transparent, and allow for stakeholder feedback.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-550, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-550, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.070 (1)(f). WSR 18-10-074, § 82-75-550, filed 5/1/18, effective 6/1/18.*

##### **Wash. Admin. Code § 182-70-560** Process to establish fee schedules. {#sec-182-70-560 omnilex-key=us-wa-regs-official--title-182--182-70-560}

(1) The lead organization must develop a draft fee schedule consistent with the requirements in RCW 43.371.020 (5)(g). The lead organization must maintain documentation that supports the development of and final decisions regarding the fee schedule.

(2) The lead organization must present the draft fee schedule and supporting documentation to the data policy committee for review and feedback. The lead organization must provide any other available data requested by the DPC that supports the development and draft fee schedule presented.

(3) The DPC must review the draft fee schedule, supporting documentation, and adopt recommendations, including the basis for each recommendation, as to whether the fee schedule should be approved by the authority. The DPC must provide the recommendations to the lead organization for its consideration.

(4) The lead organization must review the DPC recommendations and make any changes to the draft fee schedule based on the recommendations. The lead organization must document which recommendations it implemented into the fee schedule. For those recommendations that the lead organization did not act upon, the lead organization must document the reasons why each recommendation was not accepted.

(5) The lead organization must provide the authority the draft fee schedule, as modified, supporting documentation, the DPC recommendations, and the reasoning for why the lead organization did not make changes for any recommendation not accepted. The lead organization must also provide any other available data requested by the authority that supports the development and draft fee schedule provided to the authority.

(6) The authority shall post on the agency website the draft fee schedule, and solicit public comment for thirty days. The authority may also convene a stakeholder meeting to provide an opportunity for interested parties another avenue to give feedback on the draft fee schedule. If the authority decides to hold a stakeholder meeting, the meeting may be in person, by telephone or other electronic means, as determined by the authority.

After the comment period, the authority will review all the stakeholder feedback, recommendations of the DPC, and any data received from the lead organization and make a final determination regarding the fee schedule. The authority shall provide the final determination to the lead organization, publish the final determination on the agency website, and send notification through the authority listserv or other electronic means.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-560, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-560, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.070 (1)(f). WSR 18-10-074, § 82-75-560, filed 5/1/18, effective 6/1/18.*

##### **Wash. Admin. Code § 182-70-570** Process to modify fee schedules. {#sec-182-70-570 omnilex-key=us-wa-regs-official--title-182--182-70-570}

(1) Fee schedules shall be reissued no less frequently than on an annual basis. The reissuance of the fee schedule can include maintaining the fee schedule without modification, modifying the fee schedule, or a combination of these two actions.

(2) The lead organization shall review fee schedules at least once every year. Annual period shall be from the date upon which the fee schedule is adopted. The review shall include whether any fee should be changed, removed from the schedule, or new fees added. The lead organization must maintain documentation that supports the recommended changes from the review of the fee schedule.

(3) The lead organization must present the changes, supporting documentation, and proposed modifications to the fee schedule to the data policy committee for review and feedback. The lead organization must provide any other available data requested by the DPC that supports the proposed modifications to the fee schedule.

(4) The DPC must review the changes, supporting documentation, and proposed modifications to the fee schedule and adopt recommendations, including the basis for each recommendation, as to whether the changes should be accepted and the modified fee schedule approved by the authority. The DPC must provide the recommendations to the lead organization for its consideration.

(5) The lead organization must review the DPC recommendations and make any changes to the recommendations and proposed modifications to the fee schedule based on the recommendations. The lead organization must document which recommendations it implemented into the fee schedule. For those recommendations that the lead organization did not act upon, the lead organization must document the reasons why each recommendation was not accepted.

(6) The lead organization must provide the authority the proposed modifications to the fee schedule, as modified, with supporting documentation, the DPC recommendations, and the reasoning for why the lead organization did not make changes for any recommendation not accepted. The lead organization must provide any other available data requested by the authority that supports the changes and proposed modified fee schedule provided to the authority.

(7) The authority shall post on the agency website the recommendations and proposed modifications to the fee schedule, and solicit public comment for thirty days. The authority may also convene a stakeholder meeting to provide an opportunity for interested parties another avenue to give feedback on the draft fee schedule. If the authority decides to hold a stakeholder meeting, the meeting may be in person, by telephone or other electronic means, as determined by the authority.

(8) After the comment period, the authority will review all the stakeholder feedback, recommendations of the DPC, and any data received from the lead organization and make a final determination regarding the fee schedule. The authority shall provide the final determination to the lead organization, publish the final determination on the agency website, and send notification through the authority listserv or other electronic means.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-570, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-570, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.070 (1)(f). WSR 18-10-074, § 82-75-570, filed 5/1/18, effective 6/1/18.*

##### **Wash. Admin. Code § 182-70-600** Causes for penalties. {#sec-182-70-600 omnilex-key=us-wa-regs-official--title-182--182-70-600}

WAC 182-70-600

(1) The authority may impose penalties for the inappropriate disclosure or use of direct patient identifiers and indirect patient identifiers received from, provided to, or contained in the WA-APCD.

(2) Any penalty imposed pursuant to this subchapter and in accordance with RCW 43.371.050 must be in addition to and does not prevent the assessment of penalties authorized by state or federal law, contract, or court order.

(3) The following definitions apply to WAC 182-70-600 through 182-70-665.

(a) "Inappropriate disclosures" or "uses" are those that are inconsistent or in violation of the requirements in RCW 43.371.050. In addition, inappropriate disclosure or uses also include defamatory or malicious use and disclosure or use and disclosure with the intent to cause harm.

(b) "Protected information" is direct patient identifiers and indirect patient identifiers.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 43.371.070, and 2025 c 305. WSR 26-11-002, s 182-70-600, filed 5/7/26, effective 7/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 43.371.020. WSR 20-08-059, § 182-70-600, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-600, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.070 (1)(h). WSR 18-15-002, § 82-75-600, filed 7/5/18, effective 8/5/18.*

##### **Wash. Admin. Code § 182-70-605** Alleging a violation. {#sec-182-70-605 omnilex-key=us-wa-regs-official--title-182--182-70-605}

(1) Any person, as defined in WAC 182-70-030, may bring to the attention of the lead organization or the authority information concerning the inappropriate disclosure or use of protected information as set forth in RCW 43.371.050 and WAC 182-70-600.

(2) The authority must conduct an investigation unless it determines that the complaint is without merit or is frivolous, regardless of how the authority has received the information that led to that belief, including information derived from any audit conducted by or at the direction of the authority.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-605, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-605, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.070 (1)(h). WSR 18-15-002, § 82-75-605, filed 7/5/18, effective 8/5/18.*

##### **Wash. Admin. Code § 182-70-610** Complaints. {#sec-182-70-610 omnilex-key=us-wa-regs-official--title-182--182-70-610}

(1) Any complaint filed pursuant to WAC 182-70-605 must be in writing and include the following information, if known:

(a) The name and contact information of the complainant;

(b) The specific facts supporting the violation alleged, including the dates, and locations for all events upon which the complaint is made;

(c) The facts upon which the complaint is based; and

(d) The name of the individual(s) and organization the complainant believes has committed an inappropriate disclosure or use of protected information and should be subject to penalties.

(2) If sufficient information is provided as required in subsection (1)(b) through (d) of this section, the authority will accept the complaint without the complainant's name and contact information. In cases when the name and contact information is not provided, the complainant waives any future contact or notification from the authority regarding the complaint.

(3) The complainant must provide additional information if requested by the lead organization or the authority.

(4) Complaints alleging the lead organization made inappropriate disclosure or use of protected information must be filed directly with the authority. The complaint must contain the information required in subsection (1) of this section. If a complaint of this nature is filed with the lead organization, the lead organization must forward to the authority within one business day of receipt, without further review or action.

(5) Regardless of whether the complaint was filed with the authority or the lead organization, except as provided by subsection (4) of this section, the lead organization will review the complaint and compile any information it may have related to the complaint. The lead may review the complaint as to whether the facts as presented support the finding of an inappropriate disclosure or use of protected information. The lead organization must forward the complaint, and all supporting documents to the authority, including the result of any initial review the lead may have undertaken.

(6) The authority must review the information provided by the lead organization pursuant to subsection (5) of this section.

(a) If the authority determines that the facts as presented, if true, support the finding of an inappropriate disclosure or use of protected information, the authority will conduct an investigation to substantiate the allegations.

(b) If the authority determines that the facts as presented, if true, do not support the finding of an inappropriate disclosure or use of protected information, the authority will close the complaint without further action. If closed without further action, the notice will include the basis for that determination.

(c) The authority may conduct the investigation, or contract with a third party, other than the lead organization or a subcontractor to the lead organization, to conduct the investigation.

(7) The authority will notify the complainant in writing and state whether the complaint will be investigated or closed without action.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-610, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-610, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.070 (1)(h). WSR 18-15-002, § 82-75-610, filed 7/5/18, effective 8/5/18.*

##### **Wash. Admin. Code § 182-70-615** Investigation. {#sec-182-70-615 omnilex-key=us-wa-regs-official--title-182--182-70-615}

(1) If the authority accepts a complaint and conducts an investigation, the authority will notify the person(s) that is the subject of the complaint in writing.

(2) The notice will include the following information:

(a) The factual allegations supporting each alleged inappropriate disclosure or use of protected information violation in terms sufficient to put the persons on notice of the specific reasons for the investigation;

(b) The statutory and administrative code provisions addressing the allegations, if applicable;

(c) A request that the person provide a written response to the allegations including any documents that support the response, and notice that failure to respond will result in the authority making a decision without the person's input; and

(d) A directive to cease using or destroy the data received from the WA-APCD until the investigation has been completed and the person is notified that he/she may again use the data provided. The person shall complete an attestation that the person has complied with this directive. A violation of this directive shall be grounds for finding a separate violation of the inappropriate disclosure or use of protected information.

(3) The lead organization and the data vendor shall cooperate with the investigator and timely respond to requests for information or documents during the course of an investigation.

(4) At the conclusion of the investigation, the investigator will issue a report to the WA-APCD program director that includes the following information:

(a) Facts found by the investigator;

(b) Whether the facts support finding inappropriate disclosures or uses of protected information; and

(c) A recommendation to dismiss the complaint with no further action or to issue an order with a penalty, which recommendation may include a penalty amount and any other actions that the authority should take as a result of the violation(s).

(5) A finding that the person inappropriately disclosed or used protected information is a violation for purposes of this section. In the case of a continuing inappropriate disclosure or use of protected information, each day of the inappropriate disclosure or use is a separate violation.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-615, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-615, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.070 (1)(h). WSR 18-15-002, § 82-75-615, filed 7/5/18, effective 8/5/18.*

##### **Wash. Admin. Code § 182-70-620** Notice of violation and recommended penalty. {#sec-182-70-620 omnilex-key=us-wa-regs-official--title-182--182-70-620}

(1) If, based on the investigation, the WA-APCD program director determines that the facts support finding an inappropriate disclosure or use of protected information and imposition of a penalty as set forth in the investigation report, the WA-APCD program director shall notify the alleged violator. The WA-APCD program director shall cause service of the notice of violation and recommended penalty on each alleged violator. The notice shall include the following information:

(a) Date when the recommended penalty and other actions imposed will take effect, if not appealed;

(b) Each inappropriate disclosure or use of protected information found and the facts supporting each inappropriate disclosure or use of protected information;

(c) The recommended penalty, other monetary amounts to be assessed, including the cost of the investigation, and any other action authorized by WAC 182-70-625 and 182-70-630;

(d) If the person will be prohibited from receiving data from the WA-APCD in the future, the period of the recommended prohibition;

(e) Notice that each alleged violator may request a hearing in accordance with WAC 182-70-645 to dispute the finding of a violation, the recommended penalty, or both. The notice shall state that if no hearing is requested within thirty days of the date of issuance of the notice, the authority shall issue a final, unappealable order.

(2) In the event the alleged violator or violators do not timely request a hearing, the WA-APCD program director will provide the report and recommendation to the director, who shall issue a final order, which will include the date upon which the order becomes effective.

(3) The WA-APCD program director shall provide a copy of the investigation report and the notice prepared pursuant to subsection (1) of this section to all data suppliers with protected information identified in the report as having been inappropriately disclosed or used. This notice is separate and in addition to any other notice required by law.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-620, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-620, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.070 (1)(h). WSR 18-15-002, § 82-75-620, filed 7/5/18, effective 8/5/18.*

##### **Wash. Admin. Code § 182-70-625** Monetary penalties that may be imposed upon finding a violation of inappropriate disclosures or uses. {#sec-182-70-625 omnilex-key=us-wa-regs-official--title-182--182-70-625}

WAC 182-70-625

(1) If a person has been found to have made inappropriate disclosures or uses of protected information received from the WA-APCD, the director may impose one or more of the following monetary penalties:

(a) A civil penalty determined pursuant to the criteria and requirements in this chapter;

(b) Cost, including reasonable investigative costs, that do not exceed the amount of any civil penalty;

(c) The cost of any audit performed that uncovered the violation, or was conducted as a result of investigating an alleged violation; and

(d) Up to three times the amount of financial gain received by the alleged violator or financial loss of any person whose protected information was inappropriately disclosed or used.

(2) The director will include with the decision regarding the monetary penalty assessment, the director's reasoning for the specific penalty, or lack thereof, that is being assessed.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 43.371.070, and 2025 c 305. WSR 26-11-002, s 182-70-625, filed 5/7/26, effective 7/1/26. WSR 19-24-090, recodified as § 182-70-625, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.070 (1)(h). WSR 18-15-002, § 82-75-625, filed 7/5/18, effective 8/5/18.*

##### **Wash. Admin. Code § 182-70-630** Nonmonetary penalties that may be imposed upon finding a violation of inappropriate disclosures or uses. {#sec-182-70-630 omnilex-key=us-wa-regs-official--title-182--182-70-630}

WAC 182-70-630

In addition to the monetary penalties set forth in WAC 182-70-625, if a person has been found to have made inappropriate disclosures or uses of protected information received from the WA-APCD, the director may order the following nonmonetary penalties:

(1)(a) Direct WA-APCD program director to review the contract between the person and lead organization to determine whether the finding is a breach of that contract, and take appropriate action including requiring all WA-APCD data provided to be destroyed, termination of the contract, and seeking damages if the contract has been breached; or

(b) In lieu of (a) of this subsection, direct the lead organization to review whether the finding is also a breach of any contract between the person and the lead organization, and take appropriate action including requiring all WA-APCD data provided to be destroyed, termination of the contract, and seeking damages if the contract has been breached, unless the lead organization is the violator, in which case (a) of this subsection applies.

(2) Demand the destruction of all WA-APCD data provided, whether stand alone or combined with other data, all data products, and derivatives produced from WA-APCD data, and in the person's custody or contract, including proof of the destruction in the form and manner as prescribed by the authority;

(3) Bar the person from receiving any data from the WA-APCD for a designated period of time; and

(4) Notify the funding entity of the violation, when the violation involves research funded by another entity, and any other regulatory agency that has oversight over the person or the data that the person requested.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 43.371.070, and 2025 c 305. WSR 26-11-002, s 182-70-630, filed 5/7/26, effective 7/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 43.371.020. WSR 20-08-059, § 182-70-630, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-630, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.070 (1)(h). WSR 18-15-002, § 82-75-630, filed 7/5/18, effective 8/5/18.*

##### **Wash. Admin. Code § 182-70-635** Penalty ranges based on culpability. {#sec-182-70-635 omnilex-key=us-wa-regs-official--title-182--182-70-635}

(1) In determining the appropriate sanction, including the amount of any civil penalty, the director will consider the level of culpability associated with the violation. The levels of culpability, in the order of less severe to severe, are as follows:

(a) Did not know. The person did not know and by exercising reasonable diligence, would not have known the violation had occurred.

(b) Reasonable cause. The person knew, or by exercising diligence should have known, that the violation had taken place, but the person did not act with willful negligence.

(c) Willful neglect - Corrected. The violation was due to the person's conscious, intentional failure or reckless indifference, and the violation was corrected within thirty days from the date the person knew or with reasonable diligence should have known of the inappropriate disclosure or use.

(d) Willful neglect - Uncorrected. The violation was due to the person's conscious, intentional failure or reckless indifference, and the violation was not corrected within thirty days from the date the person knew or with reasonable diligence should have known of the inappropriate disclosure or use.

(2) The penalty ranges for each level of culpability and the yearly cap for violations of a similar nature are as follows:

| Culpability Category | Penalty Range per Violation | Yearly Cap for Similar Violations |
| --- | --- | --- |
| Did not know | $5,000 - $100,000 | $2,500,000 |
| Reasonable cause | $10,000 - $250,000 | $2,500,000 |
| Willful neglect - Corrected | $50,000 - $500,000 | $5,000,000 |
| Willful neglect - Not corrected | $100,000 - $1,500,000 | $10,000,000 |

(3) Violations that involve malicious intent, as that term is defined in WAC 182-70-030, are not subject to the yearly caps set forth in subsection (2) of this section.

(4) The director may assess a penalty outside the penalty ranges set forth in subsection (2) of this section if the person has previously committed the same violation in the same culpability category.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-635, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-635, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.070 (1)(h). WSR 18-15-002, § 82-75-635, filed 7/5/18, effective 8/5/18.*

##### **Wash. Admin. Code § 182-70-640** Other factors that may be considered in determining the penalty for a violation of this chapter. {#sec-182-70-640 omnilex-key=us-wa-regs-official--title-182--182-70-640}

In addition to the culpability category set forth in WAC 182-70-635, to determine the penalty amount, the director may consider the following factors:

(1) The nature and extent of the violation including, but not limited to, the number of persons affected, the duration of the violation, and whether the violation was done with malicious intent.

(2) The nature and extent of the harm resulting from the violation including, but not limited to:

(a) Whether the violation resulted in physical harm;

(b) Whether the violation resulted in financial harm;

(c) Whether the violation resulted in harm to a person's reputation;

(d) Whether the violation hindered an individual's ability to obtain health care;

(e) Whether the violation resulted in any other actual or potential harm.

(3) The history of compliance with the statutory, regulatory, and contractual provisions related to prior data release from the WA-APCD including, but not limited to:

(a) Whether the current violation is the same or similar to previous noncompliance;

(b) Whether and to what extent the person has attempted to correct previous noncompliance;

(c) How the person has responded to the complaint, investigation and any assistance provided to correct and mitigate any effect from the violation;

(d) How the person has responded to prior complaints for the same or similar violations including, but not limited to, changes in process or procedures for securing the confidentiality of the protected information, changes in recruitment, retention, or training requirements for employees or contractor with access to protected information.

(4) Any other factor relevant to the violation or the impact of the violation including, but not limited to:

(a) The frequency of incidents and/or duration of the wrongdoing;

(b) Whether there is a pattern or prior history of wrongdoing;

(c) Whether the person has accepted responsibility for the wrongdoing and recognizes the seriousness of violation;

(d) Whether the person paid or agreed to pay any criminal, civil, and administrative liabilities for the improper activity, including any investigative or administrative costs incurred by the government, and has made or agreed to make full restitution;

(e) Whether the person has cooperated fully during the investigation and any administrative action. In determining the extent of cooperation, the director may consider when the cooperation began and whether the person disclosed all known pertinent information;

(f) The kind of positions held by the individuals involved in the wrongdoing;

(g) Whether the person fully investigated the circumstances surrounding the violation and, if so, made the result of the investigation available to the reviewing official, and took appropriate corrective action or remedial measures;

(h) Whether effective standards of conduct and internal control systems were in place at the time the violation occurred;

(i) Whether appropriate disciplinary action was taken against the individuals responsible for the activity that constitutes the violation.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-640, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-640, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.070 (1)(h). WSR 18-15-002, § 82-75-640, filed 7/5/18, effective 8/5/18.*

##### **Wash. Admin. Code § 182-70-645** Process to appeal determination of a violation and assessed penalties. {#sec-182-70-645 omnilex-key=us-wa-regs-official--title-182--182-70-645}

(1) Each person to whom a notice of a violation and recommended penalty is issued may request a hearing to be conducted in accordance with WAC 182-70-655.

(2) The request for a hearing must be submitted to the director in writing within thirty days after receipt of written notification of the notice provided pursuant to WAC 182-70-620. The person requesting a hearing must also provide a copy of the request to the WA-APCD program director.

(3) The request for hearing must be in writing and specify:

(a) The name of the person requesting the hearing and the person's or representative's contact information;

(b) The items, facts, or conclusions in the notice of violation being contested; and

(c) The basis for contesting the penalty, if applicable, including any mitigating factors upon which the person relies and the outcome the requestor is seeking.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-645, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-645, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.070 (1)(h). WSR 18-15-002, § 82-75-645, filed 7/5/18, effective 8/5/18.*

##### **Wash. Admin. Code § 182-70-650** Informal dispute resolution prior to a hearing. {#sec-182-70-650 omnilex-key=us-wa-regs-official--title-182--182-70-650}

(1) The following procedures are available for informal dispute resolution prior to a hearing that may make more elaborate proceedings under the Administrative Procedure Act unnecessary.

(2) Settlements. Any appeal of a notice of violation and recommended penalty before the director or director's designee, for which a hearing has not yet been held, may be resolved by settlement. The respondent shall communicate his or her request to the WA-APCD program director, setting forth all pertinent facts and the desired remedy. Settlement negotiations shall be informal and without prejudice to rights of a participant in the negotiations.

(3) Stipulations. The WA-APCD program director and respondent may agree to terms of any stipulation of facts, violations, and/or penalty. If a stipulation is reached, the WA-APCD program director shall prepare the stipulation for presentation to the director.

(a) Any proposed stipulation shall be in writing and signed by each party to the stipulation or his or her representative. The WA-APCD program director shall sign for the authority. Any stipulation shall be provided no later than three business days preceding the hearing.

(b) The director has the option of accepting, rejecting, or modifying the proposed stipulation or asking for additional facts to be presented. If the director accepts the stipulation or modifies the stipulation with the agreement of the parties, the director shall enter an order in conformity with the terms of the stipulation. If the director rejects the stipulation or one or both of the parties does not agree to the director's proposed modifications to the stipulation, then the hearing shall be scheduled and held.

(4) Informal dispute resolution negotiations shall be informal and without prejudice to the rights of the participants.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-650, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-650, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.070 (1)(h). WSR 18-15-002, § 82-75-650, filed 7/5/18, effective 8/5/18.*

##### **Wash. Admin. Code § 182-70-655** Hearing and final order. {#sec-182-70-655 omnilex-key=us-wa-regs-official--title-182--182-70-655}

For penalties imposed under WAC 182-70-600, the WA-APCD program director or the director's designee conducts a hearing and prepares a final order in accordance with WAC 182-526-0206.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 43.71C.110, and 2019 c 334. WSR 21-11-039, § 182-70-655, filed 5/12/21, effective 6/12/21. Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-655, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-655, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.070 (1)(h). WSR 18-15-002, § 82-75-655, filed 7/5/18, effective 8/5/18.*

##### **Wash. Admin. Code § 182-70-665** Posting of information related to inappropriate disclosure or use of protected information. {#sec-182-70-665 omnilex-key=us-wa-regs-official--title-182--182-70-665}

(1) Except as provided in subsection (2) of this section, the authority will maintain a website to provide public access to information related to the inappropriate disclosure or use of protected information. For each complaint for which an investigation is conducted, the authority will post the complaint, the information that the lead organization provided to the authority pursuant to WAC 182-70-610(5), investigation report and final disposition of the complaint. In addition, if the complaint finds a violation, the authority will post the notice of violation and the final hearing order, if a hearing is requested.

(2) If any of the records specified for posting in subsection (1) of this section contains confidential or protected information, that information is privileged and not subject to disclosure under the Public Records Act, chapter 42.56 RCW, and will be redacted from any documents posted on the authority website.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-665, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-665, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.070 (1)(h). WSR 18-15-002, § 82-75-665, filed 7/5/18, effective 8/5/18.*

##### **Wash. Admin. Code § 182-70-700** Purpose of audits. {#sec-182-70-700 omnilex-key=us-wa-regs-official--title-182--182-70-700}

There are two primary areas for which audits may be performed to ensure compliance with laws and rules related to the WA-APCD.

(1) Audits may be performed to determine if data suppliers are in compliance with the requirements for the submission of data to the WA-APCD including, but not limited to:

(a) Compliance with the data submission guide including, but not limited to, accuracy of financial fields;

(b) Data integrity, as opposed to data quality checks that the data vendor performs using thresholds and variances;

(c) Finding data that is missing or being withheld from submission into the WA-APCD; and

(d) Documenting the process for determining the number of Washington covered persons for each line of business in order to ensure that data suppliers are not artificially creating lines of business with small numbers of covered lives in order to meet the minimum threshold for exclusion to report.

(2) Audits can be performed to determine whether requestors who receive data from the WA-APCD are in compliance with the data release requirements or agreements, whether provided datasets or licenses to the data enclave including, but not limited to:

(a) For physical datasets, compliance with data use agreements, confidentiality agreements, compliance with collecting, storing, analyzing, and destroying the data; and

(b) For data enclave licenses, compliance with data use agreements, confidentiality agreements, compliance with analyzing, storing, destroying, and user license access to the data.

(3) For purposes of this section, the following definitions apply:

(a) "Data quality checks" means the extent to which data is missing or the data conforms with the data format requirements; and

(b) "Data integrity checks" means the completeness and validity of the submitted data, whether the submitted values are consistent with the instructions and intent of the data submission guide.

**History**
- *WSR 19-24-090, recodified as § 182-70-700, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.070. WSR 18-22-095, § 82-75-700, filed 11/5/18, effective 12/6/18.*

##### **Wash. Admin. Code § 182-70-705** When an audit may be commenced. {#sec-182-70-705 omnilex-key=us-wa-regs-official--title-182--182-70-705}

WAC 182-70-705

(1) The authority may initiate a random audit to ensure compliance with data release requirements. A data requestor may not be subject to a random audit more frequently than once every three years.

(2) The authority may initiate an audit of a data supplier or data requestor upon notice that one of the following events has occurred:

(a) Reports from the data vendor that there is a material change, without justification or a reasonable basis for the change provided by the data supplier, in the number of claims submitted from a data supplier. Before submitting a report under this subsection, the data vendor should have worked with the data supplier to cure any inadvertent data submission issues.

(b) Reports from the data vendor that certain types of claims are missing for a data supplier.

(c) Notice that the data requestor or data user is publishing data in reports that are not compliant with data use agreements. Violations of the data use agreements are subject to penalties in accordance with the process set forth in this chapter.

(d) Notice that the data requestor or data user is publishing PHI not in compliance with state or federal requirements.

(e) Other occurrence that could indicate that the data supplier or data requestor is not in compliance with the requirements in law or rule regarding the WA-APCD.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 43.371.070, and 2025 c 305. WSR 26-11-002, s 182-70-705, filed 5/7/26, effective 7/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 43.371.020. WSR 20-08-059, § 182-70-705, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-705, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.070. WSR 18-22-095, § 82-75-705, filed 11/5/18, effective 12/6/18.*

##### **Wash. Admin. Code § 182-70-710** Audit process. {#sec-182-70-710 omnilex-key=us-wa-regs-official--title-182--182-70-710}

(1) Once the authority determines an audit will be conducted, either as a random audit or based on a triggering event set forth in WAC 182-70-705(2), the authority shall provide written notice to the subject of the audit at least thirty days before the start of the audit. The notice must include the name of the company or individuals who will be conducting the audit and the subject of the audit, including the time period for which the audit covers, which time period must be no longer than the prior three years. If the audit is the result of a triggering event, the notice will include information regarding the triggering event. The notice will also include information regarding the audit entrance conference that has been scheduled to take place within fourteen days before the audit will begin. The notice will include the location, date and time and contact person for the entrance conference and such other information as required. The authority will work with the subject of the audit to ensure sufficient time is provided between providing the written notice, the date of the entrance conference, and the start of the audit.

(2) The subject of the audit is required to cooperate with the auditor, providing the information as requested. If there is a dispute during the audit, the issue should be brought to the attention of the WA-APCD program director, who will resolve the dispute. Both the auditor and the subject of the audit will be provided an opportunity to present its issues regarding the dispute, either in writing or in person. The WA-APCD program director may engage a mediator to help resolve the dispute.

(3) The auditor will be required to prepare an audit report. A draft of the audit report shall be provided to the subject of the audit for review and comments. The subject of the audit should be provided no less than thirty days to provide comment to the draft report.

(4) After receiving and reviewing any comments, and revising the draft audit report as deemed necessary, the auditor shall schedule an exit conference with the subject of the audit to review the audit and final audit report. The subject of the audit shall be provided an opportunity to submit comments or responses to the findings in the audit. The auditor shall provide a deadline, not less than thirty days after the exit conference for submission of any response to the audit.

(5) The auditor shall issue a final audit report no later than thirty days after the deadline for submission of any response. The report shall be provided to the authority and the subject of the audit. The final report shall include any response provided by the subject of the audit. The authority shall publish the final report on the agency website.

(6) The auditor shall be required to sign a confidentiality/nondisclosure agreement if the auditor will have access to any confidential or proprietary information.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-710, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-710, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.070. WSR 18-22-095, § 82-75-710, filed 11/5/18, effective 12/6/18.*

##### **Wash. Admin. Code § 182-70-715** Audit guide. {#sec-182-70-715 omnilex-key=us-wa-regs-official--title-182--182-70-715}

(1) The authority shall develop the audit guide with input from the data vendor, lead organization, and stakeholders. The audit guide shall include, but is not limited to, the following topics:

(a) The audit standards that will be used for all audits to ensure compliance with generally accepted auditing practices;

(b) The process that will be used to select an auditor, including the auditor qualifications, process to identify and address conflicts of interest;

(c) Specific contract terms that should be included in any contract with an auditor including retention and destruction process for working papers.

(2) The authority shall develop a process to allow for stakeholder review and comment on drafts of the audit guide and all subsequent changes to the guide. Prior to final adoption, the DPC shall be given an opportunity to review and provide comments on the draft audit guide to the authority. The authority shall have final approval authority over the adoption of the audit guide and all subsequent changes.

(3) The authority shall conduct an annual review of the audit guide. The authority will post notice that the review is being conducted and provide a time period for stakeholder to submit comments and changes to the audit guide. The authority will follow the process developed pursuant to subsection (2) of this section for review and comment on draft changes to the guide.

(4) The authority shall notify data suppliers before changes to the audit guide are final. Notification shall occur no less than one hundred twenty calendar days prior to the effective date of any change.

(5) The version of the audit guide that is in effect must be posted on the authority website. Notice should be given through the authority listserv when a new audit guide is posted.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-715, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-715, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.070. WSR 18-22-095, § 82-75-715, filed 11/5/18, effective 12/6/18.*

##### **Wash. Admin. Code § 182-70-720** Audit findings of a violation. {#sec-182-70-720 omnilex-key=us-wa-regs-official--title-182--182-70-720}

(1) If the audit finds that any person has violated laws, rules or data use agreements, the WA-APCD program director shall require an investigation be conducted in accordance with WAC 182-70-615. If the investigation determines that a violation or violations have occurred, the authority will take appropriate action as set forth in this chapter.

(2) In addition to any other penalties authorized by law or rule, the audited party may be required to pay the cost of the audit if, after an investigation conducted pursuant to this chapter, a violation is found. The subject of the audit may contest the requirement to pay the cost of the audit or the amount requested using the appeal process set forth in this chapter for the appeal of penalties.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 43.371.020. WSR 20-08-059, § 182-70-720, filed 3/25/20, effective 4/25/20. WSR 19-24-090, recodified as § 182-70-720, filed 12/3/19, effective 1/1/20. Statutory Authority: RCW 43.371.070. WSR 18-22-095, § 82-75-720, filed 11/5/18, effective 12/6/18.*

## **Chapter 182-100** Problem gambling. {#struct-chapter-182-100}

##### **Wash. Admin. Code § 182-100-0100** Problem gambling and gambling disorder treatment services. {#sec-182-100-0100 omnilex-key=us-wa-regs-official--title-182--182-100-0100}

(1) Under RCW 41.05.750, the Washington state health care authority (HCA) administers a program to:

(a) Prevent and treat problem gambling and gambling disorder; and

(b) Train professionals to identify and treat problem gambling issues and gambling disorders. Training must be administered by a qualified person who has training and experience in treatment services for people experiencing a problem gambling issue or gambling disorder.

(2) To be eligible to receive treatment under this program, a person must participate in a behavioral health assessment process under WAC 246-341-0610 to determine that the person:

(a) Has a problem gambling issue or gambling disorder;

(b) Wants treatment and is willing to do the work necessary to undergo treatment; and

(c) Is unable to afford treatment.

(3) Family members of a person who has a problem gambling issue or gambling disorder may be eligible to receive treatment if they are unable to afford treatment.

(4) Treatment under this section is available only to the extent of the funds appropriated or otherwise made available to HCA for this purpose.

(5) Problem gambling and gambling disorder treatment services include diagnostic screening and assessment, and individual, group, couples, and family counseling and case management.

(6) An agency providing problem gambling and gambling disorder services must meet the behavioral health agency licensure, certification, administration, personnel, clinical, and outpatient requirements in WAC 246-341-0754 and 246-341-0300 through 246-341-0650.

(7) Definitions for the purposes of this section only.

(a) "Gambling disorder" means a mental disorder as defined in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders and is characterized by loss of control over gambling, progression in preoccupation with gambling and in obtaining money to gamble, and continuation of gambling despite adverse consequences;

(b) "Problem gambling" means at-risk behavior that compromises, disrupts, or damages family or personal relationships, or vocational pursuits.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-100-0100, filed 11/27/19, effective 1/1/20.*

## **Chapter 182-110** Partnership access line and psychiatric consultation line. {#struct-chapter-182-110}

##### **Wash. Admin. Code § 182-110-0100** General. {#sec-182-110-0100 omnilex-key=us-wa-regs-official--title-182--182-110-0100}

(1) The Washington state health care authority (authority), the University of Washington department of psychiatry and behavioral sciences, and Seattle children's hospital administer the partnership access lines described in RCW 71.24.061, relating to mental health services for children and the treatment of depression in pregnant women and new mothers.

(2) The authority and the University of Washington department of psychiatry and behavioral sciences administer the psychiatric consultation line described in RCW 71.24.062 to give certain providers on-demand access to psychiatric and substance use disorder clinical consultation for adult patients.

(3) The authority or its designee:

(a) Determines the administrative costs for each program identified in subsections (1) and (2) of this section;

(b) Calculates the proportion of clients that are covered by programs administered under chapter 74.09 RCW; and

(c) Collects a proportionate share of program costs that are not for covered lives from the assessed entities under contract with the authority as medicaid managed care organizations.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 71.24.061, and 71.24.062. WSR 21-07-013, § 182-110-0100, filed 3/4/21, effective 4/4/21.*

##### **Wash. Admin. Code § 182-110-0200** Definitions. {#sec-182-110-0200 omnilex-key=us-wa-regs-official--title-182--182-110-0200}

For the purposes of this chapter:

(1) "Assessed entity" means:

(a) Health carriers, as defined in RCW 48.43.005;

(b) Self-funded multiple employer welfare arrangements, as defined in RCW 48.125.010; and

(c) Employers or other entities that provide health care in Washington, including self-funding entities or employee welfare benefit plans.

(2) "Covered lives" means a Washington resident who is covered by an assessed entity, including an enrollee, subscriber, policyholder, beneficiary of a group plan, or person covered by any other health plan.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 71.24.061, and 71.24.062. WSR 21-07-013, § 182-110-0200, filed 3/4/21, effective 4/4/21.*

##### **Wash. Admin. Code § 182-110-0300** Registration requirements. {#sec-182-110-0300 omnilex-key=us-wa-regs-official--title-182--182-110-0300}

(1) An assessed entity must register with the authority or its designee and provide the required contact information. Reporting entities must comply with the authority's or its designee's processes for registering and submitting data, as outlined in the data submission guide published on the authority's or its designee's website.

(2) Reregistration is required only if there is a change in the contact information previously provided. Assessed entities are responsible for maintaining current and accurate contact information with the authority or its designee.

(3) Failure to register and provide or maintain accurate contact information with the authority or its designee may result in an assessed entity's inability to submit required data in compliance with this chapter.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 71.24.061, and 71.24.062. WSR 21-07-013, § 182-110-0300, filed 3/4/21, effective 4/4/21.*

##### **Wash. Admin. Code § 182-110-0400** Data reporting. {#sec-182-110-0400 omnilex-key=us-wa-regs-official--title-182--182-110-0400}

(1) Beginning July 1, 2021, no later than the end of forty-five calendar days after the end of each calendar quarter, an assessed entity must submit to the authority or its designee, in the required format, the total number of Washington resident covered lives for each calendar month from the prior quarter.

(2) An assessed entity must immediately notify the authority or its designee if it identifies a covered lives reporting error.

(3) Each assessed entity must collect and maintain the data in a manner consistent with applicable state and federal health information privacy laws.

(4) Failure to report accurate data to the authority or its designee may result in an assessed entity's inability to maintain compliance with this chapter.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 71.24.061, and 71.24.062. WSR 21-07-013, § 182-110-0400, filed 3/4/21, effective 4/4/21.*

##### **Wash. Admin. Code § 182-110-0500** Assessment. {#sec-182-110-0500 omnilex-key=us-wa-regs-official--title-182--182-110-0500}

Each assessed entity receives a quarterly invoice for its share of the total amount of program costs that are for the proportion of the entity's covered lives. Entities must timely send payment to fund the partnership access lines described in RCW 71.24.061 and the psychiatric consultation line described in RCW 71.24.062.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 71.24.061, and 71.24.062. WSR 21-07-013, § 182-110-0500, filed 3/4/21, effective 4/4/21.*

## **Chapter 182-115** Certified peer counselor. {#struct-chapter-182-115}

##### **Wash. Admin. Code § 182-115-0100** Certified peer counselor. {#sec-182-115-0100 omnilex-key=us-wa-regs-official--title-182--182-115-0100}

(1) A certified peer counselor may provide medicaid-reimbursable peer services only:

(a) Through December 31, 2026;

(b) Under the clinical supervision of a mental health professional, or substance use disorder professional, or both:

(i) Who understands rehabilitation and recovery; and

(ii) Whose expertise aligns with the needs of the populations served by the certified peer counselor;

(c) When the services are provided in a licensed community behavioral health agency, as defined in WAC 246-341-0200; and

(d) When the certified peer counselor is credentialed as an agency-affiliated counselor under chapter 18.19 RCW.

(2) On January 1, 2027, the profession of certified peer support specialist, as defined in RCW 18.420.010, will supersede certified peer counselors. On and after that date, only certified peer support specialists and peer support specialist trainees may provide medicaid-reimbursable peer services.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 18.420.010. WSR 25-23-022, s 182-115-0100, filed 11/7/25, effective 12/8/25. Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.920. WSR 25-08-033, s 182-115-0100, filed 3/26/25, effective 7/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-05-059, § 182-115-0100, filed 2/10/22, effective 3/13/22.*

##### **Wash. Admin. Code § 182-115-0300** Peer support specialist supervisor training. {#sec-182-115-0300 omnilex-key=us-wa-regs-official--title-182--182-115-0300}

Only certified peer counselors or certified peer support specialists may qualify to take the authority's training to become recognized by the department of health as an approved supervisor.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 18.420.010. WSR 25-23-022, s 182-115-0300, filed 11/7/25, effective 12/8/25. Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.920. WSR 25-08-033, s 182-115-0300, filed 3/26/25, effective 7/1/25*
- *WSR 25-01-118, s 182-115-0300, filed 12/16/24, effective 1/16/25.*

## **Chapter 182-116** Certified peer support specialist. {#struct-chapter-182-116}

##### **Wash. Admin. Code § 182-116-0100** Certified peer support specialist and certified peer support specialist trainee—General. {#sec-182-116-0100 omnilex-key=us-wa-regs-official--title-182--182-116-0100}

(1) A certified peer support specialist or certified peer support specialist trainee credentialed by the department of health who provides medicaid-reimbursable peer support services must meet the requirements in WAC 182-116-0200.

(2) Certified peer support specialists or certified peer support specialist trainees who provide services to people enrolled in medicaid must practice:

(a) Under the clinical supervision of a mental health professional or a substance use disorder professional who understands rehabilitation and recovery. The clinical supervisor's expertise must be aligned with the needs of the populations served by the certified peer support specialist or certified peer support specialist trainee; and

(b) In a community behavioral health agency licensed, certified, or subject to an approved tribal attestation by the department of health.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 18.420.010. WSR 25-23-022, s 182-116-0100, filed 11/7/25, effective 12/8/25. Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.920. WSR 25-08-033, s 182-116-0100, filed 3/26/25, effective 7/1/25*
- *WSR 25-01-118, s 182-116-0100, filed 12/16/24, effective 1/16/25.*

##### **Wash. Admin. Code § 182-116-0200** Certified peer support specialist and certified peer support trainee—Application, training, examination, and authority approval. {#sec-182-116-0200 omnilex-key=us-wa-regs-official--title-182--182-116-0200}

(1) People applying with the authority for peer support specialist training must:

(a) Be age 18 or older; and

(b) Attest on the authority's application that they self-identify as:

(i) A person with one or more years of recovery from behavioral health experiences/challenges; or

(ii) The parent or legal guardian of a person who has applied for, is eligible for, or has received behavioral health services.

(2) After a person meets the training requirements and passes the authority's examination, the authority issues a letter stating the person has met the educational requirements needed to apply for the credential of certified peer support specialist or certified peer support specialist trainee through the department.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 18.420.010. WSR 25-23-022, s 182-116-0200, filed 11/7/25, effective 12/8/25. Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.920. WSR 25-08-033, s 182-116-0200, filed 3/26/25, effective 7/1/25*
- *WSR 25-01-118, s 182-116-0200, filed 12/16/24, effective 1/16/25.*

## **Chapter 182-125** Tribal-designated crisis responder. {#struct-chapter-182-125}

##### **Wash. Admin. Code § 182-125-0100** Tribal-designated crisis responder. {#sec-182-125-0100 omnilex-key=us-wa-regs-official--title-182--182-125-0100}

(1) The Washington state health care authority (the authority) appoints a tribal-designated crisis responder upon request and after consultation with one or more federally recognized Indian tribes or after meeting and conferring with one or more Indian health care providers. This rule does not apply to matters heard in tribal court.

(2) This rule does not apply to counties' independent authority to appoint designated crisis responders in collaboration with tribes under RCW 71.05.020(15). This rule does not eliminate the responsibility of the agency providing crisis services to serve American Indian/Alaska Native individuals.

(3) A tribal-designated crisis responder must meet the qualifications under RCW 71.05.760.

(4) A tribe or Indian health care provider located in Washington state may request that the authority appoint a qualified person as a tribal-designated crisis responder by submitting a letter of recommendation that includes the following:

(a) The person's name and contact information.

(b) An explanation of how the person meets the qualifications under RCW 71.05.760, including dates on which the person completed or will complete required designated crisis responder training.

(c) A copy of the policy and procedures for the designated crisis responder services. The policy and procedures must describe the tribe's or Indian health care provider's plan for training, back-up, information sharing, and communication for designated crisis responders who respond to private homes or nonpublic settings.

(d) A copy of the tribe's or Indian health care provider's behavioral health agency license and certification or attestation to provide emergency involuntary detention services under WAC 246-341-0810, including documentation of any applicable exemptions under WAC 246-341-0302.

(5) Upon appointment, the authority:

(a) Issues a certification and tribal-designated crisis responder card to the requesting tribe or Indian health care provider.

(b) Notifies all behavioral health administrative services organizations, tribal courts, and superior courts.

(6) Within twenty-four hours of responding to an event or as soon as feasible, tribal-designated crisis responders serving as officers of a superior court must submit involuntary treatment information to the Washington Indian behavioral health hub, a statewide resource supported by the authority and the department of health for the purpose of assisting American Indian and Alaska Native individuals and their providers to refer individuals to voluntary and involuntary crisis services, including evaluation and treatment facilities and withdrawal management and stabilization facilities.

(7) The Washington Indian behavioral health hub must submit all tribal-designated crisis responder data related to tribal-designated crisis responders' service as officers of a superior court to the authority within twenty-four hours of receiving the data or as soon as feasible.

(8) Tribal-designated crisis responders must comply with reporting requirements pertaining to no bed available reports under RCW 71.05.750. A tribal-designated crisis responder may submit a request for a single bed certification under RCW 71.05.745.

(9) Tribal-designated crisis responders designated by the authority may operate anywhere in Washington state and provide services to any person in Washington state.

(10) The local designated crisis responder office for any region in which a tribal-designated crisis responder provides services is expected to provide technical assistance if requested.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-21-021, § 182-125-0100, filed 10/8/21, effective 1/1/22.*

## **Chapter 182-130** Family initiated treatment (FIT). {#struct-chapter-182-130}

##### **Wash. Admin. Code § 182-130-0100** Family initiated treatment (FIT)—Appropriately trained professional person. {#sec-182-130-0100 omnilex-key=us-wa-regs-official--title-182--182-130-0100}

(1) An appropriately trained professional person means a psychiatrist, psychologist, psychiatric nurse, social worker, licensed marriage and family therapist, licensed mental health counselor, psychiatric advanced registered nurse practitioner, and other mental health professionals as defined by the department of health under chapter 71.05 RCW.

(2) An appropriately trained professional person can also be a substance use disorder professional, or those who hold co-occurring substance use disorder and mental health credentials as defined by the department of health under chapter 18.205 RCW.

(3) The professional person evaluating for purposes of admission or outpatient treatment for a mental health disorder must hold mental health or co-occurring credentials.

(4) The professional person evaluating for purposes of admission or outpatient treatment for a substance use disorder must hold substance use disorder or co-occurring credentials.

**History**
- *Statutory Authority: RCW 71.34.670, 41.05.021, and 41.05.160. WSR 22-15-105, § 182-130-0100, filed 7/19/22, effective 8/19/22*
- *WSR 21-18-058, § 182-130-0100, filed 8/26/21, effective 9/26/21.*

## **Chapter 182-135** Recovery residence program. {#struct-chapter-182-135}

##### **Wash. Admin. Code § 182-135-0100** Purpose and scope. {#sec-182-135-0100 omnilex-key=us-wa-regs-official--title-182--182-135-0100}

(1) The health care authority operates programs to support people who are in recovery from substance use disorder. Recovery residences provide housing for people in recovery from substance use disorder. These residences are safe, established homes that meet the standards set by the authority for the accreditation process.

(2) This chapter addresses recovery residence referrals, accreditation, and start-up loans.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-20-044, § 182-135-0100, filed 9/27/23, effective 10/28/23. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.762 and 42 U.S.C. § 300x-25(a). WSR 21-17-089, § 182-135-0100, filed 8/13/21, effective 9/13/21.*

##### **Wash. Admin. Code § 182-135-0110** Definitions. {#sec-182-135-0110 omnilex-key=us-wa-regs-official--title-182--182-135-0110}

The following definitions apply to this chapter:

"Accredited" for the purposes of this chapter, means an organization approved by the National Alliance of Recovery Residences (NAAR).

"Appropriate client" means a person in recovery from substance use disorder who meets the requirements established by a recovery residence on the registry.

"Approved recovery residence" means a home-like environment free from alcohol and illicit drug use with a focus on peer support, assistance with obtaining addiction services, and other recovery services and support that:

(a) Is approved through the health care authority's contracted accreditation process; and

(b) Appears on the registry.

"Licensed or certified service provider" means a person licensed, certified, registered, or otherwise authorized by the department of health and the relevant health profession, to provide services under Title 18 RCW.

"Refer" means providing an appropriate client with option-based information pertaining to potential recovery residences and does not include client placement.

"Registry" means a list of recovery residences that are accredited and agency-approved, as described in RCW 41.05.760.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-20-044, § 182-135-0110, filed 9/27/23, effective 10/28/23.*

##### **Wash. Admin. Code § 182-135-0120** Recovery residence referrals. {#sec-182-135-0120 omnilex-key=us-wa-regs-official--title-182--182-135-0120}

A licensed or certified service provider may refer an appropriate client only to a recovery residence that is included in the registry, except as provided in WAC 182-135-0130.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-20-044, § 182-135-0120, filed 9/27/23, effective 10/28/23.*

##### **Wash. Admin. Code § 182-135-0130** Approved recovery residences—Exception. {#sec-182-135-0130 omnilex-key=us-wa-regs-official--title-182--182-135-0130}

If an approved recovery residence is not located in an appropriate client's desired county, a licensed or certified service provider may refer the client to another suitable placement or service.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-20-044, § 182-135-0130, filed 9/27/23, effective 10/28/23.*

##### **Wash. Admin. Code § 182-135-0200** Operating fund. {#sec-182-135-0200 omnilex-key=us-wa-regs-official--title-182--182-135-0200}

(1) Purpose. The health care authority has established the recovery residence operating revolving loan to maintain an ongoing revolving fund, as authorized by 42 U.S.C. Sec. 300x-25(a) and as described in RCW 41.05.762.

(2) Fund. The fund identified in subsection (1) of this section lends money to pay for the operating start-up costs associated with recovery residence programs. These costs include, but are not limited to:

(a) One-time rent or mortgage payments;

(b) Utility security deposits;

(c) Salaries for on-site staff;

(d) Minimal maintenance costs; and

(e) Furnishings purchased for recovery residences.

(3) Maximum loan amount. A loan from the fund is for an amount of up to four thousand dollars.

(4) Eligible recipients. To be an eligible recovery residence recipient, an entity must:

(a) Be on the registry published on the authority's website or be actively seeking certification and registration under RCW 41.05.760;

(b) Be a Washington state nonprofit organization;

(c) Operate a recovery residence for a group of at least six people;

(d) Prohibit the use of alcohol, marijuana, or any illegal drug in the residence;

(e) Have a policy in place to address any use of alcohol, marijuana, or an illegal drug by residents; and

(f) Allow the use of any prescribed medication for physical health, mental health, and substance use disorders.

(5) Requirements for residents. Residents must:

(a) Pay for the cost of recovery residence housing, including any rent or fees; and

(b) Through a majority vote, establish policies governing residence in the housing, including how residence applications are approved.

(6) Application requirement. To be an applicant, an entity that meets the requirements of subsection (4) of this section must apply for a recovery residence operating loan using the application process described on the authority's website.

(7) Loan repayments.

(a) Each recovery residence loan made under this section must be repaid by the residents of the recovery residence that received the funds. The loan must be paid in full within two years from the date the loan was made.

(b) Residents must repay the loan through monthly installments set by the authority.

(8) Assessment of penalties. The authority may assess a reasonable penalty for each failure to pay the monthly installment described in subsection (7) of this section by the date specified in the loan agreement between the authority and the recovery residence operator involved in the agreement.

(9) Appeals.

(a) An applicant or recipient may appeal an adverse decision notice and request an administrative hearing under chapter 182-526 WAC by following the instructions included in the notice.

(i) An applicant may appeal a denial of a loan request as described in (a) of this subsection.

(ii) A recipient may appeal the following actions including, but not limited to:

(A) Late payment fees;

(B) Default due to nonpayment; or

(C) Default due to losing Washington alliance for quality recovery residences accreditation.

(b) An applicant or recipient of this program has 90 days from the receipt of the adverse decision to appeal and must follow the process contained in the notice.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-20-044, § 182-135-0200, filed 9/27/23, effective 10/28/23. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.762 and 42 U.S.C. § 300x-25(a). WSR 21-17-089, § 182-135-0200, filed 8/13/21, effective 9/13/21.*

## **Chapter 182-140** Mobile rapid response crisis team endorsement standards. {#struct-chapter-182-140}

##### **Wash. Admin. Code § 182-140-0010** General. {#sec-182-140-0010 omnilex-key=us-wa-regs-official--title-182--182-140-0010}

(1) This chapter establishes standards for issuing endorsements to mobile rapid response crisis teams (MRRCTs) and community-based crisis teams (CBCTs) according to RCW 71.24.903 and the authority's best practice guide. MRRCTs and CBCTs provide on-site interventions for people experiencing behavioral health emergencies.

(2) Subject to available funding, eligible MRRCTs and CBCTs may receive an endorsement from the authority that allows a team under contract with a behavioral health administrative services organization (BH-ASO) to receive enhanced rates and supplemental performance payments.

(3) Tribal governments may seek an endorsement using the attestation process described in WAC 182-140-0060.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-10-026, s 182-140-0010, filed 4/29/26, effective 6/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.903. WSR 24-18-088, § 182-140-0010, filed 8/30/24, effective 9/30/24.*

##### **Wash. Admin. Code § 182-140-0020** Definitions. {#sec-182-140-0020 omnilex-key=us-wa-regs-official--title-182--182-140-0020}

The following definitions apply to this chapter:

"Authority" means the Washington state health care authority.

"Behavioral health administrative services organization (BH-ASO)" means the same as in WAC 182-538-050.

"Behavioral health emergency" means a person is experiencing a significant behavioral health crisis that requires an immediate in-person response due to level of risk or lack of means for safety planning.

"Behavioral health support specialist" means the same as in WAC 182-538D-0200.

"Calendar days" means all days, including Saturdays, Sundays, and designated holidays under WAC 357-31-005.

"Community-based crisis team (CBCT)" means a team that is part of an emergency medical services agency, a fire service agency, a public health agency, a medical facility, a nonprofit crisis response provider, or a city or county government entity, other than a law enforcement agency, that provides the on-site, community-based interventions of a mobile rapid response crisis team (MRRCT) for people who are experiencing behavioral health emergencies.

"Eligible organization" means an entity serving as a mobile rapid response crisis team (MRRCT) or a community-based crisis team (CBCT) that is seeking an endorsement. An eligible organization must be one of the following:

• Any entity below operated by a tribal government;

• City or county government entity, other than a law enforcement agency;

• Emergency medical service agency;

• Fire department;

• Fire service agency;

• Licensed or certified behavioral health agency;

• Medical facility;

• Nonprofit crisis response provider;

• Nonprofit organization; or

• Public health agency.

"Endorsed team" means a mobile rapid response crisis team (MRRCT) or a community-based crisis team (CBCT) that meets the endorsements standards in this chapter.

"Endorsement" or "certificate of endorsement" means a voluntary credential issued by the authority to a mobile rapid response crisis team (MRRCT) or a community-based crisis team (CBCT), which allows the team to become eligible for supplemental performance payments.

"Enhanced rate" means the increased rate paid to endorsed mobile rapid response crisis teams (MRRCT) and community-based crisis teams (CBCT) as described in RCW 71.24.903.

"Exempt community-based crisis team" means a team comprised solely of an emergency medical services agency, whether part of a fire service agency or a private entity, located in a rural county in eastern Washington with a population of less than 60,000 residents. Under RCW 71.24.903, minimum personnel standards do not apply in exempt eastern Washington counties.

"Exempt eastern Washington counties" means the following counties: Adams, Asotin, Columbia, Douglas, Ferry, Garfield, Kittitas, Klickitat, Lincoln, Okanogan, Pend Oreille, Skamania, Stevens, and Whitman.

"Mental health care provider (MHCP)" means a provider recognized by the department of health as a registered, agency-affiliated counselor who has primary responsibility for implementing an individualized plan for mental health rehabilitation services.

"Mental health professional (MHP)" means the same as in RCW 71.05.020.

"Mobile rapid response crisis team (MRRCT)" means a team that provides professional, on-site, community-based interventions such as outreach, de-escalation, stabilization, resource connection, and follow-up support for people who are experiencing a behavioral health emergency. A MRRCT must:

• Include certified peer support specialists as a best practice to the extent practical based on workforce availability; and

• Meet standards for response times established by the authority's contracted BH-ASO.

"Regional dispatch protocols" means the protocols adopted by the regional BH-ASO to establish guidelines for dispatching necessary crisis services.

"Rural area" means a zip code with a population of less than 500 residents per square mile, an Indian reservation, and any location that requires travel by ferry or international travel to reach.

"Suburban area" means a zip code with a population of more than 500 residents per square mile but less than 3,000 residents per square mile.

"Supplemental performance payment" means an optional, additional payment described in RCW 71.24.903(10) that is greater than the enhanced rate. Endorsed teams are eligible for the supplemental performance payment if they demonstrate that they meet the required standards in this chapter.

"Urban area" means a zip code with a population of more than 3,000 residents per square mile.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-10-026, s 182-140-0020, filed 4/29/26, effective 6/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.903. WSR 24-18-088, § 182-140-0020, filed 8/30/24, effective 9/30/24.*

##### **Wash. Admin. Code § 182-140-0030** Application process. {#sec-182-140-0030 omnilex-key=us-wa-regs-official--title-182--182-140-0030}

(1) Application. To apply for an endorsement, an eligible organization must submit an application for endorsement to the authority and all documentation required in subsection (3) of this section. Eligible organizations may apply:

(a) Online through the authority's website; or

(b) By completing the Crisis Team Endorsement Application form (HCA 82-0588) and mailing it to the authority.

(2) Submission periods for applications.

(a) A team must submit its completed application by the deadline published on the authority's endorsement web page. (See https://www.hca.wa.gov/billers-providers-partners/program-information-providers/mobile-crisis-response-endorsement-program).

(b) Providers must meet all application deadlines and endorsement criteria to be eligible for endorsement.

(c) The authority defers submissions received after the deadlines in (a) of this subsection until the next contract cycle.

(3) Required documentation. An eligible organization applying for an endorsement must also submit:

(a) A current contract with the behavioral health administrative services organization (BH-ASO) serving the region where the eligible organization will operate or a letter of intent to contract once the team is endorsed;

(b) The eligible organization's policies and procedures and the authority's training verification tool, which outlines how the eligible organization currently complies with the training requirements in WAC 182-140-0090;

(c) A copy of the transportation plan outlined in WAC 182-140-0100;

(d) A copy of the eligible organization's Endorsement Staffing Plan form (HCA 82-0624) described in WAC 182-140-0080; and

(e) A mobile crisis response information template (MCRIT) supplied by the authority.

(4) Community-based crisis teams (CBCT). A CBCT that intends to contract with a licensed and certified behavioral health agency (BHA) to provide staff must also submit:

(a) The contracting BHA's active contract with the BH-ASO located in the region where the CBCT will operate; or

(b) A letter of intent from the BH-ASO to establish a contractual relationship with the contracting BHA upon the CBCT receiving an endorsement; and

(c) A letter of intent from the contracting BHA to establish a contractual relationship with the CBCT upon the CBCT receiving an endorsement.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-10-026, s 182-140-0030, filed 4/29/26, effective 6/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.903. WSR 24-18-088, § 182-140-0030, filed 8/30/24, effective 9/30/24.*

##### **Wash. Admin. Code § 182-140-0040** Application requirements for exempt community-based crisis teams. {#sec-182-140-0040 omnilex-key=us-wa-regs-official--title-182--182-140-0040}

A community-based crisis team (CBCT) exempt from minimum personnel standards must submit the application described in WAC 182-140-0030(1) and:

(1) Policies and procedures that outline how the exempt CBCT will comply with the training requirements in WAC 182-140-0090;

(2) A memorandum of understanding with a licensed behavioral health agency (BHA) certified to provide crisis services and direct, real-time consultation through a behavioral health provider while the team is responding to a crisis call;

(3) A copy of the BHA's active contract with the behavioral health administrative services organization (BH-ASO) located in the region where the exempt CBCT will operate;

(4) A written plan describing how the responders will access the required real-time consultation with the behavioral health clinicians, which includes:

(a) The equipment to be used; and

(b) How the consultation will be documented and by which party.

(5) A staffing plan that identifies:

(a) How the exempt CBCT will be staffed 24 hours per day, seven days a week, with an outline of when each position is available to respond; and

(b) Policies and procedures that describe how staff will respond safely and meet the time requirements in the regional dispatch protocols.

(6) Policies and procedures to ensure follow-up crisis services are provided after an initial response or a copy of a memorandum of understanding with a mobile rapid response crisis team (MRRCT) to provide follow-up crisis services. The memorandum of understanding must:

(a) Be with an MRRCT that is licensed and certified to provide crisis services that are clinically appropriate; and

(b) Contain clear guidelines on how and when the transfer of care will occur and the expectation to follow up within a defined set of time.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.903. WSR 24-18-088, § 182-140-0040, filed 8/30/24, effective 9/30/24.*

##### **Wash. Admin. Code § 182-140-0050** Endorsement renewal. {#sec-182-140-0050 omnilex-key=us-wa-regs-official--title-182--182-140-0050}

An endorsed team seeking renewal must:

(1) Renew its endorsement every three years.

(2) Submit its renewal application by the deadline established on the authority's endorsement web page. (See https://www.hca.wa.gov/billers-providers-partners/program-information-providers/mobile-crisis-response-endorsement-program).

(3) Meet all renewal application deadlines and endorsement criteria established on the authority's endorsement web page to remain eligible for endorsement.

(4) Failure to timely complete this requirement may result in suspension or revocation of the team's endorsement and denial of any enhanced rates or supplemental payments.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-10-026, s 182-140-0050, filed 4/29/26, effective 6/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.903. WSR 24-18-088, § 182-140-0050, filed 8/30/24, effective 9/30/24.*

##### **Wash. Admin. Code § 182-140-0060** Tribal endorsement process. {#sec-182-140-0060 omnilex-key=us-wa-regs-official--title-182--182-140-0060}

(1) Tribal eligible organizations may seek endorsement through the government-to-government process described in this section.

(2) Under this process, a tribal eligible organization must submit:

(a) The endorsement application and materials described in WAC 182-140-0030, as applicable;

(b) A Tribal Endorsement Attestation form (HCA 82-0599), confirming the organization meets the state minimum standards for mobile crisis services as described in WAC 182-140-0080, 182-140-0090, and 182-140-0100;

(c) A copy of its policies and procedures for the endorsement standards identified in (b) of this subsection; and

(d) Photographs showing that the organization's vehicle or vehicles meet the requirements of WAC 182-140-0100 (2), (3), and (4).

(3) After all materials are submitted, the authority and the tribal eligible organization meet to review and finalize all application materials and discuss any technical assistance needed.

(4) Following review and acceptance of the application and related materials, the authority issues the tribal eligible organization a certificate of endorsement and:

(a) Notifies all behavioral health administrative services organizations; and

(b) Negotiates a Sovereign Nation Agreement (SNA) with the tribe that outlines:

(i) Government-to-government monitoring; and

(ii) Denial, suspension, and revocation procedures under the terms of the parties' negotiated SNA.

(5) The provisions of WAC 182-140-0120 and 182-140-0130 do not apply to tribal eligible organizations.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-10-026, s 182-140-0060, filed 4/29/26, effective 6/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.903. WSR 24-18-088, § 182-140-0060, filed 8/30/24, effective 9/30/24.*

##### **Wash. Admin. Code § 182-140-0070** On-site review process. {#sec-182-140-0070 omnilex-key=us-wa-regs-official--title-182--182-140-0070}

Eligible organizations must successfully complete and pass an on-site review.

(1) On-site review. The authority schedules the on-site review after it receives and approves all documentation required for an endorsement as described in this chapter. The on-site review examines the following:

(a) Employee files;

(b) Training materials and trainer qualifications;

(c) Any vehicle operated by an eligible organization; and

(d) Records of training certificates, if required, and driver licenses for all personnel who operate the vehicle.

(2) Completion of on-site review. After completing its on-site review, the authority sends the eligible organization a notice for any items that do not meet endorsement standards.

(a) The eligible organization has 60 calendar days from the date of the notice to resolve any items that do not meet endorsement standards.

(b) If the eligible organization has not resolved all outstanding issues within 60 days, the authority may deny the application.

(3) Issuance of endorsement. The authority issues a certificate of endorsement after it has reviewed and approved all required documentation and the eligible organization has satisfactorily completed its on-site review. Once endorsed, the eligible organization receives the enhanced rate.

(4) Tribal exemption. Tribal eligible organizations seeking endorsement through the process described in WAC 182-140-0060 are exempt from the on-site review.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-10-026, s 182-140-0070, filed 4/29/26, effective 6/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.903. WSR 24-18-088, § 182-140-0070, filed 8/30/24, effective 9/30/24.*

##### **Wash. Admin. Code § 182-140-0080** Staffing standards. {#sec-182-140-0080 omnilex-key=us-wa-regs-official--title-182--182-140-0080}

To be endorsed, eligible organizations must meet the staffing standards described in this section.

(1) Staffing plan. An eligible organization must have a staffing plan that includes:

(a) How an eligible organization will be staffed 24 hours a day, seven days a week, including when each position is available to respond and where the teams are located;

(b) How peers will be incorporated into the response team;

(c) How peers will be recruited and any anticipated challenges for them;

(d) Policies and procedures for how staff will respond safely and meet the time requirements in the regional dispatch protocols; and

(e) Policies and procedures for ensuring follow-up crisis services occur after an initial response, as clinically and developmentally appropriate.

(2) Additional staffing documentation for community-based crisis teams (CBCT). A CBCT that contracts with a licensed and certified behavioral health agency to meet the staffing requirements described in WAC 182-140-0090 must have a staffing plan that includes:

(a) Which staff are involved in the agreement;

(b) The role of each staff member;

(c) How staff will access clinical supervision 24 hours a day, seven days a week, for real-time consultation; and

(d) How frequently clinical supervisors will provide ongoing coaching, case consultation, and clinical debriefing in a trauma informed manner, including how to:

(i) Review charts; and

(ii) Provide clinical quality assurance.

(3) Mobile rapid response crisis teams and nonexempt CBCTs. Eligible organizations that are not seeking the personnel exemption in RCW 71.24.903(3) must have sufficient response team staffing to ensure an in-person response is available 24 hours a day, seven days a week, and must:

(a) Meet the required response times identified in the BH-ASO contract;

(b) Provide all outreach in pairs unless it is not clinically appropriate;

(c) Provide follow-up services as clinically appropriate to a person seeking behavioral health assistance and connect the person to ongoing support; and

(d) Be composed of the following behavioral health clinical staff who are appropriately credentialed or licensed within their scope of practice and meet the criteria below:

| Provider type | Criteria: To ensure all outreach is provided in pairs, a response team must include: | | |
| --- | --- | --- | --- |
| (i) | Behavioral health clinical staff: • A mental health professional (MHP) • A mental health care provider (MHCP) • A behavioral health support specialist (BHSS) | (A) | One behavioral health clinical staff; and |
| | (B) | Another provider type identified in subsection (ii) or (iii) of this table. If a provider type identified in subsection (ii) or (iii) of this table is unavailable, the second team member must be a behavioral health clinical staff, as clinically appropriate. | |
| (ii) | Certified peers who meet the criteria of chapter 182-115 or 182-116 WAC, as applicable: | | A certified peer, when available, or a provider from subsection (iii) of this table. |
| | • Certified peer counselor (CPC) • Certified peer support specialist (CPSS) • Certified peer support specialist trainee (CPSST) | | |
| (iii) | Other: A behavioral health or medical professional working within their scope of practice under an approved staffing plan | | A behavioral health or medical professional, as needed, to meet staffing requirements or a provider from subsection (ii) of this table. |

(e) Include at least one:

(i) MHP, MHCP, or BHSS during an initial response; and

(ii) One CPSS, when available; or

(iii) One of the provider types described in subsection (d)(iii) of this section.

(f) Have an MHP supervise when the responding team staff are in the field; and

(g) Have access to an MHP 24 hours a day, seven days a week, for consultation. The consulting MHP may be the team supervisor or another MHP.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-10-026, s 182-140-0080, filed 4/29/26, effective 6/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.903. WSR 24-18-088, § 182-140-0080, filed 8/30/24, effective 9/30/24.*

##### **Wash. Admin. Code § 182-140-0090** Training standards. {#sec-182-140-0090 omnilex-key=us-wa-regs-official--title-182--182-140-0090}

An eligible organization must complete the authority's training verification tool and provide the organization's policies and procedures that meet the training standards in this section to receive endorsement. In addition, the authority may require all staff to complete additional training, as applicable to endorsement.

(1) Required staff training. All current staff must receive the training described in this section, as applicable, before an eligible organization submits its application. Staff hired during or after the application process must complete the training described in this section, following the time requirements in subsections (2) and (3) of this section.

(2) Training required within 90 days. All staff must receive the following training within 90 calendar days of their hiring date:

(a) Required developmentally appropriate modules developed and provided by the authority, when available, or other authority-approved trainings covering the same subject areas when authority-provided trainings are not available. Required modules include:

(i) Trauma-informed care;

(ii) Harm reduction; and

(iii) Basic de-escalation training.

(b) CPR;

(c) First aid;

(d) Naloxone administration;

(e) Suicide prevention training for health professionals approved by the department of health. Training required for behavioral health clinical staff licensure meets this standard if it is kept up to date; and

(f) Confidentiality standards established in chapters 70.02, 71.34, and 71.05 RCW, and other applicable laws.

(3) Training required within 180 days. All staff must complete the following training within 180 calendar days of their hiring date:

(a) Authority-approved crisis intervention specialist training;

(b) Regional crisis system training approved by the behavioral health administrative services organization (BH-ASO), as available; and

(c) Authority-approved training on the Indian health care delivery system, including the government-to-government relationship between the state of Washington and federally recognized Indian tribes.

(4) Exception for tribes. The authority considers the staff of teams operated by or for a tribe to meet the applicable requirements in subsection (3)(b) and (c) of this section.

(5) Crisis supervision training for supervisors. Supervisors must complete authority-approved crisis supervision training that includes the following:

(a) Trauma-informed supervision; and

(b) Monitoring for staff burnout.

(6) Vehicle operation training. Before operating an eligible organization's vehicle, staff must be trained in the following:

(a) Defensive driving;

(b) Operation of equipment compliant with the Americans with Disabilities Act; and

(c) Any specialized training necessary to operate the vehicle.

(7) Additional training. Eligible organizations must also provide any additional training required by the authority.

(8) Approval of existing training materials. An eligible organization may apply to have its training materials approved to meet the criteria required in this section. The organization must submit its training materials to the authority for approval as part of the application process described in WAC 182-140-0030.

(9) Approved trainers. Trainers must be approved by the authority. An organization may apply to have its own staff become approved trainers when:

(a) The staff member has completed the initial trainer course for specified trainings; and

(b) The organization has reviewed the staff member's credentials to ensure the person is competent to train others about the subject matter.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-10-026, s 182-140-0090, filed 4/29/26, effective 6/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.903. WSR 24-18-088, § 182-140-0090, filed 8/30/24, effective 9/30/24.*

##### **Wash. Admin. Code § 182-140-0100** Transportation, equipment, and communication standards. {#sec-182-140-0100 omnilex-key=us-wa-regs-official--title-182--182-140-0100}

An eligible organization must meet the transportation, vehicle, and communication standards in this section to receive an endorsement.

(1) Transportation plan. An eligible organization must have a transportation plan.

(a) The plan's policies and procedures must explain how the organization will:

(i) Comply with regional transportation procedures;

(ii) Provide timely transportation when a transport need is identified, as clinically and developmentally appropriate;

(iii) Ensure safe transport for passengers and staff;

(iv) Ensure all staff who transport passengers are legally qualified to operate the vehicle;

(v) Arrange for alternative transport when the team is unable to provide transportation;

(vi) Ensure that people experiencing mobility disabilities have safe transport to a facility; and

(vii) Document the reasons for an unsuccessful transport and how to address them in the future.

(b) An eligible organization must follow incident reporting guidelines for any critical incidents or accidents that occur during transport.

(2) Vehicle requirements. An eligible organization must have access to an adequate number of vehicles to respond to and transport people experiencing significant behavioral health emergencies to a location that will provide the appropriate level of crisis stabilization services.

(a) Vehicles must:

(i) Be owned or leased by the eligible organization;

(ii) Have proper licensing and registration;

(iii) Be maintained in good working order; and

(iv) Meet all safety requirements.

An automotive service excellence (ASE) certified mechanic must complete a certificate of safety to demonstrate that the vehicle has passed a uniform vehicle safety inspection before the authority issues an endorsement or renewal. If there is concern that a vehicle does not meet all safety requirements after receiving an ASE certification, the authority or the behavioral health administrative services organization (BH-ASO) may require another formal inspection by a qualified professional.

(v) Have vehicle insurance coverage that applies to private, nonprofit transportation providers and meets the minimum limits of WAC 480-31-070;

(vi) Have 24 hour, seven days a week access to vehicles that meet the Americans with Disabilities Act (ADA) requirements for transporting a person experiencing mobility disabilities or be a licensed ambulance or aid vehicle as described in chapter 18.73 RCW.

(b) If an eligible team does not have a vehicle that meets the requirements of (a)(vi) of this subsection, the team must have policies and procedures on how it will transport someone experiencing mobility disabilities.

(3) Equipment. All equipment must be maintained in good working order and requires a formal inspection by a qualified professional when requested by the authority or the contracted behavioral health administrative services organization (BH-ASO).

(a) Vehicle equipment. Vehicles operated by eligible organizations must have:

(i) The appropriate equipment to ensure the person being transported is unable to interfere with the driver's safe operation of the vehicle;

(ii) Doors and windows that can be secured by the driver to prevent unauthorized entry;

(iii) Appropriate seat belts for the safety of staff and the person being transported, including child safety seats or booster seats as necessary;

(iv) Appropriate or necessary equipment to respond to weather conditions and roadside emergencies; and

(v) The ability to track the location of the vehicle and team.

(b) Communication equipment. All vehicles must be equipped with communication equipment that is in good working order.

(i) Equipment must allow for:

(A) Direct two-way communication between the team and its dispatch control point; and

(B) Communication with emergency services.

(ii) All teams must be equipped to access electronic health records (EHR) and referral records through a remote means, where coverage is available, and be able to print records when needed; and

(iii) All equipment must be compatible with authority-designated technology platforms.

(4) Other equipment. Eligible organizations must carry Naloxone.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-10-026, s 182-140-0100, filed 4/29/26, effective 6/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.903. WSR 24-18-088, § 182-140-0100, filed 8/30/24, effective 9/30/24.*

##### **Wash. Admin. Code § 182-140-0110** Endorsed team supplemental performance payment. {#sec-182-140-0110 omnilex-key=us-wa-regs-official--title-182--182-140-0110}

(1) Only endorsed teams that respond to behavioral health emergencies and meet the response times described in RCW 71.24.903 for rural, suburban, and urban areas are eligible to receive a supplemental performance payment.

(2) Teams must follow behavioral health administrative services organization (BH-ASO) data reporting requirements to document their response times.

(3) The authority calculates response times based on the reported information on a quarterly basis.

(4) The authority certifies a team that has met performance requirements and directs the BH-ASO to issue the performance payment.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.903. WSR 24-18-088, § 182-140-0110, filed 8/30/24, effective 9/30/24.*

##### **Wash. Admin. Code § 182-140-0120** Notice of noncompliance. {#sec-182-140-0120 omnilex-key=us-wa-regs-official--title-182--182-140-0120}

(1) Denial of application. The authority sends a notice of noncompliance that may result in the denial of an eligible organization's initial application or the denial of an endorsed team's renewal application if the eligible organization or endorsed team:

(a) Fails to meet the applicable endorsement standards described in WAC 182-140-0080, 182-140-0090, and 182-140-0100;

(b) Fails to cooperate or disrupts the authority's representatives during an on-site review or during a behavioral health administrative services organization's (BH-ASO) complaint investigation under its contract with the endorsed team;

(c) Knowingly, or with reason to know, makes a false statement of fact or fails to submit required information;

(d) Holds itself out as endorsed when the authority has denied or revoked the organization's endorsement, or the organization has surrendered its endorsement;

(e) Fails to timely provide satisfactory application materials;

(f) Fails to comply with any other requirement for endorsement described in this chapter; or

(g) Fails to meet the terms of its contract with the BH-ASO.

(2) Endorsement suspension. The authority sends an endorsed team a notice of noncompliance that may result in an endorsement suspension if the endorsed team fails to:

(a) Submit renewal materials prior to the closing of the application period;

(b) Schedule or timely complete the on-site review;

(c) Meet the endorsement standards outlined in WAC 182-140-0080, 182-140-0090, and 182-140-0100;

(d) Provide the services for which the eligible organization is endorsed;

(e) Follow the terms of their BH-ASO contract; or

(f) Comply with all federal and state laws, including federal confidentiality laws under HIPAA and 42 C.F.R. Part 2, as well as state confidentiality laws under chapters 70.02, 71.05, and 71.34 RCW.

(3) Exception for tribal organizations. Subsections (1) and (2) of this section and WAC 182-140-0130 do not apply to tribal eligible organizations or tribal endorsed organizations. Tribal organizations follow the process laid out in the organization's Sovereign Nation Agreement described in WAC 182-140-0060 regarding any noncompliance with the endorsement standards in this chapter.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-10-026, s 182-140-0120, filed 4/29/26, effective 6/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.903. WSR 24-18-088, § 182-140-0120, filed 8/30/24, effective 9/30/24.*

##### **Wash. Admin. Code § 182-140-0130** Correction of noncompliance. {#sec-182-140-0130 omnilex-key=us-wa-regs-official--title-182--182-140-0130}

If an eligible organization or endorsed team receives a notice of noncompliance, the organization or team may demonstrate compliance as follows:

(1) Correction of application. For notices of noncompliance for an eligible organization's application:

(a) An eligible organization has 60 calendar days from the date of the notice of noncompliance to submit proof of all corrected deficiencies.

(b) The authority reviews the supplemental information and responds to the eligible organization within 30 calendar days of receipt.

(c) If the organization or team fails to timely submit proof of the corrected deficiency, the authority denies the application.

(2) Correction of endorsement standards. An endorsed team has 30 calendar days from the date of the notice of noncompliance to submit proof of all corrected deficiencies.

(a) An endorsed team must submit:

(i) Documentation proving compliance with standards; or

(ii) A plan to be approved by the authority to correct noncompliant compliance procedures within 90 calendar days of the notice of noncompliance, or both.

(b) The endorsed team must provide the authority with evidence of the correction within 90 calendar days of the notice of noncompliance.

(c) The authority reviews the evidence of the correction and, within 30 calendar days of receipt, determines whether the team is compliant.

(d) If the authority's evaluation confirms the endorsed team has satisfied the requirements for compliance, the authority provides written notice confirming the team's compliance.

(e) If an endorsed team fails to satisfy the requirements for compliance within the 30-day period, the authority issues a 90-calendar-day suspension notice. A suspended team is not eligible for supplemental performance payments during its suspension, and the suspension may impact the team's priority response status within the regional dispatch protocols.

(f) If an endorsed team fails to satisfy the requirements for compliance within the suspension period, the authority issues a notice of revocation of endorsement.

(3) Endorsement revocation. The authority sends an eligible organization a notice of noncompliance that may result in an endorsement revocation if the eligible organization fails to:

(a) Timely renew its endorsement every three years; or

(b) Remedy the cause of a suspended endorsement.

(4) Surrender of endorsement. An endorsed team may surrender its endorsement at any time. A team that surrenders its endorsement may continue to operate, but is no longer eligible to receive enhanced payments or supplemental performance payments.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-10-026, s 182-140-0130, filed 4/29/26, effective 6/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.903. WSR 24-18-088, § 182-140-0130, filed 8/30/24, effective 9/30/24.*

## **Chapter 182-145** Behavioral health preadmission screening and resident review (PASRR) for serious mental illness. {#struct-chapter-182-145}

##### **Wash. Admin. Code § 182-145-100** General. {#sec-182-145-100 omnilex-key=us-wa-regs-official--title-182--182-145-100}

WAC 182-145-100

(1) This chapter describes the behavioral health (BH) preadmission screening and resident review (PASRR) program and a person's rights relating to PASRR. For admission screening regulations for people with intellectual disabilities or a related condition, see chapter 388-834 WAC.

(2) The goals of the PASRR process are to ensure that people:

(a) Who have a mental illness, serious mental illness, intellectual disabilities, or a related condition are not inappropriately admitted to a medicaid-certified nursing facility; and

(b) Who are appropriately admitted to a nursing facility receive the recommended specialized services for their BH PASRR condition.

(3) For PASRR rules relating to nursing facility compliance, see WAC 388-97-1910 through 388-97-2000.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-15-082, s 182-145-100, filed 7/16/26, effective 8/16/26.*

##### **Wash. Admin. Code § 182-145-200** Definitions. {#sec-182-145-200 omnilex-key=us-wa-regs-official--title-182--182-145-200}

WAC 182-145-200

The following definitions apply to this chapter:

"Behavioral health notice of determination (NOD)" means a written notice to a person that a behavioral health PASRR evaluation and determination has been made regarding the person's nursing facility stay, including the person's existing or suspected behavioral health diagnosis, and whether the person may need or benefit from behavioral health services. This is provided to facilities to document that the behavioral health (BH) PASRR evaluation is complete and the level 2 evaluation or invalidation is pending. The NOD indicates that BH PASRR requirements have been met prior to nursing facility admission.

"Behavioral health PASRR determination" means a written notice from the behavioral health PASRR evaluator that indicates completion of either a level 2 evaluation or a level 2 invalidation.

"Behavioral health PASRR evaluator (BH PASRR evaluator)" means an authority-appointed, licensed mental health provider who provides behavioral health PASRR level 2 evaluations and PASRR determinations.

"Behavioral health PASRR level 2 evaluation" means an evaluation that is completed when a possible behavioral health (BH) PASRR condition is identified by the PASRR level 1 screening. The BH PASRR level 2 evaluation determines whether the person has credible suspicion of a BH PASRR condition, needs nursing facility care, and may need specialized services while in the nursing facility.

"Behavioral health PASRR level 2 invalidation" means the form (HCA 82-0034) used to determine that a person residing in a nursing facility or a nursing facility applicant who has been identified as positive on a PASRR level 1 screening does not require specialized service recommendations.

"Categorical determination" means a determination by a behavioral health or developmental disabilities administration (DDA) PASRR evaluator that a person may be admitted to a nursing facility on a temporary basis.

"Credible suspicion (of a behavioral health PASRR condition)" means a person exhibits or is reliably reported to exhibit one or more functional limitations, or there is some evidence that a serious mental illness may exist due to symptoms, behaviors, or other indicators. This is also considered a "known or suspected" condition.

"Developmental disabilities administration (DDA)" means the division of the department of social and health services that provides support to people with intellectual and developmental disabilities.

"Exempted hospital discharge" means the process by which a person may be admitted to a nursing facility without a behavioral health PASRR level 2 evaluation, due to the anticipated length of stay being 30 days or fewer, even though the person may have a behavioral health PASRR condition.

"Interfacility transfer" means a person who is transferred from one nursing facility to another nursing facility, with or without an intervening hospital stay. The person is not considered a new admission and does not need a preadmission screening.

"Mental illness" means a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet the diagnostic criteria specified within the current Diagnostic and Statistical Manual of Mental Disorders (DSM).

"Minimum data set" means a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in medicare or medicaid.

"PASRR condition" means a mental illness, serious mental illness, intellectual or developmental disability, or related condition, as defined in 42 C.F.R. § 483.102(b) or successor rule or governing statute.

"PASRR level 1 screening" means a screening that is completed when a person:

(a) Is referred to a medicaid-certified nursing facility by a physician, hospital, or other referring entity; or

(b) Residing in a nursing facility experiences a significant change in condition.

"Preadmission screening and resident review (PASRR) process" or "PASRR process" means the process required by federal law to determine if admission to a nursing facility is appropriate for a person who has a BH PASRR condition, and if so, to determine whether specialized services are necessary during the nursing facility stay.

"Referent" means both the licensed medical professional who completes a PASRR level 1 screening form and their employer or organization.

"Serious mental illness" means, for the purposes of this chapter, any known or suspected mental illness that:

(a) Resulted in functional impairment, which substantially limits one or more major life activities such as employment, school, or social relationships; or

(b) Would have caused an impairment absent treatment or support services.

"Significant change in condition" means a deterioration or improvement in the physical or mental condition of a person with a PASRR condition, such that:

(a) The person may reasonably require new, different, or fewer specialized services;

(b) The person's care plan requires changes regarding a known or suspected behavioral health PASRR condition; or

(c) Significant improvements have led to the possibility of community placement as a reasonable consideration for the person.

"Specialized services" means services, as described in 42 C.F.R. § 483.120 or successor laws or governing statute and provided or arranged for by the authority or department of social and health services, that are in addition to nursing facility care. These services enable a person residing in a nursing facility with a behavioral health PASRR condition to preserve or increase their functional status, self-determination, and independence.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-15-082, s 182-145-200, filed 7/16/26, effective 8/16/26.*

##### **Wash. Admin. Code § 182-145-300** Screening requirements. {#sec-182-145-300 omnilex-key=us-wa-regs-official--title-182--182-145-300}

WAC 182-145-300

(1) Any person referred to a medicaid-certified nursing facility, regardless of whether the person has private insurance, must have a behavioral health preadmission screening and resident review (PASRR) level 1 screening and determination prior to nursing facility admission.

(2) For new nursing facility admissions, a hospital or primary care provider, as defined in RCW 74.09.010, is a referring provider and is responsible for initiating the behavioral health PASRR level 1 screening. For hospital-specific regulations, see WAC 246-320-226.

(3) For existing nursing facility residents, the behavioral health level 1 screening may be initiated by a licensed medical professional.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-15-082, s 182-145-300, filed 7/16/26, effective 8/16/26.*

##### **Wash. Admin. Code § 182-145-400** Screening and evaluation process. {#sec-182-145-400 omnilex-key=us-wa-regs-official--title-182--182-145-400}

WAC 182-145-400

The behavioral health (BH) preadmission screening and resident review (PASRR) process must include the following steps:

(1) A referring provider, such as a hospital, physician, or other licensed medical professional, must conduct a BH PASRR level 1 screening to identify whether there is a known or suspected BH PASRR condition;

(2) The referent conducting the screening must use the standardized form and guidelines developed by the department of social and health services' PASRR program to conduct the BH PASRR level 1 screening;

(3) The developmental disabilities administration (DDA) division or authority-appointed behavioral health (BH) PASRR evaluator, or both, as appropriate, must make the BH PASRR determination.

(a) DDA provides determinations for an intellectual disability or related condition (ID/RC);

(b) The authority provides determinations for a serious mental illness; and

(c) If a person shows indicators of both a serious mental illness and ID/RC, the referent must provide the PASRR level 1 screening form to both DDA and the authority.

(4) Based upon the BH PASRR level 1 screening, a person who has a known mental illness, or a person with a suspected serious mental illness must undergo an evaluation; and

(5) The BH PASRR determination results in either a BH PASRR level 2 invalidation or a BH PASRR level 2 evaluation. A BH PASRR level 2 evaluation must include the following information:

(a) Whether the person has a mental illness, or has a suspected serious mental illness;

(b) For a person who has a BH PASRR condition, whether nursing facility placement is appropriate given their behavioral health PASRR condition; and

(c) If nursing facility placement is appropriate:

(i) Whether the person requires specialized services while residing at the nursing facility; and

(ii) Which specialized services would be beneficial to the person while residing there.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-15-082, s 182-145-400, filed 7/16/26, effective 8/16/26.*

##### **Wash. Admin. Code § 182-145-500** Requirements for nursing facilities prior to admission. {#sec-182-145-500 omnilex-key=us-wa-regs-official--title-182--182-145-500}

WAC 182-145-500

(1) If a person's behavioral health (BH) preadmission screening resident review (PASRR) level 1 screening does not identify a known or suspected BH PASRR condition, a nursing facility may directly admit the person, and the person's BH PASRR level 1 documentation must become part of their medical record.

(2) If a BH PASRR level 1 screening indicates a known or suspected BH PASRR condition, the referent must forward the screening to the behavioral health (BH PASRR) evaluator for a BH PASRR determination before the person's hospital discharge. For nursing facility-specific guidelines, see WAC 388-97-1915.

(a) The BH PASRR evaluator must make a BH PASRR determination prior to nursing facility admission, unless the person meets the criteria for an exempted hospital discharge as described in subsection (8) of this section or meets the definition of an interfacility transfer.

(b) The nursing facility must:

(i) Verify the referring hospital or provider completed the person's BH PASRR level 1 screening or deny admission until that screening is complete; and

(ii) Verify the person has a complete BH PASRR determination when the BH PASRR level 1 screening indicates the person may have a BH PASRR condition.

(3) A person must have, at a minimum, either a completed BH PASRR level 2 invalidation or a BH notice of determination (NOD) before admission to a nursing facility to indicate completion of a BH PASRR determination.

(4) The BH PASRR evaluator must provide the:

(a) BH NOD to the discharging hospital and if possible, the admitting nursing facility; and

(b) BH PASRR level 2 evaluation, once completed, to:

(i) The person evaluated and their legal representative; and

(ii) The admitting or retaining nursing facility.

(5) The BH PASRR level 2 evaluation must include:

(a) Whether a nursing facility level of service is appropriate based on the person's behavioral health needs; and

(b) Recommendations for specialized services, if necessary.

(6) A BH NOD from the BH PASRR evaluator is only required if documentation of the final BH PASRR determination is not complete prior to the person's hospital discharge. For developmental disabilities administration-specific PASRR requirements for a person with an intellectual disability or a related condition (ID/RC), see WAC 388-97-1910 through 388-97-2000.

(7) The nursing facility must deny admission until the person's BH PASRR determination is completed, unless:

(a) All the criteria are met for an exempted hospital discharge; and

(b) The referring facility documents them on the BH PASRR level 1 screening.

(8) The criteria for exempted hospital discharge are:

(a) The nursing facility admits the person directly from a hospital after the person received acute inpatient care;

(b) The person requires nursing facility services for the same condition for which the person received hospital care; and

(c) The person's attending physician certifies on the BH PASRR level 1 screening the person is likely to require nursing facility services for 30 days or fewer.

(9) The nursing facility must decline admission to any person whose BH PASRR determination indicates that the person does not require nursing facility services or that nursing facility placement is otherwise inappropriate.

(10) The nursing facility must coordinate proactively with BH PASRR evaluators to minimize duplicate assessments and to ensure continuity of care for nursing facility residents who have a BH PASRR condition.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-15-082, s 182-145-500, filed 7/16/26, effective 8/16/26.*

##### **Wash. Admin. Code § 182-145-600** Categorical determination. {#sec-182-145-600 omnilex-key=us-wa-regs-official--title-182--182-145-600}

WAC 182-145-600

(1) A behavioral health preadmission screening and resident review (BH PASRR) evaluator may categorically determine that specialized services are not needed for the following types of admission:

(a) A protective services stay of seven days or fewer;

(b) Respite in a nursing facility for 30 days or fewer.

(2) A BH PASRR evaluator must make categorical determinations for behavioral health PASRR admissions.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-15-082, s 182-145-600, filed 7/16/26, effective 8/16/26.*

##### **Wash. Admin. Code § 182-145-700** Requirements for behavioral health preadmission screening and resident review (PASRR) level 2 evaluations. {#sec-182-145-700 omnilex-key=us-wa-regs-official--title-182--182-145-700}

WAC 182-145-700

As part of a behavioral health preadmission screening and resident review (PASRR) level 2 evaluation, the behavioral health (BH) PASRR evaluator must review the person's medical records and speak with the person and others who have relevant information. The BH PASRR evaluator must determine whether:

(1) The person has a PASRR condition. If the BH PASRR evaluator suspects a person has an intellectual disability or related condition (ID/RC), the referent must submit the PASRR level 1 screening form to the ID/RC team;

(2) Nursing facility admission is appropriate to meet the person's needs; and

(3) The person requires specialized services while at the nursing facility.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-15-082, s 182-145-700, filed 7/16/26, effective 8/16/26.*

##### **Wash. Admin. Code § 182-145-800** Behavioral health preadmission screening and resident review (PASRR) requirements—After admission. {#sec-182-145-800 omnilex-key=us-wa-regs-official--title-182--182-145-800}

WAC 182-145-800

(1) Before a person's admission, the nursing facility must ensure the behavioral health (BH) preadmission screening and resident review (PASRR) level 1 screening is complete and accurate.

(2) If the BH PASRR level 1 screening identifies a possible PASRR-eligible condition:

(a) The person's record must include the final BH PASRR determination; and

(b) The nursing facility must ensure that the recommended specialized services, if indicated, are incorporated into the person's care plan.

(3) The nursing facility must complete a new BH PASRR level 1 screening using the department of social and health services' standardized form and submit the form to the regional BH PASRR evaluator point of contact, if needed, based on the person's change in condition, behaviors, or mood, or when indicated by a minimum data set (MDS) review.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-15-082, s 182-145-800, filed 7/16/26, effective 8/16/26.*

##### **Wash. Admin. Code § 182-145-900** Behavioral health preadmission screening and resident review (PASRR) appeals. {#sec-182-145-900 omnilex-key=us-wa-regs-official--title-182--182-145-900}

WAC 182-145-900

(1) People who have been evaluated by a behavioral health (BH) preadmission screening and resident review (PASRR) evaluator have the right to an administrative hearing to dispute the following determinations by the BH PASRR evaluator:

(a) Nursing facility placement is not appropriate to meet the person's needs; or

(b) The person does not require specialized services.

(2) Any decision rendered by the office of administrative hearings (OAH) is an initial decision appealable to the authority's board of appeals.

(3) For additional information regarding PASRR appeals, see WAC 388-97-0140.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-15-082, s 182-145-900, filed 7/16/26, effective 8/16/26.*

## **Chapter 182-155** Involuntary treatment—Legal representation provided by the office of public defense. {#struct-chapter-182-155}

##### **Wash. Admin. Code § 182-155-0050** Authority and purpose. {#sec-182-155-0050 omnilex-key=us-wa-regs-official--title-182--182-155-0050}

WAC 182-155-0050

This chapter implements the requirements of RCW 71.05.110 and 71.05.620 regarding appointed counsel and access to court records related to long-term and short-term civil commitment proceedings governed by chapters 71.05 and 71.34 RCW, and RCW 2.70.020.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 71.05.620(2). WSR 26-15-040, s 182-155-0050, filed 7/8/26, effective 8/8/26.*

##### **Wash. Admin. Code § 182-155-0100** Definitions. {#sec-182-155-0100 omnilex-key=us-wa-regs-official--title-182--182-155-0100}

WAC 182-155-0100

"Authority" - See RCW 41.05.011.

"Attorney of the person" - The defense attorney assigned to represent a person subject to a petition under chapters 71.05 and 71.34 RCW as well as the office of public defense when it exercises its authority to assign the defense attorney who represents the person.

"Director" - The director of the authority.

"Office of public defense" or "OPD" - See RCW 2.70.005.

"State facility" - See RCW 71.05.020.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 71.05.620(2). WSR 26-15-040, s 182-155-0100, filed 7/8/26, effective 8/8/26.*

##### **Wash. Admin. Code § 182-155-0200** Appointing the office of public defense as trial counsel. {#sec-182-155-0200 omnilex-key=us-wa-regs-official--title-182--182-155-0200}

WAC 182-155-0200

(1) The county where the individual is detained administers appointed counsel under RCW 71.05.110. When a county governing body decides to request the office of public defense (OPD) contract with the authority to provide representation for an individual detained at a state facility, it must send written notice to the director.

(2) The director, or designee, will notify OPD of the opportunity to contract for representation services.

(3) OPD will inform the authority in writing whether it will agree to contract with the authority to provide representation services in the county requested.

(4) The director, or designee, will respond to the county's request within 30 days of receiving a response from OPD.

(5) As of January 1, 2026, OPD provides representation services under RCW 71.05.110 in the following counties for individuals detained at a state facility: King County.

(6) When OPD provides representation under this section, OPD is considered an attorney of the person under RCW 71.05.620.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 71.05.620(2). WSR 26-15-040, s 182-155-0200, filed 7/8/26, effective 8/8/26.*

##### **Wash. Admin. Code § 182-155-0300** Role of the office of public defense as legal appellate counsel. {#sec-182-155-0300 omnilex-key=us-wa-regs-official--title-182--182-155-0300}

WAC 182-155-0300

(1) Individuals detained under chapter 71.05 or 71.34 RCW have the right to appointed counsel at every stage of civil commitment proceedings. The right to counsel extends to appeals of trial court decisions per In re Grove, 127 Wn.2d 221 (1995).

(2) The office of public defense (OPD) administers appointed appellate counsel statewide for indigent persons under RCW 2.70.020. OPD provides appellate representation through contracted counsel under RCW 2.70.023.

(3) When OPD provides representation under this section, OPD is considered an attorney of the person under RCW 71.05.620.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 71.05.620(2). WSR 26-15-040, s 182-155-0300, filed 7/8/26, effective 8/8/26.*

## **Chapter 182-300** Single bed certification. {#struct-chapter-182-300}

##### **Wash. Admin. Code § 182-300-0100** Single bed certification. {#sec-182-300-0100 omnilex-key=us-wa-regs-official--title-182--182-300-0100}

At the discretion of the health care authority (HCA) or HCA's designee, an exception may be granted to a facility that is not certified under chapter 246-341 WAC, for a person on an initial detention, a five-day detention pending a revocation proceeding, or a fourteen-day commitment in order to allow timely and appropriate treatment. An exception may also be granted for renewable periods of thirty days to allow a community facility to provide treatment to a person on a ninety- or one hundred eighty-day inpatient involuntary commitment order or to a person who has been revoked from a less restrictive alternative order or conditional release. For involuntarily detained or committed children, an exception may be granted to allow timely and appropriate treatment in a facility not certified under chapter 246-341 WAC, until the child's discharge from that setting to the community, or until they transfer to a bed in a children's long-term inpatient program (CLIP).

(1) In the case of an adult, the behavioral health administrative services organization (BH-ASO) or a designee must submit a written request for a single bed certification to HCA or HCA's designee. In the case of a child, the facility must submit the written request to HCA or HCA's designee and provide a copy to the BH-ASO. HCA or HCA's designee must receive and approve the request in order for a facility to accept a person for timely and appropriate treatment under this section. If HCA or HCA's designee has assumed the duties assigned to a nonparticipating BH-ASO, HCA or HCA's designee may designate an entity to request a single bed certification as described in this section.

(2) HCA or HCA's designee may issue a single bed certification in writing to the facility for timely and appropriate mental health treatment when the following requirements are met in each instance where such certification is sought for a person:

(a) The facility that is the site of the proposed single bed certification confirms that it is willing and able to provide directly, or by direct arrangement with other public or private agencies, timely and appropriate mental health treatment to the person for whom the single bed certification is sought; and

(b) The request for single bed certification describes why the person meets at least one of the following criteria:

(i) The person is expected to be ready for discharge from inpatient services at the facility referred to in (a) of this subsection within the next thirty days and remaining at that facility would facilitate continuity of care, consistent with the person's individual treatment needs;

(ii) The person can receive appropriate mental health treatment in a residential treatment facility, as defined in WAC 246-337-005; or

(iii) The person can receive appropriate mental health treatment in a hospital with a psychiatric unit, a psychiatric hospital, or a hospital that is willing and able to provide timely and appropriate mental health treatment, including a temporary health care facility that has a mental health component credentialed or approved by the department of health.

(3) In order to provide timely and appropriate mental health treatment, the facility receiving the single bed certification, or the public or private agency the facility has a direct arrangement with to provide mental health treatment, must:

(a) Implement standards for administration that include written procedures to assure that a mental health professional, as defined in RCW 71.05.020, and a licensed physician, psychiatric advanced registered nurse practitioner, or physician assistant are available for consultation and communication with both the person and the direct patient care staff;

(b) Use a plan of care or treatment. The person's medical or clinical record must contain documentation that:

(i) An individualized mental health treatment plan was developed, when possible, collaboratively with the person. If the person is unwilling or unable to participate in development of the plan, documentation must be made in the record. Development of this plan may include participation of a multidisciplinary team, a mental health professional as defined in RCW 71.05.020, or collaboration with members of the person's support system as identified by the person; and

(ii) A mental health professional, as defined in RCW 71.05.020, has had contact with the person at least daily for the purposes of:

(A) Observation and evaluation;

(B) Assessing whether the person is appropriate for release from involuntary commitment to accept treatment on a voluntary basis; and

(c) Have standards for administration and monitoring of medication, including psychiatric medications. A person has a right to make an informed decision regarding the use of antipsychotic medication consistent with RCW 71.05.215.

(4) If a person requires medical services that are not generally available at a facility certified under chapter 246-341 WAC, or at a state psychiatric hospital, or a facility that meets the requirements of subsections (2) and (3) of this section, HCA or HCA's designee may issue a single bed certification to that facility for the person as follows:

(a) The single bed certification request must adequately describe why the person requires medical services that are not available at a facility certified under chapter 246-341 WAC, a state psychiatric hospital, or a facility that meets the requirements of subsections (2) and (3) of this section;

(b) The facility that is the site of the requested single bed certification must confirm that it is willing and able to provide the medical services; and

(c) The facility has documented that one of the following has been met:

(i) With the authorization of the facility, and consistent with any applicable facility policies and procedures, the BH-ASO assigns a mental health professional to provide the person appropriate mental health treatment at the facility, including observation and evaluation, during the period of time the person is provided medical services; or

(ii) The facility provides medical services and a plan that addresses the person's mental health treatment needs until the person is medically stable and the BH-ASO or a designee identifies an appropriate facility for the person that is one of the following:

(A) The facility providing services;

(B) A facility that is certified as an evaluation and treatment (E&T) facility; or

(C) A facility that can meet the person's needs under the single bed certification criteria in this section.

(d) If a qualified medical professional determines that mental health treatment for the person is not appropriate due to medical instability, the requirements in (c) of this subsection do not apply. When the person is determined to be medically stable, the facility must ensure the requirements in (c) of this subsection are met;

(e) A person who receives services under a single bed certification under this section must be transferred to an evaluation and treatment facility, state hospital, or other placement as soon as the attending physician considers the person medically stable and a bed becomes available, unless the treating facility consents to continue treatment and continued treatment in the current setting is consistent with the best clinical interests of the person.

(5) HCA or HCA's designee may make site visits at any time to verify that the terms of the single bed certification are being met. Failure to comply with any term of this exception may result in corrective action. If HCA or HCA's designee determines that the violation places people in imminent jeopardy, immediate revocation of this exception can occur.

(6) The BH-ASO retains the responsibility for ensuring due process required by RCW 71.24.300 (6)(b).

(7) Neither a person nor a facility has fair hearing rights as defined under chapter 182-526 WAC regarding single bed certification decisions made by HCA or HCA's designee staff.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2018 c 201. WSR 20-24-082, § 182-300-0100, filed 11/25/20, effective 12/26/20.*

## **Chapter 182-400** Public option plans (Cascade Care Select). {#struct-chapter-182-400}

##### **Wash. Admin. Code § 182-400-0100** Public option hospital participation—Purpose and scope. {#sec-182-400-0100 omnilex-key=us-wa-regs-official--title-182--182-400-0100}

(1) The Washington health benefit exchange, in partnership with the health care authority, administers public purchasing of the Washington state public option plans known as Cascade Care Select.

(2) Each hospital should consider all valid offers from public option plans to ensure compliance with this chapter and to avoid sanctions by failing to contract with at least one public option plan.

(3) In accordance with RCW 41.05.405, beginning in plan year 2023, a hospital that receives payments through a medical assistance program under chapter 74.09 RCW, or a public employees benefits board (PEBB) or a school employees benefits board (SEBB) program under chapter 41.05 RCW must contract with at least one carrier offering public option plans to provide in-network coverage to enrollees, if the hospital received a valid offer to contract with a carrier offering public option plans to provide in-network services.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2021 c 246. WSR 22-10-023, § 182-400-0100, filed 4/25/22, effective 6/1/22.*

##### **Wash. Admin. Code § 182-400-0200** Definitions. {#sec-182-400-0200 omnilex-key=us-wa-regs-official--title-182--182-400-0200}

For the purposes of this chapter:

"Authority" means the Washington state health care authority.

"Carrier" is defined in RCW 48.43.005.

"Health benefit exchange" means the Washington state health benefit exchange established in RCW 43.71.020.

"Hospital" means any hospital licensed under chapter 70.41 RCW that receives payment for services provided:

(a) To enrollees in the public employees benefits program or school employees benefits program under chapter 41.05 RCW; or

(b) Through a medical assistance program under chapter 74.09 RCW.

"Parties" means carriers and hospitals as defined in this chapter.

"Plan year" means the 12-month period beginning on January 1st of each year and ending on December 31st of the same year.

"Public option plan" means a qualified health plan contracted by or offered in a response to a procurement issued by the authority under RCW 41.05.410.

"Valid offer to contract" means:

(a) A written offer made by a carrier to a hospital to enter into a contract with the carrier to provide in-network coverage to enrollees of the carrier's public option plans; and

(b) The carrier's offer must contain sufficient information so that a reasonable person would understand that a good faith offer has been made. The carrier must, at a minimum, include the reimbursement rate offered in a manner that constitutes a legally binding document that the parties could execute.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2021 c 246. WSR 22-10-023, § 182-400-0200, filed 4/25/22, effective 6/1/22.*

##### **Wash. Admin. Code § 182-400-0300** Enforcement. {#sec-182-400-0300 omnilex-key=us-wa-regs-official--title-182--182-400-0300}

(1) Compliance. The authority conducts investigations, as needed, to ensure compliance with this chapter.

(2) Investigations. The authority may open an investigation:

(a) When the authority receives information from a carrier that a hospital failed to contract with that carrier to provide in-network coverage to enrollees of the carrier's public option plans after making a valid offer to contract;

(b) When there are no public option plans available in the county where the hospital is located; or

(c) On a case-by-case basis at the authority's sole discretion.

(3) Procedure.

(a) The authority sends a written investigation notice explaining the nature of the allegation to both the hospital and to bidding or contracted carriers.

(b) The authority may request additional information or documentation from the carrier or carriers and the hospital. If the authority sends a written request for information, parties have 30 calendar days to:

(i) Provide the requested information or documentation; or

(ii) Request additional time to complete the request, which the authority may grant on a case-by-case basis.

(c) The authority may request the following information or documentation from any party during an investigation:

(i) A copy of all written communications, including emails, between the hospital and the carriers related to any potential contract offers, or contracts that have been executed related to public option plans and related discussions;

(ii) A copy, including the provider reimbursement rates, of any offer to contract or executed contract;

(iii) A statement from a party explaining the party's position, including information regarding why the offer was not accepted;

(iv) A statement regarding any mitigating factors the hospital or carrier would like the authority to take into consideration when determining whether a sanction is warranted; and

(v) Any other information the authority decides is relevant in determining whether a sanction is appropriate.

(d) If the authority determines that any party has failed to fully and timely respond to the authority's request for information or documentation, the authority may impose an immediate sanction for noncompliance for each incident of noncompliance, as follows:

| Number of incidents of noncompliance | Sanction amount |
| --- | --- |
| First | $10,000 |
| Second | $25,000 |
| Third | $50,000 |
| Fourth and subsequent incidents | $100,000 |

(e) The authority may issue a sanction for each missing item, or for each failure to provide documentation or information within the required time or may issue sanctions for both. Sanctions under this section are cumulative and immediate but may be stayed if the sanctioned party files an appeal under WAC 182-400-0400.

(f) When issuing an immediate sanction under (d) of this subsection, the authority sends a written notice to demand payment. The authority must receive payment within 28 calendar days of the date the party received the notice.

(4) Sanctions for failure to accept valid contract offer.

(a) After an investigation conducted under subsection (3) of this section, if, in the authority's sole discretion, the authority determines that a hospital failed to accept a valid offer to contract from a carrier, and is not contracted with any other public option plan for that plan year, the sanction amount for that plan year is as follows:

(i) For hospitals with 50 beds or fewer, $182,500; or

(ii) For hospitals with more than 50 beds, $3,650 per bed.

(b) A party may appeal a sanction notice under WAC 182-400-0400.

(5) Public disclosure. The information submitted according to this section is not subject to public disclosure under chapter 42.56 RCW, to the extent set forth in RCW 41.05.410 (3)(b).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2021 c 246. WSR 22-10-023, § 182-400-0300, filed 4/25/22, effective 6/1/22.*

##### **Wash. Admin. Code § 182-400-0400** Notice of sanction appeal process. {#sec-182-400-0400 omnilex-key=us-wa-regs-official--title-182--182-400-0400}

(1) The process described in this section applies only if a party receives a written sanction notice from the authority for noncompliance with this chapter.

(2) The authority must receive a party's appeal within 28 calendar days of the date the party received the notice of sanction.

(a) To file an appeal, a party must send a written request for an administrative hearing to the address listed on the notice of sanction in a manner that provides proof of receipt.

(b) The request for the administrative hearing must provide a copy of the notice of sanction in dispute.

(3) The authority conducts hearings and appeals under the Washington state Administrative Procedure Act (chapter 34.05 RCW) and the administrative hearing rules for medical services programs (chapter 182-526 WAC).

(4) Under WAC 182-526-0025(2), the authority, in its sole discretion, may conduct the administrative hearing or may transfer the hearing to the office of administrative hearings (OAH).

(a) If the authority conducts the administrative hearing, it issues the final agency decision.

(b) If OAH conducts the administrative hearing, it issues an initial order with instructions on how to file an appeal with the authority's board of appeals.

(5) Repayment of sanctions is stayed only if a party timely files an appeal under this section.

(6) If the final order upholds the notice of sanction, the authority immediately begins collection activities.

(7) The authority may impose a one percent interest charge for each month sanctions are unpaid.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2021 c 246. WSR 22-10-023, § 182-400-0400, filed 4/25/22, effective 6/1/22.*

## **Chapter 182-500** Medical definitions. {#struct-chapter-182-500}

##### **Wash. Admin. Code § 182-500-0005** Definitions. {#sec-182-500-0005 omnilex-key=us-wa-regs-official--title-182--182-500-0005}

Chapter 182-500 WAC contains definitions of words and phrases used in rules for medical assistance and other health care programs. When a term is not defined in this chapter, other agency or agency's designee WAC, or state or federal law, the medical definitions found in the Taber's Cyclopedic Medical Dictionary will apply. For general terms not defined in this chapter, other agency or agency's designee WAC, or state or federal law, the definitions in Webster's New World Dictionary apply. If a definition in this chapter conflicts with a definition in another chapter of Title 182 WAC, the definition in the specific WAC prevails.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-16-084, § 182-500-0005, filed 7/29/16, effective 8/29/16. WSR 11-14-075, recodified as § 182-500-0005, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. WSR 11-14-053, § 388-500-0005, filed 6/29/11, effective 7/30/11. Statutory Authority: RCW 34.05.353 (2)(d), 74.08.090, and chapters 74.09, 74.04 RCW. WSR 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. WSR 98-15-066, § 388-500-0005, filed 7/13/98, effective 7/30/98. Statutory Authority: RCW 74.08.090. WSR 95-22-039 (Order 3913, #100246), § 388-500-0005, filed 10/25/95, effective 10/28/95*
- *WSR 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.*

##### **Wash. Admin. Code § 182-500-0010** Medical assistance definitions—A. {#sec-182-500-0010 omnilex-key=us-wa-regs-official--title-182--182-500-0010}

"Administrative renewal" means the agency uses electronically available income and resources data sources to verify and recertify a person's Washington apple health benefits for a subsequent certification period. A case is administratively renewed when the person's self-attested income and resources are reasonably compatible (as defined in WAC 182-500-0095) with the information available to the agency from the electronic data sources and the person meets citizenship, immigration, Social Security number, and age requirements.

"After-pregnancy coverage (APC)" means full-scope Washington apple health (medicaid) health care coverage for people up to 12 months after the month their pregnancy ends under WAC 182-505-0115.

"Agency" or "medicaid agency" means the Washington state health care authority (HCA).

"Agency's designee" means any entity expressly designated by the agency to act on its behalf.

"Allowable costs" are the documented costs as reported after any cost adjustment, cost disallowances, reclassifications, or reclassifications to nonallowable costs which are necessary, ordinary and related to the outpatient care of medical care clients or not expressly declared nonallowable by applicable statutes or regulations. Costs are ordinary if they are of the nature and magnitude which prudent and cost-conscious management would pay.

"Alternative benefits plan" means the range of health care services included within the scope of service categories described in WAC 182-501-0060 available to persons eligible to receive health care coverage under the Washington apple health modified adjusted gross income (MAGI)-based adult coverage described in WAC 182-505-0250.

"Ancillary services" means additional services ordered by the provider to support the core treatment provided to the patient. These services may include, but are not limited to, laboratory services, radiology services, drugs, physical therapy, occupational therapy, and speech therapy.

"Apple health for kids" is the umbrella term for health care coverage for certain groups of children that is funded by the state and federal governments under Title XIX medicaid programs, Title XXI Children's Health Insurance Program, or solely through state funds (including the program formerly known as the children's health program). Funding for any given child depends on the program for which the child is determined to be eligible. Apple health for kids programs are included in the array of health care programs available through Washington apple health (WAH).

"Attested income" or "attested resources" means a self-declared statement of a person's income or resources made under penalty of perjury to be true. (See also "self-attestation.")

"Authorization" means the agency's or the agency's designee's determination that criteria are met, as one of the preconditions to the agency's or the agency's designee's decision to provide payment for a specific service or device. (See also "expedited prior authorization" and "prior authorization.")

"Authorized representative" is defined under WAC 182-503-0130.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-22-050, § 182-500-0010, filed 10/25/23, effective 11/25/23. Statutory Authority: RCW 41.05.021, 41.05.160, and 74.09.830. WSR 22-21-086, § 182-500-0010, filed 10/14/22, effective 11/14/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-02-122, § 182-500-0010, filed 1/6/16, effective 2/6/16*
- *WSR 15-15-143, § 182-500-0010, filed 7/17/15, effective 8/17/15. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-500-0010, filed 12/9/13, effective 1/9/14. WSR 11-14-075, recodified as § 182-500-0010, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. WSR 11-14-053, § 388-500-0010, filed 6/29/11, effective 7/30/11.*

##### **Wash. Admin. Code § 182-500-0015** Medical assistance definitions—B. {#sec-182-500-0015 omnilex-key=us-wa-regs-official--title-182--182-500-0015}

"Benefit package" means the set of health care service categories included in a client's health care program. See WAC 182-501-0060.

"Benefit period" means the time period used to determine whether medicare can pay for covered Part A services. A benefit period begins the first day a beneficiary receives inpatient hospital or extended care services from 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.

"Billing instructions" means provider guides. See WAC 182-500-0085.

"Blind" is a category of medical program eligibility that requires:

(a) A central visual acuity of 20/200 or less in the better eye with the use of a correcting lens; or

(b) A field of vision limitation so the widest diameter of the visual field subtends an angle no greater than twenty degrees from central.

"By report (BR)" means a method of payment in which the agency or the agency's designee determines the amount it will pay for a service when the rate for that service is not included in the agency's published fee schedules. The provider must submit a report which describes the nature, extent, time, effort and equipment necessary to deliver the service.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-19-141, § 182-500-0015, filed 9/22/21, effective 10/23/21. Statutory Authority: RCW 41.05.021, 41.05.160, 2014 c 225. WSR 16-06-053, § 182-500-0015, filed 2/24/16, effective 4/1/16. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-21-063, § 182-500-0015, filed 10/19/15, effective 11/19/15. WSR 11-14-075, recodified as § 182-500-0015, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. WSR 11-14-053, § 388-500-0015, filed 6/29/11, effective 7/30/11.*

##### **Wash. Admin. Code § 182-500-0020** Definitions—C. {#sec-182-500-0020 omnilex-key=us-wa-regs-official--title-182--182-500-0020}

"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).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 74.09.830. WSR 22-21-086, § 182-500-0020, filed 10/14/22, effective 11/14/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-04-095, § 182-500-0020, filed 2/5/19, effective 3/8/19*
- *WSR 17-23-040, § 182-500-0020, filed 11/8/17, effective 12/9/17*
- *WSR 16-18-019, § 182-500-0020, filed 8/26/16, effective 9/26/16*
- *WSR 15-17-013, § 182-500-0020, filed 8/7/15, effective 9/7/15. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-500-0020, filed 7/29/14, effective 8/29/14. WSR 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. WSR 11-14-053, § 388-500-0020, filed 6/29/11, effective 7/30/11.*

##### **Wash. Admin. Code § 182-500-0025** Definitions—D. {#sec-182-500-0025 omnilex-key=us-wa-regs-official--title-182--182-500-0025}

"Delayed certification" means agency or the agency's designee approval of a person's eligibility for medical assistance made after the established application processing time limits.

"Dental consultant" means a dentist employed or contracted by the agency or the agency's designee.

"Department" means the state department of social and health services.

"Disabled" means unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that:

(a) Can be expected to result in death;

(b) Has lasted or can be expected to last for a continuous period of not less than twelve months; or

(c) In the case of a child age seventeen or younger, means any physical or mental impairment of comparable severity.

Decisions on SSI-related disability are subject to the authority of federal statutes and rules codified at 42 U.S.C. Sec 1382c and 20 C.F.R., parts 404 and 416, as amended, and controlling federal court decisions, which define the old-age, survivors, and disability insurance (OASDI) and SSI disability standard and determination process. See WAC 182-500-0015 for definition of "blind."

"Domestic partner" means an adult who meets the requirements for a valid state registered domestic partnership as established by RCW 26.60.030 and who has been issued a certificate of state registered domestic partnership from the Washington secretary of state.

"Dual eligible client" means a client who has been found eligible as a categorically needy (CN) or medically needy (MN) medicaid client and is also a medicare beneficiary. This does not include a client who is only eligible for a medicare savings program as described in chapter 182-517 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-02-046, § 182-500-0025, filed 12/27/18, effective 1/27/19. WSR 11-14-075, recodified as § 182-500-0025, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. WSR 11-14-053, § 388-500-0025, filed 6/29/11, effective 7/30/11.*

##### **Wash. Admin. Code § 182-500-0030** Definitions—E. {#sec-182-500-0030 omnilex-key=us-wa-regs-official--title-182--182-500-0030}

"Early periodic screening, diagnosis, and treatment (EPSDT)" is defined under WAC 182-534-0050.

"Early elective delivery" means any nonmedically necessary induction or cesarean section before 39 weeks of gestation. Thirty-nine weeks of gestation is greater than 38 weeks and six days.

"Electronic signature" means a signature in electronic form attached to or associated with an electronic record including, but not limited to, a digital signature.

"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:

(a) Placing the patient's health in serious jeopardy;

(b) Serious impairment to bodily functions; or

(c) Serious dysfunction of any bodily organ or part.

"Employer-sponsored dependent coverage" means creditable health coverage for dependents offered by a family member's employer or union, for which the employer or union may contribute in whole or in part towards the premium. Extensions of such coverage (e.g., COBRA extensions) also qualify as employer-sponsored dependent coverage as long as there remains a contribution toward the premiums by the employer or union.

"Evidence-based medicine (EBM)" means the application of a set of principles and a method for the review of well-designed studies and objective clinical data to determine the level of evidence that proves to the greatest extent possible, that a health care service is safe, effective, and beneficial when making:

(a) Population-based health care coverage policies (WAC 182-501-0055 describes how the agency or its designee determines coverage of services for its health care programs by using evidence and criteria based on health technology assessments); and

(b) Individual medical necessity decisions (WAC 182-501-0165 describes how the agency or its designee uses the best evidence available to determine if a service is medically necessary as defined in WAC 182-500-0030).

"Exception to rule." See WAC 182-501-0160 for exceptions to noncovered health care services, supplies, and equipment. See WAC 182-503-0090 for exceptions to program eligibility.

"Expedited prior authorization (EPA)" means the process for obtaining authorization for selected health care services in which providers use a set of numeric codes to indicate to the agency or the agency's designee which acceptable indications, conditions, or agency or agency's designee-defined criteria are applicable to a particular request for authorization. EPA is a form of "prior authorization."

"Extended care services" means nursing and rehabilitative care in a skilled nursing facility provided to a recently hospitalized medicare patient.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-21-142, s 182-500-0030, filed 10/21/25, effective 11/21/25*
- *WSR 19-04-095, § 182-500-0030, filed 2/5/19, effective 3/8/19*
- *WSR 15-24-021, § 182-500-0030, filed 11/19/15, effective 1/1/16. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-500-0030, filed 7/29/14, effective 8/29/14. WSR 11-14-075, recodified as § 182-500-0030, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. WSR 11-14-053, § 388-500-0030, filed 6/29/11, effective 7/30/11.*

##### **Wash. Admin. Code § 182-500-0035** Medical assistance definitions—F. {#sec-182-500-0035 omnilex-key=us-wa-regs-official--title-182--182-500-0035}

"Fee-for-service (FSS)" - The general payment method the agency or agency's designee uses to pay for covered medical services provided to clients, except those services covered under the agency's prepaid managed care programs.

"Fiscal intermediary" means an organization having an agreement with the federal government to process medicare claims under Part A.

"Full-scope coverage" means that the client is entitled to the benefits in the scope of service categories under WAC 182-501-0060.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 74.09.830. WSR 22-21-086, § 182-500-0035, filed 10/14/22, effective 11/14/22. WSR 11-14-075, recodified as § 182-500-0035, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. WSR 11-14-053, § 388-500-0035, filed 6/29/11, effective 7/30/11.*

##### **Wash. Admin. Code § 182-500-0040** Medical assistance definitions—G. {#sec-182-500-0040 omnilex-key=us-wa-regs-official--title-182--182-500-0040}

"Grandfathered client" means a noninstitutionalized person who meets all current requirements for medicaid eligibility except the criteria for blindness or disability; and:

(1) Was eligible for medicaid in December 1973 as blind or disabled whether or not the person was receiving cash assistance in December 1973;

(2) Continues to meet the criteria for blindness or disability and other conditions of eligibility used under the medicaid plan in December 1973; or

(3) Was an institutionalized person who:

(a) Was eligible for medicaid in December 1973, or any part of that month, as an inpatient of a medical institution or a resident of a facility that is known as an intermediate care facility that was participating in the medicaid program and for each consecutive month after December 1973; and

(b) 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.

**History**
- *WSR 11-14-075, recodified as § 182-500-0040, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. WSR 11-14-053, § 388-500-0040, filed 6/29/11, effective 7/30/11.*

##### **Wash. Admin. Code § 182-500-0045** Medical assistance definitions—H. {#sec-182-500-0045 omnilex-key=us-wa-regs-official--title-182--182-500-0045}

"Health benefit exchange" means the public-private partnership created pursuant to chapter 43.71 RCW.

"Health insurance premium tax credit (HIPTC)" is a premium tax credit that is refundable and can also be paid in advance from the Internal Revenue Service to a taxpayer's insurance company to help cover the cost of premiums for a taxpayer enrolled in a qualified health plan (QHP) through the health benefit exchange. This tax credit is specified in Section 36B of the Internal Revenue Code of 1986.

"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 agency on a prepaid capitation risk basis.

"Health care professional" means a provider of health care services licensed or certified by the state in which they practice.

"Health care service category" means a grouping of health care services listed in the table in WAC 182-501-0060. A health care service category is included or excluded depending on the client's medical assistance benefits package.

"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 entity that is licensed as an acute care hospital in accordance with applicable state laws and rules, or the applicable state laws and rules of the state in which the entity is located when the entity is out-of-state, and is certified under Title XVIII of the federal Social Security Act. The term "hospital" includes a medicare or state-certified distinct rehabilitation unit or a psychiatric hospital.

**History**
- *Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-500-0045, filed 12/9/13, effective 1/9/14. WSR 11-14-075, recodified as § 182-500-0045, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. WSR 11-14-053, § 388-500-0045, filed 6/29/11, effective 7/30/11.*

##### **Wash. Admin. Code § 182-500-0050** Washington apple health definitions—I. {#sec-182-500-0050 omnilex-key=us-wa-regs-official--title-182--182-500-0050}

"Ineligible spouse" see "spouse" in WAC 182-500-0100.

"Institution" means an entity that furnishes (in single or multiple facilities) food, shelter, and some treatment or services to four or more people unrelated to the proprietor. Eligibility for a Washington apple health program may vary depending upon the type of institution in which an individual resides. For the purposes of apple health programs, "institution" includes all the following:

(1) "Institution for mental diseases (IMD)" - A hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment or care of people with mental diseases, including medical attention, nursing care and related services. An IMD may include inpatient substance use disorder (SUD) facilities of more than 16 beds which provide residential treatment for SUD.

(2) "Intermediate care facility for individuals with intellectual disabilities (ICF/IID)" - An institution or distinct part of an institution that is:

(a) Defined in 42 C.F.R. 440.150;

(b) Certified to provide ICF/IID services under 42 C.F.R. 483, Subpart I; and

(c) Primarily for the diagnosis, treatment, or rehabilitation for people with intellectual disabilities or a related condition.

(3) "Medical institution" - An entity that is organized to provide medical care, including nursing and convalescent care. The terms "medical facility" and "medical institution" are sometimes used interchangeably throughout Title 182 WAC.

(a) To meet the definition of medical institution, the entity must:

(i) Be licensed as a medical institution under state law;

(ii) Provide medical care, with the necessary professional personnel, equipment, and facilities to manage the health needs of the patient on a continuing basis under acceptable standards; and

(iii) Include adequate physician and nursing care.

(b) Medical institutions include:

(i) "Hospice care center" - An entity licensed by the department of health (DOH) to provide hospice services. Hospice care centers must be medicare-certified, and approved by the agency or the agency's designee to be considered a medical institution.

(ii) "Hospital" - Defined in WAC 182-500-0045.

(iii) "Nursing facility (NF)" - An entity certified to provide skilled nursing care and long-term care services to medicaid recipients under Social Security Act Sec. 1919(a), 42 U.S.C. Sec. 1396r. Nursing facilities that may become certified include nursing homes licensed under chapter 18.51 RCW, and nursing facility units within hospitals licensed by DOH under chapter 70.41 RCW. This includes the nursing facility section of a state veteran's facility.

(iv) "Psychiatric hospital" - An institution, or a psychiatric unit located in a hospital, licensed as a hospital under applicable Washington state laws and rules, that is primarily engaged to provide psychiatric services for the diagnosis and treatment of mentally ill people under the supervision of a physician.

(v) "Psychiatric residential treatment facility (PRTF)" - A nonhospital residential treatment center licensed by DOH, and certified by the agency or the agency's designee to provide psychiatric inpatient services to medicaid-eligible people age 21 and younger. A PRTF must be accredited by the Joint Commission on Accreditation of Health care Organizations (JCAHO) or any other accrediting organization with comparable standards recognized by Washington state. A PRTF must meet the requirements in 42 C.F.R. 483, Subpart G, regarding the use of restraint and seclusion.

(vi) "Residential habilitation center (RHC)" - A state-operated facility for persons with developmental disabilities governed by chapter 71A.20 RCW.

(c) Medical institutions do not include entities licensed by the agency or the agency's designee as adult family homes (AFHs) and boarding homes. AFHs and boarding homes include assisted living facilities, adult residential centers, enhanced adult residential centers, and developmental disability group homes.

(4) "Public institution" means an entity that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control.

(a) Public institutions include:

(i) Correctional facility - An entity such as a state prison, or city, county, or tribal jail, or juvenile rehabilitation or juvenile detention facility.

(ii) Eastern and Western State mental hospitals. (Medicaid coverage for these institutions is limited to people age 21 and younger, and people age 65 and older.)

(iii) Certain facilities administered by Washington state's department of veteran's affairs (see (b) of this subsection for facilities that are not considered public institutions).

(b) Public institutions do not include intermediate care facilities, entities that meet the definition of medical institution (such as Harborview Medical Center and University of Washington Medical Center), or facilities in Retsil, Orting, and Spokane that are administered by the department of veteran's affairs and licensed as nursing facilities.

"Institution for mental diseases (IMD)" see "institution" in this section.

"Institutional review board" – A board or committee responsible for reviewing research protocols and determining whether:

(1) Risks to subjects are minimized;

(2) Risks to subjects are reasonable in relation to anticipated benefits, if any, to subjects, and the importance of the knowledge that may reasonably be expected to result;

(3) Selection of subjects is equitable;

(4) Informed consent will be sought from each prospective subject or the subject's legally authorized representative;

(5) Informed consent will be appropriately documented;

(6) When appropriate, the research plan makes adequate provision for monitoring the data collected to ensure the safety of subjects;

(7) When appropriate, there are adequate provisions to protect the privacy of subjects and to maintain the confidentiality of data; and

(8) When some or all of the subjects are likely to be vulnerable to coercion or undue influence, such as children, prisoners, pregnant people, mentally disabled persons, or economically or educationally disadvantaged persons, additional safeguards have been included in the study to protect the rights and welfare of these subjects.

"Institutionalized spouse" see "spouse" in WAC 182-500-0100.

"Intermediate care facility for individuals with intellectual disabilities (ICF/IID)" see "institution" in this section.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 71A.10.020(11), and chapter 18.205 RCW. WSR 23-04-071, § 182-500-0050, filed 1/30/23, effective 3/2/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-07-105, § 182-500-0050, filed 3/23/22, effective 4/23/22*
- *WSR 21-19-141, § 182-500-0050, filed 9/22/21, effective 10/23/21*
- *WSR 17-12-017, § 182-500-0050, filed 5/30/17, effective 6/30/17*
- *WSR 15-17-013, § 182-500-0050, filed 8/7/15, effective 9/7/15. WSR 11-14-075, recodified as § 182-500-0050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. WSR 11-14-053, § 388-500-0050, filed 6/29/11, effective 7/30/11.*

##### **Wash. Admin. Code § 182-500-0065** Definitions—L. {#sec-182-500-0065 omnilex-key=us-wa-regs-official--title-182--182-500-0065}

"Limitation extension" see WAC 182-501-0169.

"Limited casualty program (LCP)" means the medically needy (MN) program.

"Long-term civil commitment" means inpatient mental health treatment for clients on 90-day or 180-day court orders whose treatment is authorized by the agency in agency-contracted beds.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-17-167, § 182-500-0065, filed 8/24/22, effective 9/24/22*
- *WSR 19-02-046, § 182-500-0065, filed 12/27/18, effective 1/27/19. WSR 11-14-075, recodified as § 182-500-0065, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. WSR 11-14-053, § 388-500-0065, filed 6/29/11, effective 7/30/11.*

##### **Wash. Admin. Code § 182-500-0070** Definitions—M. {#sec-182-500-0070 omnilex-key=us-wa-regs-official--title-182--182-500-0070}

"Managed care organization (MCO)" see WAC 182-538-050.

"Medicaid" means the federal medical aid program under Title XIX of the Social Security Act that provides health care to eligible people.

"Medicaid agency" means the state agency that administers the medicaid program. The Washington state health care authority (HCA) is the state's medicaid agency.

"Medicaid transformation project" refers to the demonstration granted to the state by the federal government under section 1115 of the Social Security Act. Under this demonstration, the federal government allows the state to engage in a five-year demonstration to support health care systems, to implement reform, and to provide new targeted medicaid services to eligible clients with significant needs.

"Medical assistance" is the term the agency and its predecessors use to mean all federal or state-funded health care programs, or both, administered by the agency or its designees. Medical assistance programs are referred to as Washington apple health.

"Medical care services (MCS)" means the limited scope health care program financed by state funds for clients who are eligible for the aged, blind, or disabled (ABD) cash assistance (see WAC 388-400-0060) or the housing and essential needs (HEN) referral program (see WAC 388-400-0065) and not eligible for other full-scope programs due to their citizenship or immigration status.

"Medical consultant" means a physician employed by or contracted with the agency or the agency's designee.

"Medical facility" means a medical institution or clinic that provides health care services.

"Medical institution" See "institution" in WAC 182-500-0050.

"Medical services card"or "services card" means the card the agency issues at the initial approval of a person's Washington apple health benefit. The card identifies the person's name and medical services identification number but is not proof of eligibility. The card may be replaced upon request if it is lost or stolen, but is not required to access health care through Washington apple health.

"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 purposes of this section, "course of treatment" may include mere observation or, where appropriate, no medical treatment at all.

"Medically needy (MN)" or "medically needy program (MNP)" means the state and federally funded health care program available to specific groups of people who would be eligible as categorically needy (CN), except their monthly income is above the CN standard. Some long-term care clients with income or resources above the CN standard may also qualify for MN.

"Medically needy income level (MNIL)" means the standard the agency uses to determine eligibility under the medically needy program. See WAC 182-519-0050.

"Medicare" is the federal government health insurance program under Titles II and XVIII of the Social Security Act. For additional information, see www.Medicare.gov.

"Medicare assignment" means the process by which a provider agrees to provide services to a medicare beneficiary and accept medicare's payment for the services.

"Medicare cost-sharing" means out-of-pocket medical expenses related to services provided by medicare. For clients enrolled in medicare, cost-sharing may include Part A and Part B premiums, co-insurance, deductibles, and copayments for medicare services. See chapter 182-517 WAC.

"Minimum essential coverage" means coverage under 26 U.S.C. Sec. 5000A(f).

"Modified adjusted gross income (MAGI)" means the adjusted gross income as determined by the Internal Revenue Service under the Internal Revenue Code of 1986 (IRC) increased by:

(a) Any amount excluded from gross income under 26 U.S.C. Sec. 911;

(b) Any amount of interest received or accrued by the client during the taxable year which is exempt from tax; and

(c) Any amount of Title II Social Security income or Tier 1 railroad retirement benefits excluded from gross income under 26 U.S.C. Sec. 86. See chapter 182-509 WAC for additional rules regarding MAGI.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2017 3rd sp.s. c 1 § 213 (1)(c). WSR 19-09-058, § 182-500-0070, filed 4/15/19, effective 7/1/19. Statutory Authority: RCW 41.05.021, 41.05.160, 2014 c 225 § 9 (1)(i) and 2016 1st sp.s c 36 § 213 (1)(f) and (g). WSR 17-11-136, § 182-500-0070, filed 5/24/17, effective 7/1/17. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-06-109, § 182-500-0070, filed 3/2/16, effective 4/2/16. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-500-0070, filed 12/9/13, effective 1/9/14. Statutory Authority: RCW 41.05.021, 74.09.035, and 2011 1st sp.s. c 36. WSR 12-19-051, § 182-500-0070, filed 9/13/12, effective 10/14/12. WSR 11-14-075, recodified as § 182-500-0070, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. WSR 11-14-053, § 388-500-0070, filed 6/29/11, effective 7/30/11.*

##### **Wash. Admin. Code § 182-500-0075** Medical assistance definitions—N. {#sec-182-500-0075 omnilex-key=us-wa-regs-official--title-182--182-500-0075}

"National correct coding initiative (NCCI)" is a national standard for the accurate and consistent description of medical goods and services using procedural codes. The standard is based on coding conventions defined in the American Medical Association's Current Procedural Terminology (CPT®) manual, current standards of medical and surgical coding practice, input from professional societies, and analysis of current coding practices. The Centers for Medicare and Medicaid Services (CMS) maintain NCCI policy. Information can be found at: http://www.cms.hhs.gov/NationalCorrectCodInitEd/.

"National provider indicator (NPI)" is a unique identification number for covered health care providers.

"NCCI edit" is a software step used to determine if a claim is billing for a service that is not in accordance with federal and state statutes, federal and state regulations, agency or the agency's designee's fee schedules, billing instructions, and other publications. The agency or the agency's designee has the final decision whether the NCCI edits allow automated payment for services that were not billed in accordance with governing law, NCCI standards or agency or agency's designee policy.

"Nonapplying spouse" see "spouse" in WAC 182-500-0100.

"Nonbilling provider" see definition for provider in WAC 182-500-0085.

"Noncovered service" see "covered service" in WAC 182-500-0020.

"Nonphysician practitioner" means the following professionals who work in collaboration with an ordering physician: Nurse practitioner, clinical nurse specialist, certified nurse midwife, or physician assistant.

"Nursing facility" see "institution" in WAC 182-500-0050.

"Nursing facility long-term care services" are services in a nursing facility when a person does not meet the criteria for rehabilitation. Most long-term care assists people with support services. (Also called custodial care.)

"Nursing facility rehabilitative services" are the planned interventions and procedures which constitute a continuing and comprehensive effort to restore a person to the person's former functional and environmental status, or alternatively, to maintain or maximize remaining function.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-21-061, § 182-500-0075, filed 10/12/23, effective 11/12/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Section 440.70. WSR 18-24-023, § 182-500-0075, filed 11/27/18, effective 1/1/19. Statutory Authority: 42 C.F.R. 455.410, RCW 41.05.021. WSR 13-19-037, § 182-500-0075, filed 9/11/13, effective 10/12/13. WSR 11-14-075, recodified as § 182-500-0075, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. WSR 11-14-053, § 388-500-0075, filed 6/29/11, effective 7/30/11.*

##### **Wash. Admin. Code § 182-500-0080** Medical assistance definitions—O. {#sec-182-500-0080 omnilex-key=us-wa-regs-official--title-182--182-500-0080}

"Ordering and referring provider" means any physician or other health care professional who orders or refers items or services for clients eligible for Washington's health care programs administered by the agency.

"Outpatient" means a patient receiving care in a hospital outpatient setting or a hospital emergency department, or away from a hospital such as in a physician's office or clinic, the patient's own home, or a nursing facility.

"Overhead costs" means those costs that have been incurred for common or joint objectives and cannot be readily identified with a particular final cost objective. Overhead costs that are allocated must be clearly distinguished from other functions and identified as a benefit to a direct service.

**History**
- *Statutory Authority: 42 C.F.R. 455.410, RCW 41.05.021. WSR 13-19-037, § 182-500-0080, filed 9/11/13, effective 10/12/13. WSR 11-14-075, recodified as § 182-500-0080, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. WSR 11-14-053, § 388-500-0080, filed 6/29/11, effective 7/30/11.*

##### **Wash. Admin. Code § 182-500-0085** Medical assistance definitions—P. {#sec-182-500-0085 omnilex-key=us-wa-regs-official--title-182--182-500-0085}

"Patient transportation" means client transportation to or from covered health care services under federal and state health care programs.

"Physician" means a doctor of medicine, osteopathy, naturopathy, or podiatry who is legally authorized to perform the functions of the profession by the state in which the services are performed.

"Prescribing provider" means a health care professional authorized by law or rule to prescribe drugs to Washington apple health clients.

"Prior authorization" means the requirement that a provider must request, on behalf of a client and when required by rule or agency billing instructions, the agency or the agency's designee's approval to provide a health care service before the client receives the health care service, prescribed drug, device, or drug-related supply. The agency or the agency's designee's approval is based on medical necessity. Receipt of prior authorization does not guarantee payment. Expedited prior authorization and limitation extension are types of prior authorization.

"Prosthetic device" means a preventive, replacement, corrective, or supportive device prescribed by a licensed provider within their scope of practice under state law.

"Provider" means an institution, agency, or person that is licensed, certified, accredited, credentialed, or registered according to state law, is an eligible provider type according to WAC 182-502-0002, authorized to provide services to Washington apple health clients, and has a signed core provider agreement, a nonbilling provider agreement, or other contract with the agency or is a servicing provider.

(a) "Servicing provider" means a health care professional screened and enrolled with the agency under a group, facility, or organization that has a signed core provider agreement (CPA).

(b) "Nonbilling provider" means a health care professional enrolled with the agency only as an ordering, referring, prescribing provider for the Washington medicaid program and who is not otherwise enrolled as a medicaid provider with the agency.

"Provider guide" means an agency publication that describes a specific benefit covered under Washington apple health, which includes client eligibility verification instructions, provider responsibilities, authorization requirements, coverage, billing, and how to complete and submit claims.

"Public institution" see "institution" in WAC 182-500-0050.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-21-061, § 182-500-0085, filed 10/12/23, effective 11/12/23*
- *WSR 15-21-063, § 182-500-0085, filed 10/19/15, effective 11/19/15. Statutory Authority: RCW 41.05.021, 2013 2nd sp.s. c 4, and Patient Protection and Affordable Care Act (P.L. 111-148). WSR 14-06-045, § 182-500-0085, filed 2/26/14, effective 3/29/14. Statutory Authority: 42 C.F.R. 455.410, RCW 41.05.021. WSR 13-19-037, § 182-500-0085, filed 9/11/13, effective 10/12/13. WSR 11-14-075, recodified as § 182-500-0085, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. WSR 11-14-053, § 388-500-0085, filed 6/29/11, effective 7/30/11.*

##### **Wash. Admin. Code § 182-500-0090** Medical assistance definitions—Q. {#sec-182-500-0090 omnilex-key=us-wa-regs-official--title-182--182-500-0090}

"Qualified health plan (QHP)" means a health insurance plan that has been certified by the Washington health benefit exchange to meet at minimum the standards described in 45 C.F.R. Part 156, Subpart C and RCW 43.71.065 and offered in accordance with the process described in 45 C.F.R. Part 155, Subpart K and RCW 43.71.065.

**History**
- *Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-500-0090, filed 12/9/13, effective 1/9/14.*

##### **Wash. Admin. Code § 182-500-0095** Medical assistance definitions—R. {#sec-182-500-0095 omnilex-key=us-wa-regs-official--title-182--182-500-0095}

"Reasonably compatible" means the amount of a person's self-attested income or resources (as defined in WAC 182-500-0100) and the amount of a person's income or resources verified via electronic data sources are either both above or both below the applicable income or resources standard for Washington apple health (WAH). When self-attested income or resources is less than the standard for WAH, but income or resources from available data sources is more than the WAH standard, or when the self-attested income or resources cannot be verified via electronic data sources, the self-attested income or resources are considered not reasonably compatible.

"Retroactive period" means approval of medical coverage for any or all of the retroactive period. A client may be eligible only in the retroactive period or may have both current eligibility and a separate retroactive period of eligibility approved.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-22-050, § 182-500-0095, filed 10/25/23, effective 11/25/23. Statutory Authority: RCW 41.05.021, 41.05.160, 2014 c 225. WSR 16-06-053, § 182-500-0095, filed 2/24/16, effective 4/1/16. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-500-0095, filed 12/9/13, effective 1/9/14. WSR 11-14-075, recodified as § 182-500-0095, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. WSR 11-14-053, § 388-500-0095, filed 6/29/11, effective 7/30/11.*

##### **Wash. Admin. Code § 182-500-0100** Definitions—S. {#sec-182-500-0100 omnilex-key=us-wa-regs-official--title-182--182-500-0100}

"Self-attestation" means a person's written, verbal, or electronic declaration of the person's income, resources, or circumstances made under penalty of perjury, confirming a statement to be true. (See also "attested income" or "attested resources.")

"Spenddown" is a term used in the medically needy (MN) program and 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 agency. See WAC 182-519-0110.

"Spouse" means a person who is legally married to another person. Washington state recognizes other states' determinations of legal and common-law marriages between two persons.

(1) "Community spouse" means a person who:

(a) Does not reside in a medical institution; and

(b) Is legally married to a client who resides in a medical institution or receives services from a home and community-based waiver program. A person is considered married if not divorced, even when physically or legally separated from the person's spouse.

(2) "Eligible spouse" means an aged, blind or disabled husband or wife of an SSI-eligible person, who lives with the SSI-eligible person, and is also eligible for SSI.

(3) "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) for a client in December 1973, who continues to live in the home and remains married to the client.

(4) "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.

(5) "Institutionalized spouse" means a legally married person who has attained institutional status as described in chapter 182-513 WAC, and receives services in a medical institution or from a home or community-based waiver program described in chapter 182-515 WAC. A person is considered married if not divorced, even when physically or legally separated from the person's spouse.

(6) "Nonapplying spouse" means an SSI-related person's husband or wife, who has not applied for medical assistance.

"SSI-related" means an aged, blind or disabled person not receiving an SSI cash grant.

"State supplemental payment (SSP)" is a state-funded cash benefit for certain individuals who are either recipients of the Title XVI supplemental security income (SSI) program or who are clients of the division of developmental disabilities. The SSP allotment for Washington state is a fixed amount of $28,900,000 and must be shared between all individuals who fall into one of the groups listed below. The amount of the SSP may vary each year depending on the number of individuals who qualify. The following groups are eligible for an SSP:

(1) Mandatory SSP group—SSP made to a mandatory income level client (MIL) who was grandfathered into the SSI program. To be eligible in this group, an individual must have been receiving cash assistance in December 1973 under the department of social and health services former old age assistance program or aid to the blind and disability assistance. Individuals in this group receive an SSP to bring their income to the level they received prior to the implementation of the SSI program in 1973.

(2) Optional SSP group—SSP made to any of the following:

(a) An individual who receives SSI and has an ineligible spouse.

(b) An individual who receives SSI based on meeting the age criteria of 65 or older.

(c) An individual who receives SSI based on blindness.

(d) An individual who has been determined eligible for SSP by the division of developmental disabilities.

(e) An individual who is eligible for SSI as a foster child as described in WAC 388-474-0012.

"Substance use disorder professional (SUDP)" - See WAC 246-811-010.

"Supplemental security income (SSI) program (Title XVI)" is the federal grant program for aged, blind, and disabled persons, established by section 301 of the Social Security amendments of 1972, and subsequent amendments, and administered by the Social Security Administration (SSA).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2024 c 371, and chapter 246-929 WAC. WSR 25-22-061, s 182-500-0100, filed 10/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-22-050, § 182-500-0100, filed 10/25/23, effective 11/25/23. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-500-0100, filed 12/9/13, effective 1/9/14. WSR 11-14-075, recodified as § 182-500-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. WSR 11-14-053, § 388-500-0100, filed 6/29/11, effective 7/30/11.*

##### **Wash. Admin. Code § 182-500-0105** Medical assistance definitions—T. {#sec-182-500-0105 omnilex-key=us-wa-regs-official--title-182--182-500-0105}

"Tax dependent" means a person for whom a tax filer claims an exemption on his or her federal income tax return. A tax dependent may be either a qualifying child or a qualifying relative under 26 U.S.C. Sec. 152 for a taxable year.

"Tax filer" means a person who expects to file a federal income tax return.

"Third party" means an entity other than the medicaid agency or the agency's designee that may be liable to pay all or part of the cost of health care for a Washington apple health (WAH) client.

"Third-party liability (TPL)" means the legal responsibility of an identified third party or parties to pay all or part of the cost of health care for a WAH client. See client obligations in establishing TPL under WAC 182-503-0540.

"Title XIX" is the portion of the federal Social Security Act, 42 U.S.C. 1396 et seq., that authorizes funding to states for health care programs. Title XIX is also called medicaid.

"Title XXI" is the portion of the federal Social Security Act, 42 U.S.C. 1397aa et seq., that authorizes funding to states for the children's health insurance program (CHIP).

"Transfer of assets" means changing ownership or title of an asset such as income, real property, or personal property by one of the following:

(a) An intentional act that changes ownership or title; or

(b) A failure to act that results in a change of ownership or title.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-21-063, § 182-500-0105, filed 10/19/15, effective 11/19/15. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-500-0105, filed 2/28/14, effective 3/31/14. WSR 11-14-075, recodified as § 182-500-0105, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. WSR 11-14-053, § 388-500-0105, filed 6/29/11, effective 7/30/11.*

##### **Wash. Admin. Code § 182-500-0110** Medical assistance definitions—U. {#sec-182-500-0110 omnilex-key=us-wa-regs-official--title-182--182-500-0110}

"Urgent care" means an unplanned appointment for a covered medical service with verification from an attending physician or facility that the client must be seen that day or the following day.

"Usual and customary charge" means the amount a provider typically charges to fifty percent or more of patients who are not medical assistance clients.

**History**
- *WSR 11-14-075, recodified as § 182-500-0110, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. WSR 11-14-053, § 388-500-0110, filed 6/29/11, effective 7/30/11.*

##### **Wash. Admin. Code § 182-500-0120** Medical assistance definitions—W. {#sec-182-500-0120 omnilex-key=us-wa-regs-official--title-182--182-500-0120}

"Washington apple health" means the public health insurance programs for eligible Washington residents. Washington apple health is the name used in Washington state for medicaid, the children's health insurance program (CHIP), and state-only funded health care programs.

"Washington Healthplanfinder" is a marketplace for individuals, families, and small businesses in Washington state to compare and enroll in health insurance coverage and gain access to premium tax credits, reduced cost sharing, and public programs such as Washington apple health. Washington Healthplanfinder is administered by the Washington health benefit exchange.

**History**
- *Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 13-14-019, § 182-500-0120, filed 6/24/13, effective 7/25/13.*

## **Chapter 182-501** Administration of medical programs—General. {#struct-chapter-182-501}

##### **Wash. Admin. Code § 182-501-0050** Health care general coverage. {#sec-182-501-0050 omnilex-key=us-wa-regs-official--title-182--182-501-0050}

WAC 182-501-0050 through 182-501-0065 describe the health care services available to a client on a fee-for-service basis or to a client enrolled in a managed care organization (MCO) (defined in WAC 182-538-050). For the purposes of this section, health care services includes treatment, equipment, related supplies, and drugs. WAC 182-501-0070 describes noncovered services.

(1) Health care service categories listed in WAC 182-501-0060 do not represent a contract for health care services.

(2) For the provider to receive payment, the client must be eligible for the covered health care service on the date the health care service is performed or provided.

(3) Under the agency's fee-for-service programs, providers must be enrolled with the agency or its designee and meet the requirements of chapter 182-502 WAC to be paid for furnishing health care services to clients.

(4) The agency or its designee pays only for the health care services that are:

(a) Included in the client's health care benefits package as described in WAC 182-501-0060;

(b) Covered - See subsection (9) of this section;

(c) Ordered or prescribed by a health care provider who meets the requirements of chapter 182-502 WAC;

(d) Medically necessary as defined in WAC 182-500-0070;

(e) Submitted for authorization, when required, in accordance with WAC 182-501-0163;

(f) Approved, when required, in accordance with WAC 182-501-0165;

(g) Furnished by a provider according to chapter 182-502 WAC; and

(h) Billed in accordance with agency or its designee program rules and the agency's current published billing instructions.

(5) The agency does not pay for any health care service requiring prior authorization from the agency or its designee, if prior authorization was not obtained before the health care service was provided; unless:

(a) The client is determined to be retroactively eligible for medical assistance; and

(b) The request meets the requirements of subsection (4) of this section.

(6) The agency does not reimburse clients for health care services purchased out-of-pocket.

(7) The agency does not pay for the replacement of agency-purchased equipment, devices, or supplies which have been sold, gifted, lost, broken, destroyed, or stolen as a result of the client's carelessness, negligence, recklessness, deliberate intent, or misuse unless:

(a) Extenuating circumstances exist that result in a loss or destruction of agency-purchased equipment, devices, or supplies, through no fault of the client that occurred while the client was exercising reasonable care under the circumstances; or

(b) Otherwise allowed under specific agency program rules.

(8) The agency's refusal to pay for replacement of equipment, device, or supplies will not extend beyond the limitations stated in specific agency program rules.

(9) Covered health care services.

(a) Covered health care services are either:

(i) "Federally mandated" - Means the state of Washington is required by federal regulation (42 C.F.R. 440.210 and 220) to cover the health care service for medicaid clients; or

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

(b) The agency may limit the scope, amount, duration, and/or frequency of covered health care services. Limitation extensions are authorized according to WAC 182-501-0169.

(10) Noncovered health care services.

(a) The agency does not pay for any health care service listed as noncovered in WAC 182-501-0070 or in any other agency program rule, unless the agency grants a request for an exception to rule allowing payment for the noncovered service. The agency evaluates a request for a noncovered health care service only if an exception to rule is requested according to the provisions in WAC 182-501-0160.

(b) For children age 20 and younger, providers must follow the rules for the early periodic screening, diagnosis, and treatment (EPSDT) program; see chapter 182-534 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-21-142, s 182-501-0050, filed 10/21/25, effective 11/21/25. Statutory Authority: RCW 41.05.021. WSR 13-15-044, § 182-501-0050, filed 7/11/13, effective 8/11/13. WSR 11-14-075, recodified as § 182-501-0050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-07-116, § 388-501-0050, filed 3/22/10, effective 4/22/10. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 09-23-112, § 388-501-0050, filed 11/18/09, effective 12/19/09*
- *WSR 06-24-036, § 388-501-0050, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090. WSR 01-12-070, § 388-501-0050, filed 6/4/01, effective 7/5/01. Statutory Authority: RCW 74.04.050 and 74.08.090. WSR 00-01-088, § 388-501-0050, filed 12/14/99, effective 1/14/00.*

##### **Wash. Admin. Code § 182-501-0055** Health care coverage—How the agency determines coverage of services for its health care programs using health technology assessments. {#sec-182-501-0055 omnilex-key=us-wa-regs-official--title-182--182-501-0055}

(1) The medicaid agency uses health technology assessments to determine whether a new technology, new indication, or existing technology approved by the Food and Drug Administration (FDA) is a covered service under agency health care programs. The agency only uses health technology assessments when coverage is not mandated by federal or state law. A health technology assessment may be conducted by or on behalf of:

(a) The agency; or

(b) The health technology assessment clinical committee (HTACC) under RCW 70.14.080 through 70.14.140.

(2) The agency reviews available evidence relevant to a medical or dental service or health care-related equipment and uses a technology evaluation matrix to:

(a) Determine its efficacy, effectiveness, and safety;

(b) Determine its impact on health outcomes;

(c) Identify indications for use;

(d) Identify potential for misuse or abuse; and

(e) Compare to alternative technologies to assess benefit vs. harm and cost effectiveness.

(3) The agency may determine the technology, device, or technology-related supply is:

(a) Covered (see WAC 182-501-0060 for the scope of coverage under Washington apple health (WAH) programs);

(b) Covered with authorization (see WAC 182-501-0165 for the process on how authorization is determined);

(c) Covered with limitations (see WAC 182-501-0169 for how limitations can be extended); or

(d) Noncovered (see WAC 182-501-0070 for noncovered services).

(4) The agency may periodically review existing technologies, devices, or technology-related supplies and reassign authorization requirements as necessary using the provisions in this section for new technologies, devices, or technology-related supplies.

(5) The agency evaluates the evidence and criteria from HTACC to determine whether a service is covered under WAC 182-501-0050 (9) and (10) and this section.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-15-053, § 182-501-0055, filed 7/9/15, effective 8/9/15. WSR 11-14-075, recodified as § 182-501-0055, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-07-116, § 388-501-0055, filed 3/22/10, effective 4/22/10. Statutory Authority: RCW 74.08.090 and 70.14.090. WSR 09-17-004, § 388-501-0055, filed 8/6/09, effective 9/6/09.*

##### **Wash. Admin. Code § 182-501-0060** Health care coverage—Program benefit packages—Scope of service categories. {#sec-182-501-0060 omnilex-key=us-wa-regs-official--title-182--182-501-0060}

(1) This rule provides a table that lists:

(a) The following Washington apple health programs:

(i) The alternative benefits plan (ABP) medicaid;

(ii) Categorically needy (CN) medicaid;

(iii) Medically needy (MN) medicaid; and

(iv) Medical care services (MCS) programs (includes incapacity-based and aged, blind, and disabled medical care services), as described in WAC 182-508-0005; and

(b) The benefit packages showing what service categories are included for each program.

(2) Within a service category included in a benefit package, some services may be covered and others noncovered.

(3) Services covered within each service category included in a benefit package:

(a) Are determined in accordance with WAC 182-501-0050 and 182-501-0055 when applicable.

(b) May be subject to limitations, restrictions, and eligibility requirements contained in agency rules.

(c) May require prior authorization (see WAC 182-501-0165) or expedited prior authorization when allowed by the agency.

(d) Are paid for by the agency or the agency's designee and subject to review both before and after payment is made. The agency or the client's managed care organization may deny or recover payment for such services, equipment, and supplies based on these reviews.

(4) The agency does not pay for covered services, equipment, or supplies that:

(a) Require prior authorization from the agency or the agency's designee, if prior authorization was not obtained before the service was provided;

(b) Are provided by providers who are not contracted with the agency as required under chapter 182-502 WAC;

(c) Are included in an agency or the agency's designee waiver program identified in chapter 182-515 WAC; or

(d) Are covered by a third-party payor (see WAC 182-501-0200), including medicare, if the third-party payor has not made a determination on the claim or has not been billed by the provider.

(5) Programs not addressed in the table:

(a) Medical assistance programs for noncitizens (see chapter 182-507 WAC); and

(b) Family planning only programs (see WAC 182-532-500 through 182-532-570);

(c) Postpartum and family planning extension (see WAC 182-523-0130(4) and 182-505-0115(5));

(d) Eligibility for pregnant minors (see WAC 182-505-0117); and

(e) Kidney disease program (see chapter 182-540 WAC).

(6) Scope of service categories. The following table lists the agency's categories of health care services.

(a) Under the ABP, CN, and MN headings, there are two columns. One addresses clients 20 years of age and younger, and the other addresses clients 21 years of age and older.

(b) The letter "Y" means a service category is included for that program. Services within each service category are subject to limitations and restrictions listed in the specific medical assistance program rules and agency issuances.

(c) The letter "N" means a service category is not included for that program.

(d) Refer to WAC 182-501-0065 for a description of each service category and for the specific program rules containing the limitations and restrictions to services.

| Service Categories | ABP 20- | ABP 21+ | CN1 20- | CN 21+ | MN 20- | MN 21+ | MCS |
| --- | --- | --- | --- | --- | --- | --- | --- |
| Ambulance (ground and air) | Y | Y | Y | Y | Y | Y | Y |
| Applied behavior analysis (ABA) | Y | Y | Y | Y | Y | Y | N |
| Behavioral health services | Y | Y | Y | Y | Y | Y | Y |
| Blood/blood products/related services | Y | Y | Y | Y | Y | Y | Y |
| Dental services | Y | Y | Y | Y | Y | Y | Y |
| Diagnostic services (lab and X-ray) | Y | Y | Y | Y | Y | Y | Y |
| Early and periodic screening, diagnosis, and treatment (EPSDT) services | Y | N | Y | N | Y | N | N |
| Enteral nutrition program | Y | Y | Y | Y | Y | Y | Y |
| Habilitative services | Y | Y | N | N | N | N | N |
| Health care professional services | Y | Y | Y | Y | Y | Y | Y |
| Health homes | Y | Y | Y | Y | N | N | N |
| Hearing evaluations | Y | Y | Y | Y | Y | Y | Y |
| Hearing aids | Y | Y | Y | Y | Y | Y | Y |
| Home health services | Y | Y | Y | Y | Y | Y | Y |
| Home infusion therapy/parenteral nutrition program | Y | Y | Y | Y | Y | Y | Y |
| Hospice services | Y | Y | Y | Y | Y | Y | N |
| Hospital services Inpatient/outpatient | Y | Y | Y | Y | Y | Y | Y |
| Intermediate care facility/services for persons with intellectual disabilities | Y | Y | Y | Y | Y | Y | N |
| Maternity care and delivery services | Y | Y | Y | Y | Y | Y | Y |
| Medical equipment, supplies, and appliances | Y | Y | Y | Y | Y | Y | Y |
| Medical nutrition therapy | Y | Y | Y | Y | Y | Y | Y |
| Nursing facility services | Y | Y | Y | Y | Y | Y | Y |
| Organ transplants | Y | Y | Y | Y | Y | Y | Y |
| Orthodontic services | Y | N | Y | N | Y | N | N |
| Out-of-state services | Y | Y | Y | Y | Y | Y | N |
| Outpatient rehabilitation services (OT, PT, ST) | Y | Y | Y | Y | Y | Y | Y |
| Personal care services | Y | Y | Y | Y | N | N | Y* |
| Prescription drugs | Y | Y | Y | Y | Y | Y | Y |
| Private duty nursing | Y | Y | Y | Y | Y | Y | N |
| Prosthetic/orthotic devices | Y | Y | Y | Y | Y | Y | Y |
| Reproductive health services | Y | Y | Y | Y | Y | Y | Y |
| Respiratory care (oxygen) | Y | Y | Y | Y | Y | Y | Y |
| School-based medical services | Y | N | Y | N | Y | N | N |
| Vision care Exams, refractions, and fittings | Y | Y | Y | Y | Y | Y | Y |
| Vision hardware Frames and lenses | Y | N | Y | N | Y | N | N |

| 1 | Clients enrolled in the Washington apple health for kids and Washington apple health for kids with premium programs, which includes the children's health insurance program (CHIP), receive CN-scope of health care services. |
| --- | --- |
| * | These services are available only in an adult family home or assisted living facility setting. |

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-11-001, s 182-501-0060, filed 5/7/26, effective 6/7/26*
- *WSR 23-07-132, § 182-501-0060, filed 3/22/23, effective 4/22/23. Statutory Authority: RCW 41.05.021, 41.05.160, and Thurston County Superior Court in J.C. and H.S. v. Washington State Health Care Authority, no. 20-2-01813-34. WSR 22-08-035, § 182-501-0060, filed 3/29/22, effective 4/29/22. Statutory Authority: RCW 41.05.021, 41.05.160, 2018 c 159. WSR 19-14-020, § 182-501-0060, filed 6/24/19, effective 7/25/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-07-083, § 182-501-0060, filed 3/17/15, effective 4/17/15. Statutory Authority: RCW 41.05.021, 2013 2nd sp.s. c 4, and Patient Protection and Affordable Care Act (P.L. 111-148). WSR 14-06-045, § 182-501-0060, filed 2/26/14, effective 3/29/14. Statutory Authority: RCW 41.05.021. WSR 13-15-044, § 182-501-0060, filed 7/11/13, effective 8/11/13. WSR 11-14-075, recodified as § 182-501-0060, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-501-0060, filed 11/30/06, effective 1/1/07.*

##### **Wash. Admin. Code § 182-501-0065** Health care coverage—Description of service categories. {#sec-182-501-0065 omnilex-key=us-wa-regs-official--title-182--182-501-0065}

This rule provides a brief description of the medical, dental, mental health, and substance use disorder (SUD) service categories listed in the table in WAC 182-501-0060. The description of services under each category is not intended to be all inclusive.

(1) For alternative benefits plan (ABP), categorically needy (CN), medically needy (MN), and medical care services (MCS), refer to the WAC citations listed in the following descriptions for specific details regarding each service category.

(2) The following service categories are subject to the exclusions, limitations, restrictions, and eligibility requirements contained in agency rules:

(a) Ambulance - Emergency medical transportation and ambulance transportation for nonemergency medical needs. (WAC 182-546-0001 through 182-546-4000.)

(b) Applied behavior analysis (ABA) - (Chapter 182-531A WAC.)

(c) Behavioral health services - (Chapter 182-538D WAC, Behavioral health services, WAC 182-531-1400 Psychiatric physician-related services and other professional mental health services, and chapter 246-341 WAC, Behavioral health services administrative requirements.)

(d) Blood, blood products, and related services - Blood and/or blood derivatives, including synthetic factors, plasma expanders, and their administration. (WAC 182-550-1400 and 182-550-1500.)

(e) Community behavioral health support services (CBHS) - (Chapter 182-561 WAC.)

(f) Dental services - Diagnosis and treatment of dental problems including emergency treatment and preventive care. (Chapters 182-535 and 182-535A WAC.)

(g) Diagnostic services - Clinical testing and imaging services. (WAC 182-531-0100; WAC 182-550-1400 and 182-550-1500.)

(h) Early and periodic screening, diagnosis, and treatment (EPSDT) - (Chapter 182-534 WAC and WAC 182-501-0050(10).)

(i) Enteral nutrition program - Enteral nutrition products, equipment, and related supplies. (Chapter 182-554 WAC.)

(j) Habilitative services - (Chapter 182-545 WAC.)

(k) Health care professional services - The following services found in chapter 182-531 WAC:

(i) Office visits and vaccinations;

(ii) Screening/brief intervention/referral to treatment (SBIRT), emergency room, and nursing facility services;

(iii) Home-based and hospital-based services;

(iv) Surgery, anesthesia, pathology, radiology, and laboratory services;

(v) Obstetric services;

(vi) Kidney dialysis and renal disease services;

(vii) Advanced registered nurse practitioner, naturopathy, osteopathy, podiatry, physiatry, and pulmonary/respiratory services; and

(viii) Allergen immunotherapy services.

(l) Health homes - (Chapter 182-557 WAC.)

(m) Hearing evaluations - The following services found in WAC 182-531-0375:

(i) Audiology;

(ii) Diagnostic evaluations; and

(iii) Hearing exams and testing.

(n) Hearing aids - (Chapter 182-547 WAC.)

(o) Home health services - Intermittent, short-term skilled nursing care, occupational therapy, physical therapy, speech therapy, home infusion therapy, and health aide services, provided in the home. (WAC 182-551-2000 through 182-551-2220.)

(p) Home infusion therapy/parenteral nutrition program - Supplies and equipment necessary for parenteral infusion of therapeutic agents. (Chapter 182-553 WAC.)

(q) Hospice services - Physician services, skilled nursing care, medical social services, counseling services for client and family, drugs, medications (including biologicals), medical equipment and supplies needed for palliative care, home health aide, homemaker, personal care services, medical transportation, respite care, and brief inpatient care. This benefit also includes services rendered in a hospice care center and pediatric palliative care services. (WAC 182-551-1210 through 182-551-1850.)

(r) Hospital services—Inpatient/outpatient - Emergency room; hospital room and board (includes nursing care); inpatient services, supplies, equipment, and prescription drugs; surgery, anesthesia; diagnostic testing, laboratory work, blood/blood derivatives; radiation and imaging treatment and diagnostic services; and outpatient or day surgery, and obstetrical services. (Chapter 182-550 WAC.)

(s) Intermediate care facility/services for persons with intellectual disabilities - Habilitative training, health-related care, supervision, and residential care. (Chapter 388-835 WAC.)

(t) Maternity care and delivery services - Community health nurse visits, nutrition visits, behavioral health visits, midwife services, maternity and infant case management services, family planning services and community health worker visits. (WAC 182-533-0330.)

(u) Medical equipment, supplies, and appliances - Medical equipment and appliances, including wheelchairs, hospital beds, respiratory equipment; casts, splints, crutches, trusses, and braces. Medical supplies, including antiseptics, germicides, bandages, dressings, tape, blood monitoring/testing supplies, braces, belts, supporting devices, decubitus care products, ostomy supplies, syringes, needles, and urological supplies. (Chapter 182-543 WAC.)

(v) Medical nutrition therapy – Outpatient medical nutrition therapy and associated follow-ups. (Chapter 182-555 WAC.)

(w) Nursing facility services - Nursing, therapies, dietary, and daily care services delivered in a licensed nursing facility. (Chapter 388-97 WAC.)

(x) Organ transplants - Solid organs, e.g., heart, kidney, liver, lung, pancreas, and small bowel; bone marrow and peripheral stem cell; skin grafts; and corneal transplants. (WAC 182-550-1900 and 182-556-0400.)

(y) Orthodontic services - (Chapter 182-535A WAC.)

(z) Out-of-state services - (WAC 182-502-0120.)

(aa) Outpatient rehabilitation services (OT, PT, ST) - Evaluations, assessments, and treatment. (WAC 182-545-200.)

(bb) Personal care services - Assistance with activities of daily living (e.g., bathing, dressing, eating, managing medications) and routine household chores (e.g., meal preparation, housework, essential shopping, transportation to medical services). (Chapters 388-106 and 388-845 WAC.)

(cc) Prescription drugs - Outpatient drugs (including in nursing facilities), both generic and brand name; drug devices and supplies; some over-the-counter drugs; oral, topical, injectable drugs; vaccines, immunizations, and biologicals; and family planning drugs, devices, and supplies. (WAC 182-530-2000.) Additional coverage for medications and prescriptions is addressed in specific program WAC sections.

(dd) Private duty nursing - Continuous skilled nursing services provided in a private residence, including client assessment, administration of treatment, and monitoring of medical equipment and client care. For benefits for clients age 17 and younger, see WAC 182-551-3000 through 182-551-3400. For benefits for clients age 18 and older, see WAC 388-106-1000 through 388-106-1055.

(ee) Prosthetic/orthotic devices - Artificial limbs and other external body parts; devices that prevent, support, or correct a physical deformity or malfunction. (WAC 182-543-5000.)

(ff) Reproductive health services - Gynecological exams; contraceptives, drugs, and supplies, including prescriptions; sterilization; screening and treatment of sexually transmitted diseases; and educational services. (WAC 182-532-001 through 182-532-140.)

(gg) Respiratory care (oxygen) - All services, oxygen, equipment, and supplies related to respiratory care. (Chapter 182-552 WAC.)

(hh) School-based health care services - Early intervention services or special education health-related services provided in schools to medicaid-eligible children ages birth through 20 who have an individualized education program (IEP) or individualized family service plan (IFSP). (Chapter 182-537 WAC.)

(ii) Vision care - Eye exams, refractions, fittings, visual field testing, vision therapy, ocular prosthetics, and surgery. (WAC 182-531-1000.)

(jj) Vision hardware - Frames and lenses. (Chapter 182-544 WAC.)

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-10-081, § 182-501-0065, filed 4/30/24, effective 7/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, 2018 c 159. WSR 19-14-020, § 182-501-0065, filed 6/24/19, effective 7/25/19. Statutory Authority: RCW 41.05.021, 2013 2nd sp.s. c 4, and Patient Protection and Affordable Care Act (P.L. 111-148). WSR 14-06-045, § 182-501-0065, filed 2/26/14, effective 3/29/14. Statutory Authority: RCW 41.05.021. WSR 13-15-044, § 182-501-0065, filed 7/11/13, effective 8/11/13. WSR 11-14-075, recodified as § 182-501-0065, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-501-0065, filed 11/30/06, effective 1/1/07.*

##### **Wash. Admin. Code § 182-501-0070** Health care coverage—Noncovered services. {#sec-182-501-0070 omnilex-key=us-wa-regs-official--title-182--182-501-0070}

(1) The medicaid agency or the agency's designee does not pay for any health care service not listed or referred to as a covered health care service under the medical programs described in WAC 182-501-0060, regardless of medical necessity. For the purposes of this section, health care services includes treatment, equipment, related supplies, and drugs. Circumstances in which clients are responsible for payment of health care services are described in WAC 182-502-0160.

(2) This section does not apply to health care services provided as a result of the early and periodic screening, diagnosis, and treatment (EPSDT) program as described in chapter 182-534 WAC.

(3) The agency or the agency's designee does not pay for any ancillary health care service(s) provided in association with a noncovered health care service.

(4) The following list of noncovered health care services is not intended to be exhaustive. Noncovered health care services include, but are not limited to:

(a) Any health care service specifically excluded by federal or state law;

(b) Acupuncture, Christian Science practice, faith healing, herbal therapy, homeopathy, massage, massage therapy, and sanipractice;

(c) Chiropractic care for adults;

(d) Cosmetic, reconstructive, or plastic surgery, and any related health care services, not specifically allowed under WAC 182-531-0100(4) or 182-531-1675;

(e) Discography;

(f) Ear or other body piercing;

(g) Face lifts or other facial cosmetic enhancements;

(h) Fertility, infertility or sexual dysfunction testing, and related care, drugs, and/or treatment including, but not limited to:

(i) Artificial insemination;

(ii) Donor ovum, donor sperm, or gestational carrier;

(iii) In vitro fertilization;

(iv) Penile implants;

(v) Reversal of sterilization; and

(vi) Sex therapy.

(i) Hair transplants;

(j) Epilation (hair removal) and electrolysis not specifically allowed under WAC 182-531-1675;

(k) Marital counseling;

(l) Motion analysis, athletic training evaluation, work hardening condition, high altitude simulation test, and health and behavior assessment;

(m) Nonmedical equipment;

(n) Penile implants;

(o) Prosthetic testicles not specifically allowed under WAC 182-531-1675;

(p) Psychiatric sleep therapy;

(q) Subcutaneous injection filling;

(r) Tattoo removal;

(s) Transport of Involuntary Treatment Act (ITA) clients to or from out-of-state treatment facilities, including those in bordering cities;

(t) Upright magnetic resonance imaging (MRI); and

(u) Vehicle purchase - New or used vehicle.

(5) For a specific list of noncovered health care services in the following service categories, refer to the WAC citation:

(a) Ambulance transportation and nonemergent transportation as described in chapter 182-546 WAC;

(b) Dental services as described in chapter 182-535 WAC;

(c) Durable medical equipment as described in chapter 182-543 WAC;

(d) Hearing care services as described in chapter 182-547 WAC;

(e) Home health services as described in WAC 182-551-2130;

(f) Hospital services as described in WAC 182-550-1600;

(g) Health care professional services as described in WAC 182-531-0150;

(h) Prescription drugs as described in chapter 182-530 WAC;

(i) Vision care hardware for clients 20 years of age and younger as described in chapter 182-544 WAC; and

(j) Vision care exams as described in WAC 182-531-1000.

(6) A client has a right to request an administrative hearing, if one is available under state and federal law. When the agency or its designee denies all or part of a request for a noncovered health care service(s), the agency or its designee sends the client and the provider written notice, within 10 business days of the date the decision is made, that includes:

(a) A statement of the action the agency or its designee intends to take;

(b) Reference to the specific WAC provision upon which the denial is based;

(c) Sufficient detail to enable the recipient to:

(i) Learn why the agency's or its designee's action was taken; and

(ii) Prepare a response to the agency's or its designee's decision to classify the requested health care service as noncovered.

(d) The specific factual basis for the intended action; and

(e) The following information:

(i) Administrative hearing rights;

(ii) Instructions on how to request the hearing;

(iii) Acknowledgment that a client may be represented at the hearing by legal counsel or other representative;

(iv) Instructions on how to request an exception to rule (ETR);

(v) Information regarding agency-covered health care services, if any, as an alternative to the requested noncovered health care service; and

(vi) Upon the client's request, the name and address of the nearest legal services office.

(7) A client can request an exception to rule (ETR) as described in WAC 182-501-0160.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-23-096, s 182-501-0070, filed 11/19/24, effective 1/1/25*
- *WSR 22-07-105, § 182-501-0070, filed 3/23/22, effective 4/23/22*
- *WSR 16-22-024, § 182-501-0070, filed 10/24/16, effective 11/24/16*
- *WSR 15-16-084, § 182-501-0070, filed 7/31/15, effective 8/31/15. Statutory Authority: RCW 41.05.021. WSR 13-15-044, § 182-501-0070, filed 7/11/13, effective 8/11/13. Statutory Authority: RCW 41.05.021 and section 1927 of the Social Security Act. WSR 12-18-062, § 182-501-0070, filed 8/31/12, effective 10/1/12. WSR 11-14-075, recodified as § 182-501-0070, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 09-23-112, § 388-501-0070, filed 11/18/09, effective 12/19/09*
- *WSR 07-04-036, § 388-501-0070, filed 1/29/07, effective 3/1/07.*

##### **Wash. Admin. Code § 182-501-0100** Subrogation. {#sec-182-501-0100 omnilex-key=us-wa-regs-official--title-182--182-501-0100}

(1) For the purpose of this section, "liable third party" means:

(a) The tort-feasor, or insurer of the tort-feasor, or both; and

(b) Any person, entity or program that is or may be liable to provide coverage for the illness or injuries for which the medicaid agency is providing assistance or residential care.

(2) As a condition of medical care eligibility, a client must assign to the state any right the client may have to receive payment from any liable third party for medical expenses, assistance, or residential care.

(3) To the extent authorized by a contract executed under RCW 74.09.522, a managed health care plan has the rights and remedies of the agency under RCW 41.05A.070, 43.20B.060, and 74.09.180.

(4) The agency is not responsible for medical care payment(s) for a client whose personal injuries are caused by the negligence or wrongdoing of another. However, the agency may provide the medical care required as a result of an injury or illness to the client if the client is otherwise eligible for medical care.

(5) The agency may pursue its right to recover the value of medical care provided to an eligible client from any liable third party or third-party settlement or judgment as a subrogee, assignee, or by enforcement of its public assistance lien under RCW 41.05A.050 through 41.05A.070, 43.20B.040 through 43.20B.070, 74.09.180, and 74.09.185.

(6) Notice to the agency and determining the reimbursement amount:

(a) The client or the client's legal representative must notify the agency in writing when filing any claim against a third party, commencing an action at law, negotiating a settlement, or accepting an offer from the liable third party. Send notices under this section to:

Health Care Authority

COB Casualty Unit

P.O. Box 45561

Olympia, WA 98504-5561

Fax: 360-753-3077

(b) The client or the client's legal representative must give the agency documentation proposing allocation of damages, if any, to be used for settlement or to be proven at trial.

(c) Where damages, including medical damages, have not been designated in the settlement or judgment, the client or the client's legal representative must contact the agency to determine the appropriate reimbursement amount for payments the agency made for the client's benefit.

(d) If the client and the agency cannot agree upon the appropriate reimbursement amount, any party may bring a motion in superior court for a hearing to determine the amount of reimbursement to the agency from settlement or judgment proceeds.

(7) The agency director or the director's designee must consent in writing to any discharge or compromise of any settlement or judgment of a lien created under RCW 41.05A.070 and 43.20B.060. The agency considers the compromise or discharge of a medical care lien only as authorized by federal regulation at 42 C.F.R. 433.139.

(8) The doctrine of equitable subrogation does not apply to defeat, reduce, or prorate any recovery made by the agency based on its assignment, lien, or subrogation rights.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and chapter 41.05A RCW. WSR 25-16-002, s 182-501-0100, filed 7/23/25, effective 8/23/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-15-053, § 182-501-0100, filed 7/9/15, effective 8/9/15. WSR 11-14-075, recodified as § 182-501-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: 42 U.S.C. §§ 1396a, 1396k, 1396p, chapter 43.20B RCW, RCW 74.08.090, 74.09.180, 74.09.185. WSR 08-17-046, § 388-501-0100, filed 8/14/08, effective 12/1/08. Statutory Authority: RCW 74.08.090 and 74.09.185. WSR 07-23-080 and 08-01-041, § 388-501-0100, filed 11/19/07 and 12/12/07, effective 12/1/08. Statutory Authority: RCW 74.04.050 and 74.08.090. WSR 00-01-088, § 388-501-0100, filed 12/14/99, effective 1/14/00.*

##### **Wash. Admin. Code § 182-501-0125** Advance directives. {#sec-182-501-0125 omnilex-key=us-wa-regs-official--title-182--182-501-0125}

In this section "advance directive" means a written instruction, recognized under state law, relating to the provision of health care when an individual is incapacitated.

(1) All agencies, health maintenance organizations (HMOs), and facilities including hospitals, critical access hospitals, skilled nursing and nursing facilities, and providers of in-home care services that serve medical assistance clients eighteen years of age or older must have written policies and procedures concerning advance directives.

(2) The agencies, HMOs, and facilities must give the following information to each adult client, in writing and orally, and in a language the client understands:

(a) A statement about the client's right to:

(i) Make decisions concerning the client's medical care;

(ii) Accept or refuse surgical or medical treatment;

(iii) Execute an advance directive;

(iv) Revoke an advance directive at any time;

(b) The written policies of the agency, HMO, or facility concerning advance directives, including any policy that would preclude it from honoring the client's advance directive; and

(c) The client's rights under state law.

(3) The agencies, HMOs, and facilities must provide the information described in subsection (2) of this section to adult clients as follows:

(a) Hospitals at the time the client is admitted as an inpatient;

(b) Nursing facilities at the time the client is admitted as a resident;

(c) Providers of in-home care services before the client comes under the care of the provider or at the time of the first home visit so long as it is provided prior to care being rendered;

(d) Hospice programs at the time the client initially receives hospice care from the program; and

(e) HMOs at the time the client enrolls with the organization.

(4) If the client is incapacitated at the time of admittance or enrollment and is unable to receive information or articulate whether or not the client has executed an advance directive, the agencies, HMOs, and facilities:

(a) May give information about advance directives to the person authorized by RCW 7.70.065 to make decisions regarding the client's health care;

(b) Must document in the client's file that the client was unable to communicate whether an advance directive exists if no one comes forward with a previously executed advance directive; and

(c) Must give the information described in subsection (2) to the client once the client is no longer incapacitated.

(5) The agencies, HMOs, and facilities must:

(a) Review each client's medical record prior to admittance or enrollment to determine if the client has an advance directive;

(b) Honor the directive or follow the process explained in subsection (6); and

(c) Not refuse, put conditions on care, or otherwise discriminate against a client based on whether or not the client has executed an advance directive.

(6) If an agency, HMO, or facility has a policy or practice that would keep it from honoring a client's advance directive, the facility or organization must:

(a) Tell the client prior to admission or enrollment or when the client executes the directive;

(b) Provide the client with a statement clarifying the differences between institution-wide conscience objections and those that may be raised by individual physicians and explaining the range of medical conditions or procedures affected;

(c) Prepare and keep a written plan of intended actions according to the requirements in RCW 70.122.060 if the client still chooses to retain the facility or organization; and

(d) Make a good faith effort to transfer the client to another health care practitioner who will honor the directive if the client chooses not to retain the facility or organization.

(7) A health care practitioner may refuse to implement a directive, and may not be discriminated against by the facility or organization for refusing to withhold or withdraw life-sustaining treatment.

(8) The agencies, HMOs, and facilities must document, in a prominent place in each client's medical record, whether or not the client has executed an advance directive.

(9) The agencies, HMOs, and facilities must educate staff and the community on issues concerning advance directives.

(10) The agencies, HMOs, and facilities must comply with state and federal laws and regulations concerning advance directives, including but not limited to: 42 U.S.C. 1396a, subsection (w); 42 C.F.R. 417.436; 42 C.F.R. 489 Subpart I; and chapter 70.122 RCW.

**History**
- *WSR 11-14-075, recodified as § 182-501-0125, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.035. WSR 00-19-050, § 388-501-0125, filed 9/14/00, effective 10/15/00. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-501-0125, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-017.*

##### **Wash. Admin. Code § 182-501-0135** Patient review and coordination (PRC). {#sec-182-501-0135 omnilex-key=us-wa-regs-official--title-182--182-501-0135}

(1) Patient review and coordination (PRC) is a health and safety program that coordinates care and ensures clients enrolled in PRC use services appropriately and in accordance with agency rules and policies.

(a) PRC applies to medical assistance fee-for-service (FFS) clients and managed care organization (MCO) enrollees.

(b) PRC is authorized under federal medicaid law by 42 U.S.C. 1396n (a)(2) and 42 C.F.R. 431.54.

(2) Definitions. Definitions found in chapter 182-500 WAC and WAC 182-526-0010 apply to this section. The following definitions apply to this section:

"Agency's designee" – See WAC 182-500-0010.

"Appropriate use" - Use of health care services that are safe and effective for a client's health care needs.

"Assigned provider" - An agency-enrolled health care provider or one participating with an agency-contracted managed care organization (MCO) who agrees to be assigned as a primary provider and coordinator of services for an FFS client or MCO enrollee in the PRC program. Assigned providers can include a primary care provider (PCP), a pharmacy, a prescriber of controlled substances, and a hospital for nonemergency services.

"At-risk" - A term used to describe one or more of the following:

(a) A client with a medical history of:

(i) Seeking and obtaining health care services at a frequency or amount that is not medically necessary; or

(ii) Potential life-threatening events or life-threatening conditions that required or may require medical intervention.

(b) Behaviors or practices that could jeopardize a client's medical treatment or health including, but not limited to:

(i) Indications of forging or altering prescriptions;

(ii) Referrals from medical personnel, social services personnel, or MCO personnel about inappropriate behaviors or practices that place the client at risk;

(iii) Noncompliance with medical or drug and alcohol treatment;

(iv) Paying cash for medical services that result in a controlled substance prescription or paying cash for controlled substances;

(v) Arrests for diverting controlled substance prescriptions;

(vi) Positive urine drug screen for illicit street drugs or nonprescribed controlled substances;

(vii) Negative urine drug screen for prescribed controlled substances; or

(viii) Unauthorized use of a client's services card for an unauthorized purpose.

"Care management" - Services provided to MCO enrollees with multiple health, behavioral, and social needs to improve care coordination, client education, and client self-management skills.

"Client" – See WAC 182-500-0020.

"Conflicting" - Drugs or health care services that are incompatible or unsuitable for use together because of undesirable chemical or physiological effects.

"Contraindicated" - A medical treatment, procedure, or medication that is inadvisable or not recommended or warranted.

"Duplicative" - Applies to the use of the same or similar drugs and health care services without due medical justification. Example: A client receives health care services from two or more providers for the same or similar condition(s) in an overlapping time frame, or the client receives two or more similarly acting drugs in an overlapping time frame, which could result in a harmful drug interaction or an adverse reaction.

"Emergency department information exchange (EDIE)" - An internet-delivered service that enables health care providers to better identify and treat high users of the emergency department and special needs patients. When patients enter the emergency room, EDIE can proactively alert health care providers through different venues such as fax, phone, email, or integration with a facility's current electronic medical records.

"Emergency medical condition" - See WAC 182-500-0030.

"Emergency services" - See 42 C.F.R. 438.114.

"Fee-for-service" or "FFS" – See WAC 182-500-0035.

"Fee-for-service client" or "FFS client" – A client not enrolled in an agency-contracted MCO.

"Just cause" - A legitimate reason to justify the action taken including, but not limited to, protecting the health and safety of the client.

"Managed care organization (MCO) enrollee" - A medical assistance client enrolled in, and receiving health care services from, an agency-contracted managed care organization (MCO).

"Prescriber of controlled substances" - Any of the following health care professionals who, within their scope of professional practice, are licensed to prescribe and administer controlled substances (see chapter 69.50 RCW, Uniform Controlled Substance Act) for a legitimate medical purpose:

(a) A physician under chapter 18.71 RCW;

(b) A physician assistant under chapter 18.71A RCW;

(c) An osteopathic physician under chapter 18.57 RCW; and

(d) An advanced registered nurse practitioner under chapter 18.79 RCW.

"Primary care provider" or "PCP" - A person licensed or certified under Title 18 RCW including, but not limited to, a physician, an advanced registered nurse practitioner (ARNP), or a physician assistant (PA) who supervises, coordinates, and provides health care services to a client, initiates referrals for specialty and ancillary care, and maintains the client's continuity of care.

(3) Clients selected for PRC review. The agency or agency's designee selects a client for PRC review when either or both of the following occur:

(a) An agency or MCO claims utilization review report indicates the client has not used health care services appropriately; or

(b) Medical providers, social service agencies, or other concerned parties have provided direct referrals to the agency or MCO.

(4) Clients not selected for PRC review. Clients are not reviewed or placed into the PRC program when they:

(a) Are in foster care;

(b) Are covered under state-only funded programs;

(c) Do not have medicaid as the primary payor; or

(d) Are covered under the alien emergency medical (AEM) program, according to WAC 182-507-0115.

(5) Prior authorization. When an FFS client is selected for PRC review, the prior authorization process as defined in WAC 182-500-0085 may be required:

(a) Before or during a PRC review; or

(b) When the FFS client is currently in the PRC program.

(6) Review for placement in the PRC program. When the agency or MCO selects a client for PRC review, the agency or MCO staff, with clinical oversight, reviews either the client's medical history or billing history, or both, to determine if the client has used health care services at a frequency or amount that is not medically necessary (42 C.F.R. 431.54(e)).

(7) Usage guidelines for PRC placement. Agency or MCO staff use the following usage guidelines to initiate review for PRC placement. A client may be reviewed for placement in the PRC program when the review shows the usage is not medically necessary and either the client's medical history or billing history, or both, documents any of the following:

(a) Any two or more of the following conditions occurred in a period of 90 consecutive calendar days in the previous 12 months. The client:

(i) Received services from four or more different providers, including physicians, ARNPs, and PAs not located in the same clinic or practice;

(ii) Had prescriptions filled by four or more different pharmacies;

(iii) Received 10 or more prescriptions;

(iv) Had prescriptions written by four or more different prescribers not located in the same clinic or practice;

(v) Received similar services in the same day not located in the same clinic or practice; or

(vi) Had 10 or more office visits;

(b) Any one of the following occurred within a period of 90 consecutive calendar days in the previous 12 months. The client:

(i) Made two or more emergency department visits;

(ii) Exhibits "at-risk" usage patterns;

(iii) Made repeated and documented efforts to seek health care services that are not medically necessary; or

(iv) Was counseled at least once by a health care provider, or an agency or MCO staff member with clinical oversight, about the appropriate use of health care services;

(c) The client received prescriptions for controlled substances from two or more different prescribers not located in the same clinic or practice in any one month within the 90-day review period; or

(d) The client has either a medical history or billing history, or both, that demonstrates a pattern of the following at any time in the previous 12 months:

(i) Using health care services in a manner that is duplicative, excessive, or contraindicated; or

(ii) Seeking conflicting health care services, drugs, or supplies that are not within acceptable medical practice.

(8) PRC review results. As a result of the PRC review, the agency or MCO may take any of the following steps:

(a) Determine that no action is needed and close the client's file;

(b) Send the client and, if applicable, the client's authorized representative a one-time only written notice of concern with information on specific findings and notice of potential placement in the PRC program; or

(c) Determine that the usage guidelines for PRC placement establish that the client has used health care services at an amount or frequency that is not medically necessary, in which case one or more of the following actions take place:

(i) The MCO:

(A) Refers the MCO enrollee:

(I) For education on appropriate use of health care services; or

(II) To other support services or agencies; or

(B) Places the MCO enrollee into the PRC program for an initial placement period of no less than 24 months. For MCO enrollees younger than 18 years of age, the MCO must get agency approval before placing the MCO enrollee into the PRC program; or

(ii) The agency places the FFS client into the PRC program for an initial placement period of no less than 24 months.

(9) Initial placement in the PRC program.

(a) When an FFS client is initially placed in the PRC program, the agency places the FFS client for no less than 24 months with a primary care provider (PCP) for care coordination and a pharmacy for all medication prescriptions and one or more of the following types of health care providers:

(i) Prescriber of controlled substances if different than PCP;

(ii) Hospital for nonemergency services unless referred by the assigned PCP or a specialist. An FFS client may receive covered emergency services from any hospital;

(iii) Another qualified provider type, as determined by agency program staff on a case-by-case basis; or

(iv) Additional pharmacies on a case-by-case basis.

(b) Based on a medical necessity determination, the agency may make an exception to PRC rules when in the best interest of the client. See WAC 182-501-0165 and 182-501-0160.

(c) When an MCO enrollee is initially placed in the PRC program, the MCO restricts the MCO enrollee for no less than 24 months with a primary care provider (PCP) for care coordination and a primary pharmacy for all medication prescriptions and one or more of the following types of health care providers:

(i) Prescriber of controlled substances if different than PCP;

(ii) Hospital for nonemergency services unless referred by the assigned PCP or a specialist. An MCO enrollee may receive covered emergency services from any hospital;

(iii) Another qualified provider type, as determined by MCO program staff on a case-by-case basis; or

(iv) Additional pharmacies on a case-by-case basis.

(10) MCO enrollees changing MCOs. MCO enrollees:

(a) Remain in the same MCO for no less than 12 months for initial placement and whenever the enrollee changes MCOs, unless:

(i) The MCO enrollee moves to a residence outside the MCO's service area and the MCO is not available in the new location;

(ii) The MCO enrollee's assigned PCP no longer participates with the MCO and is available in another MCO, and the MCO enrollee wishes to remain with the current provider;

(iii) The MCO enrollee is in a voluntary enrollment program or a voluntary enrollment county;

(iv) The MCO enrollee is in the address confidentiality program (ACP), indicated by P.O. Box 257, Olympia, WA 98507; or

(v) The MCO enrollee is an American Indian/Alaska Native.

(b) Placed in the PRC program must remain in the PRC program for no less than 24 months regardless of whether the MCO enrollee changes MCOs or becomes an FFS client.

(11) Notifying the client about placement in the PRC program. When the client is initially placed in the PRC program, the agency or the MCO sends the client and, if applicable, the client's authorized representative, a written notice that:

(a) Informs the client of the reason for the PRC program placement;

(b) Informs the client of the providers the client has been assigned to;

(c) Directs the client to respond to the agency or MCO to take the following actions if applicable:

(i) Change assigned providers, subject to agency or MCO approval;

(ii) Submit additional health care information, justifying the client's use of health care services; or

(iii) Request assistance, if needed, from agency or MCO program staff; and

(d) Informs the client of administrative hearing or appeal rights (see subsection (16) of this section).

(12) Selection and role of assigned provider. A client has a limited choice of providers.

(a) The following providers are not available:

(i) A provider who is being reviewed by the agency or licensing authority regarding quality of care;

(ii) A provider who has been suspended or disqualified from participating as an agency-enrolled or MCO-contracted provider; or

(iii) A provider whose business license is suspended or revoked by the licensing authority.

(b) For a client placed in the PRC program, the assigned:

(i) Provider(s) must be located in the client's local geographic area, in the client's selected MCO, and be reasonably accessible to the client.

(ii) PCP supervises and coordinates health care services for the client, including continuity of care and referrals to specialists when necessary.

(A) The PCP:

(I) Provides the plan of care for clients that have documented use of the emergency department for a reason that is not deemed to be an emergency medical condition;

(II) Files the plan of care with each emergency department that the client is using or with the emergency department information exchange; and

(III) Makes referrals to behavioral health treatment for clients who are using the emergency department for behavioral health treatment issues.

(B) The assigned PCP must be one of the following:

(I) A physician;

(II) An advanced registered nurse practitioner (ARNP); or

(III) A licensed physician assistant (PA).

(iii) Prescriber of controlled substances prescribes all controlled substances for the client;

(iv) Pharmacy fills all prescriptions for the client; and

(v) Hospital provides all hospital nonemergency services.

(c) A client placed in the PRC program must remain with the assigned providers for 12 months after the assignments are made, unless:

(i) The client moves to a residence outside the provider's geographic area;

(ii) The provider moves out of the client's local geographic area and is no longer reasonably accessible to the client;

(iii) The provider refuses to continue to serve the client;

(iv) The client did not select the provider. The client may request to change an assigned provider once within 30 calendar days of the assignment;

(v) The MCO enrollee's assigned PCP no longer participates with the MCO. In this case, the MCO enrollee may select a new provider from the list of available providers in the MCO network or follow the assigned provider to the new MCO; or

(vi) The client is in the address confidentiality program (ACP), indicated by P.O. Box 257, Olympia, WA 98507.

(d) When an assigned prescribing provider no longer contracts with the agency or the MCO:

(i) All prescriptions from the provider are invalid 30 calendar days following the date the contract ends; and

(ii) The client must choose or be assigned another provider according to the requirements in this section.

(13) PRC placement.

(a) The initial PRC placement is no less than 24 consecutive months.

(b) The second PRC placement is no less than an additional 36 consecutive months.

(c) Each subsequent PRC placement is no less than 72 consecutive months.

(14) Agency or MCO review of a PRC placement period. The agency or MCO reviews a client's use of health care services before the end of each PRC placement period described in subsection (13) of this section using the guidelines in subsection (7) of this section.

(a) The agency or MCO assigns the next PRC placement if the usage guidelines for PRC placement in subsection (7) of this section apply to the client.

(b) When the agency or MCO assigns a subsequent PRC placement, the agency or MCO sends the client and, if applicable, the client's authorized representative, a written notice informing the client:

(i) Of the reason for the subsequent PRC program placement;

(ii) Of the length of the subsequent PRC placement;

(iii) That the current providers assigned to the client continue to be assigned to the client during the subsequent PRC placement;

(iv) That all PRC program rules continue to apply;

(v) Of administrative hearing or appeal rights (see subsection (16) of this section); and

(vi) Of the rules that support the decision.

(c) The agency or MCO may remove a client from PRC placement if the client:

(i) Successfully completes a treatment program that is provided by a substance use disorder (SUD) service provider certified by the agency under chapter 182-538D WAC;

(ii) Submits documentation of completion of the approved treatment program to the agency; and

(iii) Maintains appropriate use of health care services within the usage guidelines described in subsection (7) of this section for six consecutive months after the date the treatment ends; or

(iv) Successfully stabilizes due to the usage of treatment medications including, but not limited to, Buprenorphine.

(d) The agency or MCO determines the appropriate placement for a client who has been placed back into the program.

(e) A client remains placed in the PRC program regardless of change in eligibility program type or change in address.

(15) Client financial responsibility. A client placed in the PRC program may be billed by a provider and held financially responsible for nonemergency health care services obtained from a nonpharmacy provider when the provider is not an assigned or appropriately referred provider as described in subsection (12) of this section. See WAC 182-502-0160.

(16) Right to administrative hearing or appeal.

(a) An FFS client who disagrees with an agency decision regarding placement or continued placement in the PRC program has the right to an administrative hearing regarding this placement. An FFS client must request an administrative hearing from the agency within 90 days of the written notice of placement or continued placement to exercise this right.

(b) An MCO enrollee who disagrees with an MCO decision regarding placement or continued placement in the PRC program has a right to appeal this decision in the same manner as an adverse benefit determination under chapter 182-538 WAC.

(c) The agency conducts an administrative hearing according to chapter 182-526 WAC.

(d) A client who requests an administrative hearing or appeal within 10 calendar days from the date of the written notice of an initial PRC placement will not be placed in the PRC program until ordered by an administrative law judge (ALJ) or review judge.

(e) A client who requests an administrative hearing or appeal more than 10 calendar days from the date of the written notice of initial PRC placement will remain placed in the PRC program until a final administrative order is entered that orders the client's removal from the program.

(f) A client who requests an administrative hearing or appeal in all other cases and who has already been assigned providers will remain placed in the PRC program unless a final administrative order is entered that orders the client's removal from the program.

(g) An ALJ may rule the client be placed in the PRC program prior to the date the record is closed and before the date the initial order is issued based on a showing of just cause.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-21-163, s 182-501-0135, filed 10/23/24, effective 11/23/24*
- *WSR 23-14-073, § 182-501-0135, filed 6/29/23, effective 8/1/23*
- *WSR 21-08-090, § 182-501-0135, filed 4/7/21, effective 5/8/21*
- *WSR 18-08-075, § 182-501-0135, filed 4/3/18, effective 5/4/18. Statutory Authority: RCW 41.05.021 and 2011 1st sp.s. c 50. WSR 13-05-006, § 182-501-0135, filed 2/6/13, effective 3/9/13. WSR 11-14-075, recodified as § 182-501-0135, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-501-0135, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090 and 42 C.F.R. 431.51, 431.54(e) and 456.1*
- *42 U.S.C. 1396n. WSR 08-05-010, § 388-501-0135, filed 2/7/08, effective 3/9/08. Statutory Authority: RCW 74.08.090, 74.09.520, 74.04.055, and 42 C.F.R. 431.54. WSR 06-14-062, § 388-501-0135, filed 6/30/06, effective 7/31/06. Statutory Authority: RCW 74.08.090, 74.04.055, and 42 C.F.R. Subpart B 431.51, 431.54 (e) and (3), and 456.1. WSR 04-01-099, § 388-501-0135, filed 12/16/03, effective 1/16/04. Statutory Authority: RCW 74.08.090. WSR 01-02-076, § 388-501-0135, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-501-0135, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 97-03-038, § 388-501-0135, filed 1/9/97, effective 2/9/97. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-501-0135, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-100.*

##### **Wash. Admin. Code § 182-501-0160** Exception to rule—Request for a noncovered health care service. {#sec-182-501-0160 omnilex-key=us-wa-regs-official--title-182--182-501-0160}

A client or the client's provider may request that the medicaid agency or its designee pay for a noncovered health care service. This is called an exception to rule (ETR). The request for ETR must be made before the service is rendered.

(1) The agency's medical director or designee evaluates and considers requests on a case-by-case basis. The agency's medical director has final authority to approve or deny a request for ETR.

(2) The agency or its designee cannot approve an ETR if the requested service is excluded under state statute.

(3) Any item or service for which an ETR is requested must:

(a) Fall within accepted standards and precepts of good medical practice;

(b) Represent cost-effective use of public funds; and

(c) Be submitted to the agency or its designee in writing within ninety days of the date of the written notification denying authorization for the noncovered service.

(4) For the agency or its designee to consider the ETR request:

(a) The client or the client's health care provider must submit sufficient client-specific information and documentation to the agency's medical director or designee which demonstrate that the client's clinical condition is so different from the majority that there is no equally effective, less costly covered service or equipment that meets the client's need.

(b) The client's health care provider must certify that medical treatment or items of service which are covered under the client's Washington apple health program and which, under accepted standards of medical practice, are indicated as appropriate for the treatment of the illness or condition, have been found to be:

(i) Medically ineffective in the treatment of the client's condition; or

(ii) Inappropriate for that specific client.

(5) Within fifteen business days of receiving the request, the agency or its designee must send written notification to the provider and the client:

(a) Approving the ETR request;

(b) Denying the ETR request; or

(c) Requesting additional information.

(i) The additional information must be received by the agency or its designee within thirty days of the date the information was requested.

(ii) The agency or its designee must approve or deny the ETR request within five business days of receiving the additional information.

(iii) If the requested information is insufficient or not provided within thirty days, the agency or its designee denies the ETR request.

(6) A client does not have a right to a fair hearing on ETR decisions.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-044, § 182-501-0160, filed 8/27/15, effective 9/27/15. Statutory Authority: RCW 41.05.021. WSR 13-18-035, § 182-501-0160, filed 8/28/13, effective 9/28/13. Statutory Authority: RCW 41.05.021 and section 1927 of the Social Security Act. WSR 12-18-062, § 182-501-0160, filed 8/31/12, effective 10/1/12. WSR 11-14-075, recodified as § 182-501-0160, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-501-0160, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.04.050, 74.09.035. WSR 00-03-035, § 388-501-0160, filed 1/12/00, effective 2/12/00. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-501-0160, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-030.*

##### **Wash. Admin. Code § 182-501-0163** Health care coverage—Process for submitting a valid request for authorization. {#sec-182-501-0163 omnilex-key=us-wa-regs-official--title-182--182-501-0163}

(1) The medicaid agency requires providers to obtain authorization for certain health care services under this section, chapters 182-501 and 182-502 WAC, other applicable agency rules, current published agency billing instructions, and numbered memoranda. For the purposes of this section, health care services include treatment, equipment, related supplies, and drugs.

(a) For health care services that require prior authorization (PA), a provider (as defined in WAC 182-500-0085) must submit a written, electronic, or telephonic request to the agency. To be a valid request for PA, the provider must send the request and follow the agency's current published program billing instructions, numbered memoranda, and any additional requirements in Washington Administrative Code (WAC) and Revised Code of Washington (RCW).

(b) For expedited prior authorization (EPA), a provider must certify that the client's clinical condition meets the appropriate EPA criteria outlined in the agency's current published program billing instructions, numbered memoranda, and any additional requirements in WAC and RCW. The provider must use the agency-assigned EPA number when submitting a claim for payment to the agency.

(c) The agency requires PA for covered health care services when the applicable EPA criteria are not met.

(d) Upon request, a provider must send documentation to the agency showing how the client's condition meets the required criteria for PA or EPA.

(2) Agency authorization requirements for covered health care services are not a denial of service.

(3) The agency returns invalid requests to the provider and takes no further action unless the request for authorization is resubmitted. The return of an invalid request is not a denial of service.

(4) Failure of a provider to request authorization for a health care service that requires it or a provider's failure to do so properly is not a denial of service.

(5) The agency's authorization of health care services does not guarantee payment. See WAC 182-501-0050 for other general requirements that must be satisfied before payment can be made for a health care service requested and authorized under this section.

(6) The agency evaluates a request for authorization of a health care service that exceeds identified limitations on a case-by-case basis and under WAC 182-501-0169.

(7) The agency may recoup any payment made to a provider if the agency later determines the health care service was not properly authorized or did not meet EPA criteria. See chapters 182-502 and 182-502A WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-15-053, § 182-501-0163, filed 7/9/15, effective 8/9/15. WSR 11-14-075, recodified as § 182-501-0163, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 09-23-112, § 388-501-0163, filed 11/18/09, effective 12/19/09.*

##### **Wash. Admin. Code § 182-501-0165** Medical and dental coverage—Fee-for-service (FFS) prior authorization—Determination process for payment. {#sec-182-501-0165 omnilex-key=us-wa-regs-official--title-182--182-501-0165}

(1) This section applies to fee-for-service (FFS) requests for medical or dental services and medical equipment that:

(a) Are identified as covered services or early and periodic screening, diagnosis, and treatment services; and

(b) Require prior authorization by the medicaid agency.

(2) The following definitions and those found in chapter 182-500 WAC apply to this section:

"Controlled studies" - Studies in which defined groups are compared with each other to reduce bias.

"Credible evidence" - Type I-IV evidence or evidence-based information from any of the following sources:

• Clinical guidelines

• Government sources

• Independent medical evaluation (IME)

• Independent review organization (IRO)

• Independent technology assessment organizations

• Medical and hospital associations

• Policies of other health plans

• Regulating agencies (for example, the Federal Drug Administration or Department of Health)

• Treating provider

• Treatment pathways

"Evidence-based" - The ordered and explicit use of the best evidence available (see "hierarchy of evidence" in subsection (6)(a) of this section) when making health care decisions.

"Health outcome" - Changes in health status (mortality and morbidity) which result from the provision of health care services.

"Institutional review board (IRB)" - A board or committee responsible for reviewing research protocols and determining whether:

(1) The rights and welfare of human subjects are adequately protected;

(2) The risks to people are minimized and are not unreasonable;

(3) The risks to people are outweighed by the potential benefit to them or by the knowledge to be gained; and

(4) The proposed study design and methods are adequate and appropriate in the light of stated study objectives.

"Independent review organization (IRO)" - A panel of medical and benefit experts intended to provide unbiased, independent, clinical, evidence-based reviews of adverse decisions.

"Independent medical evaluation (IME)" - An objective medical examination of the client to establish the medical facts.

"Provider" - The person who is responsible for diagnosing, prescribing, and providing medical, dental, or behavioral health services to agency clients.

(3) The agency authorizes, on a case-by-case basis, requests described in subsection (1) of this section when the agency determines the service or equipment is medically necessary as defined in WAC 182-500-070. The process the agency uses to assess medical necessity is based on:

(a) The evaluation of submitted and obtainable medical, dental, or behavioral health evidence as described in subsections (4) and (5) of this section; and

(b) The application of the evidence-based rating process described in subsection (6) of this section.

(4) The agency reviews available evidence relevant to a medical, dental, or behavioral health service or equipment to:

(a) Determine its efficacy, effectiveness, and safety;

(b) Determine its impact on health outcomes;

(c) Identify indications for use;

(d) Evaluate pertinent client information;

(e) Compare to alternative technologies; and

(f) Identify sources of credible evidence that use and report evidence-based information.

(5) The agency considers and evaluates all available clinical information and credible evidence relevant to the client's condition. The provider responsible for the client's diagnosis, or treatment, or both, must submit with the request credible evidence specifically related to the client's condition including, but not limited to:

(a) A physiological description of the client's disease, injury, impairment, or other ailment;

(b) Pertinent laboratory findings;

(c) Pertinent X-ray and/or imaging reports;

(d) Individual patient records pertinent to the case or request;

(e) Photographs, or videos, or both, if requested; and

(f) Objective medical/dental/behavioral health information such as medically/dentally acceptable clinical findings and diagnoses resulting from physical or behavioral health examinations.

(6) The agency uses the following processes to determine whether a requested service described in subsection (1) is medically necessary:

(a) Hierarchy of evidence - How defined. The agency uses a hierarchy of evidence to determine the weight given to available data. The weight of medical evidence depends on objective indicators of its validity and reliability including the nature and source of the evidence, the empirical characteristics of the studies or trials upon which the evidence is based, and the consistency of the outcome with comparable studies. The hierarchy (in descending order with Type I given the greatest weight) is:

(i) Type I: Meta-analysis done with multiple, well-designed controlled studies;

(ii) Type II: One or more well-designed experimental studies;

(iii) Type III: Well-designed, quasi-experimental studies such as nonrandomized controlled, single group pre-post, cohort, time series, or matched case-controlled studies;

(iv) Type IV: Well-designed, nonexperimental studies, such as comparative and correlation descriptive, and case studies (uncontrolled); and

(v) Type V: Credible evidence submitted by the provider.

(b) Hierarchy of evidence - How classified. Based on the quality of available evidence, the agency determines if the requested service is effective and safe for the client by classifying it as an "A,""B,""C," or "D" level of evidence:

(i) "A" level evidence: Shows the requested service or equipment is a proven benefit to the client's condition by strong scientific literature and well-designed clinical trials such as Type I evidence or multiple Type II evidence or combinations of Type II, III or IV evidence with consistent results (An "A" rating cannot be based on Type III or Type IV evidence alone).

(ii) "B" level evidence: Shows the requested service or equipment has some proven benefit supported by:

(A) Multiple Type II or III evidence or combinations of Type II, III or IV evidence with generally consistent findings of effectiveness and safety (A "B" rating cannot be based on Type IV evidence alone); or

(B) Singular Type II, III, or IV evidence in combination with agency-recognized:

(I) Clinical guidelines;

(II) Treatment pathways; or

(III) Other guidelines that use the hierarchy of evidence in establishing the rationale for existing standards.

(iii) "C" level evidence: Shows only weak and inconclusive evidence regarding safety, or efficacy, or both. For example:

(A) Type II, III, or IV evidence with inconsistent findings; or

(B) Only Type V evidence is available.

(iv) "D" level evidence: Is not supported by any evidence regarding its safety and efficacy, for example that which is considered investigational or experimental.

(c) Hierarchy of evidence - How applied. After classifying the available evidence, the agency:

(i) Approves "A" and "B" rated requests if the service or equipment:

(A) Does not place the client at a greater risk of mortality or morbidity than an equally effective alternative treatment; and

(B) Is not more costly than an equally effective alternative treatment.

(ii) Approves a "C" rated request only if the provider shows the requested service is the optimal intervention for meeting the client's specific condition or treatment needs, and:

(A) Does not place the client at a greater risk of mortality or morbidity than an equally effective alternative treatment;

(B) Is less costly to the agency than an equally effective alternative treatment; and

(C) Is the next reasonable step for the client in a well-documented tried-and-failed attempt at evidence-based care.

(iii) Denies "D" rated requests unless:

(A) The requested service or equipment has a humanitarian device exemption from the Food and Drug Administration (FDA); or

(B) There is a local institutional review board (IRB) protocol addressing issues of efficacy and safety of the requested service that satisfies both the agency and the requesting provider.

(7) Within fifteen days of receiving the request from the client's provider, the agency reviews all evidence submitted and:

(a) Approves the request;

(b) Denies the request if the requested service is not medically necessary; or

(c) Requests the provider submit additional justifying information. The agency sends a copy of the request to the client at the same time.

(i) The provider must submit the additional information within thirty days of the agency's request.

(ii) The agency approves or denies the request within five business days of the receipt of the additional information.

(iii) If the provider fails to provide the additional information, the agency will deny the requested service.

(8) When the agency denies all or part of a request for a covered service or equipment, the agency sends the client and the provider written notice, within ten business days of the date the information is received, that:

(a) Includes a statement of the action the agency intends to take;

(b) Includes the specific factual basis for the intended action;

(c) Includes reference to the specific WAC provision upon which the denial is based;

(d) Is in sufficient detail to enable the recipient to:

(i) Learn why the agency's action was taken; and

(ii) Prepare an appropriate response.

(e) Is in sufficient detail to determine what additional or different information might be provided to challenge the agency's determination;

(f) Includes the client's administrative hearing rights;

(g) Includes an explanation of the circumstances under which the denied service is continued or reinstated if a hearing is requested; and

(h) Includes examples(s) of "lesser cost alternatives" that permit the affected party to prepare an appropriate response.

(9) If an administrative hearing is requested, the agency or the client may request an independent review organization (IRO) or independent medical examination (IME) to provide an opinion regarding whether the requested service or equipment is medically necessary. The agency pays for the independent assessment if the agency agrees that it is necessary, or an administrative law judge orders the assessment.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-14-057, § 182-501-0165, filed 6/26/20, effective 7/27/20*
- *WSR 15-15-053, § 182-501-0165, filed 7/9/15, effective 8/9/15. WSR 11-14-075, recodified as § 182-501-0165, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 05-23-031, § 388-501-0165, filed 11/8/05, effective 12/9/05. Statutory Authority: RCW 74.08.090, 74.04.050, 74.09.035. WSR 00-03-035, § 388-501-0165, filed 1/12/00, effective 2/12/00. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-501-0165, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-038.*

##### **Wash. Admin. Code § 182-501-0169** Health care coverage—Limitation extension. {#sec-182-501-0169 omnilex-key=us-wa-regs-official--title-182--182-501-0169}

This section addresses requests for limitation extensions regarding scope, amount, duration, and frequency of a covered health care service. For the purposes of this section, health care services includes treatment, equipment, related supplies, and drugs. The medicaid agency does not authorize or pay for any covered health care services exceeding identified limitations unless authorization is obtained before the client receives the service.

(1) No limitation extension of covered health care services is authorized when prohibited by specific program rules.

(2) When a limitation extension is not prohibited by specific program rules, the client's provider may request a limitation extension.

(3) The agency evaluates requests for limitation extensions as follows:

(a) For a fee-for-service client, the process described in WAC 182-501-0165.

(b) For a managed care enrollee, the client's managed care organization (MCO) evaluates requests for limitation extensions according to the MCO's prior authorization process.

(c) Both the agency and MCO consider the following in evaluating a request for a limitation extension:

(i) The level of improvement the client has shown to date related to the requested health care service and the reasonably calculated probability of continued improvement if the requested health care service is extended; and

(ii) The reasonably calculated probability the client's condition will worsen if the requested health care service is not extended.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-15-053, § 182-501-0169, filed 7/9/15, effective 8/9/15. WSR 11-14-075, recodified as § 182-501-0169, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 09-23-112, § 388-501-0169, filed 11/18/09, effective 12/19/09*
- *WSR 06-24-036, § 388-501-0169, filed 11/30/06, effective 1/1/07.*

##### **Wash. Admin. Code § 182-501-0175** Medical care provided in bordering cities. {#sec-182-501-0175 omnilex-key=us-wa-regs-official--title-182--182-501-0175}

(1) An eligible Washington state resident may receive medical care in a recognized out-of-state bordering city on the same basis as in-state care.

(2) The only recognized bordering cities are:

(a) Coeur d'Alene, Moscow, Sandpoint, Priest River, and Lewiston, Idaho; and

(b) Portland, The Dalles, Hermiston, Hood River, Rainier, Milton-Freewater, and Astoria, Oregon.

**History**
- *WSR 11-14-075, recodified as § 182-501-0175, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050 and 74.08.090. WSR 00-01-088, § 388-501-0175, filed 12/14/99, effective 1/14/00. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-501-0175, filed 5/3/94, effective 6/3/94. Formerly WAC 388-82-130.*

##### **Wash. Admin. Code § 182-501-0180** Health care services provided outside the state of Washington—General provisions. {#sec-182-501-0180 omnilex-key=us-wa-regs-official--title-182--182-501-0180}

WAC 182-501-0180 through 182-501-0184 describe the health care services available to a Washington apple health client on a fee-for-service basis or to a client enrolled in a managed care organization (MCO) (defined in WAC 182-538-050).

(1) Subject to the requirements, exceptions, and limitations in this section, WAC 182-501-0182, and 182-501-0184, the medicaid agency covers emergency and nonemergency out-of-state health care services provided to eligible Washington apple health recipients when the services are:

(a) Within the scope of the client's or enrollee's health care program as specified under chapter 182-501 WAC or other program rules;

(b) Allowed to be provided outside the state of Washington by specific program WAC; and

(c) Medically necessary as defined in WAC 182-500-0070.

(2) The agency does not cover services provided outside the state of Washington under the Involuntary Treatment Act (chapter 71.05 RCW), including designated bordering cities.

(3) When the agency pays for covered health care services furnished to an eligible Washington apple health client or enrollee outside the state of Washington, its payment is payment in full according to 42 C.F.R. 447.15. No additional payment may be sought from the client (see WAC 182-502-0160).

(4) The agency determines coverage for transportation services provided out of state, including ambulance services, according to chapter 182-546 WAC.

(5) With the exception of designated bordering cities (see WAC 182-501-0175), if the client or enrollee travels out of state expressly to obtain health care, the service must be prior authorized by the agency. See WAC 182-501-0182 for requirements related to out-of-state nonemergency treatment and WAC 182-501-0165 for the agency's medical necessity determination process.

(6) The agency does not cover health care services provided outside the United States and U.S. territories, except in British Columbia, Canada. See WAC 182-501-0184 for limitations on coverage of, and payment for, health care provided to Washington apple health clients or enrollees in British Columbia, Canada.

(7) See WAC 182-502-0120 for provider requirements for payment of health care provided outside the state of Washington.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-23-064, § 182-501-0180, filed 11/16/20, effective 12/17/20*
- *WSR 15-15-053, § 182-501-0180, filed 7/9/15, effective 8/9/15. WSR 11-14-075, recodified as § 182-501-0180, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.04.057 and 74.09.510. WSR 11-14-054, § 388-501-0180, filed 6/29/11, effective 7/30/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035. WSR 08-08-064, § 388-501-0180, filed 3/31/08, effective 5/1/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-501-0180, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090 and 74.09.035. WSR 01-01-011, § 388-501-0180, filed 12/6/00, effective 1/6/01. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-501-0180, filed 5/3/94, effective 6/3/94. Formerly parts of WAC 388-82-135 and 388-92-015.*

##### **Wash. Admin. Code § 182-501-0182** Health care provided in another state or U.S. territory—Nonemergency. {#sec-182-501-0182 omnilex-key=us-wa-regs-official--title-182--182-501-0182}

(1) This rule applies to nonemergency treatment situations occurring in another state or U.S. territory. Applicable situations include, but are not limited to:

(a) Health care services the medicaid agency has prior authorized for a client; and

(b) Health care services obtained by the client, independent of the agency, while traveling or visiting.

(2) Under the prior authorization process described in WAC 182-501-0165, except as specified in subsection (3) of this section, the agency pays for covered nonemergency health care services provided to an eligible Washington apple health (WAH) recipient in another state or U.S. territory to the same extent that it pays for covered nonemergency services provided within the state of Washington when the agency determines that:

(a) Services are medically necessary and the client's health will be endangered if the client must travel to the state of Washington to receive the needed care;

(b) Medically necessary services are not available in Washington state or designated bordering cities (see WAC 182-501-0175) and are more readily available in another state; or

(c) It is general practice for clients in a particular Washington state locality to use medically necessary resources in a bordering state.

(3) The agency pays for covered nonemergency health care services for an eligible WAH recipient in another state or U.S. territory, unless the out-of-state provider will not accept the agency's payment as payment in full under 42 C.F.R. 447.15. The agency does not pay when the provider refuses to accept the agency's payment as payment in full.

(4) The agency does not pay for medically necessary, nonsymptomatic treatment (i.e., preventive care) furnished outside the state of Washington unless it is furnished in a designated bordering city, which is considered the same as an in-state city for the purposes of health care coverage (see WAC 182-501-0175). Covered nonemergency services requiring prior authorization, when provided in the state of Washington, also require prior authorization, when provided in a designated bordering city (see WAC 182-501-0165 for the agency's medical necessity determination process).

(5) See WAC 182-501-0180 for additional information regarding health care services provided outside the state of Washington.

(6) The agency's director or designee reviews all exception to rule (ETR) requests.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-15-053, § 182-501-0182, filed 7/9/15, effective 8/9/15. WSR 11-14-075, recodified as § 182-501-0182, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035. WSR 08-08-064, § 388-501-0182, filed 3/31/08, effective 5/1/08.*

##### **Wash. Admin. Code § 182-501-0184** Health care services provided outside of the United States and U.S. territories or in a foreign country. {#sec-182-501-0184 omnilex-key=us-wa-regs-official--title-182--182-501-0184}

For the purposes of this section, the term "health care services" does not include the diagnosis and treatment for alcohol, substance abuse, and mental health services.

(1) The provisions of WAC 182-501-0182 apply to this section.

(2) The medicaid agency does not pay for health care services furnished in a foreign country, except for medical services furnished in the province of British Columbia, Canada, under this section. The agency pays for medical services furnished in British Columbia, Canada, to Washington apple health (WAH) clients only when those clients:

(a) Reside in Point Roberts, Washington;

(b) Reside in Washington communities along the border with British Columbia, Canada (see subsection (3) of this section for further clarification); or

(c) Are members of the Canadian First Nations who live in Washington state.

(3) For WAH clients identified in subsection (2) of this section, the agency covers emergency and nonemergency medical services provided in British Columbia, Canada, when the services are:

(a) Within the scope of the client's health care program as specified in chapter 182-501 WAC;

(b) Allowed to be provided outside the United States and U.S. territories by specific program WAC; and

(c) Medically necessary as defined in WAC 182-500-0070.

(4) For WAH clients identified in subsection (2) of this section, the agency covers nonemergency medical services in British Columbia, Canada, only when:

(a) It is general practice for WAH clients to use medically necessary resources across the Canadian border; or

(b) The medical services in British Columbia, Canada, are closer or more readily accessible to the client's Washington state residence. As applied to nonemergency medical services, the phrase "closer or more readily accessible to the client's Washington state residence" means:

(i) There is not a United States provider for the service within twenty-five miles of the client's Washington state residence; and

(ii) The closest Canadian provider of the service is closer than the closest U.S. provider of the service.

(5) The agency does not cover services provided in British Columbia, Canada, under the Involuntary Treatment Act (chapter 71.05 RCW and chapter 388-865 WAC).

(6) The agency's payment for covered medical services furnished to a WAH client in British Columbia, Canada, is payment in full according to 42 C.F.R. 447.15.

(7) A British Columbia, Canada, provider who furnished health care services or covered items to a WAH client receives payment from the agency only when:

(a) The reimbursement is made to a financial institution or entity located within the United States in U.S. dollars; and

(b) The participating British Columbia, Canada, provider:

(i) Has signed a core provider agreement with the agency;

(ii) Satisfies all medicaid conditions of participation;

(iii) Meets functionally equivalent licensing requirements; and

(iv) Complies with the same utilization control standards as in-state providers.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-15-053, § 182-501-0184, filed 7/9/15, effective 8/9/15. WSR 11-14-075, recodified as § 182-501-0184, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.04.057 and 74.09.510. WSR 11-14-054, § 388-501-0184, filed 6/29/11, effective 7/30/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035. WSR 08-08-064, § 388-501-0184, filed 3/31/08, effective 5/1/08.*

##### **Wash. Admin. Code § 182-501-0200** Third-party resources. {#sec-182-501-0200 omnilex-key=us-wa-regs-official--title-182--182-501-0200}

(1) The medicaid agency requires a provider to seek timely reimbursement from a responsible third party when a client has available third-party resources, except as described under subsections (2) and (3) of this section. Responsible third parties include health insurers and other third parties legally liable for health care items and services received by clients.

(2) The agency pays for medical services and seeks reimbursement from a responsible third party when the claim is for preventive pediatric services as covered under the early and periodic screening, diagnosis and treatment (EPSDT) program.

(3) The agency pays for medical services and seeks reimbursement from any responsible third party when both of the following apply:

(a) The provider submits to the agency documentation of billing the third party and the provider has not received payment after 100 days from the date of services; and

(b) The claim is for a covered service provided to a client on whose behalf the office of support enforcement is enforcing a noncustodial parent to pay support. For the purpose of this section, "is enforcing" means the noncustodial parent either:

(i) Is not complying with an existing court order; or

(ii) Received payment directly from the third party and did not pay for the medical services.

(4) Responsible third parties, except those identified in subsection (5) of this section, must:

(a) Respond within 60 days to any agency inquiry regarding a claim for payment for any health care item or service submitted within three years after the date the item or service was provided; and

(b) Not deny a claim submitted by the agency solely based on:

(i) The submission date of the claim;

(ii) The type or format of the claim form;

(iii) Lack of prior authorization under the responsible third-party's rules; or

(iv) Any other requirement as described in RCW 74.09A.030.

(5) The following programs found in Title XVIII of the federal Social Security Act are exempt from subsection (4) of this section:

(a) The original medicare fee-for-service program under parts A and B;

(b) A medicare advantage plan offered by a medicare advantage organization under part C;

(c) A reasonable cost reimbursement plan under section 1876 of the federal Social Security Act;

(d) A health care prepayment plan under section 1833 of the federal Social Security Act; or

(e) A prescription drug plan offered under part D that requires prior authorization for an item or service furnished to a person eligible to receive medical assistance under Title XIX of the federal Social Security Act.

(6) The provider may not bill the agency or the client for a covered service when a third party pays a provider the same amount as or more than the agency rate.

(7) When the provider receives payment from a third party after receiving reimbursement from the agency, the provider must refund to the agency the amount of the:

(a) Third-party payment when the payment is less than the agency's maximum allowable rate; or

(b) Agency payment when the third-party payment is equal to or more than the agency's maximum allowable rate.

(8) The agency does not pay for medical services if third-party benefits are available to pay for the client's medical services when the provider bills the agency, except under subsections (2) and (3) of this section.

(9) The client is liable for charges for covered medical services that would be paid by the third-party payment when the client either:

(a) Receives direct third-party reimbursement for the services; or

(b) Fails to execute legal signatures on insurance forms, billing documents, or other forms necessary to receive insurance payments for services rendered. See WAC 182-503-0540 for assignment of rights.

(10) The agency considers an adoptive family to be a third-party resource for the medical expenses of the birth parent and child only when there is a written contract between the adopting family and either the birth parent, the attorney, the provider, or the adoption service. The contract must specify that the adopting family will pay for the medical care associated with the pregnancy.

(11) A provider cannot refuse to furnish covered services to a client because of a third-party's potential liability for the services.

(12) For third-party liability on personal injury litigation claims, the agency or managed care organization (MCO) is responsible for providing medical services under WAC 182-501-0100.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and § 1902 (a)(25)(I) of CAA, 2022 (P.L. 117-103). WSR 23-21-064, § 182-501-0200, filed 10/12/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, 42 U.S.C. Sec. 1902 (a)(25)(E), section 53102 (a)(1) of the Bipartisan Budget Act of 2018 and 42 U.S.C. Sec. 1305 (7)(a). WSR 20-15-015, § 182-501-0200, filed 7/6/20, effective 8/6/20. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. 1396a (a)(25)(E). WSR 19-23-008, § 182-501-0200, filed 11/6/19, effective 12/7/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-23-021, § 182-501-0200, filed 11/4/16, effective 1/1/17*
- *WSR 15-15-053, § 182-501-0200, filed 7/9/15, effective 8/9/15. WSR 11-14-075, recodified as § 182-501-0200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-501-0200, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 00-11-141, § 388-501-0200, filed 5/23/00, effective 6/23/00*
- *WSR 00-01-088, § 388-501-0200, filed 12/14/99, effective 1/14/00.*

##### **Wash. Admin. Code § 182-501-0213** Case management services. {#sec-182-501-0213 omnilex-key=us-wa-regs-official--title-182--182-501-0213}

(1) The medicaid agency provides case management services to Washington apple health recipients:

(a) By contract with providers of case management services.

(b) Limited to target groups of clients as determined by the contract.

(c) Limited to services as determined by the contract.

(2) Case management services are services which will assist clients in gaining access to needed medical, social, educational, and other services.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-15-053, § 182-501-0213, filed 7/9/15, effective 8/9/15. WSR 11-14-075, recodified as § 182-501-0213, filed 6/30/11, effective 7/1/11. WSR 00-23-067, recodified as § 388-501-0213, filed 11/15/00, effective 11/15/00. Statutory Authority: RCW 74.08.090. WSR 87-22-094 (Order 2555), § 388-86-017, filed 11/4/87.*

##### **Wash. Admin. Code § 182-501-0215** Wraparound with intensive services (WISe). {#sec-182-501-0215 omnilex-key=us-wa-regs-official--title-182--182-501-0215}

(1) Wraparound with intensive services (WISe) is a service delivery model that provides comprehensive behavioral health covered services and support to:

(a) Clients age 20 or younger with complex behavioral health needs who are eligible for coverage under WAC 182-505-0210; and

(b) Their families.

(2) The authority, the managed care organizations, and the WISe provider agencies must use, continue to use, and substantially comply with the WISe quality plan (WISe QP) for the delivery of WISe. The purpose of the WISe QP is to:

(a) Provide a framework for quality management goals, objectives, processes, tools, and resources to measure the implementation and success of the WISe service delivery model; and

(b) Guide production, dissemination, and use of measures used to inform and improve WISe service delivery.

(3) The WISe QP, as may be amended from time to time, is incorporated by reference and is available online at www.hca.wa.gov/billers-providers-partners/program-information-providers/wraparound-intensive-services-wise.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-04-033, § 182-501-0215, filed 1/25/23, effective 2/25/23. Statutory Authority: RCW 41.05.021, 41.05.160, and Thurston County Superior Court in A.G.C. v. Washington State Health Care Authority, no. 21-2-00479-34. WSR 22-08-013, § 182-501-0215, filed 3/24/22, effective 4/24/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-15-026, § 182-501-0215, filed 7/7/20, effective 8/7/20.*

##### **Wash. Admin. Code § 182-501-0300** Telemedicine and store and forward technology. {#sec-182-501-0300 omnilex-key=us-wa-regs-official--title-182--182-501-0300}

(1) Purpose and scope.

(a) This section identifies the requirements and limitations for coverage, authorization, and payment of health care services provided through telemedicine or store and forward technologies as defined in subsection (2) of this section.

(b) This section applies to health care services, including behavioral health services, provided to clients enrolled in:

(i) An agency-contracted managed care organization (MCO) and fee-for-service programs; and

(ii) Other agency-contracted programs, including grant-funded health care services and health care services administered by behavioral health administrative services organizations (BH-ASOs).

(2) Definitions. The following definitions and those found in RCW 71.24.335, 74.09.325, and chapter 182-500 WAC apply to this section.

(a) "Audio-only telemedicine" means the delivery of health care services through the use of audio-only technology, permitting real-time communication between the client at the originating site and the provider, for the purposes of diagnosis, consultation, or treatment.

(b) "Distant site" means the same as in RCW 71.24.335 or 74.09.325.

(c) "Established relationship" means the same as in RCW 71.24.335 or 74.09.325.

(d) "Hospital" means a facility licensed under chapter 70.41, 71.12, or 72.23 RCW.

(e) "In person" means the client and the provider are in the same location.

(f) "Originating site" means the same as in RCW 71.24.335 or 74.09.325.

(g) "Store and forward technology" see RCW 71.24.335 or 74.09.325.

(h) "Telemedicine" means the delivery of health care services using interactive audio and video technology, permitting real-time communication between the client at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment. Telemedicine includes audio-only telemedicine, but does not include the following services:

(i) Email and facsimile transmissions;

(ii) Installation or maintenance of any telecommunication devices or systems;

(iii) Purchase, rental, or repair of telemedicine equipment; and

(iv) Incidental services or communications that are not billed separately, such as communicating laboratory results.

(3) Requirements and authorized use of telemedicine and store and forward technology.

(a) Governing authority. The medicaid agency determines the health care services that may be paid for when provided through telemedicine or store and forward technology as authorized by state law, including RCW 71.24.335, 74.09.325, and 74.09.327.

(b) Coverage, authorization, and payment. Health care services approved for delivery through telemedicine or store and forward technology must comply with the agency's program rules. The program rules include coverage, authorization, and payment by the agency or the agency's designee, including an agency-contracted managed care entity (managed care organization or behavioral health administrative services organization).

(c) Billing requirements. Providers must bill for health care services as required by the program rules and provider guides of the agency or the agency's designee, including a contracted managed care entity.

(d) Criteria for health care services.

(i) The agency determines the health care services that may be provided through telemedicine or store and forward technology based on whether the health care service is:

(A) A covered service when provided in person by the provider;

(B) Medically necessary;

(C) Determined to be safely and effectively provided through telemedicine or store and forward technology based on generally accepted health care practices and standards; and

(D) Provided through a technology that meets the standards required by state and federal laws governing the privacy and security of protected health information.

(ii) For health care services provided by audio-only telemedicine, the provider and client must have an established relationship.

(iii) For behavioral health services authorized for delivery through store and forward technology, there must be an associated visit between the referring provider and the client.

(4) Health care services authorized for telemedicine and store and forward technology.

(a) Health care services that are authorized to be provided through telemedicine or store and forward technology are identified in the agency's provider guides and fee schedules.

(b) For covered health care services approved for delivery through telemedicine or store and forward technology, the agency or the agency's designee, including an agency-contracted managed care entity (managed care organization (MCO) or behavioral health administrative services organization (BH-ASO)), may require:

(i) Utilization review;

(ii) Prior authorization; and

(iii) Deductible, copayment, or coinsurance requirements that are applicable to coverage of a comparable in-person health care service.

(5) Payment of health care services delivered through telemedicine or store and forward technology.

(a) The agency's designee, including an agency-contracted managed care entity (managed care organization (MCO) or behavioral health administrative services organization (BH-ASO)), pays providers for health care services delivered through telemedicine or store and forward technology in the same amount as when the health care services are provided in person, except as provided in these rules, RCW 71.24.335, and 74.09.325.

(b) The agency or the agency's designee, including an agency-contracted managed care entity (managed care organization or behavioral health administrative services organization) pays for encounter-eligible health care services authorized for delivery through telemedicine at the encounter rate when provided by:

(i) Rural health clinics;

(ii) Federally qualified health centers; or

(iii) Direct Indian health service clinics, tribal clinics, or tribal federally qualified health centers.

(6) Client consent for audio-only telemedicine services.

(a) To receive payment for an audio-only telemedicine service, a provider must obtain client consent before delivering the service to the client.

(b) The client's consent to receive services via audio-only telemedicine must:

(i) Acknowledge the provider will bill the agency or the agency's designee, including an agency-contracted managed care entity (managed care organization or behavioral health administrative services organization) for the service; and

(ii) Be documented in the client's medical record.

(c) A provider may only bill a client for services if they comply with the requirements in WAC 182-502-0160.

(7) Originating site and distant site.

(a) Originating sites and distant sites must be located within the 50 United States, the District of Columbia, or United States territories.

(b) Originating sites may be paid facility fee for infrastructure and client preparation except as noted in (c) of this subsection.

(c) Originating sites facility fees are not paid when the:

(i) Service is provided by audio-only telemedicine;

(ii) Service is store and forward;

(iii) Originating site is:

(A) The client's home;

(B) A hospital, for inpatient services;

(C) A hospital or a hospital provider-based clinic that is an originating site for audio-only telemedicine;

(D) A skilled nursing facility;

(E) Any other location receiving payment for the client's room and board;

(F) Unable to qualify as a provider as defined in WAC 182-500-0085; or

(G) A provider employed by or affiliated with the same entity as the distant site.

(d) A facility fee payment may be subject to a negotiated agreement between the originating site and the managed care organization or the behavioral health administrative services organization.

(e) A distant site may not charge or be paid a facility fee for infrastructure and client preparation.

(8) Recordkeeping.

(a) Providers who furnish a health care service through telemedicine or store and forward technology must comply with the recordkeeping requirements in WAC 182-502-0020.

(b) Providers using telemedicine or store and forward technology must document in the client's medical record the:

(i) Technology used to deliver the health care service by telemedicine or store and forward technology (audio, visual, or other means) and any assistive technologies used;

(ii) Client's location for telemedicine only. This information is not required when a provider uses store and forward technology;

(iii) People attending the appointment with the client (e.g., family, friends, or caregivers) during the delivery of the health care service;

(iv) Provider's location;

(v) Names and credentials (MD, ARNP, RN, PA, CNA, LMHP, etc.) of all originating and distant site providers involved in the delivery of the health care service;

(vi) Start and end time or duration of service when billing is based on time;

(vii) Client's consent for the billing of audio-only telemedicine services.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2021 c 157. WSR 23-04-048, § 182-501-0300, filed 1/26/23, effective 2/26/23.*

## **Chapter 182-502** Administration of medical programs—Providers. {#struct-chapter-182-502}

##### **Wash. Admin. Code § 182-502-0002** Eligible provider types. {#sec-182-502-0002 omnilex-key=us-wa-regs-official--title-182--182-502-0002}

The following health care professionals, health care entities, suppliers or contractors of service may request enrollment with the Washington state health care authority (medicaid agency) to provide covered health care services to eligible clients. For the purposes of this chapter, health care services include treatment, equipment, related supplies, and drugs.

(1) Professionals:

(a) Advanced registered nurse practitioners;

(b) Anesthesia providers, as provided in WAC 182-531-0300:

(i) Physician anesthesiologists;

(ii) Anesthesiology residents;

(iii) Certified anesthesiologist assistants; and

(iv) Certified registered nurse anesthetists;

(c) Applied behavior analysis (ABA) professionals, as provided in WAC 182-531A-0800:

(i) Licensed behavior analysts;

(ii) Licensed assistant behavior analysts; and

(iii) Certified behavior technicians;

(d) Audiologists;

(e) Birth doulas;

(f) Certified peer counselors;

(g) Certified behavioral health support specialists;

(h) Certified peer support specialists;

(i) Certified peer support specialist trainees;

(j) Chiropractors;

(k) Community health workers (CHWs);

(l) Dental health aide therapists, as provided in chapter 70.350 RCW;

(m) Dental hygienists;

(n) Dental therapists;

(o) Denturists;

(p) Dentists;

(q) Dietitians or nutritionists;

(r) Hearing aid fitters/dispensers;

(s) Home health aides credentialed with the department of health (DOH) as nursing assistants certified or nursing assistants registered;

(t) Licensed independent clinical social worker associates;

(u) Licensed independent clinical social workers;

(v) Licensed marriage and family therapists;

(w) Licensed marriage and family therapist associates;

(x) Licensed mental health counselors;

(y) Licensed mental health counselor associates;

(z) Licensed practical nurses;

(aa) Licensed social workers advanced;

(bb) Licensed social worker associates advanced;

(cc) Midwives;

(dd) Naturopathic physicians;

(ee) Nurse anesthetists;

(ff) Ocularists;

(gg) Occupational therapists;

(hh) Ophthalmologists;

(ii) Opticians;

(jj) Optometrists;

(kk) Orthodontists;

(ll) Orthotists;

(mm) Osteopathic physicians;

(nn) Osteopathic physician assistants;

(oo) Podiatric physicians;

(pp) Pharmacists;

(qq) Physicians;

(rr) Physician assistants;

(ss) Physical therapists;

(tt) Prosthetists;

(uu) Psychiatrists;

(vv) Psychological associates;

(ww) Psychologists;

(xx) Radiologists;

(yy) Registered nurses;

(zz) Registered nurse delegators;

(aaa) Registered nurse first assistants;

(bbb) Respiratory therapists;

(ccc) Speech/language pathologists; and

(ddd) Substance use disorder professionals.

(2) Agencies, centers, and facilities:

(a) Adult day health centers;

(b) Ambulance services (ground and air);

(c) Ambulatory surgery centers (medicare-certified);

(d) Birthing centers (licensed by DOH);

(e) Cardiac diagnostic centers;

(f) Case management agencies;

(g) Substance use disorder treatment facilities certified by DOH;

(h) Withdrawal management treatment facilities certified by DOH;

(i) Community acquired immune deficiency syndrome (AIDS) services alternative agencies;

(j) Community behavioral health support services provider facilities;

(k) Community mental health centers;

(l) Diagnostic centers;

(m) Family planning clinics;

(n) Federally qualified health centers (designated by the federal department of health and human services);

(o) Genetic counseling agencies;

(p) Health departments;

(q) Health maintenance organizations (HMOs)/managed care organizations (MCOs);

(r) Human immunodeficiency virus (HIV)/AIDS case management agencies;

(s) Home health agencies;

(t) Hospice agencies;

(u) Hospitals;

(v) Independent diagnostic testing facilities;

(w) Indian health service facilities/tribal 638 facilities;

(x) Inpatient psychiatric facilities;

(y) Intermediate care facilities for individuals with intellectual disabilities (ICF-IID);

(z) Kidney centers;

(aa) Laboratories (clinical laboratory improvement amendments (CLIA) certified);

(bb) Maternity support services agencies; maternity case managers; infant case management, first steps providers;

(cc) Neuromuscular and neurodevelopmental centers;

(dd) Nurse services/delegation;

(ee) Nursing facilities (approved by the department of social and health services home and community living administration);

(ff) Pathology laboratories;

(gg) Pharmacies;

(hh) Private duty nursing agencies;

(ii) Radiology - Stand-alone clinics;

(jj) Rural health clinics (medicare-certified);

(kk) School districts and educational service districts;

(ll) Sleep study centers; and

(mm) Tribal or urban Indian clinics.

(3) Suppliers of:

(a) Blood, blood products, and related services;

(b) Complex rehabilitation technologies;

(c) Durable and nondurable medical equipment and supplies;

(d) Hearing aids;

(e) Infusion therapy equipment and supplies;

(f) Prosthetics/orthotics; and

(g) Respiratory care, equipment, and supplies.

(4) Contractors:

(a) Eyeglass and contact lens providers;

(b) Independent sign language interpreters;

(c) Spoken language interpreter services agencies; and

(d) Transportation brokers.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2024 c 371, and chapter 246-929 WAC. WSR 25-22-061, s 182-502-0002, filed 10/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-12-057, s 182-502-0002, filed 5/29/25, effective 7/1/25*
- *WSR 24-23-096, s 182-502-0002, filed 11/19/24, effective 1/1/25*
- *WSR 24-12-036, § 182-502-0002, filed 5/30/24, effective 7/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-502-0002, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, 71A.10.020(11), and chapter 18.205 RCW. WSR 23-04-071, § 182-502-0002, filed 1/30/23, effective 3/2/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-15-115, § 182-502-0002, filed 7/20/22, effective 8/20/22*
- *WSR 22-07-105, § 182-502-0002, filed 3/23/22, effective 4/23/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 415 § 211(49). WSR 19-20-046, § 182-502-0002, filed 9/25/19, effective 10/26/19. Statutory Authority: RCW 41.05.021, 2013 c 178, and 2013 2nd sp.s. c 4. WSR 14-06-054, § 182-502-0002, filed 2/27/14, effective 3/30/14. WSR 11-14-075, recodified as § 182-502-0002, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0002, filed 5/9/11, effective 6/9/11.*

##### **Wash. Admin. Code § 182-502-0003** Noneligible provider types. {#sec-182-502-0003 omnilex-key=us-wa-regs-official--title-182--182-502-0003}

The medicaid agency does not enroll licensed or unlicensed health care practitioners not specifically listed in WAC 182-502-0002, including, but not limited to:

(1) Acupuncturists;

(2) Sanipractors;

(3) Homeopaths;

(4) Herbalists;

(5) Massage therapists;

(6) Christian science practitioners, theological healers, and spiritual healers;

(7) Chemical dependency professional trainee (CDPT); and

(8) Mental health trainee (MHT).

**History**
- *Statutory Authority: RCW 41.05.021, 2013 c 178, and 2013 2nd sp.s. c 4. WSR 14-06-054, § 182-502-0003, filed 2/27/14, effective 3/30/14. WSR 11-14-075, recodified as § 182-502-0003, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0003, filed 5/9/11, effective 6/9/11.*

##### **Wash. Admin. Code § 182-502-0005** Provider enrollment—Core provider agreement (CPA) or nonbilling provider agreement. {#sec-182-502-0005 omnilex-key=us-wa-regs-official--title-182--182-502-0005}

(1) The agency only enrolls a health care professional, health care entity, supplier, or contractor of service through approval of an application for:

(a) A core provider agreement (CPA);

(b) A nonbilling provider agreement; or

(c) Adding a servicing provider under either a CPA or a nonbilling provider agreement.

(2) The agency may enter into a single case agreement or other forms of written agreements with a health care professional, health care entity, supplier, or contractor of service.

(3) Servicing providers must comply with the requirements for providers in the agreement under which they are enrolled and agency rules.

(4) Only a licensed health care professional whose scope of practice includes ordering, prescribing, or referring under their licensure may enroll as a nonbilling provider.

(5) An individual who is enrolled through a nonbilling provider agreement is exempt from the rules in WAC 182-502-0160 and may bill a client for health care services when:

(a) The provider is not enrolled with a managed care organization (MCO) that has a contract with the agency under WAC 182-538-067;

(b) The provider is not acting in their capacity as an ordering, prescribing, or referring provider of health care services for clients; and

(c) The provider documents that the client was informed prior to the delivery of services that:

(i) The provider is enrolled only for purposes of ordering, prescribing, or referring health care services for clients; and

(ii) The client may be billed for the health care services being provided.

(6) For services provided out-of-state, refer to WAC 182-501-0180, 182-501-0182, 182-501-0184, and 182-502-0120.

(7) Effective date of enrollment of a provider.

(a) Enrollment of a provider applicant is effective on the date the agency approves the provider application for enrollment or a date designated by the agency.

(b) A provider applicant may request an exception allowing an effective date earlier than the agency's approval of the provider application by submitting a written request to the agency.

(c) The request for an exception must specify the requested effective date and include an explanation justifying the earlier effective date.

(d) The agency will not authorize an effective date requested by the provider that is earlier than the effective date of any required license or certification.

(e) The agency may approve an exception as requested by the provider as follows for:

(i) Emergency services;

(ii) Agency-approved out-of-state services;

(iii) Medicaid provider entities that are subject to survey and certification by CMS or the state survey agency;

(iv) Retroactive client eligibility; or

(v) Other critical agency need.

(f) For federally qualified health centers (FQHCs), see WAC 182-548-1200. For rural health clinics (RHCs), see WAC 182-549-1200.

(g) Exceptions granted under this subsection do not supersede or otherwise change the agency's timely billing requirements under WAC 182-502-0150.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-23-009, s 182-502-0005, filed 11/8/24, effective 12/9/24*
- *WSR 23-21-061, § 182-502-0005, filed 10/12/23, effective 11/12/23. Statutory Authority: 42 C.F.R. 455.410, RCW 41.05.021. WSR 13-19-037, § 182-502-0005, filed 9/11/13, effective 10/12/13. Statutory Authority: RCW 41.05.021 and 42 C.F.R. 455 subpart E Provider Screening and Enrollment requirements. WSR 12-12-032, § 182-502-0005, filed 5/29/12, effective 7/1/12. WSR 11-14-075, recodified as § 182-502-0005, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0005, filed 5/9/11, effective 6/9/11.*

##### **Wash. Admin. Code § 182-502-0010** When the medicaid agency enrolls. {#sec-182-502-0010 omnilex-key=us-wa-regs-official--title-182--182-502-0010}

(1) Nothing in this chapter obligates the medicaid agency to enroll any eligible health care professional, health care entity, supplier, or contractor of service who requests enrollment.

(2) To enroll as a provider (as defined in WAC 182-500-0085) with the agency, a health care professional, health care entity, supplier, or contractor of service must, on the date of application:

(a) Be currently licensed, certified, accredited, or registered according to the requirements of:

(i) Washington state laws and rules if the services are to be provided in Washington state;

(ii) The state laws and rules where the provider renders services if located outside of the state of Washington;

(b) Have a current state business license as required according to the state laws and rules in the state where the services are to be provided;

(c) Have current professional liability coverage, individually or as a member of a group, to the extent the health care professional, health care entity, supplier or contractor is not covered by the Federal Tort Claims Act, including related rules and regulations;

(d) Have a current federal drug enforcement agency (DEA) certificate, if applicable to the profession's scope of practice;

(e) Meet the conditions in this chapter and other chapters regulating the specific type of health care practitioner;

(f) Sign, without modification, a core provider agreement (CPA) or nonbilling provider agreement, and a debarment form. Servicing providers are not required to sign as their enrollment is based upon being included under an organizational CPA or nonbilling provider agreement;

(g) Agree to accept the payment from the agency as payment in full in accordance with 42 C.F.R. § 447.15 requiring acceptance of state payment as payment in full (see also WAC 182-502-0160 billing a client);

(h) Fully disclose ownership, employees who manage, and other control interests (e.g., member of a board of directors or office), as requested by the agency. Indian health services clinics are exempt from this requirement;

(i) Have screened employees and contractors with whom they do business prior to hiring or contracting to assure that employees and contractors are not excluded from receiving federal funds as required by 42 U.S.C. 1320a-7 and 42 U.S.C. 1320c-5;

(j) Pass the agency's screening process, including license verifications, database checks, site visits, and criminal background checks, including fingerprint-based criminal background checks as required by 42 C.F.R. 455.434 if considered high-risk under 42 C.F.R. 455.450.

(i) The agency uses the same screening level risk categories that apply under medicare.

(ii) For those provider types that are not recognized under medicare, the agency assesses the risk of fraud, waste, and abuse using similar criteria to those used in medicare; and

(k) Pay an application fee, if required by CMS under 42 C.F.R. 455.460.

(3) Servicing providers performing services for a client must be enrolled under the billing providers' CPA or a nonbilling provider agreement.

(4) Only a licensed health care professional whose scope of practice under their licensure includes ordering, prescribing, or referring may enroll as a nonbilling provider.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-10-096, s 182-502-0010, filed 5/7/25, effective 6/7/25*
- *WSR 24-23-009, s 182-502-0010, filed 11/8/24, effective 12/9/24. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. 455.432. WSR 15-10-003, § 182-502-0010, filed 4/22/15, effective 5/23/15. Statutory Authority: RCW 41.05.021 and 42 C.F.R. 455. WSR 13-03-068, § 182-502-0010, filed 1/14/13, effective 2/14/13. Statutory Authority: RCW 41.05.021 and Affordable Care Act (ACA) - 76 Fed. Reg. 5862, 42 C.F.R. Parts 405, 424, 447, 455, 457, and 498. WSR 12-15-015, § 182-502-0010, filed 7/10/12, effective 9/1/12. WSR 11-14-075, recodified as § 182-502-0010, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0010, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.09.521. WSR 08-12-030, § 388-502-0010, filed 5/29/08, effective 7/1/08. Statutory Authority: RCW 74.08.090, 74.09.080, 74.09.120. WSR 03-14-106, § 388-502-0010, filed 6/30/03, effective 7/31/03. Statutory Authority: RCW 74.08.090, 74.09.500, and 74.09.530. WSR 01-07-076, § 388-502-0010, filed 3/20/01, effective 4/20/01*
- *WSR 00-15-050, § 388-502-0010, filed 7/17/00, effective 8/17/00.*

##### **Wash. Admin. Code § 182-502-0012** When the medicaid agency does not enroll. {#sec-182-502-0012 omnilex-key=us-wa-regs-official--title-182--182-502-0012}

(1) The medicaid agency does not enroll a health care professional, health care entity, supplier, or contractor of service for reasons which include, but are not limited to, the following:

(a) The agency determines that:

(i) There is a quality of care issue with significant risk factors that may endanger client health, or safety, or both (see WAC 182-502-0030(1)); or

(ii) There are risk factors that affect the credibility, honesty, or veracity of the health care practitioner (see WAC 182-502-0030(1)).

(b) The health care professional, health care entity, supplier or contractor of service:

(i) Is excluded from participation in medicare, medicaid or any other federally funded health care program;

(ii) Has a current formal or informal pending disciplinary action, statement of charges, or the equivalent from any state or federal professional disciplinary body at the time of initial application;

(iii) Has a suspended, terminated, revoked, or surrendered professional license as defined under chapter 18.130 RCW;

(iv) Has a restricted, suspended, terminated, revoked, or surrendered professional license in any state;

(v) Is noncompliant with the department of health or other state health care agency's stipulation of informal disposition, agreed order, final order, or similar licensure restriction;

(vi) Is suspended or terminated by any agency within the state of Washington that arranges for the provision of health care;

(vii) Fails a background check, including a fingerprint-based criminal background check, performed by the agency. See WAC 182-502-0014 and 182-502-0016; or

(viii) Does not have sufficient liability insurance according to WAC 182-502-0016 for the scope of practice, to the extent the health care professional, health care entity, supplier or contractor of service is not covered by the Federal Tort Claims Act, including related rules and regulations.

(c) A site visit under 42 C.F.R. 455.432 reveals that the provider has failed to comply with a state or federal requirement.

(2) If the agency denies an enrollment application under this section, the applicant may reapply.

(3) Under 42 C.F.R. 455.470, the agency:

(a) Will impose a temporary moratorium on enrollment when directed by CMS; or

(b) May initiate and impose a temporary moratorium on enrollment when approved by CMS.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-23-009, s 182-502-0012, filed 11/8/24, effective 12/9/24*
- *WSR 19-21-067, § 182-502-0012, filed 10/11/19, effective 11/11/19. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. 455.432. WSR 15-10-003, § 182-502-0012, filed 4/22/15, effective 5/23/15. Statutory Authority: RCW 41.05.021. WSR 13-17-047, § 182-502-0012, filed 8/13/13, effective 10/1/13. Statutory Authority: RCW 41.05.021 and 42 C.F.R. 455. WSR 13-03-068, § 182-502-0012, filed 1/14/13, effective 2/14/13. WSR 11-14-075, recodified as § 182-502-0012, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0012, filed 5/9/11, effective 6/9/11.*

##### **Wash. Admin. Code § 182-502-0014** Review and consideration of an applicant's history. {#sec-182-502-0014 omnilex-key=us-wa-regs-official--title-182--182-502-0014}

(1) The medicaid agency may consider enrolling a health care professional, health care entity, supplier or contractor of service for reasons which include, but are not limited to, the following:

(a) The agency determines that:

(i) There is not a quality of care issue with significant risk factors that endanger client health or safety, or both;

(ii) There are not risk factors that affect the credibility, honesty, or veracity of the applicant; and

(iii) The applicant is not likely to repeat the violation that led to a restriction or sanction.

(b) The health care professional, health care entity, supplier or contractor of service has:

(i) Been excluded from participation in medicare, medicaid, or any other federally funded health care program but is not currently excluded; or

(ii) A history of probation, suspension, termination, revocation, or a surrendered professional license, certification, accreditation, or registration as defined under chapter 18.130 RCW but currently has an active license, certification, accreditation, or registration; or

(iii) A restricted or limited professional license, certification, accreditation, or registration as defined under RCW 18.130.160; or

(iv) A history of denial, limitation, suspension or termination of participation or privileges by any health care institution, plan, facility, clinic, or state agency for quality of care issues or inappropriate billing practices and the quality of care issue or inappropriate billing practices have been corrected to the agency's satisfaction.

(2) The agency conducts a screening process as specified in WAC 182-502-0010 (2)(j) on any applicant applying for a core provider agreement (CPA) or enrolling to provide services to eligible clients.

(3) The agency's response to a review of a request for enrollment is based on the information available to the agency at the time of application.

**History**
- *Statutory Authority: RCW 41.05.021 and 42 C.F.R. 455. WSR 13-03-068, § 182-502-0014, filed 1/14/13, effective 2/14/13. WSR 11-14-075, recodified as § 182-502-0014, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0014, filed 5/9/11, effective 6/9/11.*

##### **Wash. Admin. Code § 182-502-0016** Continuing requirements. {#sec-182-502-0016 omnilex-key=us-wa-regs-official--title-182--182-502-0016}

(1) To continue to provide services for eligible clients and be paid for those services, a provider must:

(a) Provide all services without discriminating on the grounds of race, creed, color, age, sex, sexual orientation, religion, national origin, marital status, the presence of any sensory, mental or physical handicap, or the use of a trained dog guide or service animal by a person with a disability;

(b) Provide all services according to federal and state laws and rules, medicaid agency billing instructions, provider alerts issued by the agency, and other written directives from the agency;

(c) Inform the agency of any changes to the provider's application or contract including, but not limited to, changes in:

(i) Ownership (see WAC 182-502-0018);

(ii) Address or telephone number;

(iii) The professional practicing under the billing provider number; or

(iv) Business name;

(d) Retain a current:

(i) Professional state license, registration, or certification in accordance with the state law where the service is being provided, and update the agency of all changes;

(ii) State business license as required according to the state law where the service is being provided, and update the agency of all changes;

(e) Inform the agency in writing within seven calendar days of changes applicable to the provider's clinical privileges;

(f) Inform the agency in writing within seven business days of receiving any informal or formal disciplinary order, disciplinary decision, disciplinary action or other action(s) including, but not limited to, restrictions, limitations, conditions and suspensions resulting from the practitioner's acts, omissions, or conduct against the provider's license, registration, or certification in any state;

(g) Screen employees and contractors with whom they do business prior to hiring or contracting, and on a monthly ongoing basis thereafter, to assure that employees and contractors are not excluded from receiving federal funds as required by 42 U.S.C. 1320a-7 and 42 U.S.C. 1320c-5;

(h) Report immediately to the agency any information discovered regarding an employee's or contractor's exclusion from receiving federal funds in accordance with 42 U.S.C. 1320a-7 and 42 U.S.C. 1320c-5. See WAC 182-502-0010 (2)(j) for information on the agency's screening process;

(i) Pass any portion of the agency's screening process as specified in WAC 182-502-0010 (2)(j) when the agency requires such information to reassess a provider;

(j) Maintain professional and general liability coverage to the extent the provider is not covered:

(i) Under agency, center, or facility professional and general liability coverage; or

(ii) By the Federal Tort Claims Act, including related rules and regulations;

(k) Not surrender, voluntarily or involuntarily, the provider's professional state license, registration, or certification in any state while under investigation by that state or due to findings by that state resulting from the practitioner's acts, omissions, or conduct;

(l) Furnish documentation or other assurances as determined by the agency in cases where a provider has an alcohol or chemical dependency problem, to adequately safeguard the health and safety of medical assistance clients that the provider:

(i) Is complying with all conditions, limitations, or restrictions to the provider's practice both public and private; and

(ii) Is receiving treatment adequate to ensure that the dependency problem will not affect the quality of the provider's practice;

(m) Submit to a revalidation process at least every five years. This process includes, but is not limited to:

(i) Updating provider information including, but not limited to, disclosures;

(ii) Submitting forms as required by the agency including, but not limited to, a new core provider agreement; and

(iii) Passing the agency's screening process as specified in WAC 182-502-0010 (2)(j);

(n) Comply with the employee education requirements regarding the federal and the state false claims recovery laws, the rights and protections afforded to whistleblowers, and related provisions in Section 1902 of the Social Security Act (42 U.S.C. 1396a(68)) and chapter 74.66 RCW when applicable. See WAC 182-502-0017 for information regarding the agency's requirements for employee education about false claims recovery.

(2) A provider may contact the agency with questions regarding its programs. However, the agency's response is based solely on the information provided to the agency's representative at the time of inquiry, and in no way exempts a provider from following the laws and rules that govern the agency's programs.

(3) The agency may refer the provider to the appropriate state health professions quality assurance commission.

(4) In addition to the requirements in subsections (1), (2), and (3) of this section, to continue to provide services for eligible clients and be paid for those services, residential treatment facilities that provide substance use disorder (SUD) services (also see chapter 246-337 WAC) must:

(a) Not deny entry or acceptance of clients into the facility solely because the client is prescribed medication to treat SUD;

(b) Facilitate access to medications specific to the client's diagnosed clinical needs, including medications used to treat SUD;

(c) Make any decisions regarding adjustments to medications used to treat SUD after individual assessment by a prescribing provider;

(d) Coordinate care upon discharge for the client to continue without interruption the medications specific to the client's diagnosed clinical needs, including medications used to treat SUD. See RCW 71.24.585.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-10-096, s 182-502-0016, filed 5/7/25, effective 6/7/25. Statutory Authority: RCW 41.05.021, 41.05.160, 71.24.035, 71.24.520, 71.24.585 and 42 U.S.C. 1315 (Sec. 1115). WSR 21-10-081, § 182-502-0016, filed 5/3/21, effective 6/3/21. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. Sec. 1396 (a)(68). WSR 19-20-060, § 182-502-0016, filed 9/26/19, effective 10/27/19. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. 455.432. WSR 15-10-003, § 182-502-0016, filed 4/22/15, effective 5/23/15. Statutory Authority: RCW 41.05.021 and 42 C.F.R. 455. WSR 13-03-068, § 182-502-0016, filed 1/14/13, effective 2/14/13. WSR 11-14-075, recodified as § 182-502-0016, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0016, filed 5/9/11, effective 6/9/11.*

##### **Wash. Admin. Code § 182-502-0017** Employee education about false claims recovery. {#sec-182-502-0017 omnilex-key=us-wa-regs-official--title-182--182-502-0017}

(1) The medicaid agency (agency) requires any entity (including providers) that makes or receives medical assistance payments from the agency or the agency designee of at least $5,000,000 annually under the state plan to meet the requirements of Section 1902 (a)(68) of the Social Security Act in order to receive payments.

(2) Entity policies and procedures. Entities must adopt and disseminate policies and procedures for their employees, contractors, and agents regarding federal and state false claims and whistleblower protection laws.

(a) Written policies and procedures may be in paper or electronic form, but must be readily available to all employees, contractors, and agents.

(b) If the entity has an employee handbook, it must include a specific discussion of the laws described in written policies regarding the rights of employees to be protected as whistleblowers, and a specific discussion of the entity's policies and procedures for detecting and preventing fraud, waste, and abuse.

(3) Entity. An "entity" may include, but is not limited to, individual providers, a governmental agency, organization, unit, corporation, partnership, or other business arrangement irrespective of the form of business structure by which it exists or whether for-profit or not-for-profit.

(a) An organization may have multiple subsidiaries, locations, federal employer identification numbers (FEIN), or provider numbers and still be combined for the purposes of meeting the definition of an entity.

(b) Whether subsidiaries would be aggregated or viewed as separate entities depends on the corporate structure and assessment of the largest separate organizational unit that furnishes medicaid health care items or services.

(c) The agency and its designee administering the medicaid program, or any agent performing an administrative function, are not considered entities.

(4) Payments received. For any entity that receives medical assistance payments under the state plan of at least $5,000,000 annually, the total amount includes:

(a) All payments received by an entity who furnishes items or services at one or more location(s);

(b) All payments received by an entity who furnishes items or services under one or more contractual or other payment arrangement(s);

(c) Only the amounts received from the agency or the agency designee. The amounts paid by a managed care organization (MCO) to the entity are only counted against the MCO, not the entity, when calculating the $5,000,000 threshold; and

(d) Only payments received from Washington state. Payments from multiple states are not aggregated to reach the $5,000,000 annual threshold.

(5) Annual monitoring. At the conclusion of each federal fiscal year, the agency identifies who qualifies as an entity subject to the requirements in Section 1902 (a)(68) of the Social Security Act.

(a) If the agency determines that an entity is subject to and must comply with Section 1902 (a)(68) of the act:

(i) The agency provides written notice to the entity that it must comply;

(ii) The entity must submit an attestation to the agency under penalty of perjury to verify the entity has adopted and disseminated compliant, written policies as required; and

(iii) The agency may request copies of the written policies and proof of dissemination to verify compliance with the requirements.

(b) If the agency does not receive the required documentation by the due date, the agency sends a warning to the entity to become compliant by a specified deadline.

(c) If the entity remains noncompliant after the deadline, the agency ceases medical assistance payments until the entity is compliant.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. Sec. 1396 (a)(68). WSR 19-20-060, § 182-502-0017, filed 9/26/19, effective 10/27/19.*

##### **Wash. Admin. Code § 182-502-0018** Change of ownership. {#sec-182-502-0018 omnilex-key=us-wa-regs-official--title-182--182-502-0018}

(1) A provider must notify the medicaid agency in writing within seven calendar days of ownership or control changes of any kind. An entity is considered to have an ownership or control interest in another entity if it has direct or indirect ownership of five percent or more, or is a managing employee (e.g., a general manager, business manager, administrator, or director) who exercises operational or managerial control over the entity or who directly or indirectly conducts day-to-day operations of the entity. The agency determines whether a new core provider agreement (CPA) must be completed for the new entity.

(2) When a provider obtains a new federal tax identification (ID) following a change of ownership, the agency terminates the provider's CPA as of the date of the change in federal tax ID. The provider may reapply for a new CPA.

(3) All new ownership enrollments are subject to the requirements in WAC 182-502-0010. In addition to those requirements, the applicant must:

(a) Complete a change of ownership form;

(b) Provide the agency with a copy of the contract of sale identifying previous and current owners; and

(c) Provide the agency with a list of all provider numbers affected by the change of ownership.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-039, § 182-502-0018, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0018, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0018, filed 5/9/11, effective 6/9/11.*

##### **Wash. Admin. Code § 182-502-0020** Health care record requirements. {#sec-182-502-0020 omnilex-key=us-wa-regs-official--title-182--182-502-0020}

This section applies to providers, as defined under WAC 182-500-0085 and under WAC 182-538-050. Providers must:

(1) Maintain documentation in the client's medical or health care records to verify the level, type, and extent of services provided to each client to fully justify the services and billing, including, but not limited to:

(a) Client's name and date of birth;

(b) Dates of services;

(c) Name and title of person performing the service;

(d) Chief complaint or reason for each visit;

(e) Pertinent past and present medical history;

(f) Pertinent findings on examination at each visit;

(g) Medication(s) or treatment prescribed and/or administered;

(h) Name and title of individual prescribing or administering medication(s);

(i) Equipment and/or supplies prescribed or provided;

(j) Name and title of individual prescribing or providing equipment and/or supplies;

(k) Detailed description of treatment provided;

(l) Subjective and objective findings;

(m) Clinical assessment and diagnosis;

(n) Recommendations for additional treatments, procedures, or consultations;

(o) Radiographs (X-rays), diagnostic tests and results;

(p) Plan of treatment and/or care, and outcome;

(q) Specific claims and payments received for services;

(r) Correspondence pertaining to client dismissal or termination of health care practitioner/patient relationship;

(s) Advance directives, when required under WAC 182-501-0125;

(t) Patient treatment agreements (examples: Opioid agreement, medication and treatment compliance agreements); and

(u) Informed consent documentation.

(2) Keep legible, accurate, and complete charts and records;

(3) Meet any additional record requirements of the department of health (DOH);

(4) Assure charts are authenticated by the person who gave the order, provided the care, or performed the observation, examination, assessment, treatment or other service to which the entry pertains;

(5) Make charts and records available to the medicaid agency, its contractors or designees, and the United States Department of Health and Human Services (DHHS) upon request, for six years from the date of service or longer if required specifically by federal or state law or regulation. The agency does not separately reimburse for copying of health care records, reports, client charts and/or radiographs, and related copying expenses; and

(6) Permit the agency, DHHS, and its agents or designated contractors, access to its physical facilities and its records to enable the agency and DHHS to conduct audits, inspections, or reviews without prior announcement.

**History**
- *Statutory Authority: RCW 41.05.021 and 42 C.F.R. 455. WSR 13-03-068, § 182-502-0020, filed 1/14/13, effective 2/14/13. WSR 11-14-075, recodified as § 182-502-0020, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0020, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 74.09.530. WSR 01-07-076, § 388-502-0020, filed 3/20/01, effective 4/20/01*
- *WSR 00-15-050, § 388-502-0020, filed 7/17/00, effective 8/17/00.*

##### **Wash. Admin. Code § 182-502-0022** Provider preventable conditions (PPCs)—Payment policy. {#sec-182-502-0022 omnilex-key=us-wa-regs-official--title-182--182-502-0022}

(1) This section establishes the agency's payment policy for services provided to medicaid clients on a fee-for-service basis or to a client enrolled in a managed care organization (defined in WAC 182-538-050) by health care professionals and inpatient hospitals that result in provider preventable conditions (PPCs).

(2) The rules in this section apply to:

(a) All health care professionals who bill the agency directly; and

(b) Inpatient hospitals.

(3) Definitions. The following definitions and those found in chapter 182-500 WAC apply to this section:

(a) Agency - See WAC 182-500-0010.

(b) Health care-acquired conditions (HCAC) - A condition occurring in any inpatient hospital setting (identified as a hospital acquired condition by medicare other than deep vein thrombosis/pulmonary embolism as related to a total knee replacement or hip replacement surgery in pediatric and obstetric patients.) Medicare's list of hospital acquired conditions is also available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html.

(c) Other provider preventable conditions (OPPC) - The list of serious reportable events in health care as identified by the department of health in WAC 246-302-030 and published by the National Quality Forum.

(d) Present on admission (POA) indicator - A status code the hospital uses on an inpatient claim that indicates if a condition was present at the time the order for inpatient admission occurs.

(e) Provider preventable condition (PPC) - An umbrella term for hospital and nonhospital acquired conditions identified by the agency for nonpayment to ensure the high quality of medicaid services. PPCs include two distinct categories: Health care-acquired conditions (HCACs) and other provider-preventable conditions (OPPCs).

(4) Health care-acquired condition (HCAC) - The agency will deny or recover payment to health care professionals and inpatient hospitals for care related only to the treatment of the consequences of a HCAC.

(a) HCAC conditions include:

(i) Foreign object retained after surgery;

(ii) Air embolism;

(iii) Blood incompatibility;

(iv) Stage III and IV pressure ulcers;

(v) Falls and trauma:

(A) Fractures;

(B) Dislocations;

(C) Intracranial injuries;

(D) Crushing injuries;

(E) Burns;

(F) Other injuries.

(vi) Manifestations of poor glycemic control:

(A) Diabetic ketoacidosis;

(B) Nonketotic hyperosmolar coma;

(C) Hypoglycemic coma;

(D) Secondary diabetes with ketoacidosis;

(E) Secondary diabetes with hyperosmolarity.

(vii) Catheter-associated urinary tract infection (UTI);

(viii) Vascular catheter-associated infection;

(ix) Surgical site infection, mediastinitis, following coronary artery bypass graft (CABG);

(x) Surgical site infection following bariatric surgery for obesity:

(A) Laparoscopic gastric bypass;

(B) Gastroenterostomy; or

(C) Laparoscopic gastric restrictive surgery.

(xi) Surgical site infection following certain orthopedic procedures:

(A) Spine;

(B) Neck;

(C) Shoulder;

(D) Elbow.

(xii) Surgical site infection following cardiac implantable electronic device (CIED).

(xiii) Deep vein thrombosis/pulmonary embolism (DVT/PE) following certain orthopedic procedures:

(A) Total knee replacement; or

(B) Hip replacement.

(xiv) Latrogenic pneumothorax with venous catheterization.

(b) Hospitals must include the present on admission (POA) indicator when submitting inpatient claims for payment. The POA indicator is to be used according to the official coding guidelines for coding and reporting and the CMS guidelines. The POA indicator may prompt a review, by the agency or the agency's designee, of inpatient hospital claims with an HCAC diagnosis code when appropriate according to the CMS guidelines. The agency will identify professional claims using the information provided on the hospital claims.

(c) HCACs are based on current medicare inpatient prospective payment system rules with the inclusion of POA indicators. Health care professionals and inpatient hospitals must report HCACs on claims submitted to the agency for consideration of payment.

(5) Other provider preventable condition (OPPC) - The agency will deny or recoup payment to health care professionals and inpatient hospitals for care related only to the treatment of consequences of an OPPC when the condition:

(a) Could have reasonably been prevented through the application of nationally recognized evidence based guidelines;

(b) Is within the control of the hospital;

(c) Occurred during an inpatient hospital admission;

(d) Has a negative consequence for the beneficiary;

(e) Is auditable; and

(f) Is included on the list of serious reportable events in health care as identified by the department of health in WAC 246-302-030 effective on the date the incident occurred. The list of serious reportable events in health care, as of the publishing of this rule, includes:

(i) Surgical or invasive procedure events:

(A) Surgical or other invasive procedure performed on the wrong site;

(B) Surgical or other invasive procedure performed on the wrong patient;

(C) Wrong surgical or other invasive procedure performed on a patient;

(D) Unintended retention of a foreign object in a patient after surgery or other invasive procedure;

(E) Intraoperative or immediately postoperative/postprocedure death in an ASA Class 1 patient.

(ii) Product or device events:

(A) Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the hospital;

(B) Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used or functions other than as intended;

(C) Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a hospital.

(iii) Patient protection events:

(A) Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person;

(B) Patient death or serious injury associated with patient elopement;

(C) Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a hospital.

(iv) Care management events:

(A) Patient death or serious injury associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration);

(B) Patient death or serious injury associated with unsafe administration of blood products;

(C) Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a hospital;

(D) Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy;

(E) Patient death or serious injury associated with a fall while being cared for in a hospital;

(F) Any stage 3, stage 4, or unstageable pressure ulcers acquired after admission/presentation to a hospital (not present on admission);

(G) Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen;

(H) Patient death or serious injury resulting from failure to follow-up or communicate laboratory, pathology, or radiology test results.

(v) Environmental events:

(A) Patient death or serious injury associated with an electric shock in the course of a patient care process in a hospital;

(B) Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or is contaminated by toxic substances;

(C) Patient death or serious injury associated with a burn incurred from any source in the course of a patient care process in a hospital;

(D) Patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a hospital.

(vi) Radiologic events: Death or serious injury of a patient associated with the introduction of a metallic object into the magnetic resonance imaging (MRI) area.

(vii) Potential criminal event:

(A) Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider;

(B) Abduction of a patient of any age;

(C) Sexual abuse/assault on a patient within or on the grounds of a health care setting;

(D) Death or serious injury of a patient resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a health care setting.

(6) Reporting PPCs.

(a) The agency requires inpatient hospitals to report PPCs (as appropriate according to (d) and (e) of this subsection) to the agency by using designated present on admission (POA) indicator codes and appropriate HCPCs modifiers that are associated:

(i) With claims for medical assistance payment; or

(ii) With courses of treatment furnished to clients for which medical assistance payment would otherwise be available.

(b) Health care professionals and inpatient hospitals must report PPCs associated with medicaid clients to the agency even if the provider does not intend to bill the agency.

(c) Use of the appropriate POA indicator codes informs the agency of the following:

(i) A condition was present at the time of inpatient hospital admission or at the time the client was first seen by the health care professional or hospital; or

(ii) A condition occurred during admission or encounter with a health care professional either inpatient or outpatient.

(d) Hospitals must notify the agency of an OPPC associated with an established medicaid client within 45 calendar days of the confirmed OPPC in accordance with RCW 70.56.020. If the client's medicaid eligibility status is not known or established at the time the OPPC is confirmed, the agency allows hospitals 30 days to notify the agency once the client's eligibility is established or known.

(i) Notification must be in writing, addressed to the agency's office of program integrity, and include the OPPC, date of service, client identifier, and the claim number if the facility submits a claim to the agency.

(ii) Hospitals must complete the appropriate portion of the HCA 12-200 form to notify the agency of the OPPC. Agency forms are available for download at https://www.hca.wa.gov/billers-providers-partners/forms-and-publications.

(e) Health care professionals or designees responsible for or may have been associated with the occurrence of a PPC involving a medicaid client must notify the agency within 45 calendar days of the confirmed PPC in accordance with chapter 70.56 RCW. Notifications must be in writing, addressed to the agency's chief medical officer, and include the PPC, date of service, and client identifier. Providers must complete the appropriate portion of the HCA 12-200 form to notify the agency of the PPC. Agency forms are available for download at www.hca.wa.gov/billers-providers-partners/forms-and-publications.

(f) Failure to report, code, bill or claim PPCs according to the requirements in this section will result in loss or denial of payments.

(7) Identifying PPCs. The agency may identify PPCs as follows:

(a) Through the department of health (DOH); or

(b) Through the agency's program integrity efforts, including:

(i) The agency's claims payment system;

(ii) Retrospective hospital utilization review process (see WAC 182-550-1700);

(iii) The agency's provider payment review process (see WAC 182-502-0230);

(iv) The agency's provider audit process (see chapter 182-502A WAC); and

(v) A provider or client complaint.

(8) Payment adjustment for PPCs. The agency or its designee conducts a review of the PPC prior to reducing or denying payment.

(a) The agency does not reduce, recoup, or deny payment to a provider for a PPC when the condition:

(i) Existed prior to the initiation of treatment for that client by that provider. Documentation must be kept in the client's clinical record to clearly support that the PPC existed prior to initiation of treatment; or

(ii) Is directly attributable to a comorbid condition(s).

(b) The agency reduces payment to a provider when the following applies:

(i) The identified PPC would otherwise result in an increase in payment; and

(ii) The portion of the professional services payment directly related to the PPC, or treatment of the PPC, can be reasonably isolated for nonpayment.

(c) The agency does not make additional payments for services on claims for covered health care services that are attributable to HCACs and/or are coded with POA indicator codes "N" or "U."

(d) Medicare crossover claims. The agency applies the following rules for these claims:

(i) If medicare denies payment for a claim at a higher rate for the increased costs of care under its PPC policies:

(A) The agency limits payment to the maximum allowed by medicare;

(B) The agency does not pay for care considered nonallowable by medicare; and

(C) The client cannot be held liable for payment.

(ii) If medicare denies payment for a claim under its national coverage determination agency from Section 1862 (a)(1)(A) of the Social Security Act (42 U.S.C. 1395) for an adverse health event:

(A) The agency does not pay the claim, any medicare deductible or any coinsurance related to the inpatient hospital and health care professional services; and

(B) The client cannot be held liable for payment.

(9) The agency will calculate its reduction, denial or recoupment of payment based on the facts of each OPPC or HCAC. Any overpayment applies only to the health care professional or hospital where the OPPC or HCAC occurred and does not apply to care provided by other health care professionals and inpatient hospitals, should the client subsequently be transferred or admitted to another hospital for needed care.

(10) Medicaid clients are not liable for payment of an item or service related to an OPPC or HCAC or the treatment of consequences of an OPPC or HCAC that would have been otherwise payable by the agency, and must not be billed for any item or service related to a PPC.

(11) Provider dispute process for PPCs.

(a) A health care professional or inpatient hospital may dispute the agency's reduction, denial or recoupment of payment related to a PPC as described in chapter 182-502A WAC.

(b) The disputing health care professional or inpatient hospital must provide the agency with the following information:

(i) The health care professional or inpatient hospital's assessment of the PPC; and

(ii) A complete copy of the client's medical record and all associated billing records, to include itemized statement or explanation of charges.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-04-033, § 182-502-0022, filed 1/25/23, effective 2/25/23*
- *WSR 19-08-037, § 182-502-0022, filed 3/28/19, effective 4/28/19. Statutory Authority: RCW 41.05.021. WSR 13-19-038, § 182-502-0022, filed 9/11/13, effective 10/12/13. Statutory Authority: 42 C.F.R. § 447.26. WSR 13-11-051, § 182-502-0022, filed 5/14/13, effective 7/1/13.*

##### **Wash. Admin. Code § 182-502-0025** Electronic health records (EHR) incentive program. {#sec-182-502-0025 omnilex-key=us-wa-regs-official--title-182--182-502-0025}

The purpose of this section is to establish the medicaid electronic health records (EHR) incentive program under the American Recovery and Reinvestment Act of 2009 (ARRA). The medicaid EHR incentive program promotes the adoption and meaningful use of certified EHR technology by offering financial incentives to eligible professionals and hospitals. This program is administered by the medicaid agency.

(1) The agency provides incentive payments to eligible providers and hospitals that adopt and meaningfully use certified EHR technology under 42 C.F.R. Parts 412, 413, 422, and any other federal regulations that apply.

(2) Providers and hospitals eligible to participate in EHR incentive program are identified in 42 C.F.R. Part 495.304 and other applicable rules.

(3) As authorized by 42 C.F.R. Parts 412, 413, 422, chapters 43.20B and 74.09 RCW, and any other federal or state rules that apply, the agency monitors and reviews all providers and hospitals participating in the EHR incentive program. By the same authority, the agency reviews all practices, documentation, and data related to EHR technology to determine whether professionals and hospitals participating in the EHR incentive program are eligible and complying with state and federal rules and regulations.

(4) The agency may determine that a participating professional or hospital has not met the eligibility or performance requirements to receive an EHR incentive payment, or should receive an incentive payment in an amount less than the amount anticipated by the provider or hospital. Areas of possible dispute in the EHR incentive program include, at a minimum, any of the following:

(a) Patient volume thresholds and calculations, as outlined in 42 C.F.R. Parts 495.304 and 495.306.

(b) Eligibility criteria and payment limitations, as outlined in 42 C.F.R. Parts 495.10, 495.304, 495.306, and 495.310.

(c) Attestations and compliance demonstrations including, at a minimum:

(i) Attestations that certified EHR technology has been adopted, implemented, or upgraded; and

(ii) Demonstrations of meaningful use, as outlined in 42 C.F.R. Parts 495.6, 495.8, 495.306, 495.310, and in any future published federal regulations and requirements, as applicable.

(d) The payment process and incentive payment amounts, as outlined in 42 C.F.R. Parts 495.310, 495.312, and 495.314.

(e) Additional issues regarding EHR incentive program eligibility, participation, documentation, and compliance as outlined in 42 C.F.R. Parts 412, 413, 422, and in any future published federal regulations and requirements, as applicable.

(5) All matters of dispute are subject to the Administrative Procedure Act (APA) appeal process under chapter 34.05 RCW. A provider who disagrees with an agency action under this section may request a hearing. The hearing request must:

(a) Be in writing;

(b) Be received by the agency, at the address identified in the notice of action, within twenty-eight days of the date of the notice of action by certified mail (return receipt); and

(c) State the reason or reasons why the provider thinks the action is incorrect.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-039, § 182-502-0025, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0025, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-13-053, § 388-502-0025, filed 6/10/11, effective 7/11/11.*

##### **Wash. Admin. Code § 182-502-0030** Termination of provider enrollment—For cause. {#sec-182-502-0030 omnilex-key=us-wa-regs-official--title-182--182-502-0030}

WAC 182-502-0030

(1) The medicaid agency may immediately terminate a provider's enrollment for any one or more of the following reasons, each of which constitutes cause:

(a) Moral turpitude;

(b) Sexual misconduct according to chapter 246-16 WAC or in profession specific rules of the department of health (DOH);

(c) A statement of allegations or statement of charges by DOH or equivalent from other state licensing boards;

(d) Restrictions or limitations placed by any state licensing, credentialing, or certification agency on the provider's current credentials or practice;

(e) Limitations, restrictions, or loss of hospital privileges or participation in any health care plan or failure to disclose the reasons to the agency;

(f) Negligence, incompetence, inadequate or inappropriate treatment, or lack of appropriate follow-up treatment;

(g) Patient drug mismanagement, failure to identify substance use disorder, or failure to refer the patient for substance use disorder treatment once identified;

(h) Use of health care providers or health care staff who are unlicensed to practice or who provide health care services that are outside their recognized scope of practice or the standard of practice in the state of Washington;

(i) Failure of the health care provider to comply with the provider requirements in chapter 182-502 WAC, including WAC 182-502-0010, 182-502-0016, and 182-502-0020;

(j) Failure of the health care provider with a substance use disorder(s) to furnish documentation or other assurances as determined by the agency to adequately safeguard the health and safety of Washington apple health clients that the provider:

(i) Is complying with all conditions, limitations, or restrictions to the provider's practice both public and private; and

(ii) Is receiving treatment adequate to ensure that the disorder will not affect the quality of the provider's practice.

(k) Infection control deficiencies;

(l) Failure to maintain adequate professional malpractice coverage;

(m) Medical malpractice claims or professional liability claims that constitute a pattern of questionable or inadequate treatment, or contain any gross or flagrant incident of malpractice;

(n) Dishonesty or other unprofessional conduct;

(o) Civil or criminal findings of fraudulent or abusive billing practices through an investigation or other review (e.g., audit or record review);

(p) Exclusion from participation in medicare, medicaid, or any other federally funded health care program;

(q) Any conviction, no contest plea, or guilty plea relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct;

(r) Any conviction, no contest plea, or guilty plea of a criminal offense;

(s) Failure to comply with a DOH request for information or an ongoing DOH investigation;

(t) Noncompliance with a DOH or other state health care agency's stipulation to disposition, agreed order, final order, or other similar licensure restriction;

(u) Misrepresentation or failure to disclose information to the agency during or after enrollment including on the application for a core provider agreement (CPA), a nonbilling provider agreement, or servicing providers enrolled under a core provider agreement;

(v) Failure to comply with an agency request for information;

(w) Failure to submit adequate documentation to the agency or failure to retain adequate documentation as required by the agency;

(x) Failure to cooperate with an agency investigation, audit, or review;

(y) Providing health care services that are outside the provider's recognized scope of practice or the standard of practice in the state of Washington;

(z) Unnecessary medical, dental, or other health care procedures;

(aa) Discriminating in the furnishing of health care services, supplies, or equipment as prohibited by 42 U.S.C. § 2000d; and

(bb) Any other act that the agency determines is contrary to the interest of the agency or the health and safety of its clients.

(2) When a provider's enrollment is terminated for cause, the agency pays only for authorized services provided up to the date of termination of enrollment.

(3) When the agency terminates enrollment of a billing provider, including group practices, all servicing providers enrolled under that billing provider agreement who are not enrolled under another provider agreement may have their enrollment:

(a) Immediately inactivated; or

(b) Terminated for cause per this section.

(4) When the agency terminates enrollment of a servicing provider of an enrolled group practice who is also a full or partial owner that meets the criteria of ownership in WAC 182-502-0018, the agency terminates the enrolled group practice and inactivates all enrolled servicing providers who are not enrolled under another provider agreement.

(5) A provider whose enrollment is inactivated may reapply for participation with the agency subject to program rules, including WAC 182-502-0010.

(6) When the agency terminates a provider's enrollment for cause, the agency provides written notice to the provider in a manner which provides proof of receipt or proof of valid attempt to deliver the notice.

(7) Effective date.

(a) The effective date of the termination of a provider's enrollment is the date stated in the notice.

(b) When a provider's enrollment is terminated for misrepresentation or failure to disclose information to the agency during enrollment, the agency may:

(i) Terminate the provider's enrollment retroactively to the effective date of enrollment; and

(ii) Recoup any payments received by the provider since the date of enrollment.

(8) Administrative hearing.

(a) The provider may appeal the agency decision to terminate the provider's enrollment for cause by submitting a written request to the address contained in the decision notice within 28 calendar days of the date on the notice and in a manner that provides proof of receipt by the agency. The agency does not allow good cause exception related to this subsection.

(b) If the agency receives a timely appeal, the presiding officer will schedule a prehearing conference in accordance with WAC 182-526-0195.

(c) The administrative hearing process is governed by the Administrative Procedure Act, chapter 34.05 RCW, and chapter 182-526 WAC.

(d) Burden of proof.

(i) The provider has the burden of proof.

(ii) The standard of proof in a provider termination hearing is "clear and convincing evidence" meaning the evidence is highly and substantially more likely to be true than untrue. This is a higher standard of proof than proof by a preponderance of the evidence, but it does not require proof beyond a reasonable doubt.

(e) The filing of an appeal does not stay (stop) the effective date of termination.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-13-049, s 182-502-0030, filed 6/11/26, effective 7/12/26*
- *WSR 24-23-009, s 182-502-0030, filed 11/8/24, effective 12/9/24*
- *WSR 23-21-061, § 182-502-0030, filed 10/12/23, effective 11/12/23*
- *WSR 15-14-039, § 182-502-0030, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0030, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0030, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.530. WSR 00-15-050, § 388-502-0030, filed 7/17/00, effective 8/17/00.*

##### **Wash. Admin. Code § 182-502-0040** Termination of provider enrollment—For convenience. {#sec-182-502-0040 omnilex-key=us-wa-regs-official--title-182--182-502-0040}

WAC 182-502-0040

(1) Either the medicaid agency or the provider may terminate the provider's enrollment with the agency for convenience with 28 calendar days written notice in a manner which provides proof of receipt or proof of valid attempt to deliver the notice.

(2) Termination of enrollment for convenience is the agency's final decision.

(3) Providers may not appeal or request reconsideration of the decision to terminate their enrollment for convenience.

(4) If a provider is terminated for convenience, the agency pays for authorized services provided up to the date of termination only.

(5) Providers whose enrollment has been terminated for convenience may reapply for participation with the agency subject to program rules, including WAC 182-502-0010.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-13-049, s 182-502-0040, filed 6/11/26, effective 7/12/26*
- *WSR 24-23-009, s 182-502-0040, filed 11/8/24, effective 12/9/24*
- *WSR 19-21-067, § 182-502-0040, filed 10/11/19, effective 11/11/19. WSR 11-14-075, recodified as § 182-502-0040, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0040, filed 5/9/11, effective 6/9/11.*

##### **Wash. Admin. Code § 182-502-0050** Provider dispute of an agency action. {#sec-182-502-0050 omnilex-key=us-wa-regs-official--title-182--182-502-0050}

The process described in this section applies only when agency rules allow a provider to dispute an agency decision under this section.

(1) In order for the agency to review a decision previously made by the agency, a provider must submit the request to review the decision:

(a) Within 28 calendar days of the date on the agency's decision notice;

(b) To the address listed in the decision notice; and

(c) In a manner that provides proof of receipt.

(2) A provider's dispute request must:

(a) Be in writing;

(b) Specify the agency decision that the provider is disputing;

(c) State the basis for disputing the agency's decision; and

(d) Include documentation to support the provider's position.

(3) The agency may request additional information or documentation. The provider must submit the additional information or documentation to the agency within 28 calendar days of the date on the agency's request.

(4) The agency closes the dispute without issuing a decision and with no right to further review under subsection (6) of this section when the provider:

(a) Fails to comply with any requirement of subsections (2), (3), and (4) of this section;

(b) Fails to cooperate with, or unduly delays, the dispute process; or

(c) Withdraws the dispute request in writing.

(5) The agency will send the provider a written notice of dispute closure or written dispute decision.

(6) The provider may request the director of the health care authority or designee to review the written dispute decision according to the process in WAC 182-502-0270.

(7) This section does not apply to disputes regarding overpayment. For disputes regarding overpayment, see WAC 182-502-0230 and chapter 182-502A WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-23-009, s 182-502-0050, filed 11/8/24, effective 12/9/24. Statutory Authority: RCW 41.05.021. WSR 13-17-047, § 182-502-0050, filed 8/13/13, effective 10/1/13. WSR 11-14-075, recodified as § 182-502-0050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0050, filed 5/9/11, effective 6/9/11.*

##### **Wash. Admin. Code § 182-502-0060** Reapplying for participation. {#sec-182-502-0060 omnilex-key=us-wa-regs-official--title-182--182-502-0060}

A provider who is terminated solely under WAC 182-502-0030(3) is eligible for immediate reapplication with the medicaid agency if the provider is not a full or partial owner of a terminated group practice.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-21-067, § 182-502-0060, filed 10/11/19, effective 11/11/19*
- *WSR 15-15-050, § 182-502-0060, filed 7/9/15, effective 8/9/15. Statutory Authority: RCW 41.05.021. WSR 13-17-047, § 182-502-0060, filed 8/13/13, effective 10/1/13. WSR 11-14-075, recodified as § 182-502-0060, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0060, filed 5/9/11, effective 6/9/11.*

##### **Wash. Admin. Code § 182-502-0100** General conditions of payment. {#sec-182-502-0100 omnilex-key=us-wa-regs-official--title-182--182-502-0100}

(1) The medicaid agency pays for health care services furnished to an eligible client when the claim satisfies agency rules including all the following:

(a) The service is within the scope of care of the client's Washington apple health program;

(b) The service is medically necessary;

(c) The service is properly authorized;

(d) The provider bills within the time frame set in WAC 182-502-0150;

(e) The provider bills according to agency rules and billing instructions; and

(f) The provider follows third-party payment procedures.

(2) The agency pays for health care services only when the services are provided by or on behalf of a provider that is enrolled with the agency.

(3) In order for any services or supplies ordered, prescribed, or referred by a provider to be paid:

(a) The provider must be enrolled with the agency under their national provider identifier (NPI); and

(b) The NPI for the referring, prescribing, or ordering provider must be included on the claim form.

(4) If payment for services is to be made to a group practice, partnership, or corporation, the group, partnership, or corporation must enroll with the agency and provide its national provider identifier (NPI) (if eligible for an NPI) to be used for submitting claims as the billing provider.

(5) The agency is the payer of last resort, unless the other payer is:

(a) An Indian health service;

(b) A crime victims program through the department of labor and industries; or

(c) A school district for health services provided under the Individuals with Disabilities Education Act.

(6) The agency does not pay providers for health care services identified by the agency as client financial obligations, and deducts from the payment the costs of those services identified as client financial obligations. Client financial obligations include, but are not limited to, the following:

(a) Copayments (copays) (unless the criteria in chapter 182-517 WAC or WAC 182-501-0200 are met);

(b) Deductibles (unless the criteria in chapter 182-517 WAC or WAC 182-501-0200 are met); and

(c) Spenddown (see WAC 182-519-0110).

(7) The agency does not pay for any health care service, drug, supply, or equipment prescribed or ordered by a health care professional, health care entity, supplier, or contractor of service not currently enrolled with the agency.

(8) The agency does not pay for services provided to clients during the application process for provider enrollment, regardless of whether the agency later approves or denies the application, unless an exception for earlier enrollment is approved by the agency in accordance with WAC 182-502-0005.

(9) The agency does not pay for any health care service, drug, supply, or equipment prescribed or ordered by a health care professional, health care entity, supplier, or contractor of services whose application for enrollment has been denied or terminated.

(10) The provider must accept medicare assignment for claims involving clients eligible for both medicare and Washington apple health before the agency makes any payment.

(11) The provider is responsible for verifying whether a client has Washington apple health coverage for the dates of service.

(12) The agency may reimburse a provider for services provided to a person if it is later determined that the person was ineligible for the service when it was provided if:

(a) The agency considered the person eligible at the time of service;

(b) The service was not otherwise paid for; and

(c) The provider submits a request for payment to the agency.

(13) The agency does not pay on a fee-for-service basis for a service for a client who is enrolled in a managed care plan when the service is included in the plan's contract with the agency.

(14) Information about health care services for jail inmates is found in RCW 70.48.130.

(15) The agency pays for medically necessary services on the basis of usual and customary charges or the maximum allowable fee established by the agency, whichever is lower.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-23-009, s 182-502-0100, filed 11/8/24, effective 12/9/24. Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-502-0100, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-039, § 182-502-0100, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-014, § 388-502-0100, filed 5/9/11, effective 6/9/11*
- *WSR 10-19-057, § 388-502-0100, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 71.05.560, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530. WSR 06-13-042, § 388-502-0100, filed 6/15/06, effective 7/16/06. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.530. WSR 00-15-050, § 388-502-0100, filed 7/17/00, effective 8/17/00.*

##### **Wash. Admin. Code § 182-502-0110** Conditions of payment and prior authorization requirements—Medicare coinsurance, copayments, and deductibles. {#sec-182-502-0110 omnilex-key=us-wa-regs-official--title-182--182-502-0110}

(1) The following people are eligible for benefits under this section:

(a) Dual-eligible clients enrolled in categorically needy Washington apple health programs;

(b) Dual-eligible clients enrolled in medically needy Washington apple health programs; or

(c) Clients enrolled in the qualified medicare beneficiary (QMB) program.

(2) The agency pays the medicare coinsurance, copayments, and deductibles for Part A, Part B, and medicare advantage Part C for an eligible person under subsection (1) of this section:

(a) Up to the published or calculated medicaid-only rate; and

(b) If the provider accepts assignment for medicare payment.

(3) If a medicare Part A recipient has remaining lifetime reserve days, the agency pays the deductible and coinsurance amounts up to the allowed amount as calculated by the agency.

(4) If a medicare Part A recipient has exhausted lifetime reserve days during an inpatient hospital stay, the agency pays the deductible and coinsurance amounts up to the agency-calculated allowed amount minus any payment made by medicare, and any payment made by the agency, up to the outlier threshold. Once the outlier threshold is reached, the agency pays according to WAC 182-550-3700.

(5) If medicare and medicaid cover the service, the agency pays:

(a) The deductible and coinsurance up to medicare or medicaid's allowed amount, whichever is less; or

(b) For long-term civil commitments, as defined in WAC 182-500-0065, the greater of medicare or medicaid's allowed amount, minus what medicare paid.

(6) If only medicare covers the service, the agency pays the deductible and coinsurance up to the agency's allowed amount established for a QMB client, and at zero for a non-QMB client.

(7) If a client exhausts medicare benefits, the agency pays for medicaid-covered services under Title 182 WAC and the agency's billing instructions.

(8) When medicaid requires prior authorization for a service covered by both medicare and medicaid:

(a) Medicaid does not require prior authorization when the client's medicare benefit is not exhausted.

(b) Medicaid does require prior authorization when the client's medicare benefit is exhausted. See also WAC 182-501-0050(5).

(9) Providers must meet the timely billing requirements under WAC 182-502-0150 in order to be paid for services.

(10) Payment for services is subject to postpayment review.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-17-167, § 182-502-0110, filed 8/24/22, effective 9/24/22*
- *WSR 17-06-063, § 182-502-0110, filed 2/28/17, effective 3/31/17*
- *WSR 16-13-157, § 182-502-0110, filed 6/22/16, effective 7/23/16. WSR 11-14-075, recodified as § 182-502-0110, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.530. WSR 00-15-050, § 388-502-0110, filed 7/17/00, effective 8/17/00.*

##### **Wash. Admin. Code § 182-502-0120** Payment for health care services provided outside the state of Washington. {#sec-182-502-0120 omnilex-key=us-wa-regs-official--title-182--182-502-0120}

(1) The medicaid agency pays for health care services provided outside the state of Washington only when the service meets the provisions described in WAC 182-501-0180, 182-501-0182, 182-501-0184, and specific program WAC.

(2) With the exception of hospital services and nursing facilities, the agency pays the provider of service in designated bordering cities as if the care was provided within the state of Washington (see WAC 182-501-0175).

(3) With the exception of designated bordering cities, the agency does not pay for health care services provided to clients in medical care services (MCS) programs outside the state of Washington.

(4) With the exception of hospital services (see subsection (5) of this section), the agency pays for health care services provided outside the state of Washington at the lower of:

(a) The billed amount; or

(b) The rate established by the Washington apple health programs.

(5) The agency pays for hospital services provided in designated bordering cities and outside the state of Washington under WAC 182-550-3900, 182-550-4000, 182-550-4800, and 182-550-6700.

(6) The agency pays nursing facilities located outside the state of Washington when approved by the home and community living administration (HCLA) at the lower of the billed amount or the adjusted statewide average reimbursement rate for in-state nursing facility care, only in the following limited circumstances:

(a) Emergency situations; or

(b) When the client intends to return to Washington state and the out-of-state stay is for:

(i) Thirty days or less; or

(ii) More than 30 days if approved by HCLA.

(7) To receive payment from the agency, an out-of-state provider must:

(a) Have a signed agreement with the agency;

(b) Meet the functionally equivalent licensing requirements of the state or province in which care is rendered;

(c) Meet the conditions in WAC 182-502-0100 and 182-502-0150;

(d) Satisfy all medicaid conditions of participation;

(e) Accept the agency's payment as payment in full according to 42 C.F.R. 447.15; and

(f) If a Canadian provider, bill at the U.S. exchange rate in effect when the service was provided.

(8) For covered services for eligible clients, the agency reimburses other approved out-of-state providers at the lower of:

(a) The billed amount; or

(b) The rate paid by the Washington state Title XIX medicaid program.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-502-0120, filed 11/4/25, effective 12/5/25*
- *WSR 15-14-039, § 182-502-0120, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0120, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-502-0120, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035. WSR 08-08-064, § 388-502-0120, filed 3/31/08, effective 5/1/08. Statutory Authority: RCW 74.08.090. WSR 01-02-076, § 388-502-0120, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.04.050 and 74.08.090. WSR 00-01-088, § 388-502-0120, filed 12/14/99, effective 1/14/00.*

##### **Wash. Admin. Code § 182-502-0130** Interest penalties—Providers. {#sec-182-502-0130 omnilex-key=us-wa-regs-official--title-182--182-502-0130}

(1) Providers who are enrolled as contractors with the medicaid agency's medical care programs may be assessed interest on excess benefits or other inappropriate payments. Nursing home providers are governed by WAC 388-96-310 and are not subject to this section.

(2) The agency assesses interest when:

(a) The excess benefits or other inappropriate payments were not the result of agency error; and

(b) A provider is found liable for receipt of excess benefits or other payments under RCW 74.09.220; or

(c) A provider is notified by the agency that repayment of excess benefits or other payments is due under RCW 74.09.220.

(3) The agency assesses interest at the rate of one percent for each month the overpayment is not satisfied. Daily interest calculations and assessments are made for partial months.

(4) Interest is calculated beginning from the date the agency receives payment from the provider. Interest ceases to be calculated and collected from the provider once the overpayment amount is received by the agency.

(5) The agency calculates interest and amounts, which are identified on all agency collection notices and statements.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-039, § 182-502-0130, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0130, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050 and 74.08.090. WSR 00-01-088, recodified as § 388-502-0130, filed 12/14/99, effective 1/14/00. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-502-0250, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-044.*

##### **Wash. Admin. Code § 182-502-0150** Time limits for providers to bill the agency. {#sec-182-502-0150 omnilex-key=us-wa-regs-official--title-182--182-502-0150}

Providers must bill the medicaid agency for covered services provided to eligible clients as follows:

(1) The agency requires providers to submit initial claims and adjust prior claims in a timely manner. The agency has three timeliness standards:

(a) For initial claims, see subsections (3), (4), (5), and (6) of this section;

(b) For resubmitted claims other than prescription drug claims and claims for major trauma services, see subsections (7) and (8) of this section;

(c) For resubmitted prescription drug claims, see subsections (9) and (10) of this section; and

(d) For resubmitting claims for major trauma services, see subsection (11) of this section.

(2) The provider must submit claims to the agency as described in the agency's current published billing instructions.

(3) Providers must submit the initial claim to the agency and have a transaction control number (TCN) assigned by the agency within three hundred sixty-five calendar days from any of the following:

(a) The date the provider furnishes the service to the eligible client;

(b) The date a final fair hearing decision is entered that impacts the particular claim;

(c) The date a court orders the agency to cover the service; or

(d) The date the agency certifies a client eligible under delayed certification criteria.

(4) The agency may grant exceptions to the time limit of three hundred sixty-five calendar days for initial claims when billing delays are caused by either of the following:

(a) The agency's certification of a client for a retroactive period; or

(b) The provider proves to the agency's satisfaction that there are other extenuating circumstances.

(5) The agency requires providers to bill known third parties for services. See WAC 182-501-0200 for exceptions. Providers must meet the timely billing standards of the liable third parties in addition to the agency's billing limits.

(6) When a client is covered by both medicare and medicaid, the provider must bill medicare for the service before billing the initial claim to the agency. If medicare:

(a) Pays the claim the provider must bill the agency within six months of the date medicare processes the claim; or

(b) Denies payment of the claim, the agency requires the provider to meet the three hundred sixty-five-day requirement for timely initial claims as described in subsection (3) of this section.

(7) Within twenty-four months of the date the service was provided to the client, a provider may resubmit, modify, or adjust an initial claim, other than a prescription drug claim or a claim for major trauma services.

(8) After twenty-four months from the date the service was provided to the client, the agency does not accept any claim for resubmission, modification, or adjustment. This twenty-four-month period does not apply to overpayments that a provider must refund to the agency by a negotiable financial instrument, such as a bank check.

(9) The agency allows providers to resubmit, modify, or adjust any prescription drug claim with a timely TCN within fifteen months of the date the service was provided to the client. After fifteen months, the agency does not accept any prescription drug claim for resubmission, modification, or adjustment.

(10) The fifteen-month period described in subsection (9) of this section does not apply to overpayments that a prescription drug provider must refund to the agency. After fifteen months a provider must refund overpayments by a negotiable financial instrument, such as a bank check.

(11) The agency allows a provider of trauma care services to resubmit, modify, or adjust, within three hundred and sixty-five calendar days of the date of service, any trauma claim that meets the criteria specified in WAC 182-531-2000 (for physician claims) or WAC 182-550-5450 (for hospital claims) for the purpose of receiving payment from the trauma care fund (TCF).

(a) No increased payment from the TCF is allowed for an otherwise qualifying trauma claim that is resubmitted after three hundred sixty-five calendar days from the date of service.

(b) Resubmission of or any adjustments to a trauma claim for purposes other than receiving TCF payments are subject to the provisions of this section.

(12) The three hundred sixty-five-day period described in subsection (11) of this section does not apply to overpayments from the TCF that a trauma care provider must refund to the agency. A provider must refund an overpayment for a trauma claim that received payment from TCF using a method specified by the agency.

(13) If a provider fails to bill a claim according to the requirements of this section and the agency denies payment of the claim, the provider or any provider's agent cannot bill the client or the client's estate. The client is not responsible for the payment.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-039, § 182-502-0150, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0150, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-502-0150, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-063, § 388-502-0150, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090 and 42 C.F.R. 447.45. WSR 00-14-067, § 388-502-0150, filed 7/5/00, effective 8/5/00.*

##### **Wash. Admin. Code § 182-502-0160** Billing a client. {#sec-182-502-0160 omnilex-key=us-wa-regs-official--title-182--182-502-0160}

(1) The purpose of this section is to specify the limited circumstances in which:

(a) Fee-for-service or managed care clients can choose to self-pay for medical assistance services; and

(b) Providers (as defined in WAC 182-500-0085) have the authority to bill fee-for-service or managed care clients for medical assistance services furnished to those clients.

(2) The provider is responsible for:

(a) Verifying whether the client is eligible to receive medical assistance services on the date the services are provided;

(b) Verifying whether the client is enrolled with a medicaid agency-contracted managed care organization (MCO);

(c) Knowing the limitations of the services within the scope of the eligible client's medical program (see WAC 182-501-0050 (4)(a) and 182-501-0065);

(d) Informing the client of those limitations;

(e) Exhausting all applicable medicaid agency or agency-contracted MCO processes necessary to obtain authorization for requested service(s);

(f) Ensuring that translation or interpretation is provided to clients with limited-English proficiency (LEP) who agree to be billed for services in accordance with this section; and

(g) Retaining all documentation which demonstrates compliance with this section.

(3) Unless otherwise specified in this section, providers must accept as payment in full the amount paid by the agency or agency-contracted MCO for medical assistance services furnished to clients. See 42 C.F.R. § 447.15.

(4) A provider must not bill a client, or anyone on the client's behalf, for any services until the provider has completed all requirements of this section, including the conditions of payment described in the agency's rules, the agency's fee-for-service billing instructions, and the requirements for billing the agency-contracted MCO in which the client is enrolled, and until the provider has then fully informed the client of his or her covered options. A provider must not bill a client for:

(a) Any services for which the provider failed to satisfy the conditions of payment described in the agency's rules, the agency's fee-for-service billing instructions, and the requirements for billing the agency-contracted MCO in which the client is enrolled.

(b) A covered service even if the provider has not received payment from the agency or the client's MCO.

(c) A covered service when the agency or its designee denies an authorization request for the service because the required information was not received from the provider or the prescriber under WAC 182-501-0165 (7)(c)(i).

(5) If the requirements of this section are satisfied, then a provider may bill a fee-for-service or a managed care client for a covered service, defined in WAC 182-501-0050(9), or a noncovered service, defined in WAC 182-501-0050(10) and 182-501-0070. The client and provider must sign and date the HCA form 13-879, Agreement to Pay for Healthcare Services, before the service is furnished. Form 13-879, including translated versions, is available to download at https://www.hca.wa.gov/billers-providers-partners/forms-and-publications. The requirements for this subsection are as follows:

(a) The agreement must:

(i) Indicate the anticipated date the service will be provided, which must be no later than 90 calendar days from the date of the signed agreement;

(ii) List each of the services that will be furnished;

(iii) List treatment alternatives that may have been covered by the agency or agency-contracted MCO;

(iv) Specify the total amount the client must pay for the service;

(v) Specify what items or services are included in this amount (such as preoperative care and postoperative care). See WAC 182-501-0070(3) for payment of ancillary services for a noncovered service;

(vi) Indicate that the client has been fully informed of all available medically appropriate treatment, including services that may be paid for by the agency or agency-contracted MCO, and that he or she chooses to get the specified service(s);

(vii) Specify that the client may request an exception to rule (ETR) in accordance with WAC 182-501-0160 when the agency or its designee denies a request for a noncovered service and that the client may choose not to do so;

(viii) Specify that the client may request an administrative hearing in accordance with chapter 182-526 WAC to appeal the agency's or its designee denial of a request for prior authorization of a covered service and that the client may choose not to do so;

(ix) Be completed only after the provider and the client have exhausted all applicable agency or agency-contracted MCO processes necessary to obtain authorization of the requested service, except that the client may choose not to request an ETR or an administrative hearing regarding agency or agency designee denials of authorization for requested service(s); and

(x) Specify which reason in subsection (b) below applies.

(b) The provider must select on the agreement form one of the following reasons (as applicable) why the client is agreeing to be billed for the service(s). The service(s) is:

(i) Not covered by the agency or the client's agency-contracted MCO and the ETR process as described in WAC 182-501-0160 has been exhausted and the service(s) is denied;

(ii) Not covered by the agency or the client's agency-contracted MCO and the client has been informed of his or her right to an ETR and has chosen not to pursue an ETR as described in WAC 182-501-0160;

(iii) Covered by the agency or the client's agency-contracted MCO, requires authorization, and the provider completes all the necessary requirements; however the agency or its designee denied the service as not medically necessary (this includes services denied as a limitation extension under WAC 182-501-0169); or

(iv) Covered by the agency or the client's agency-contracted MCO and does not require authorization, but the client has requested a specific type of treatment, supply, or equipment based on personal preference which the agency or MCO does not pay for and the specific type is not medically necessary for the client.

(c) For clients with limited-English proficiency, the agreement must be the version translated in the client's primary language and interpreted if necessary. If the agreement is translated, the interpreter must also sign it;

(d) The provider must give the client a copy of the agreement and maintain the original and all documentation which supports compliance with this section in the client's file for six years from the date of service. The agreement must be made available to the agency or its designee for review upon request; and

(e) If the service is not provided within 90 calendar days of the signed agreement, a new agreement must be completed by the provider and signed by both the provider and the client.

(6) There are limited circumstances in which a provider may bill a client without executing form 13-879, Agreement to Pay for Healthcare Services, as specified in subsection (5) of this section. The following are those circumstances:

(a) The client, the client's legal guardian, or the client's legal representative:

(i) Was reimbursed for the service directly by a third party (see WAC 182-501-0200); or

(ii) Refused to complete and sign insurance forms, billing documents, or other forms necessary for the provider to bill the third party insurance carrier for the service.

(b) The client represented himself/herself as a private pay client and not receiving medical assistance when the client was already eligible for and receiving benefits under a medical assistance program. In this circumstance, the provider must:

(i) Keep documentation of the client's declaration of medical coverage. The client's declaration must be signed and dated by the client, the client's legal guardian, or the client's legal representative; and

(ii) Give a copy of the document to the client and maintain the original for six years from the date of service, for agency or the agency's designee review upon request.

(c) The bill counts toward the financial obligation of the client or applicant (such as spenddown liability, client participation as described in chapters 182-513 and 182-515 WAC, emergency medical expense requirement, deductible, or copayment required by the agency or its designee). See subsection (7) of this section for billing a medically needy client for spenddown liability;

(d) The client is placed in the agency's or an agency-contracted MCO's patient review and coordination (PRC) program and obtains nonemergency services from a nonpharmacy provider that is not an assigned or appropriately referred provider as described in WAC 182-501-0135;

(e) The client is a dual-eligible client with medicare Part D coverage or similar creditable prescription drug coverage and the conditions of WAC 182-530-7700 (2)(a)(iii) are met;

(f) The service is within a service category excluded from the client's benefits package. See WAC 182-501-0060;

(g) The services were noncovered ambulance services (see WAC 182-546-0250(2));

(h) A fee-for-service client chooses to receive nonemergency services from a provider who is not contracted with the agency or its designee after being informed by the provider that he or she is not contracted with the agency or its designee and that the services offered will not be paid by the client's health care program; and

(i) An agency-contracted MCO enrollee chooses to receive nonemergency services from providers outside of the MCO's network without authorization from the MCO, i.e., a nonparticipating provider.

(7) Under chapter 182-519 WAC, an individual who has applied for medical assistance is required to spend down excess income on health care expenses to become eligible for coverage under the medically needy program. An individual must incur health care expenses greater than or equal to the amount that he or she must spend down. The provider is prohibited from billing the individual for any amount in excess of the spenddown liability assigned to the bill.

(8) There are situations in which a provider must refund the full amount of a payment previously received from or on behalf of an individual and then bill the agency for the covered service that had been furnished. In these situations, the individual becomes eligible for a covered service that had already been furnished. Providers must then accept as payment in full the amount paid by the agency or its designee or managed care organization for medical assistance services furnished to clients. These situations are as follows:

(a) The individual was not receiving medical assistance on the day the service was furnished. The individual applies for medical assistance later in the same month in which the service was provided and the agency or its designee makes the individual eligible for medical assistance from the first day of that month;

(b) The client receives a delayed certification for medical assistance as defined in WAC 182-500-0025; or

(c) The client receives a certification for medical assistance for a retroactive period according to 42 C.F.R. § 435.914(a) and defined in WAC 182-500-0095.

(9) Regardless of any written, signed agreement to pay, a provider may not bill, demand, collect, or accept payment or a deposit from a client, anyone on the client's behalf, or the agency or its designee for:

(a) Copying, printing, or otherwise transferring health care information, as the term health care information is defined in chapter 70.02 RCW, to another health care provider. This includes, but is not limited to:

(i) Medical/dental charts;

(ii) Radiological or imaging films; and

(iii) Laboratory or other diagnostic test results.

(b) Missed, canceled, or late appointments;

(c) Shipping and/or postage charges;

(d) "Boutique," "concierge," or enhanced service packages (e.g., newsletters, 24/7 access to provider, health seminars) as a condition for access to care; or

(e) The price differential between an authorized service or item and an "upgraded" service or item (e.g., a wheelchair with more features; brand name versus generic drugs).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-19-010, s 182-502-0160, filed 9/4/25, effective 10/5/25*
- *WSR 18-08-075, § 182-502-0160, filed 4/3/18, effective 5/4/18. Statutory Authority: RCW 41.05.021. WSR 13-15-044, § 182-502-0160, filed 7/11/13, effective 8/11/13. Statutory Authority: RCW 41.05.021 and section 1927 of the Social Security Act. WSR 12-18-062, § 182-502-0160, filed 8/31/12, effective 10/1/12. WSR 11-14-075, recodified as § 182-502-0160, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-502-0160, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090 and 42 C.F.R. 447.15. WSR 10-10-022, § 388-502-0160, filed 4/26/10, effective 5/27/10. Statutory Authority: RCW 74.08.090, 74.09.055, 2001 c 7, Part II. WSR 02-12-070, § 388-502-0160, filed 5/31/02, effective 7/1/02. Statutory Authority: RCW 74.08.090. WSR 01-21-023, § 388-502-0160, filed 10/8/01, effective 11/8/01*
- *WSR 01-05-100, § 388-502-0160, filed 2/20/01, effective 3/23/01. Statutory Authority: RCW 74.08.090 and 74.09.520. WSR 00-14-069, § 388-502-0160, filed 7/5/00, effective 8/5/00.*

##### **Wash. Admin. Code § 182-502-0210** Statistical data-provider reports. {#sec-182-502-0210 omnilex-key=us-wa-regs-official--title-182--182-502-0210}

(1) At the request of the medicaid agency, all providers enrolled with agency programs must submit full reports, as specified by the agency, of goods and services furnished to eligible Washington apple health clients. The agency furnishes the provider with a standardized format to report these data.

(2) The agency analyzes the data collected from the providers' reports to secure statistics on costs of goods and services furnished and makes a report of the analysis available to the agency's advisory committee, the state welfare medical care committee, representative organizations of provider groups enrolled with the agency, and any other interested organizations or individuals.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-039, § 182-502-0210, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0210, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-502-0210, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.035. WSR 00-15-049, § 388-502-0210, filed 7/17/00, effective 8/17/00. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-502-0210, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-020.*

##### **Wash. Admin. Code § 182-502-0220** Administrative appeal contractor or provider rate reimbursement. {#sec-182-502-0220 omnilex-key=us-wa-regs-official--title-182--182-502-0220}

(1) Any enrolled contractor or provider of medical services has a right to an administrative appeal when the contractor or provider disagrees with the medicaid agency reimbursement rate. The exception to this is nursing facilities governed by WAC 388-96-904.

(2) The first level of appeal. A contractor or provider who wants to contest a reimbursement rate must file a written appeal with the agency.

(a) The appeal must include the following:

(i) A statement of the specific issue being appealed;

(ii) Supporting documentation; and

(iii) A request for the agency to recalculate the rate.

(b) When a contractor or provider appeals a portion of a rate, the agency may review all components of the reimbursement rate.

(c) To complete a review of the appeal, the agency may do one or both of the following:

(i) Request additional information; and

(ii) Conduct an audit of the documentation provided.

(d) The agency issues a decision or requests additional information within sixty calendar days of receiving the rate appeal request.

(i) When the agency requests additional information, the contractor or provider has forty-five calendar days from the date of the agency's request to submit the additional information.

(ii) The agency issues a decision within thirty calendar days of receipt of the completed information.

(e) The agency may adjust rates retroactively to the effective date of a new rate or a rate change. In order for a rate increase to be retroactive, the contractor or provider must file the appeal within sixty calendar days of the date of the rate notification letter from the agency. The agency does not consider any appeal filed after the sixty-day period to be eligible for retroactive adjustment.

(f) The agency may grant a time extension for the appeal period if the contractor or provider makes such a request within the sixty-day period described in (e) of this subsection.

(g) Any rate increase resulting from an appeal filed within the sixty-day period described in subsection (2)(e) of this section is effective retroactively to the rate effective date in the notification letter.

(h) Any rate increase resulting from an appeal filed after the sixty-day period described in subsection (2)(e) of this section is effective on the date the rate appeal is received by the agency.

(i) Any rate decrease resulting from an appeal is effective on the date specified in the appeal decision letter.

(j) Any rate change that the agency grants that is the result of fraudulent practices on the part of the contractor or provider as described under RCW 74.09.210 is exempt from the appeal provisions in this chapter.

(3) The second level of appeal. When the contractor or provider disagrees with a rate review decision, it may file a request for a dispute conference with the agency. For this section "dispute conference" means an informal administrative hearing to resolve contractor or provider disagreements with an agency action as described under subsection (1) of this section and not agreed upon at the first level of appeal. The dispute conference is not governed by the Administrative Procedure Act, chapter 34.05 RCW.

(a) If a contractor or provider files a request for a dispute conference, it must submit the request to the agency within thirty calendar days after the contractor or provider receives the rate review decision. The agency does not consider dispute conference requests submitted after the thirty-day period for the first level decision.

(b) The agency conducts the dispute conference within ninety calendar days of receiving the request.

(c) An agency-appointed conference chairperson issues the final decision within thirty calendar days of the conference. Extensions of time for extenuating circumstances may be granted if all parties agree.

(d) Any rate increase or decrease resulting from a dispute conference decision is effective on the date specified in the dispute conference decision.

(e) The dispute conference is the final level of administrative appeal within the agency and precedes judicial action.

(4) The agency considers that a contractor or provider who fails to attempt to resolve disputed rates as provided in this section has abandoned the dispute.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-039, § 182-502-0220, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0220, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-502-0220, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090 and 74.09.730. WSR 99-16-070, § 388-502-0220, filed 8/2/99, effective 9/2/99. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-502-0220, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-043.*

##### **Wash. Admin. Code § 182-502-0230** Provider overpayment disputes—General. {#sec-182-502-0230 omnilex-key=us-wa-regs-official--title-182--182-502-0230}

(1) This section applies to provider overpayment disputes with providers who furnish health care services to Washington apple health clients, except those overpayment disputes to which chapter 182-502A WAC applies. For the purposes of this section:

(a) "Agency" means the health care authority and its designees.

(b) "Provider" has the same meaning as vendor in RCW 41.05A.010(5).

(2) If the medicaid agency determines that a provider was overpaid, the agency may take any of the following actions:

(a) Review claims, encounters, or payments;

(b) Refer the provider to the agency's office of program integrity;

(c) Refer the provider to the Washington state medicaid fraud control unit;

(d) Refer the provider to the appropriate state health care professional discipline authority;

(e) Terminate the provider's participation in Washington apple health;

(f) Assess a civil penalty against the provider, per RCW 74.09.210;

(g) In the event of a prepay review, suspend some or all payments;

(h) Adjust or void an improper claim, encounter, or payment;

(i) Recover any moneys that the provider received as a result of overpayments as authorized under chapter 41.05A RCW; and

(j) Any other action authorized by Title 182 WAC.

(3) A provider may contest an overpayment by requesting a hearing.

(4) The hearing request must:

(a) Be in writing;

(b) Identify each overpayment being contested;

(c) State each reason why the provider thinks the overpayment is incorrect;

(d) Include documentation to support the provider's position; and

(e) Include a copy of the overpayment notice.

(5) The hearing request must be served on the agency at the address specified in the overpayment notice, in a manner which provides proof of receipt, no later than twenty-eight calendar days after the provider received the overpayment notice.

(6) The hearing is conducted under the Administrative Procedure Act and chapter 182-526 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-01-056, § 182-502-0230, filed 12/10/14, effective 1/10/15. WSR 11-14-075, recodified as § 182-502-0230, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0230, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.520, 34.05.020, 34.05.220. WSR 00-22-017, § 388-502-0230, filed 10/20/00, effective 11/20/00. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-502-0230, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-042.*

##### **Wash. Admin. Code § 182-502-0260** Appeals and dispute resolution for providers with contracts other than core provider agreements. {#sec-182-502-0260 omnilex-key=us-wa-regs-official--title-182--182-502-0260}

(1) Providers of medical services who have a contract, other than a core provider agreement, with a dispute resolution provision must follow the dispute resolution process described in the contract.

(2) See WAC 182-502-0220 for disputes involving rates. See chapter 182-502A WAC for disputes involving audits. See WAC 182-502-0230 for disputes involving provider reviews and termination.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-039, § 182-502-0260, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0260, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.290. WSR 00-22-016, § 388-502-0260, filed 10/20/00, effective 11/20/00.*

##### **Wash. Admin. Code § 182-502-0270** Review of agency's provider dispute decision. {#sec-182-502-0270 omnilex-key=us-wa-regs-official--title-182--182-502-0270}

(1) This section applies only when agency rules allow review of an agency dispute decision under this section. The director of the health care authority or designee conducts the review.

(2) Providers and former providers may request a review of an agency dispute decision. The request must be in writing and sent to: Health Care Authority, Attn: Appeals Administrator, P.O. Box 45504, Olympia, WA 98504-5504. The agency must receive the written dispute review request within twenty-eight calendar days of the date on the agency's written dispute decision.

(3) When the agency receives a timely dispute review request, the director or designee may schedule a dispute review conference. "Dispute review conference" means an informal conference for the purpose of resolving disagreements between the agency and a provider or former provider who is dissatisfied with an agency decision. The dispute review conference is not governed by the Administrative Procedure Act, chapter 34.05 RCW. If the director or designee chooses to schedule a dispute review conference, the director or designee will conduct the conference within ninety calendar days of the dispute review request unless the director or designee and the party requesting review agree to an extension.

(4) The director or designee will issue a dispute review decision to the provider or former provider requesting review within thirty calendar days of receiving the dispute review request or within thirty calendar days of the dispute review conference, whichever is later, unless both parties agree to an extension.

(5) The director review is the final level of agency review for disputes to which this section applies.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 13-17-047, § 182-502-0270, filed 8/13/13, effective 10/1/13. WSR 11-14-075, recodified as § 182-502-0270, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 08-12-012, § 388-502-0270, filed 5/27/08, effective 6/27/08.*

## **Chapter 182-502A** Program integrity. {#struct-chapter-182-502a}

##### **Wash. Admin. Code § 182-502A-0101** Purpose. {#sec-182-502a-0101 omnilex-key=us-wa-regs-official--title-182--182-502A-0101}

(1) Program integrity means a system of reasonable and consistent oversight of the medicaid program.

(2) The medicaid agency conducts program integrity activities to detect and prevent potential fraud, waste, and abuse. These activities include identifying improper payments and recovering overpayments.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and C.F.R. Sections 438.608 through 438.610. WSR 20-02-100, § 182-502A-0101, filed 12/31/19, effective 1/31/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-01-129, § 182-502A-0101, filed 12/19/14, effective 1/19/15.*

##### **Wash. Admin. Code § 182-502A-0201** Definitions. {#sec-182-502a-0201 omnilex-key=us-wa-regs-official--title-182--182-502A-0201}

The definitions in this section and those found in chapter 182-500 WAC apply throughout this chapter.

Adverse determination means a finding of an overpayment identified in a program integrity activity.

Algorithm means the set of rules applied to claim or encounter data to identify overpayments.

Audit means an examination of claims data, an entity's records, or both, to determine whether the entity has complied with applicable laws, rules, regulations, and agreements.

Audit, on-site means an audit conducted partially at an entity's place of business.

Audit, self means an audit conducted by the entity and reviewed by the agency.

Credible allegation of fraud - See 42 C.F.R. 455.2.

Data mining means using software to detect patterns or aberrancies in a data set.

Educational intervention means agency-provided education to an entity prior to or following an agency-initiated program integrity activity that has identified an adverse determination. Educational intervention includes, but is not limited to, any notice of adverse determinations issued by the agency or any agency training that has failed to correct the level of payment error.

Encounter includes any service provided by a federally qualified health center, rural health clinic, or tribe, which is paid an enhanced rate; and any service provided to a Washington apple health client who is covered by an MCO or other contractor, and reported to the agency.

Entity includes current and former contractors, providers, and their subcontractors.

Extrapolation means a method of estimating an unknown value by projecting the results of a sample to the universe from which the sample was drawn.

Fraud - See 42 C.F.R. 455.2.

Improper payment means any payment by the agency that was more than or less than the sum to which the payee was legally entitled.

Metrics mean the quantifiable measures used to track and assess the status of program integrity activities and entity performance.

Net payment error rate means the calculated percentage of the improper payment amount identified in the sample of claims for the audit period divided by the total payment amount sampled claims for the audit period.

Overpayment see RCW 41.05A.010, including any subsequent amendments.

Program integrity compliance plan means a document issued by the agency outlining the importance of ethical behavior on the part of the agency's contracted entities, as well as identified monitoring, auditing, and educational obligations an entity must comply with to remain an agency-contracted entity.

Record means any document or electronically stored information including writings, drawings, graphs, charts, photographs, sound recordings, images, and other data or data compilations, stored in any medium from which information can be obtained either directly or, if necessary, after translation by the entity into a reasonably usable form. This includes documentation relating to claims, encounters, and payments.

Relevant – See Federal Rule of Evidence 401.

Risk assessment means to identify potential risk of fraud, waste and abuse, and improper payments within all Washington apple health programs.

Sustained high level of payment error means the net payment error rate is equal to or exceeds five percent for the audit period.

Universe means a defined population of claims or encounters or both.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and C.F.R. Sections 438.608 through 438.610. WSR 20-02-100, § 182-502A-0201, filed 12/31/19, effective 1/31/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 c 242. WSR 18-07-050, § 182-502A-0201, filed 3/14/18, effective 4/14/18. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-01-129, § 182-502A-0201, filed 12/19/14, effective 1/19/15.*

##### **Wash. Admin. Code § 182-502A-0301** Authority to conduct program integrity activities. {#sec-182-502a-0301 omnilex-key=us-wa-regs-official--title-182--182-502A-0301}

The medicaid agency conducts program integrity activities on all Title XIX, Title XXI, and state-only-funded expenditures. See 42 C.F.R. 2.54, 431, 433, 438, 447, 455, 456, 457, 495, and 1001; 45 C.F.R. 92; 42 U.S.C. 1396a; and chapters 41.05, 41.05A, and 74.09 RCW.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and C.F.R. Sections 438.608 through 438.610. WSR 20-02-100, § 182-502A-0301, filed 12/31/19, effective 1/31/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 c 242. WSR 18-07-050, § 182-502A-0301, filed 3/14/18, effective 4/14/18. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-01-129, § 182-502A-0301, filed 12/19/14, effective 1/19/15.*

##### **Wash. Admin. Code § 182-502A-0401** Program integrity activities. {#sec-182-502a-0401 omnilex-key=us-wa-regs-official--title-182--182-502A-0401}

The medicaid agency verifies entities' compliance with applicable laws, rules, regulations, and agreements through program integrity activities.

(1) Methods. Program integrity activity methods include, but are not limited to:

(a) Data mining to identify possible fraud, waste, and abuse (FWA) for further examination;

(b) Audits and reviews to determine compliance with federal, state, and agency rules and regulations, or to identify FWA;

(c) Investigations of suspected fraud and abuse;

(d) Algorithms to identify payment, program, and system irregularities leading to improper payments;

(e) On-site reviews and inspections of an entity's premises to ensure compliance with federal, state, and agency rules and regulations;

(f) Referral of enforcement actions against entities that have committed fraud or abuse to law enforcement agencies, or licensing agencies, or both;

(g) Technical assistance and education to prevent and identify potential FWA;

(h) Outreach to and education for entities and client communities, including how to report suspected fraud, explaining federal, state, and agency rules and requirements, conducting entity self-audits and implementing compliance programs; and

(i) Initiating and reviewing entity self-audits under WAC 182-502A-0501.

(2) Location. Program integrity activities occur at the agency, an entity's premises, or at both locations.

(3) Timing. The agency may begin program integrity activities concerning any current or former agency-contracted entity or that entity's agent at any time up to six years after the date of service.

(4) Notice.

(a) The agency provides thirty-calendar-days' notice to entities before an on-site visit, except in those instances identified in (c) of this subsection.

(b) Hospitals are entitled to notice as described in RCW 70.41.045(4).

(c) The agency is not required to give notice of an on-site visit if evidence exists of danger to public health and safety or fraudulent activities.

(5) Scope. The agency determines the scope of a program integrity activity.

(6) Selecting information to evaluate.

(a) The agency may evaluate any records or other information relevant to validating that the entity received only those funds to which it is legally entitled.

(b) The agency may select information to evaluate by:

(i) Conducting a risk assessment of claim or encounter data;

(ii) Applying algorithms;

(iii) Data mining;

(iv) Claim-by-claim review;

(v) Encounter-by-encounter review;

(vi) Stratified random sampling;

(vii) Nonstratified random sampling; or

(viii) Applying any other method, or combination of methods, designed to identify relevant information.

(7) Collecting records and other information to evaluate.

(a) After the agency serves notice, an entity must submit a copy of all records and other information requested to the agency by the date stated in the request.

(b) The entity must submit records electronically or by facsimile and must follow the instructions for records submission included in the agency's notice, unless the agency gives the entity permission to submit a hard copy of the records.

(c) If sent electronically, records must be:

(i) Copied to secured media (e.g., CD or DVD) and sent to the address stated in the notice; or

(ii) Uploaded to the agency's secure file transfer protocol (SFTP) site.

(d) If an entity submits hard copy records without prior approval, the agency destroys the records and requires the entity to resubmit them in an electronic format.

(e) If an entity fails to timely comply with the request, the agency may:

(i) Deny the entity's claim under a prepay review process;

(ii) Issue a preliminary finding; or

(iii) Issue a final notice.

(f) Once a program integrity activity begins, the entity must retain all original records and supportive materials until the program integrity activity is completed and all issues resolved, even if the retention period for those records and materials extends beyond the period otherwise required by law.

(g) Unless instructed to do so by the agency, the entity must not adjust or rebill a claim or encounter that is within the scope of a program integrity activity until that activity ends and any resulting appeals are exhausted.

(8) Cooperation with on-site visits, audits, and investigations. For an on-site visit, audit, or investigation, the entity must allow the agency access to its premises and provide any records or other information requested while on-site.

(9) Evaluating information.

(a) The agency may evaluate relevant information by applying any method or combination of methods reasonably calculated to determine whether an entity has complied with an applicable law, regulation, or agreement.

(b) A health care provider's bill for services, appointment books, accounting records, or other similar documents alone do not qualify as appropriate documentation of services rendered.

(c) The agency provides the entity a description of the method or combination of methods used by the agency to select information to evaluate.

(10) Nonbilled services. Nonbilled services include any item, drug, code, or payment group that a provider does not submit on the provider's claim to the agency or contractor. When calculating improper payments, the agency does not include nonbilled services in its calculations.

(11) Paid-at-zero services. The agency considers paid-at-zero services or supplies only when conducting program integrity activities involving payment groups or encounters.

(12) Conducting on-site audits. The agency may conduct on-site audits at any entity location.

(a) During an on-site audit, the agency may create a copy of an entity's records that are potentially relevant to the audit.

(b) Failure to grant the agency access to the entity's records or premises constitutes failure to comply with a program integrity activity.

(13) Conducting interviews. The agency may interview any person it reasonably believes has relevant information regarding a program integrity activity. Interviews may consist of one or more sessions.

(14) Costs. The agency does not reimburse the costs an entity incurs complying with program integrity activities.

(15) Conducting on-site visits. The agency may conduct on-site inspections of any entity location to determine whether the entity is complying with all applicable laws, rules, regulations, and agreements.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and C.F.R. Sections 438.608 through 438.610. WSR 20-02-100, § 182-502A-0401, filed 12/31/19, effective 1/31/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 c 242. WSR 18-07-050, § 182-502A-0401, filed 3/14/18, effective 4/14/18. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-01-129, § 182-502A-0401, filed 12/19/14, effective 1/19/15.*

##### **Wash. Admin. Code § 182-502A-0501** Entity self-audits. {#sec-182-502a-0501 omnilex-key=us-wa-regs-official--title-182--182-502A-0501}

(1) The medicaid agency may require an entity to self-audit.

(a) The agency gives written notice of the instruction to self-audit.

(b) The entity must acknowledge receipt of the notice within thirty calendar days of receiving it.

(c) The entity must comply with all terms included in the notice; failure to timely comply with the notice constitutes failure to comply with a program integrity activity.

(d) The agency does not require an entity to self-audit any services or encounters that are included in an active state or federal program integrity activity, rate adjustment, cost settlement, or other payment adjustment.

(e) The agency reviews the self-audit and states in writing whether it accepts or rejects the results of the self-audit. If the agency rejects the results it may:

(i) Instruct the entity to repeat the self-audit; or

(ii) Audit the entity.

(2) When an entity self-discloses overpayments, it must:

(a) Submit to the agency written notice of the self-audit and identify each claim included in the self-audit.

(b) Report and repay the overpayment to the agency within sixty calendar days of identifying the overpayment, unless the overpayment is:

(i) Included in an active state or federal program integrity activity; or

(ii) Related to a state-initiated rate adjustment, cost settlement, or other payment adjustment.

(c) The entity's overpayment report must include:

(i) The reason for the overpayment;

(ii) How the entity calculated the overpayment; and

(iii) A list of claims associated with the overpayment.

(d) The agency reviews the self-audit and states in writing whether it accepts or rejects the methodology and findings. If the agency rejects the findings it may:

(i) Instruct the entity to repeat the self-audit; or

(ii) Audit the entity.

(e) The agency does not accept any identified overpayment as full or final repayment before the completion of its review of the entity's self-audit findings.

(3) The entity's dispute and appeal rights under this section are identical to its rights during an audit conducted by the office of program integrity.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and C.F.R. Sections 438.608 through 438.610. WSR 20-02-100, § 182-502A-0501, filed 12/31/19, effective 1/31/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-01-129, § 182-502A-0501, filed 12/19/14, effective 1/19/15.*

##### **Wash. Admin. Code § 182-502A-0601** Extrapolation. {#sec-182-502a-0601 omnilex-key=us-wa-regs-official--title-182--182-502A-0601}

(1) To determine an improper payment from a sample, the medicaid agency may extrapolate to the universe from which the sample was drawn:

(a) If the audit identifies a sustained high level of payment error involving the provider; or

(b) When the agency has documented educational intervention to the provider and the education has failed to correct the provider's level of payment error.

(2) If during the course of the audit, an entity adjusts or rebills a claim or encounter that is part of the audit sample or universe, the original claim or encounter amount remains in the audit sample or universe.

(3) When the agency uses the results of an audit sample to extrapolate the amount to be recovered, the agency provides the entity with the following information:

(a) The sample size.

(b) The method used to select the sample.

(c) The universe from which the sample was drawn.

(d) Any formulas or calculations used to determine the amount of the improper payment.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and C.F.R. Sections 438.608 through 438.610. WSR 20-02-100, § 182-502A-0601, filed 12/31/19, effective 1/31/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 c 242. WSR 18-07-050, § 182-502A-0601, filed 3/14/18, effective 4/14/18. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-01-129, § 182-502A-0601, filed 12/19/14, effective 1/19/15.*

##### **Wash. Admin. Code § 182-502A-0701** Agency outcomes. {#sec-182-502a-0701 omnilex-key=us-wa-regs-official--title-182--182-502A-0701}

(1) Following the medicaid agency's evaluation of an entity's records including, but not limited to, claims, encounter data, or payments, the agency may do any combination of the following:

(a) Deny a claim or claim line.

(b) Recover an improperly paid claim.

(c) Instruct the entity to submit:

(i) Additional documentation; or

(ii) A new claim. If the entity fails to submit a new claim within sixty calendar days, the agency denies the new claim as untimely.

(d) Request a refund of an improper payment to the agency by check.

(e) Refer an overpayment to the office of financial recovery for collection.

(f) Issue a preliminary finding, which the entity may dispute under WAC 182-502A-0801.

(i) If an entity agrees with the preliminary finding before the deadline stated in the notice, the entity must notify the agency in writing. The agency then issues a final notice.

(ii) If an entity does not respond by the agency's deadline, the agency issues a final notice.

(g) Issue an overpayment notice or final notice, which the entity may appeal under WAC 182-502A-0901.

(i) The final notice includes:

(A) The asserted overpayment or improper payment amount;

(B) The reason for an adverse determination;

(C) The specific criteria and citation of legal authority used to make the adverse determination;

(D) An explanation of the entity's appeal rights;

(E) The appropriate procedure to submit a claims adjustment, if applicable; and

(F) One or more of the following:

(I) Directives;

(II) Educational intervention; or

(III) A program integrity compliance plan.

(ii) Upon request, the agency allows an entity with an adverse determination the option of repaying the amount owed according to a negotiated repayment plan of up to twelve months. Interest may be calculated and charged on the remaining balance each month.

(h) Recover interest under RCW 41.05A.220.

(i) Impose civil penalties under RCW 74.09.210.

(j) Refer the entity to appropriate licensing authorities for disciplinary action.

(k) Refer the entity to the agency's medical dental advisory committee for review and potential termination of the contract or core provider agreement.

(l) Determine it has sufficient evidence to make a credible allegation of fraud. The agency then:

(i) Refers the case to the medicaid fraud control division and any other appropriate prosecuting authority for further action; and

(ii) Suspends some or all Washington apple health payments to the entity unless the agency determines there is good cause not to suspend payments under 42 C.F.R. 455.23.

(2) The agency may assess an overpayment and terminate the core provider agreement if an entity fails to retain adequate documentation for services billed to the agency.

(3) At any time during a program integrity activity, the agency may issue a final notice if the entity:

(a) Stops doing business with the agency;

(b) Transfers control of the business;

(c) Makes a suspicious asset transfer;

(d) Files for bankruptcy; or

(e) Fails to comply with program integrity activities.

(4) The entity must repay any overpayment identified by the agency within sixty calendar days of being notified of the overpayment, except when a repayment plan is negotiated with the agency under subsection (1)(g)(ii) of this section.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and C.F.R. Sections 438.608 through 438.610. WSR 20-02-100, § 182-502A-0701, filed 12/31/19, effective 1/31/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 c 242. WSR 18-07-050, § 182-502A-0701, filed 3/14/18, effective 4/14/18. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-01-129, § 182-502A-0701, filed 12/19/14, effective 1/19/15.*

##### **Wash. Admin. Code § 182-502A-0801** Dispute resolution process. {#sec-182-502a-0801 omnilex-key=us-wa-regs-official--title-182--182-502A-0801}

(1) An entity may informally dispute a preliminary finding. The medicaid agency must receive any request for dispute resolution within thirty calendar days of the date the entity received the preliminary finding. The request for dispute resolution must be in writing and include the following:

(a) The supporting evidence for each disputed preliminary finding; and

(b) The relief sought for each disputed preliminary finding.

(2) The dispute may include a request for a dispute resolution conference (DRC).

(a) If the agency grants the entity's request for a DRC, the DRC occurs within sixty calendar days of the date the entity received the agency's written acceptance of the request for a DRC.

(b) At least five business days before the DRC, the entity must notify the agency of who will attend the DRC on the entity's behalf.

(3) Following the timely submission of a written request for dispute resolution under subsection (1) of this section and completion of any DRC, the agency addresses in writing each written disputed preliminary finding raised by the entity.

(4) The agency may terminate the dispute resolution process and issue a final notice if the entity fails to comply with the requirements of this section.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and C.F.R. Sections 438.608 through 438.610. WSR 20-02-100, § 182-502A-0801, filed 12/31/19, effective 1/31/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 c 242. WSR 18-07-050, § 182-502A-0801, filed 3/14/18, effective 4/14/18. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-01-129, § 182-502A-0801, filed 12/19/14, effective 1/19/15.*

##### **Wash. Admin. Code § 182-502A-0901** Administrative hearing (formal appeal) right. {#sec-182-502a-0901 omnilex-key=us-wa-regs-official--title-182--182-502A-0901}

(1) An entity has a right to an administrative hearing (formal appeal), and any resulting appeals process under RCW 41.05A.170 and chapter 182-526 WAC, if the agency assesses an overpayment against the entity.

(2) An entity does not have an administrative hearing right for the denial of payment of a claim.

(3) At the administrative hearing and on appeal, the entity bears the burden of proving by a preponderance of the evidence that it has complied with applicable laws, rules, regulations, and agreements.

(4) The administrative hearing process is governed by chapter 34.05 RCW and chapter 182-526 WAC.

(5) The medicaid agency does not recoup overpayments until a decision in the administrative hearing is issued and all appeals, if any, have been exhausted.

(6) Interest on overpayments continues to accrue, but it is not collected until a decision in the administrative hearing is issued and all appeals, if any, have been exhausted. See RCW 74.09.220.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and C.F.R. Sections 438.608 through 438.610. WSR 20-02-100, § 182-502A-0901, filed 12/31/19, effective 1/31/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 c 242. WSR 18-07-050, § 182-502A-0901, filed 3/14/18, effective 4/14/18. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-01-129, § 182-502A-0901, filed 12/19/14, effective 1/19/15.*

##### **Wash. Admin. Code § 182-502A-1001** Metrics. {#sec-182-502a-1001 omnilex-key=us-wa-regs-official--title-182--182-502A-1001}

(1) The medicaid agency annually, compiles and publishes metrics for any contractor that conducts audits on the agency's behalf under RCW 74.09.195 (2)(b).

(2) The agency may publish metrics of the program integrity activities it conducts. Metrics include, but are not limited to:

(a) Adverse determinations;

(b) Identified improper payments;

(c) Cost avoidance;

(d) Payments; and

(e) Recoveries.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and C.F.R. Sections 438.608 through 438.610. WSR 20-02-100, § 182-502A-1001, filed 12/31/19, effective 1/31/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 c 242. WSR 18-07-050, § 182-502A-1001, filed 3/14/18, effective 4/14/18.*

##### **Wash. Admin. Code § 182-502A-1101** Managed care organizations. {#sec-182-502a-1101 omnilex-key=us-wa-regs-official--title-182--182-502A-1101}

This section applies to entities that contract with the medicaid agency to provide services in exchange for a capitated rate.

(1) Managed care organizations (MCOs) must comply with and enforce all applicable program integrity:

(a) Federal and state laws and regulations;

(b) Terms of their contracts with the agency; and

(c) Terms of their contracts with subcontractors and providers.

(2) MCOs must:

(a) Adopt and enforce program integrity policies and procedures that guide the contractor's officers, employees, agents, and subcontractors;

(b) Include and enforce federal and state program integrity requirements in their subcontracts and in their provider application, credentialing, and recredentialing processes;

(c) Adopt and implement methods for detecting and preventing fraud, waste, and abuse to ensure payments to subcontractors and providers are proper and comply with medicaid regulations and billing instructions;

(d) Perform ongoing analyses of their authorization, utilization, claims, providers' billing patterns, and encounter data to detect improper payments;

(e) Conduct reviews, audits, and investigations of subcontractors and providers;

(f) Report to the agency any:

(i) Fraud, waste, or abuse; and

(ii) Overpayments and recoveries.

(g) Recover overpayments to any subcontractor or provider; and

(h) Refer any suspected or potential fraud to the agency and to the medicaid fraud control division or other law enforcement agency.

(3) MCOs must establish an appeals process, similar to the dispute resolution process in WAC 182-502A-801, for their subcontractors or providers to contest an assessment of an overpayment by a managed care entity.

(4) MCOs' subcontractors or providers do not have a right to an administrative hearing under chapter 34.05 RCW or chapter 182-526 WAC to contest the results of the appeals process. The MCO will provide notice and will state in the notice that there is no right to an administrative hearing.

(5) Overpayment assessments by an MCO to its subcontractor or provider that are not appealed or that are upheld after appeal must be recovered from its subcontractors or providers within:

(a) Sixty calendar days of the overpayment being identified and assessed against the subcontractor or provider; or

(b) Sixty calendar days of completion of an appeals process for the subcontractor or provider who disputes the overpayment assessment.

(6) An MCO must report to the agency:

(a) Identification of an overpayment assessed against a subcontractor or provider.

(b) Notification of a subcontractor's or provider's appeal of an overpayment assessment.

(c) Results of an appeal of an overpayment assessment from the subcontractor or provider.

(d) Recovery of the identified overpayment assessed or settlement information as a result of the appeal.

(7) The agency may sanction an MCO or assess liquidated damages when:

(a) The agency identifies fraud, waste, or abuse by an MCO provider;

(b) The MCO fails to report MCO provider overpayments; or

(c) Other situations arise as identified in the contract.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and C.F.R. Sections 438.608 through 438.610. WSR 20-02-100, § 182-502A-1101, filed 12/31/19, effective 1/31/20.*

## **Chapter 182-503** Persons eligible for medical assistance. {#struct-chapter-182-503}

##### **Wash. Admin. Code § 182-503-0001** Insurance affordability programs—Overview. {#sec-182-503-0001 omnilex-key=us-wa-regs-official--title-182--182-503-0001}

(1) For the purposes of this chapter, "we" or "us" refers to the agency or its designee and "you" refers to the applicant for, or recipient of, health care coverage.

(2) A person may apply for all of the insurance affordability programs offered through the health care authority (HCA) or the Washington Healthplanfinder (as defined in WAC 182-500-0015):

(a) Washington apple health (WAH) programs (defined in WAC 182-500-0120). WAH includes medicaid programs (defined in WAC 182-500-0070), the children's health insurance program (CHIP) (defined in WAC 182-500-0020), and state-only funded health care programs. These programs are provided free or at low cost on a sliding scale to eligible persons based on their income. WAH program regulations for the application process and eligibility determination are found in chapters 182-503 through 182-527 WAC.

(b) Health insurance premium tax credits (defined in WAC 182-500-0045). This federal refundable tax credit partially offsets the cost of monthly premiums for qualified health plan (QHP) (defined in WAC 182-500-0090) insurance that an eligible person purchases through the Washington Healthplanfinder. Any advance payments of the tax credit are reconciled annually by the Internal Revenue Service (IRS) when the person files his or her federal tax return.

(c) Cost-sharing reductions. Cost-sharing reductions (defined in WAC 182-500-0020) are available to eligible persons enrolled in a silver-level QHP and to American Indians/Alaska Natives enrolled in any QHP.

(3) A person may also apply for and enroll in unsubsidized insurance with a QHP. This unsubsidized insurance is not an insurance affordability program.

(4) Persons choose whether or not to apply for insurance affordability programs. All persons who apply for an insurance affordability program are treated as an applicant for WAH coverage and receive an approval or denial of WAH. Applicants who are denied WAH are reviewed for other insurance affordability programs.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-503-0001, filed 7/29/14, effective 8/29/14.*

##### **Wash. Admin. Code § 182-503-0005** Washington apple health—How to apply. {#sec-182-503-0005 omnilex-key=us-wa-regs-official--title-182--182-503-0005}

(1) You may apply for Washington apple health at any time.

(2) For apple health programs for children, pregnant people, parents and caretaker relatives, and adults age 64 and under without medicare (including people who have a disability or are blind), you may apply:

(a) Online via the Washington Healthplanfinder at www.wahealthplanfinder.org;

(b) By calling the Washington Healthplanfinder customer support center and completing an application by telephone;

(c) By completing the application for health care coverage (HCA 18-001P), and mailing or faxing to Washington Healthplanfinder; or

(d) At a department of social and health services (DSHS) community services office (CSO).

(3) If you seek apple health coverage and are age 65 or older, have a disability, are blind, need assistance with medicare costs, or seek coverage of long-term services and supports, you may apply:

(a) Online via Washington Connection at www.WashingtonConnection.org;

(b) By completing the application for aged, blind, disabled/long-term care coverage (HCA 18-005) and mailing or faxing it to DSHS;

(c) By calling the DSHS customer service contact center and completing an application by telephone;

(d) In person at a local DSHS CSO or home and community services (HCS) office;

(e) As specified in subsection (2) of this section, if you are a child, pregnant, a parent or caretaker relative, or an adult age 64 and under without medicare; or

(f) Effective January 19, 2026, with your consent when you complete an application for medicare Part D low-income subsidy (LIS) benefits, the social security administration (SSA) will transmit an LIS data file to us. We will use the LIS data file to initiate an application for you for benefits under the medicare savings program (MSP) without requiring you to submit a separate MSP application.

(4) You may receive help filing an application.

(a) For households containing people described in subsection (2) of this section:

(i) Call the Washington Healthplanfinder customer support center number listed on the application for health care coverage form (HCA 18-001P); or

(ii) Contact a navigator, health care authority volunteer assistor, or broker.

(b) For people described in subsection (3) of this section who are not applying with a household containing people described in subsection (2) of this section:

(i) Call or visit a local DSHS CSO or HCS office; or

(ii) Call the DSHS community services customer service contact center number listed on the medicaid application form.

(5) To apply for tailored supports for older adults (TSOA), see WAC 182-513-1625.

(6) You must apply directly with the service provider for the following programs:

(a) The breast and cervical cancer treatment program under WAC 182-505-0120;

(b) The family planning only programs under chapter 182-532 WAC; and

(c) The kidney disease program under chapter 182-540 WAC.

(7) For the confidential pregnant minor program under WAC 182-505-0117 and for minors living independently, you must complete a separate application directly with us (the medicaid agency).

More information on how to give us an application may be found at the agency's website: www.hca.wa.gov/free-or-low-cost-health-care (search for "teen").

(8) As the primary applicant or head of household, you may start an application for apple health by providing your:

(a) Full name;

(b) Date of birth;

(c) Physical address, and mailing addresses (if different); and

(d) Signature.

(9) To complete an application for apple health, you must also give us all of the other information requested on the application.

(10) You may have an authorized representative apply on your behalf as described in WAC 182-503-0130.

(11) We help you with your application or renewal for apple health in a manner that is accessible to you. We provide equal access (EA) services as described in WAC 182-503-0120 if you:

(a) Ask for EA services, you apply for or receive long-term services and supports, or we determine that you would benefit from EA services; or

(b) Have limited-English proficiency as described in WAC 182-503-0110.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-01-043, s 182-503-0005, filed 12/10/25, effective 1/19/26*
- *WSR 23-11-007, § 182-503-0005, filed 5/4/23, effective 6/4/23*
- *WSR 22-20-052, § 182-503-0005, filed 9/28/22, effective 10/29/22*
- *WSR 18-11-071, § 182-503-0005, filed 5/15/18, effective 6/15/18*
- *WSR 17-15-061, § 182-503-0005, filed 7/13/17, effective 8/13/17. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-503-0005, filed 7/29/14, effective 8/29/14.*

##### **Wash. Admin. Code § 182-503-0010** Washington apple health—Who may apply. {#sec-182-503-0010 omnilex-key=us-wa-regs-official--title-182--182-503-0010}

(1) You may apply for Washington apple health for yourself.

(2) You may apply for apple health for another person if you are:

(a) A legal guardian;

(b) An authorized representative (as described in WAC 182-503-0130);

(c) A parent or caretaker relative of a child age 18 or younger;

(d) A tax filer applying for a tax dependent;

(e) A spouse; or

(f) A person applying for someone who is unable to apply on their own due to a health condition and who needs long-term care services.

(3) If you reside in an institution of mental diseases (as defined in WAC 182-500-0050(1)) or a public institution (as defined in WAC 182-500-0050(4)), including a Washington state department of corrections facility, city or county jail, tribal jail, juvenile confinement facility, or secure community transition or total confinement facility (as defined in RCW 71.09.020), you, your representative, or the facility may apply for you to get the apple health coverage for which you are determined eligible.

(4) You are automatically enrolled in apple health and do not need to apply if you are a:

(a) Supplemental security income (SSI) recipient;

(b) Person deemed to be an SSI recipient under 1619(b) of the SSA;

(c) Newborn as described in WAC 182-505-0210; or

(d) Child in foster care placement as described in WAC 182-505-0211.

(5) You are the primary applicant on an application if you complete and sign the application on behalf of your household.

(6) If you are an SSI recipient, then you, your authorized representative as defined in WAC 182-500-0010, or another person applying on your behalf as described in subsection (2) of this section, must turn in a signed application to apply for long-term care services as described in WAC 182-513-1315.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.715. WSR 25-11-007, s 182-503-0010, filed 5/8/25, effective 7/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-01-117, § 182-503-0010, filed 12/16/19, effective 1/16/20*
- *WSR 17-12-017, § 182-503-0010, filed 5/30/17, effective 6/30/17. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-503-0010, filed 7/29/14, effective 8/29/14.*

##### **Wash. Admin. Code § 182-503-0040** Washington apple health—Interview requirements. {#sec-182-503-0040 omnilex-key=us-wa-regs-official--title-182--182-503-0040}

(1) An individual applying for Washington apple health (WAH) (as defined in WAC 182-500-0120) is not required to have an in-person interview to determine eligibility.

(2) The agency or its designee may contact an individual by phone or in writing to gather any additional information that is needed to make an eligibility determination.

(3) A phone or in-person interview is required to determine initial financial eligibility for WAH long-term care services.

(4) The interview requirement described in subsection (3) of this section may be waived if the applicant is unable to comply:

(a) Due to his or her medical condition; or

(b) Because the applicant does not have a family member or another individual that is able to conduct the interview on his or her behalf.

**History**
- *Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 13-14-019, § 182-503-0040, filed 6/24/13, effective 7/25/13.*

##### **Wash. Admin. Code § 182-503-0050** Verification of eligibility factors. {#sec-182-503-0050 omnilex-key=us-wa-regs-official--title-182--182-503-0050}

(1) General rules.

(a) We may verify the information we use to determine, redetermine, or terminate your apple health eligibility.

(b) We verify the eligibility factors listed in WAC 182-503-0505(3).

(c) Before we ask you to provide records to verify an eligibility factor, we use information available from state databases, including data from the department of social and health services and the department of employment security, federal databases, or commercially available databases to verify the eligibility factor.

(d) We may require information from third parties, such as employers, landlords, and insurance companies, to verify an eligibility factor if the information we received:

(i) Cannot be verified through available data sources;

(ii) Did not verify an eligibility factor; or

(iii) Is contradictory, confusing, or outdated.

(e) We do not require you to submit a record unless it is necessary to determine or redetermine your eligibility.

(f) If you can obtain verification within three business days and we determine the verification is sufficient to confirm an eligibility factor, we base our initial eligibility decision upon that record.

(g) If we are unable to verify eligibility as described in (f) of this subsection, then we may consider third-party sources.

(h) If a fee is required to obtain a necessary record, we pay the fee directly to the holder of the record.

(i) We do not deny or delay your application if you failed to provide information to verify an eligibility factor in a particular type or form.

(j) Except for eligibility factors listed in WAC 182-503-0505 (3)(c) and (d), we accept alternative forms of verification. If you give us a reasonable explanation that confirms your eligibility, we may not require additional documentation.

(k) Once we verify an eligibility factor that will not change, we may not require additional verification. Examples include:

(i) U.S. citizenship;

(ii) Family relationships by birth;

(iii) Social Security numbers; and

(iv) Dates of birth, death, marriage, dissolution of marriage, or legal separation.

(l) If we cannot verify your immigration status and you are otherwise eligible for Washington apple health, we approve coverage and give additional time as needed to verify your immigration status.

(2) Submission timelines.

(a) We allow at least 10 calendar days for you to submit requested information.

(b) If you request more time to provide information, we allow the time requested.

(c) If the 10th day falls on a weekend or a legal holiday as described in RCW 1.16.050, the due date is the next business day.

(d) We do not deny or terminate your eligibility when we give you more time to provide information.

(e) If we do not receive your information by the due date, we make a determination based on all the information available.

(3) Notice requirements.

(a) When we need more information from you to determine your eligibility for apple health coverage, we send all notices according to the requirements of WAC 182-518-0015.

(b) If we cannot determine you are eligible, we send you a denial or termination notice including information on when we reconsider a denied application under WAC 182-503-0080.

(4) Equal access and limited-English proficiency services. If you are eligible for equal access services under WAC 182-503-0120 or limited-English proficiency services under WAC 182-503-0110, we provide legally sufficient support services.

(5) Eligibility factors for nonmodified adjusted gross income (MAGI)-based programs. If you apply for a non-MAGI program under WAC 182-503-0510(3), we verify the factors in WAC 182-503-0505(3). In addition, we verify:

(a) Household composition, if spousal or dependent deeming under chapter 182-512 WAC or spousal or dependent allowance under chapters 182-513 and 182-515 WAC applies;

(b) Income and income deductions;

(c) Resources, including:

(i) Trusts, annuities, life estates, and promissory notes under chapter 182-516 WAC;

(ii) Real property transactions; and

(iii) Financial records, as defined in WAC 182-503-0055, held by financial institutions.

(d) Medical expenses required to meet any spenddown liability under WAC 182-519-0110;

(e) All post-eligibility deductions used to determine cost of care for clients eligible for long-term services and supports under chapters 182-513 and 182-515 WAC;

(f) Transfers of assets under chapter 182-513 WAC and WAC 182-503-0055 when the program is subject to transfer of assets limitations;

(g) Shelter costs for long-term care cases where spousal and dependent allowances apply;

(h) Blindness or disability, if you claim either; and

(i) Social Security number for a community spouse if needed when you apply for long-term care.

(6) Verification for MAGI-based programs.

(a) After we approve your coverage based on your self-attestation, we may conduct a post-eligibility review to verify your self-attested information.

(b) When conducting a post-eligibility review, we attempt to verify eligibility factors using your self-attested information available to us through state, federal, and commercially available data sources, or other third parties, before requiring you to provide information.

(c) You may be required to provide additional information if:

(i) We cannot verify an eligibility factor through other data sources listed in subsection (b) of this section; or

(ii) The information received from the data source is not reasonably compatible with your self-attestation.

(7) Reapplication following post-eligibility review. If your eligibility for MAGI-based apple health terminates because of a post-eligibility review and you reapply, we may request verification of eligibility factors prior to determining eligibility.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 42 U.S.C. Sec. 1396w. WSR 19-21-007, § 182-503-0050, filed 10/3/19, effective 11/3/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-06-007, § 182-503-0050, filed 2/17/17, effective 3/20/17. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-503-0050, filed 3/14/14, effective 4/14/14.*

##### **Wash. Admin. Code § 182-503-0055** Asset verification system. {#sec-182-503-0055 omnilex-key=us-wa-regs-official--title-182--182-503-0055}

(1) This rule implements the asset verification system (AVS) outlined in section 1940 of the Social Security Act.

(2) This rule applies to any client, or those financially responsible for them, who is subject to:

(a) The disclosure of resources, as defined in WAC 182-512-0200, to determine eligibility; or

(b) Provisions related to the transfer of assets, as described in WAC 182-513-1363.

(3) For the purposes of this section:

(a) "Financial institution" means the same as defined in section 1101 of the Right to Financial Privacy Act, and may include, but is not limited to:

(i) Banks; or

(ii) Credit unions.

(b) "Financial record" means any record held by a financial institution pertaining to a customer's relationship with the financial institution; and

(c) "Financial responsibility" is described in WAC 182-506-0015.

(4) You and any other financially responsible people must provide authorization for us to obtain any financial record held by a financial institution.

(a) For you, the authorization may be provided by anyone described in WAC 182-503-0010 (1) and (2)(a), (b), or (c), except in the case of an authorized representative who must be designated by the client.

(b) For a financially responsible spouse, authorization may be provided by the spouse, their legal guardian, or their attorney-in-fact.

(c) The agency may grant an exception to rule as described in WAC 182-503-0090 if authorization is not provided by those listed in (a) and (b) of this subsection.

(5) The authorization, provided under subsection (4) of this section, will remain in effect until one of the following occurs:

(a) Your application for apple health is denied;

(b) Your eligibility for apple health is terminated; or

(c) You revoke your authorization in a written notification to us.

(6) We will:

(a) Use the authorization provided under subsection (4) of this section to electronically verify your financial records and those of any other financially responsible person to determine or renew your eligibility for apple health; or

(b) Inform you in writing at the time of application and renewal that we will obtain and use information available through AVS to determine your eligibility for apple health.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 42 U.S.C. § 1396w. WSR 20-17-061, § 182-503-0055, filed 8/12/20, effective 9/12/20*
- *WSR 19-21-007, § 182-503-0055, filed 10/3/19, effective 11/3/19.*

##### **Wash. Admin. Code § 182-503-0060** Washington apple health—Application processing times. {#sec-182-503-0060 omnilex-key=us-wa-regs-official--title-182--182-503-0060}

(1) We process applications for Washington apple health (medicaid) within 45 calendar days, with the following exceptions:

(a) If you are pregnant, we process your application within fifteen calendar days;

(b) If you are applying for a program that requires a disability decision, we process your application within 60 calendar days; or

(c) The modified adjusted gross income (MAGI)-based apple health application process using Washington Healthplanfinder may provide faster or real-time determination of eligibility for medicaid.

(2) For calculating time limits, "day one" is the day we get an application from you that includes at least the information described in WAC 182-503-0005 (8). If you give us your paper application during business hours, "day one" is the day you give us your application. If you give us your paper application outside of business hours, "day one" is the next business day. If you experience technical difficulties while attempting to give us your application in Washington Healthplanfinder, "day one" is the day we are able to determine, based on the evidence available, that you first tried to submit an application that included at least the information described in WAC 182-503-0005 (8).

(3) We determine eligibility as quickly as possible and respond promptly to applications and information received. We do not delay a decision by using the time limits in this section as a waiting period.

(4) If we need more information to decide if you can get apple health coverage, we will send you a letter within 20 calendar days of your initial application that:

(a) Follows the rules in chapter 182-518 WAC;

(b) States the additional information we need; and

(c) Allows at least 10 calendar days to provide it. We will allow you more time if you ask for more time or need an accommodation due to disability or limited-English proficiency.

(5) Good cause for a delay in processing the application exists when we acted as promptly as possible but:

(a) The delay was the result of an emergency beyond our control;

(b) The delay was the result of needing more information or documents that could not be readily obtained;

(c) You did not give us the information within the time frame specified in subsection (1) of this section.

(6) Good cause for a delay in processing the application does NOT exist when:

(a) We caused the delay in processing by:

(i) Failing to ask you for information timely; or

(ii) Failing to act promptly on requested information when you provided it timely; or

(b) We did not document the good cause reason before missing a time frame specified in subsection (1) of this section.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-15-009, § 182-503-0060, filed 7/8/21, effective 8/8/21. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-503-0060, filed 7/29/14, effective 8/29/14.*

##### **Wash. Admin. Code § 182-503-0070** Washington apple health—When coverage begins. {#sec-182-503-0070 omnilex-key=us-wa-regs-official--title-182--182-503-0070}

(1) Your Washington apple health coverage starts on the first day of the month you applied for and we decided you are eligible to receive coverage, unless one of the exceptions in subsection (4) of this section applies to you.

(2) Sometimes we can start your coverage up to three months before the month you applied (see WAC 182-504-0005).

(3) If you are confined or incarcerated as described in WAC 182-503-0010, your coverage cannot start before the day you are discharged, except when:

(a) You are hospitalized during your confinement and the hospital requires you to stay overnight; or

(b) You are determined to be eligible for prerelease reentry services.

(4) Your apple health coverage may not begin on the first day of the month if:

(a) Subsection (3) of this section applies to you. In that case, your coverage would start on:

(i) The first day of your hospital stay; or

(ii) When you are determined to be eligible for prerelease reentry services;

(b) You must meet a medically needy spenddown liability (see WAC 182-519-0110). In that case, your coverage would start on the day your spenddown is met; or

(c) You are eligible under the apple health alien emergency medical program (see WAC 182-507-0115). In that case, your coverage would start on the day your emergent hospital stay begins.

(5) For long-term care, the date your services start is described in WAC 388-106-0045.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.715. WSR 25-11-007, s 182-503-0070, filed 5/8/25, effective 7/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-503-0070, filed 7/29/14, effective 8/29/14.*

##### **Wash. Admin. Code § 182-503-0080** Washington apple health—Application denials and withdrawals. {#sec-182-503-0080 omnilex-key=us-wa-regs-official--title-182--182-503-0080}

(1) We follow the rules about notices and letters in chapter 182-518 WAC. We follow the rules about timelines in WAC 182-503-0060.

(2) We deny your application for apple health coverage when:

(a) You tell us either orally or in writing to withdraw your request for coverage; or

(b) Based on all information we have received from you and other sources within the time frames stated in WAC 182-503-0060, including any extra time given at your request or to accommodate a disability or limited-English proficiency:

(i) We are unable to determine that you are eligible; or

(ii) We determine that you are not eligible.

(c) You are subject to asset verification and do not provide authorization as described in WAC 182-503-0055.

(3) We send you a written notice explaining why we denied your application (per chapter 182-518 WAC).

(4) We reconsider our decision to deny your apple health coverage without a new application from you when:

(a) We receive the information that we need to decide if you are eligible within 30 days of the date on the denial notice;

(b) You give us authorization to verify your assets as described in WAC 182-503-0055 within 30 days of the date on the denial notice;

(c) You request a hearing within ninety days of the date on the denial letter and an administrative law judge (ALJ) or HCA review judge decides our denial was wrong (per chapter 182-526 WAC).

(5) If you disagree with our decision, you can ask for a hearing. If we denied your application because we do not have enough information, the ALJ will consider the information we already have and any more information you give us. The ALJ does not consider the previous absence of information or failure to respond in determining if you are eligible.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 42 U.S.C. Sec. 1396w. WSR 19-21-007, § 182-503-0080, filed 10/3/19, effective 11/3/19. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-503-0080, filed 7/29/14, effective 8/29/14.*

##### **Wash. Admin. Code § 182-503-0090** Washington apple health—Exceptions to rule. {#sec-182-503-0090 omnilex-key=us-wa-regs-official--title-182--182-503-0090}

(1) A client or client's representative may request an exception to a Washington apple health financial eligibility rule in Title 182 WAC. The request for an exception to rule (ETR) may be submitted orally or in writing. The request must:

(a) Be received within 90 calendar days of the agency action with which the client disagrees or wants waived;

(b) Identify the rule for which an exception is being requested;

(c) State what the client is requesting; and

(d) Describe how the request meets subsection (2) of this section.

(2) The agency director or designee has the discretion to grant an ETR if they determine that the client's circumstances satisfy the conditions below:

(a) The exception would not contradict a specific provision of federal or state law; and

(b) The client's situation differs from the majority; and

(c) It is in the interest of the overall economy and the client's welfare, and:

(i) It increases opportunity for the client to function effectively; or

(ii) The client has an impairment or limitation that significantly interferes with the usual procedures required to determine eligibility and payment.

(3) A client does not have a right to an administrative hearing on ETR decisions under chapter 182-526 WAC.

(4) A client is mailed a decision in writing within 10 calendar days when agency staff:

(a) Approve or deny an ETR request; or

(b) Request more information.

(5) If the ETR is approved, the notice includes information on what is approved and for what time frame.

(6) The agency designates staff at the home and community living administration (HCLA) to process all ETRs specifically relating to long-term services and supports programs described in Title 182 WAC.

(7) This section does not apply to requests that the agency pay for noncovered medical or dental services or related equipment. WAC 182-501-0160 applies to such requests.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-503-0090, filed 11/4/25, effective 12/5/25*
- *WSR 21-04-076, § 182-503-0090, filed 1/29/21, effective 3/1/21. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 13-14-019, § 182-503-0090, filed 6/24/13, effective 7/25/13.*

##### **Wash. Admin. Code § 182-503-0100** Washington apple health—Rights and responsibilities. {#sec-182-503-0100 omnilex-key=us-wa-regs-official--title-182--182-503-0100}

For the purposes of this chapter, "we" refers to the agency or its designee and "you" refers to the applicant for, or recipient of, health care coverage.

(1) If you are applying for or receiving health care coverage, you have the right to:

(a) Have your rights and responsibilities explained to you and given in writing;

(b) Be treated politely and fairly without regard to your race, color, political beliefs, national origin, religion, age, gender (including gender identity and sex stereotyping), sexual orientation, disability, honorably discharged veteran or military status, or birthplace;

(c) Ask for health care coverage using any method listed under WAC 182-503-0005 (if you ask us for a receipt or confirmation, we will provide one to you);

(d) Get help completing your application if you ask for it;

(e) Have an application processed promptly and no later than the timelines described in WAC 182-503-0060;

(f) Have at least 10 calendar days to give the agency or its designee information needed to determine eligibility and be given more time if asked for;

(g) Have personal information kept confidential; we may share information with other state and federal agencies for purposes of eligibility and enrollment in Washington apple health;

(h) Get written notice, in most cases, at least 10 calendar days before the agency or its designee denies, terminates, or changes coverage;

(i) Ask for an appeal if you disagree with a decision we make. You can also ask a supervisor or administrator to review our decision or action without affecting your right to a fair hearing;

(j) Ask for and get interpreter or translator services at no cost and without delay;

(k) Ask for voter registration assistance;

(l) Refuse to speak to an investigator if we audit your case. You do not have to let an investigator into your home. You may ask the investigator to come back at another time. Such a request will not affect your eligibility for health care coverage;

(m) Get equal access services under WAC 182-503-0120 if you are eligible;

(n) Ask for support enforcement services through the division of child support; and

(o) Refuse to cooperate with us in identifying, using, or collecting third-party benefits (such as medical support) if you fear, and can verify, that your cooperating with us could result in serious physical or emotional harm to you, your children, or a child in your care. Verification may include one of the following:

(i) A statement you sign, outlining your fears and concerns;

(ii) Civil or criminal court orders (such as domestic violence protection orders, restraining orders, and no-contact orders);

(iii) Medical, police, or court reports; or

(iv) Written statement from clergy, friends, relatives, neighbors, or co-workers.

(2) You are responsible to:

(a) Report changes in your household or family circumstances as required under WAC 182-504-0105 and 182-504-0110;

(b) Give us any information or proof needed to determine eligibility. If you have trouble getting proof, we help you get the proof or contact other persons or agencies for it;

(c) Assign the right to medical support as described in WAC 182-503-0540, unless you can submit verification (which may include one of the items listed in subsection (1)(o) of this section) that your cooperating with us could result in serious physical or emotional harm to you, your children, or a child in your care;

(d) Complete renewals when asked;

(e) Give medical providers information needed to bill us for health care services; and

(f) Cooperate with quality assurance or post enrollment review staff when asked.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-15-053, s 182-503-0100, filed 7/10/25, effective 8/10/25. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-503-0100, filed 2/28/14, effective 3/31/14.*

##### **Wash. Admin. Code § 182-503-0110** Washington apple health—Limited-English proficient (LEP) services. {#sec-182-503-0110 omnilex-key=us-wa-regs-official--title-182--182-503-0110}

(1) We provide interpreter and translation services (limited-English proficient or LEP services) free of charge to you if you have limited ability to read, write, and/or speak English. Interpreter services are those used for oral communication between two parties who do not speak the same language. Translation services are those used for written communication.

(2) We provide LEP services in your primary language.

(a) A primary language is the language you tell us that you wish to use when communicating with us. You may designate at least one primary language for oral communications and at least one primary language for written communications, and you may designate a different primary language for oral and for written communications.

(b) We note your primary languages in a record available to the agency, its designee, and health benefit exchange employees.

(3) We can provide LEP services through bilingual workers and/or contracted interpreters and translators who are expected to be competent. We consider a bilingual worker or a contracted interpreter or translator to be competent if he or she is:

(a) Certified for interpreting and/or translating in the language by the language testing and certification program of the department of social and health services;

(b) Certified or otherwise determined to be competent for interpreting and/or translating in the language by an association or organization with a regional or national reputation for certifying or determining the competence of interpreters and/or translators; or

(c) Determined competent for interpreting and/or translating in the language by us, taking into account his or her:

(i) Demonstrated proficiency in both English and the other language;

(ii) Orientation and training that includes the skills and ethics of interpreting;

(iii) Fundamental knowledge in both languages of any specialized terms or concepts peculiar to Washington apple health;

(iv) Sensitivity to cultural differences; and

(v) Demonstrated ability to convey information accurately in both languages.

(4) We provide notice of the availability of LEP services on printed applications and notices, in the Washington healthplanfinder website, and during contact with persons who appear to need LEP services.

(5) LEP services include:

(a) Spoken language interpreter (oral) services in person, over the telephone, or through other simultaneous audio or visual transmission (if available); and

(b) Translation of our forms, letters, and other text-based materials, whether printed in hard-copy or stored and presented by computer. These include, but are not limited to:

(i) Our pamphlets, brochures, and other informational material that describe our services and your health care rights and responsibilities;

(ii) Our applications and other forms you need to complete and/or sign; and

(iii) Notices of our actions affecting your eligibility for health care coverage.

(c) Direct provision of services by our bilingual employees.

(6) We provide interpreter services and translated documents in a prompt manner that allows the timely processing of your eligibility for health care coverage within time frames defined in WAC 182-503-0060, 182-503-0035, and 182-504-0125.

(7) If you believe that we have discriminated against you on the basis of race, color, national origin, birthplace, or another protected status, you may file a complaint with the U.S. Department of Health and Human Services at http://www.hhs.gov/ocr/civilrights/complaints or Regional Manager, Office of Civil Rights, U.S. Department of Health and Human Services, 2201 Sixth Ave. - M/S: RX-11, Seattle, WA 98121-1831 (voice phone 800-368-1019, fax 206-615-2297, TDD 800-537-7697).

**History**
- *Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-503-0110, filed 2/28/14, effective 3/31/14.*

##### **Wash. Admin. Code § 182-503-0120** Washington apple health—Equal access services. {#sec-182-503-0120 omnilex-key=us-wa-regs-official--title-182--182-503-0120}

(1) When you have a mental, neurological, cognitive, physical or sensory impairment, or limitation that prevents you from receiving health care coverage, we provide services to help you apply for, maintain, and understand the health care coverage options available and eligibility decisions we make. These services are called equal access (EA) services.

(2) We provide EA services on an ongoing basis to ensure that you are able to maintain health care coverage and access to services we provide. EA services include, but are not limited to:

(a) Helping you to:

(i) Apply for or renew coverage;

(ii) Complete and submit forms;

(iii) Give us information to determine or continue your eligibility;

(iv) Ask for continued coverage;

(v) Ask for reinstated (restarted) coverage after your coverage ends; and

(vi) Ask for and participate in a hearing.

(b) Giving you additional time, when needed, for you to give us information before we reduce or end your health care coverage;

(c) Explaining our decision to change, reduce, end, or deny your health care coverage;

(d) Working with your authorized representative, if you have one, and giving that person copies of notices and letters we send you; and

(e) Providing you the services of a sign language interpreter/transliterator who is certified by the Registry of Interpreters for the Deaf at the appropriate level of certification.

(i) These services may include in-person sign language interpreter services, relay interpreter services, and video interpreter services, as well as other services; we decide which services to offer you based on your communication needs and preferences.

(ii) We offer these services as a reasonable accommodation, free of charge, if you are deaf, hard-of-hearing, or a deaf-blind person who uses sign language to communicate.

(f) Not taking adverse action in your case, or automatically reinstating your coverage for up to three months after the adverse action was taken, if we determine that your impairment or limitation was the cause of your failure to follow through on something you need to do to get or keep your Washington apple health coverage, such as:

(i) Applying for or renewing coverage;

(ii) Completing and submitting forms;

(iii) Giving us information to determine or continue your eligibility;

(iv) Asking for continued or reinstated coverage; or

(v) Asking for and participating in a hearing.

(3) We inform you of your right to EA services listed in subsection (2) of this section:

(a) On printed applications and notices, including the printed rights and responsibilities form;

(b) In the Washington healthplanfinder website, including the electronic rights and responsibilities form; and

(c) During contact with us.

(4) We provide you the EA services listed in subsection (2) of this section if you ask for EA services, you are receiving services through the home and community living administration, or we determine that you would benefit from EA services. We determine you would benefit from EA services if you:

(a) Appear to have or claim to have any impairment or limitation described in subsection (1) of this section;

(b) Have a developmental disability;

(c) Are disabled by alcohol or drug addiction;

(d) Are unable to read or write in any language;

(e) Appear to have limitations in your ability to communicate, understand, remember, process information, exercise judgment and make decisions, perform routine tasks, or relate appropriately with others (whether or not you have a disability) that may prevent you from understanding the nature of EA services or affect your ability to access our programs; or

(f) Are a minor not residing with your parents.

(5) If we determine that you are eligible for EA services, we develop and document an EA plan appropriate to your needs. The plan may be updated or changed at any time based on your request or a change in your needs.

(6) You may at any time refuse the EA services offered to you.

(7) We reinstate your coverage when:

(a) We end coverage because we were unable to determine if you continue to qualify; and

(b) You provide proof that you are still qualified for coverage within 20 calendar days from when we ended your coverage. We restore your coverage retroactive to the first of the month so there is no break in your coverage.

(8) If you believe that we have discriminated against you on the basis of a disability or another protected status, the person may file a complaint with the U.S. Department of Health and Human Services at http://www.hhs.gov/ocr/civilrights/complaints or Region Manager, Office for Civil Rights, U.S. Department of Health and Human Services, 2201 Sixth Ave. - M/S: RX-11, Seattle, WA 98121-1831 (voice phone 800-368-1019, fax 206-615-2297, TDD 800-537-7697).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-503-0120, filed 11/4/25, effective 12/5/25. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-503-0120, filed 2/28/14, effective 3/31/14.*

##### **Wash. Admin. Code § 182-503-0130** Authorized representative. {#sec-182-503-0130 omnilex-key=us-wa-regs-official--title-182--182-503-0130}

(1) Designating an authorized representative (AREP).

(a) A person may designate an AREP to act on his or her behalf in eligibility-related interactions with the medicaid agency by completing the agency's Authorized Representative Designation Form (DSHS 14-532), or through any of the methods described in 42 C.F.R. 435.907(a) and 42 C.F.R. 435.923. The Authorized Representative Designation Form is available online at https://www.dshs.wa.gov/fsa/forms.

(b) A court-appointed legal guardian with authority to make financial decisions on a person's behalf is that person's AREP.

(c) An agreement creating power of attorney (POA) that grants decision-making authority regarding the person's financial interactions with the agency establishes the POA as the AREP.

(d) If a person is unable to designate an AREP due to a medical condition, an individual may designate himself or herself as the AREP by signing the agency's Authorized Representative Designation Form (DSHS 14-532).

(2) Serving as an AREP. To serve as an AREP, an individual or organization must:

(a) Have a good-faith belief that the information he or she provides to the agency is correct.

(b) Report any change in circumstance required under WAC 182-504-0105 unless doing so would exceed the scope of authorized representation or violate state or federal law.

(c) A provider, staff member, or volunteer of an organization must also comply with 42 C.F.R. 435.923(d-e).

(3) Terminating authorized representation.

(a) The person or the AREP may terminate the authorized representation at any time for any reason by notifying the agency verbally or in writing.

(b) Authorized representation terminates automatically when the person dies.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-15-143, § 182-503-0130, filed 7/17/15, effective 8/17/15.*

##### **Wash. Admin. Code § 182-503-0505** Washington apple health—General eligibility requirements. {#sec-182-503-0505 omnilex-key=us-wa-regs-official--title-182--182-503-0505}

(1) When you apply for Washington apple health programs established under chapter 74.09 RCW, you must meet the eligibility criteria in chapters 182-500 through 182-527 WAC.

(2) When you apply for apple health, we first consider you for federally funded or federally matched programs. We consider you for state-funded programs after we have determined that you are ineligible for federally funded and federally matched programs.

(3) Unless otherwise specified in a program-specific WAC, the eligibility criteria for each program are as follows:

(a) Age (WAC 182-503-0050);

(b) Residence in Washington state (WAC 182-503-0520 and 182-503-0525);

(c) Citizenship or immigration status in the United States (WAC 182-503-0535);

(d) Possession of a valid Social Security account number (WAC 182-503-0515);

(e) Assignment of medical support rights to the state of Washington (WAC 182-503-0540);

(f) Application for medicare and enrollment into medicare's prescription drug program if:

(i) You are likely entitled to medicare; and

(ii) We have authority to pay medicare cost sharing as described in chapter 182-517 WAC.

(g) If your eligibility is not based on modified adjusted gross income (MAGI) methodology, your countable resources must be within specific program limits (chapters 182-512, 182-513, 182-515, 182-517, and 182-519 WAC); and

(h) Countable income within program limits:

(i) For MAGI-based programs, see WAC 182-505-0100;

(ii) For the refugee program, see WAC 182-507-0130;

(iii) For the medical care services program, see WAC 182-508-0005;

(iv) For the health care for workers with disabilities (HWD) program, see WAC 182-511-1000;

(v) For the SSI-related program, see WAC 182-512-0010;

(vi) For long-term care programs, see chapters 182-513 and 182-515 WAC;

(vii) For medicare savings programs, see WAC 182-517-0100; and

(viii) For the medically needy program, see WAC 182-519-0050.

(4) In addition to the general eligibility requirements in subsection (3) of this section, each program has specific eligibility requirements as described in applicable WAC.

(5) If you are in a public institution, including a correctional facility, you are not eligible for full scope apple health coverage, except in the following situations:

(a) If you are age 21 or younger or age 65 or older and are a patient in an institution for mental disease (see WAC 182-513-1317(5)); or

(b) You receive inpatient hospital services outside of the public institution or correctional facility.

(6) We limit coverage for people who become residents in a public institution, under subsection (5) of this section, until they are determined to be eligible for prerelease reentry services or released.

(7) If you are terminated from SSI or lose eligibility for categorically needy (CN) or alternative benefits plan (ABP) coverage, you receive coverage under the apple health program with the highest scope of care for which you may be eligible while we determine your eligibility for other health care programs. See WAC 182-504-0125.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.715. WSR 25-11-007, s 182-503-0505, filed 5/8/25, effective 7/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-08-029, § 182-503-0505, filed 3/27/19, effective 4/27/19*
- *WSR 17-12-017, § 182-503-0505, filed 5/30/17, effective 6/30/17. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-503-0505, filed 7/29/14, effective 8/29/14. WSR 12-13-056, recodified as § 182-503-0505, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.530, 42 U.S.C., Section 1396a. WSR 07-21-005, § 388-503-0505, filed 10/4/07, effective 11/4/07. Statutory Authority: RCW 74.08.090, 74.09.530, and 2003 1st sp.s. c 25. WSR 04-07-141, § 388-503-0505, filed 3/22/04, effective 4/22/04. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. WSR 02-17-030, § 388-503-0505, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-503-0505, filed 7/31/98, effective 9/1/98. Formerly WAC 388-501-0110, 388-503-0305 and 388-505-0501.*

##### **Wash. Admin. Code § 182-503-0510** Washington apple health—Program summary. {#sec-182-503-0510 omnilex-key=us-wa-regs-official--title-182--182-503-0510}

(1) The agency categorizes Washington apple health programs into three groups based on the income methodology used to determine eligibility:

(a) Those that use a modified adjusted gross income (MAGI)-based methodology described in WAC 182-509-0300, called MAGI-based apple health programs;

(b) Those that use an income methodology other than MAGI, called non-MAGI-based apple health programs, which include:

(i) Supplemental security income (SSI)-related apple health programs;

(ii) Temporary assistance for needy families (TANF)-related apple health programs; and

(iii) Other apple health programs not based on MAGI, SSI, or TANF methodologies.

(c) Those that provide coverage based on a specific status or entitlement in federal rule and not on countable income, called deemed eligible apple health programs.

(2) MAGI-based apple health programs include the following:

(a) Apple health parent and caretaker relative program described in WAC 182-505-0240;

(b) MAGI-based apple health adult medical program described in WAC 182-505-0250, for which the scope of coverage is called the alternative benefits plan (ABP) described in WAC 182-500-0010;

(c) Apple health for pregnant women program described in WAC 182-505-0115;

(d) Apple health for kids program described in WAC 182-505-0210 (3)(a);

(e) Premium-based apple health for kids described in WAC 182-505-0215;

(f) Apple health long-term care for children and adults described in chapter 182-514 WAC; and

(g) Apple health alien emergency medical program described in WAC 182-507-0110 through 182-507-0125 when the person is eligible based on criteria for a MAGI-based apple health program.

(3) Non-MAGI-based apple health programs include the following:

(a) SSI-related programs which use the income methodologies of the SSI program (except where the agency has adopted more liberal rules than SSI) described in chapter 182-512 WAC to determine eligibility:

(i) Apple health for workers with disabilities (HWD) described in chapter 182-511 WAC;

(ii) Apple health SSI-related programs described in chapters 182-512 and 182-519 WAC;

(iii) Apple health long-term care and hospice programs described in chapters 182-513 and 182-515 WAC;

(iv) Apple health medicare savings programs described in chapter 182-517 WAC; and

(v) Apple health alien emergency medical (AEM) programs described in WAC 182-507-0110 and 182-507-0125 when the person meets the age, blindness or disability criteria specified in WAC 182-512-0050.

(b) TANF-related programs which use the income methodologies based on the TANF cash program described in WAC 388-450-0170 to determine eligibility, with variations as specified in WAC 182-509-0001(5) and program specific rules:

(i) Refugee medical assistance (RMA) program described in WAC 182-507-0130; and

(ii) Apple health medically needy (MN) coverage for pregnant women and children who do not meet SSI-related criteria.

(c) Other programs:

(i) Breast and cervical cancer program described in WAC 182-505-0120;

(ii) Family planning only programs described in chapter 182-532 WAC;

(iii) Medical care services described in WAC 182-508-0005;

(iv) Apple health for pregnant minors described in WAC 182-505-0117;

(v) Kidney disease program described in chapter 182-540 WAC; and

(vi) Tailored supports for older adults described in WAC 182-513-1610.

(4) Deemed eligible apple health programs include:

(a) Apple health SSI medical program described in chapter 182-510 WAC, or a person who meets the medicaid eligibility criteria in 1619b of the Social Security Act;

(b) Newborn medical program described in WAC 182-505-0210(2);

(c) Foster care program described in WAC 182-505-0211;

(d) Medical extension program described in WAC 182-523-0100; and

(e) Family planning extension described in WAC 182-505-0115(5).

(5) A person is eligible for categorically needy (CN) health care coverage when the household's countable income is at or below the categorically needy income level (CNIL) for the specific program.

(6) If income is above the CNIL, a person is eligible for the MN program if the person is:

(a) A child;

(b) A pregnant woman; or

(c) SSI-related (aged 65, blind or disabled).

(7) MN health care coverage is not available to parents, caretaker relatives, or adults unless they are eligible under subsection (6) of this section.

(8) A person who is eligible for the apple health MAGI-based adult program listed in subsection (2)(b) of this section is eligible for ABP health care coverage as defined in WAC 182-500-0010. Such a person may apply for more comprehensive coverage through another apple health program at any time.

(9) For the other specific program requirements a person must meet to qualify for apple health, see chapters 182-503 through 182-527 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-11-007, § 182-503-0510, filed 5/4/23, effective 6/4/23. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 1st sp.s. c 36 § 213 (1)(e), section 1115 of the Social Security Act, and 42 C.F.R. §§ 431.400 through 431.428. WSR 17-12-019, § 182-503-0510, filed 5/30/17, effective 7/1/17. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-503-0510, filed 2/28/14, effective 3/31/14. WSR 12-13-056, recodified as § 182-503-0510, filed 6/15/12, effective 7/1/12. WSR 12-02-034, recodified as § 182-505-0510, filed 12/29/11, effective 1/1/12. Statutory Authority: RCW 34.05.353 (2)(d), 74.08.090, and chapters 74.09, 74.04 RCW. WSR 08-11-047, § 388-503-0510, filed 5/15/08, effective 6/15/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.530. WSR 05-07-097, § 388-503-0510, filed 3/17/05, effective 4/17/05. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. WSR 02-17-030, § 388-503-0510, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-503-0510, filed 7/31/98, effective 9/1/98.*

##### **Wash. Admin. Code § 182-503-0515** Washington apple health—Social Security number requirements. {#sec-182-503-0515 omnilex-key=us-wa-regs-official--title-182--182-503-0515}

(1) To be eligible for Washington apple health (medicaid), or tailored supports for older adults (TSOA) described in WAC 182-513-1610, you (the applicant or recipient) must provide your valid Social Security number (SSN) or proof of application for an SSN to the medicaid agency or the agency's designee, except as provided in subsections (2) and (6) of this section.

(2) An SSN is not required if you are:

(a) Not eligible to receive an SSN or may only be issued an SSN for a valid nonwork reason described in 20 C.F.R. 422.104;

(b) A household member who is not applying for apple health coverage, unless verification of that household member's resources is required to determine the eligibility of the client;

(c) Refusing to obtain an SSN for well-established religious objections as defined in 42 C.F.R. 435.910 (h)(3); or

(d) Not able to obtain or provide an SSN because you are a victim of domestic violence.

(3) If you are receiving coverage because you meet an exception under either subsection (2)(c) or (d) of this section, we (the agency) will confirm with you at your apple health renewal, consistent with WAC 182-503-0050, that you still meet the exception.

(4) If we ask for confirmation that you continue to meet an exception in subsection (2) of this section and you do not respond in accordance with subsection (3) of this section, or if you no longer meet an exception and do not provide your SSN, we will terminate your apple health coverage according to WAC 182-518-0025.

(5) If you are not able to provide your SSN, either because you do not know it or it has not been issued, you must provide:

(a) Proof from the Social Security Administration (SSA) that you turned in an application for an SSN; and

(b) The SSN when you receive it.

(i) Your apple health coverage will not be delayed, denied, or terminated while waiting for SSA to send you your SSN. If you need help applying for an SSN, assistance will be provided to you.

(ii) We will ask you every 90 days if your SSN has been issued.

(6) An SSN is not required for the following apple health programs:

(a) Refugee medical assistance program described in WAC 182-507-0130;

(b) Alien medical programs described in WAC 182-507-0115, 182-507-0120, and 182-507-0125;

(c) Newborn medical program described in WAC 182-505-0210 (2)(a);

(d) Foster care program for a child age 18 and younger as described in WAC 182-505-0211(1);

(e) Medical programs for children and pregnant women who do not meet citizenship or immigration status described in WAC 182-503-0535 (2)(e)(ii) and (iii); or

(f) Family planning only program described in WAC 182-532-510 if you do not meet citizenship or immigration status for Washington apple health or you have made an informed choice to apply for family planning services only.

(7) If you are required to provide an SSN under this section, and you do not meet an exception under subsection (2) of this section, failure to provide your SSN may result in:

(a) Denial of your application or termination of your coverage because we cannot determine your household's eligibility; or

(b) Inability to apply the community spouse resource allocation (CSRA) or monthly maintenance needs allowance (MMNA) for a client of long-term services and supports (LTSS).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-19-142, § 182-503-0515, filed 9/22/21, effective 10/23/21*
- *WSR 18-10-014, § 182-503-0515, filed 4/23/18, effective 5/24/18. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-503-0515, filed 7/29/14, effective 8/29/14.*

##### **Wash. Admin. Code § 182-503-0520** Washington apple health—Residency requirements—Persons who are not residing in an institution. {#sec-182-503-0520 omnilex-key=us-wa-regs-official--title-182--182-503-0520}

(1) A resident is a person (including an emancipated person under age 18 and a married person under age 18 who is capable of indicating intent) who currently lives in Washington and:

(a) Intends to reside here, including persons without a fixed address; or

(b) Entered the state looking for a job; or

(c) Entered the state with a job commitment.

(2) A person does not need to live in the state for a specific period of time prior to meeting the requirements in subsection (1) of this section before being considered a resident.

(3) A child under age eighteen who is not covered by subsection (1) of this section, is a resident if:

(a) The child lives in the state, with or without a fixed address, including with a custodial parent or caretaker; or

(b) The child's parent or caretaker is a resident as defined in subsection (1) of this section.

(4) A resident applying for or receiving health care coverage can temporarily be out of the state for more than one month without their health care coverage being denied or terminated, if the person:

(a) Intends to return to the state once the purpose of his or her absence has been accomplished and provides adequate information of this intent after a request by the agency or its designee; and

(b) Has not been determined eligible for medicaid or state-funded health care coverage in another state (other than coverage in another state for incidental or emergency health care).

(5) A person who enters Washington state only for health care is not a resident and is not eligible for any medical program. The only exception is for a person who moves from another state directly into an institution in Washington state. Residency rules for institutionalized persons are described in WAC 182-503-0525.

(6) A person of any age who receives a state supplemental payment (SSP) is considered a resident of the state that is making the payment.

(7) A person who receives federal payments for foster or adoption assistance is considered a resident of the state where the person physically resides even if:

(a) The person does not live in the state that is making the foster or adoption assistance payment; or

(b) The person does not live in the state where the adoption agreement was entered.

(8) In a dispute between states, the state of residence is the state in which the person is physically located.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-503-0520, filed 7/29/14, effective 8/29/14. Statutory Authority: RCW 41.05.021, 74.09.035, and 2011 1st sp.s. c 36. WSR 12-19-051, § 182-503-0520, filed 9/13/12, effective 10/14/12.*

##### **Wash. Admin. Code § 182-503-0525** Washington apple health—Residency requirements for an institutionalized person. {#sec-182-503-0525 omnilex-key=us-wa-regs-official--title-182--182-503-0525}

(1) An institutionalized person is a person who resides in an institution as defined in WAC 182-500-0050. The term "person" used in this section means an "institutionalized person" unless otherwise indicated. It does not include persons who receive services under a home and community-based waiver program. When a state is making a placement for a person in another state, the term institution also includes foster care homes, licensed as described in 45 C.F.R. 1355.20.

(2) The agency must determine whether a person is capable of indicating their intent to reside in Washington state when deciding whether that person is a resident of the state. The agency determines that persons who meet the following criteria are deemed incapable of indicating intent to reside in the state:

(a) The person is judged legally incompetent by a court of law;

(b) A physician, psychologist or licensed medical professional in the field of intellectual disabilities has determined that the person is incapable of indicating intent; or

(c) The person is incapable of declaring intent due to a documented medical condition.

(3) When a person is placed in an out-of-state institution by the agency, its designee or by a department of social and health services-contracted agency, the state arranging the placement is considered the person's state of residence, unless the person is capable of expressing intent and:

(a) Indicates a desire to change his or her state of residence; or

(b) Asks the current state of residence for help in relocating. This may include assistance in locating an institutional placement in the new state of residence.

(4) If another state has not authorized the placement in the institution, as described in subsection (3) of this section, the agency or its designee uses one of the following criteria to determine the state of residence for a person who is age 20 or younger:

(a) The state of residence is the state where the parent or legal guardian is a resident at the time of the placement in the institution. To determine a parent's or legal guardian's place of residence, follow rules described in WAC 182-503-0520 for a noninstitutionalized person.

(b) The state of residence is the state where the parent or legal guardian currently is a resident if the person resides in an institution in that state.

(c) If the parents of the person are separated and live in different states, the state of residence is that of the parent filing the application.

(d) If the parental rights are terminated and the person has a legal guardian, the state of residence is where the legal guardian is a resident.

(e) If the person has both a guardian of the estate and a guardian of the person, the state of residence is where the guardian of the person is a resident, unless the state has laws which delegate guardianship to a state official or agency for persons who are admitted to state institutions. In that case, the state of residence for the person is the state where the institution is located (unless another state has authorized the placement).

(f) If the person has been abandoned by the parents or legal guardian, and an application is filed on their behalf by another party, the state of residence is the state where the person is institutionalized. The term abandoned also includes situations where the parents or legal guardian are deceased.

(5) A person age 21 or older that is capable of indicating intent is considered a resident of the state where he or she is living and intends to reside.

(6) A person age 21 or older who became incapable of indicating intent at age 21 or older is considered a resident of the state where the person is physically residing, unless the person has been placed in the institution by another state.

(7) A person age 21 or older who became incapable of indicating intent before the age of 21 is considered a resident of the state where the parents or legal guardian were residents at the time of the placement in the institution.

(8) If a noninstitutionalized person moves directly from another state to an institution in Washington state, it is not necessary for the person to establish residency in Washington state prior to entering the facility. The person is considered a resident if he or she intends to reside in the state unless the placement was made by the other state.

(9) A person of any age who receives a state supplemental payment (SSP) is considered a resident of the state that is making the payment.

(10) In a dispute between states, the state of residence is the state in which the person is physically located.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-503-0525, filed 7/29/14, effective 8/29/14.*

##### **Wash. Admin. Code § 182-503-0535** Washington apple health—Citizenship and immigration status. {#sec-182-503-0535 omnilex-key=us-wa-regs-official--title-182--182-503-0535}

(1) Definitions.

(a) Nonqualified alien means someone who is lawfully present in the United States (U.S.) but who is not a qualified alien, a U.S. citizen, a U.S. national, or a qualifying American Indian born abroad.

(b) Qualified alien means someone who is lawfully present in the United States and who is one or more of the following:

(i) A person lawfully admitted for permanent residence (LPR).

(ii) An abused spouse or child, a parent of an abused child, or a child of an abused spouse who no longer resides with the person who committed the abuse, and who has one of the following:

(A) A pending or approved I-130 petition or application to immigrate as an immediate relative of a U.S. citizen or as the spouse of an unmarried LPR younger than 21 years of age.

(B) Proof of a pending application for suspension of deportation or cancellation of removal under the Violence Against Women Act (VAWA).

(C) A notice of prima facie approval of a pending self-petition under VAWA. An abused spouse's petition covers his or her child if the child is younger than 21 years of age. In that case, the child retains qualified alien status even after he or she turns 21 years of age.

(iii) A person who has been granted parole into the U.S. for one year or more, under the Immigration and Nationality Act (INA) Section 212 (d)(5), including public interest parolees.

(iv) A member of a Hmong or Highland Laotian tribe that rendered military assistance to the U.S. between August 5, 1964, and May 7, 1975, including the spouse, unremarried widow or widower, and unmarried dependent child of the tribal member.

(v) A person who was admitted into the U.S. as a conditional entrant under INA Section 203 (a)(7) before April 1, 1980.

(vi) A person admitted to the U.S. as a refugee under INA Section 207.

(vii) A person who has been granted asylum under INA Section 208.

(viii) A person granted withholding of deportation or removal under INA Section 243(h) or 241 (b)(3).

(ix) A Cuban or Haitian national who was paroled into the U.S. or given other special status.

(x) An Amerasian child of a U.S. citizen under 8 C.F.R. Section 204.4(a).

(xi) A person from Iraq or Afghanistan who has been granted one of the following:

(A) Special immigrant status under INA Section 101 (a)(27);

(B) Special immigrant conditional permanent resident; or

(C) Parole under Section 602 (b)(1) of the Afghan Allies Protection Act of 2009 or Section 1059(a) of the National Defense Authorization Act of 2006.

(xii) An Afghan who, under Section 2502 of the Extending Government Funding and Delivering Emergency Assistance Act of 2021, is evaluated as a qualified alien until March 31, 2023, or the end of their parole term, whichever is later, when granted parole:

(A) Between July 31, 2021, and September 30, 2023; or

(B) After September 30, 2022, and is:

(I) Their spouse or child; or

(II) The parent or guardian of an unaccompanied minor described under this subsection.

(xiii) A citizen or national of Ukraine (or a person who last habitually resided in Ukraine) who, under section 401 of the Additional Ukraine Supplemental Appropriations Act, 2022 (AUSAA) and the Ukraine Security Supplemental Appropriations Act, 2024 (USSAA), is evaluated as a qualified alien until the end of their parole term when:

(A) Granted parole into the United States between February 24, 2022, and September 30, 2024; or

(B) Granted parole into the United States after September 30, 2024, and is:

(I) The spouse or child of a person described in (b)(xiii)(A) of this subsection; or

(II) The parent, legal guardian, or primary caregiver of a person described in (b)(xiii)(A) of this subsection who is determined to be an unaccompanied child under section 462 (g)(2) of the Homeland Security Act of 2002 or section 412 (d)(2)(B) of the Immigration and Nationality Act.

(xiv) A person who has been certified or approved as a victim of trafficking by the federal office of refugee resettlement, or who is:

(A) The spouse or child of a trafficking victim of any age; or

(B) The parent or minor sibling of a trafficking victim who is younger than 21 years of age.

(xv) A person from the Federated States of Micronesia, the Republic of Palau, or the Republic of the Marshall Islands living in the United States in accordance with the Compacts of Free Association.

(c) U.S. citizen means someone who is a United States citizen under federal law.

(d) U.S. national means someone who is a United States national under federal law.

(e) Undocumented person means someone who is not lawfully present in the U.S.

(f) Qualifying American Indian born abroad means someone who:

(i) Was born in Canada and has at least 50 percent American Indian blood, regardless of tribal membership; or

(ii) Was born outside of the United States and is a member of a federally recognized tribe or an Alaska Native enrolled by the Secretary of the Interior under the Alaska Native Claims Settlement Act.

(2) Eligibility.

(a) A U.S. citizen, U.S. national or qualifying American Indian born abroad may be eligible for:

(i) Apple health for adults;

(ii) Apple health for kids;

(iii) Apple health for pregnant women; or

(iv) Classic medicaid.

(b) A qualified alien who meets or is exempt from the five-year bar may be eligible for:

(i) Apple health for adults;

(ii) Apple health for kids;

(iii) Apple health for pregnant women; or

(iv) Classic medicaid.

(c) A qualified alien who neither meets nor is exempt from the five-year bar may be eligible for:

(i) Alien medical programs;

(ii) Apple health for kids;

(iii) Apple health for pregnant women; or

(iv) Medical care services.

(d) A nonqualified alien may be eligible for:

(i) Alien medical programs;

(ii) Apple health for kids;

(iii) Apple health for pregnant women; or

(iv) Medical care services.

(e) An undocumented person may be eligible for:

(i) Alien medical programs;

(ii) State-only funded apple health for kids; or

(iii) State-only funded apple health for pregnant women.

(3) The five-year bar.

(a) A qualified alien meets the five-year bar if he or she:

(i) Continuously resided in the U.S. for five years or more from the date he or she became a qualified alien; or

(ii) Entered the U.S. before August 22, 1996, and:

(A) Became a qualified alien before August 22, 1996; or

(B) Became a qualified alien on or after August 22, 1996, and has continuously resided in the U.S. between the date of entry into the U.S. and the date he or she became a qualified alien.

(b) A qualified alien is exempt from the five-year bar if he or she is:

(i) A qualified alien as defined in subsection (1)(b)(vi) through (xv) of this section;

(ii) An LPR, parolee, or abused person, who is also an armed services member or veteran, or a family member of an armed services member or veteran, as described below:

(A) An active-duty member of the U.S. military, other than active-duty for training;

(B) An honorably discharged U.S. veteran;

(C) A veteran of the military forces of the Philippines who served before July 1, 1946, as described in Title 38 U.S.C. Section 107; or

(D) The spouse, unremarried widow or widower, or unmarried dependent child of an honorably discharged U.S. veteran or active-duty member of the U.S. military.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 118-50. WSR 24-22-006, s 182-503-0535, filed 10/23/24, effective 11/23/24. Statutory Authority: RCW 41.05.021, 41.05.160, and Section 1501, Consolidated Appropriations Act, 2023*
- *P.L. 117-328, div. M, Title V, § 1501. WSR 23-20-043, § 182-503-0535, filed 9/27/23, effective 10/28/23. Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 117-128. WSR 22-20-074, § 182-503-0535, filed 9/30/22, effective 10/31/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-08-002, § 182-503-0535, filed 3/23/22, effective 4/23/22*
- *WSR 21-19-029, § 182-503-0535, filed 9/9/21, effective 10/10/21*
- *WSR 15-10-002, § 182-503-0535, filed 4/22/15, effective 5/23/15. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-503-0535, filed 7/29/14, effective 8/29/14.*

##### **Wash. Admin. Code § 182-503-0540** Assignment of rights and cooperation. {#sec-182-503-0540 omnilex-key=us-wa-regs-official--title-182--182-503-0540}

(1) When you become eligible for any of the agency's health care programs, you assign certain rights to the state of Washington. You assign all rights to any type of coverage or payment for health care that comes from:

(a) A court order;

(b) An administrative agency order; or

(c) Any third-party benefits or payment obligations for medical care which are the result of subrogation or contract (see WAC 182-501-0100).

(2) When you sign the application you assign the rights described in subsection (1) of this section to the state for:

(a) Yourself; and

(b) Any eligible person for whom you can legally make such assignment.

(3) You must cooperate with us in identifying, using or collecting third-party benefits. If you do not cooperate, your health care coverage may end unless you can show good reason not to cooperate with us. Examples of good reason include, but are not limited to:

(a) Your reasonable belief that cooperating with us would result in serious physical or emotional harm to you, a child in your care, or a child related to you; and

(b) Your being incapacitated without the ability to cooperate with us.

(4) Your WAH coverage will not end due solely to the noncooperation of any third party.

(5) You will have to pay for your health care services if you:

(a) Received and kept the third-party payment for those services; or

(b) Refused to give to the provider of care your legal signature on insurance forms.

(6) The state is limited to the recovery of its own costs for health care costs paid on behalf of a recipient of health care coverage. The legal term which describes the method by which the state acquires the rights of a person for whom the state has paid costs is called subrogation.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-02-046, § 182-503-0540, filed 12/27/18, effective 1/27/19. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-503-0540, filed 7/29/14, effective 8/29/14. WSR 12-13-056, recodified as § 182-503-0540, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.08.090. WSR 01-02-076, § 388-505-0540, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-505-0540, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 97-04-005, § 388-505-0540, filed 1/24/97, effective 2/24/97. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-505-0540, filed 5/3/94, effective 6/3/94. Formerly WAC 388-83-012, 388-501-0170 and 388-505-0560.*

##### **Wash. Admin. Code § 182-503-0565** Washington apple health—Age requirements for medical programs based on modified adjusted gross income (MAGI). {#sec-182-503-0565 omnilex-key=us-wa-regs-official--title-182--182-503-0565}

The following age requirements apply to persons whose eligibility for Washington apple health (WAH) is based on modified adjusted gross income (MAGI) methodology per WAC 182-509-0305.

(1) You must be age 64 or younger to be eligible for WAH MAGI-based adult coverage as described in WAC 182-505-0250.

(2) Your household must include an eligible dependent child age seventeen or younger to be eligible for WAH parent or caretaker relative coverage as described in WAC 182-505-0240. For purposes of this subsection, an "eligible dependent child" is a child related to you in one of the ways described in WAC 182-500-0020.

(3) A child must be age 18 or younger to be eligible for WAH for kids as described in WAC 182-505-0210 with the following exceptions:

(a) An institutionalized child may still qualify under a children's health care program through the age of 21 (see WAC 182-514-0230);

(b) A foster care child may qualify for WAH foster care coverage through the age of 26 (see WAC 182-505-0211).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-503-0565, filed 7/29/14, effective 8/29/14.*

## **Chapter 182-504** Certification periods and change of circumstance. {#struct-chapter-182-504}

##### **Wash. Admin. Code § 182-504-0005** Washington apple health—Retroactive certification period. {#sec-182-504-0005 omnilex-key=us-wa-regs-official--title-182--182-504-0005}

(1) The medicaid agency approves a retroactive Washington apple health (WAH) certification period for the three months immediately before the month of application when an individual:

(a) Requests retroactive WAH on his or her application, within the certification period following the retroactive period, or before the determination of benefits and any appeal process is final;

(b) Would have been eligible for WAH for any or all of the three months if he or she had applied during the retroactive period; and

(c) The individual received covered medical services as described in WAC 182-501-0060 and 182-501-0065.

(2) When an individual is eligible only during the three-month retroactive certification period, that period is the only period of certification, except when:

(a) A pregnant individual is eligible in one of the three months immediately before the month of application, but no earlier than the month of conception. Eligibility continues as described in WAC 182-504-0015(3).

(b) An individual who is applying within 12 months of their last pregnancy end date is eligible for after-pregnancy coverage in any of the three months immediately before the month of application. Continuous eligibility begins from the earliest month the individual is found eligible as described in WAC 182-504-0015 (3) and (4).

(c) A child is eligible for categorically needy (CN) WAH as described in WAC 182-505-0210 (1) through (5) and (7) in at least one of the three months immediately before the month of application. Eligibility after the retroactive period continues as described in WAC 182-504-0015(11).

(3) An individual applying for the medically needy (MN) spenddown program may be eligible for a retroactive certification period as described in WAC 182-504-0020.

(4) An individual applying for a medicare savings program may be eligible for a retroactive certification period as described in WAC 182-504-0025.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 74.09.830. WSR 22-21-086, § 182-504-0005, filed 10/14/22, effective 11/14/22. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 13-14-019, § 182-504-0005, filed 6/24/13, effective 7/25/13.*

##### **Wash. Admin. Code § 182-504-0015** Washington apple health—Certification periods for categorically needy programs. {#sec-182-504-0015 omnilex-key=us-wa-regs-official--title-182--182-504-0015}

(1) A certification period is the period of time we determine that you are eligible for a categorically needy (CN) Washington apple health program. Unless otherwise stated in this section, the certification period begins on the first day of the month of application and continues through the end of the last month of the certification period.

(2) Newborn coverage begins on the child's date of birth and continues through the end of the month of the child's first birthday.

(3) If you are eligible for apple health based on pregnancy, the certification period continues through the last day of the month the pregnancy ends. After-pregnancy coverage begins the first day of the month, following the end of the pregnancy, and ends the last day of the 12th month from the time after-pregnancy coverage began.

(4) If you are newly eligible for apple health coverage and had a pregnancy end within the last 12 months, your certification period for after-pregnancy coverage:

(a) Begins the first day of the month you are eligible; and

(b) Ends the last day of the 12th month following the end of your pregnancy.

(5) If you are eligible for the refugee program, the certification period ends at the end of the fourth month following your date of entry to the United States.

(6) If you are a child under age six receiving apple health for kids, with or without premiums, your certification period ends the last day of the month of your sixth birthday.

(7) If you are eligible for newborn coverage, your coverage continues through the last day of the month of your first birthday. Apple health for kids coverage begins automatically on the first day of the month after your newborn coverage ends and the certification period ends the last day of the month of your sixth birthday.

(8) For all other CN coverage, the certification period is 12 months.

(9) If you are a child, eligibility is continuous throughout the certification period regardless of a change in circumstances, unless you:

(a) Turn age 19;

(b) Move out-of-state; or

(c) Die.

(10) When you turn 19, the certification period ends after the redetermination process described in WAC 182-504-0125 is completed, even if the 12-month period is not over, unless:

(a) You are receiving inpatient services (described in WAC 182-514-0230) on the last day of the month you turn 19;

(b) The inpatient stay continues into the following month or months; and

(c) You remain eligible except for turning age 19.

(11) A retroactive certification period is described in WAC 182-504-0005.

(12) Coverage under premium-based programs included in apple health for kids as described in chapter 182-505 WAC begins no sooner than the month after creditable coverage ends.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 90 Fed. Reg. 13370 (March 21, 2025). WSR 25-16-101, s 182-504-0015, filed 8/6/25, effective 9/6/25. Statutory Authority: RCW 41.05.021, 41.05.160, and 2024 c 376 s 211(87). WSR 25-12-035, s 182-504-0015, filed 5/28/25, effective 7/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-20-052, s 182-504-0015, filed 9/25/24, effective 10/26/24. Statutory Authority: RCW 41.05.021, 41.05.160, and 2023 c 475 § 211(36). WSR 23-23-057, § 182-504-0015, filed 11/8/23, effective 12/9/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-21-072, § 182-504-0015, filed 10/13/22, effective 11/13/22*
- *WSR 22-12-033, § 182-504-0015, filed 5/24/22, effective 6/24/22*
- *WSR 17-12-017, § 182-504-0015, filed 5/30/17, effective 6/30/17. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-504-0015, filed 7/29/14, effective 8/29/14. WSR 11-24-018, recodified as § 182-504-0015, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, and 74.08.090, and Apple Health for Kids Act (ESHB 2128)*
- *42 U.S.C. 1305*
- *Public Law 111-3 (Children's Health Insurance Program Reauthorization Act of 2009). WSR 11-03-001, § 388-416-0015, filed 1/5/11, effective 2/5/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.402, 74.09.470, and 2008 session law. WSR 09-07-086, § 388-416-0015, filed 3/17/09, effective 4/17/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.09.700, and 2007 c 5. WSR 08-05-018, § 388-416-0015, filed 2/12/08, effective 3/14/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-416-0015, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.530, and 74.09.415. WSR 05-19-031, § 388-416-0015, filed 9/12/05, effective 10/13/05. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.04.510, and 2004 c 54. WSR 04-21-064, § 388-416-0015, filed 10/18/04, effective 11/18/04. Statutory Authority: RCW 74.08.090, 74.09.530, and 2003 c 10. WSR 04-03-019, § 388-416-0015, filed 1/12/04, effective 2/12/04. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090 and 74.09.450. WSR 00-08-002, § 388-416-0015, filed 3/22/00, effective 5/1/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-416-0015, filed 7/31/98, effective 9/1/98. Formerly 388-509-0970, 388-521-2105, 388-522-2210 and 388-522-2230.*

##### **Wash. Admin. Code § 182-504-0020** Certification periods for the noninstitutional medically needy program. {#sec-182-504-0020 omnilex-key=us-wa-regs-official--title-182--182-504-0020}

(1) The certification period for the noninstitutional medically needy (MN) program for clients with countable income equal to or below the medically needy income level (MNIL):

(a) Begins on the first day of the month in which eligibility is established; and

(b) Is approved for twelve calendar months.

(2) The certification period for the noninstitutional MN program for clients with countable income above the MNIL:

(a) Begins on the day that spenddown is met; and

(b) Continues through the last day of the final month of the base period as described in WAC 182-519-0110.

(3) A retroactive MN certification period may be established for up to three months preceding the month of application.

(4) Expenses used to meet the spenddown liability for the current or the retroactive certification periods are the responsibility of the client. The agency is not responsible for paying any expense or portion of an expense which has been used to meet the spenddown liability. See WAC 182-519-0110.

(5) A new application must be submitted for each subsequent certification period for which medically needy coverage is requested.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-13-053, § 182-504-0020, filed 6/10/15, effective 7/11/15. WSR 11-24-018, recodified as § 182-504-0020, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. WSR 08-21-108, § 388-416-0020, filed 10/16/08, effective 11/16/08. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-416-0020, filed 7/31/98, effective 9/1/98. Formerly WAC 388-521-2105 and 388-521-2130.*

##### **Wash. Admin. Code § 182-504-0025** Medicare savings program certification periods. {#sec-182-504-0025 omnilex-key=us-wa-regs-official--title-182--182-504-0025}

Certification periods for the different kinds of medicare savings programs are not all the same. The chart below explains the differences.

| Medicare Savings Program | Certification Period | Start Date |
| --- | --- | --- |
| QMB (qualified medicare beneficiary) S03 | 12 months | On the first day of the month following QMB eligibility determination |
| SLMB (Special low income medicare beneficiary) S05 | 12 months | Up to three months prior to the certification period if on the first day of the first month of certification, the person: • Is or has been enrolled in medicare Part B; and • Meets SLMB eligibility requirements. |
| QDWI (Qualified disabled working individual) S04 | 12 months | Up to three months prior to the certification period if on the first day of the first month of certification, the person: • Is or has been enrolled in medicare Part A; and • Meets QDWI eligibility requirements. |
| QI-1 (Qualified individual) S06 | Thru the end of the calendar year following QI-1 eligibility determination | Up to three months prior to the certification period if on the first day of the first month of certification, the person: • Is or has been enrolled in medicare Part B; and • Meets QI-1 eligibility requirements. |

**History**
- *WSR 11-24-018, recodified as § 182-504-0025, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530 and 42 U.S.C. 1396a(a) (Section 1902 (n)(2) of the Social Security Act of 1924). WSR 05-01-126, § 388-416-0035, filed 12/15/04, effective 1/15/05. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-416-0035, filed 7/31/98, effective 9/1/98. Formerly WAC 388-521-2150, 388-521-2155 and 388-521-2160.*

##### **Wash. Admin. Code § 182-504-0035** Washington apple health—Renewals. {#sec-182-504-0035 omnilex-key=us-wa-regs-official--title-182--182-504-0035}

(1) For all Washington apple health programs, the following applies:

(a) You are required to complete a renewal of eligibility at least every 12 months with the following exceptions:

(i) If you are eligible for apple health medically needy with spenddown, then you must complete a new application at the end of each three- or six-month base period;

(ii) If you are eligible for apple health alien emergency medical, then you are certified for a specific period of time to cover emergency inpatient hospitalization costs only (see WAC 182-507-0115(8));

(iii) If you are eligible for apple health refugee coverage, you must complete a renewal of eligibility after four months; or

(iv) If you are a child under age six on apple health for kids, with or without premiums, your first renewal is due the month of your sixth birthday.

(b) You may complete renewals online, by phone, or by paper application that you mail or fax to us (the agency or the agency's designee).

(c) If your apple health is renewed, we decide the certification period according to WAC 182-504-0015.

(d) We review all eligibility factors subject to change during the renewal process.

(e) We redetermine eligibility as described in WAC 182-504-0125 and send you written notice as described in WAC 182-518-0005 before apple health is terminated.

(f) If you need help meeting the requirements of this section, we provide equal access services as described in WAC 182-503-0120.

(2) For programs based on modified adjusted gross income (MAGI) as described in WAC 182-503-0510:

(a) Sixty days prior to the end of the certification period:

(i) When information from electronic sources shows income is reasonably compatible (as defined in WAC 182-500-0095), we administratively renew your coverage (as defined in WAC 182-500-0010) for a new certification period and send you a notice of renewal with the information used. You are required to inform us if any of the information we used is wrong.

(ii) If we are unable to complete an administrative renewal (as defined in WAC 182-500-0010), you must give us a signed renewal in order for us to decide if you will continue to get apple health coverage beyond the current certification period.

(iii) We follow the requirements described in WAC 182-518-0015 to request any additional information needed to complete the renewal process or to terminate coverage for failure to renew.

(b) If your apple health coverage is terminated because you did not renew, you have 90 days from the termination date to give us a completed renewal. If we decide you are still eligible to get apple health coverage, we will restore your apple health without a gap in coverage.

(3) For non-MAGI based programs (as described in WAC 182-503-0510):

(a) Forty-five days prior to the end of the certification period, we send notice with a renewal form. You must renew before the end of the certification period by either calling the department of social and health services at the number listed on the form to renew by telephone, renew online at www.washingtonconnection.org, or mailing or delivering to the department of social and health services a signed renewal form with the information required by WAC 182-503-0005.

(b) We follow the requirements in WAC 182-518-0015 to request any additional information needed to complete the renewal process or to terminate coverage for failure to renew.

(c) To complete your renewal, you must give us all the other information requested on the application that is needed to determine your eligibility.

(d) If you are terminated for failure to renew, you have 30 days from the termination date to submit a completed renewal. If still eligible, we will restore your apple health without a gap in coverage.

(4) If we determine that you are not eligible for renewal of your apple health coverage, we:

(a) Consider your eligibility for all other apple health programs before ending your apple health coverage; and

(b) Coordinate with the health benefit exchange any request for information that is necessary to determine your eligibility for:

(i) Other apple health programs; and

(ii) With respect to qualified health plans, health insurance premium tax credits (as defined in WAC 182-500-0045) and cost-sharing reductions (as defined in WAC 182-500-0020).

(5) We reconsider our decision that you are not eligible for apple health coverage without a new application from you when:

(a) We receive the information that we need to decide if you are eligible within 30 days of the date on the termination notice; or

(b) You request a hearing within 90 days of the date on the renewal denial letter and an administrative law judge (ALJ) or HCA review judge decides our decision was wrong (per chapter 182-526 WAC).

(6) If you disagree with our decision, you can ask for a hearing. If we decided that you are not eligible for renewal because we do not have enough information, the ALJ will consider the information we already have and anymore information you give us. The ALJ does not consider the previous absence of information or failure to respond in determining if you are eligible.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 90 Fed. Reg. 13370 (March 21, 2025). WSR 25-16-101, s 182-504-0035, filed 8/6/25, effective 9/6/25. Statutory Authority: RCW 41.05.021, 41.05.160, and 2024 c 376 s 211(87). WSR 25-12-035, s 182-504-0035, filed 5/28/25, effective 7/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, and 2023 c 475 § 211(36). WSR 23-23-057, § 182-504-0035, filed 11/8/23, effective 12/9/23. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-504-0035, filed 7/29/14, effective 8/29/14.*

##### **Wash. Admin. Code § 182-504-0105** Washington apple health—Changes that must be reported. {#sec-182-504-0105 omnilex-key=us-wa-regs-official--title-182--182-504-0105}

(1) You must report changes in your household and family circumstances to us (the agency or its designee) timely according to WAC 182-504-0110.

(2) We tell you what you are required to report at the time you are approved for WAH coverage. We also will tell you if the reporting requirements change.

(3) You must report the following:

(a) Change in residential address;

(b) Change in mailing address;

(c) Change in marital status;

(d) When family members or dependents move in or out of the residence;

(e) Pregnancy;

(f) Incarceration;

(g) Change in institutional status;

(h) Change in health insurance coverage including medicare eligibility; and

(i) Change in immigration or citizenship status.

(4) If you are eligible for a WAH long-term care program described in chapter 182-513 or 182-515 WAC, you must also report changes to the following:

(a) Income;

(b) Resources;

(c) Medical expenses; and

(d) Spouse or dependent changes in income or shelter cost when expenses are allowed for either.

(5) If you get WAH parent or caretaker (as described in WAC 182-505-0240) or WAH modified adjusted gross income (MAGI)-based adult coverage (as described in WAC 182-505-0250), you must also report changes to the following:

(a) When total income increases or total deductions decrease by one hundred fifty dollars or more a month and the change will continue for at least two months;

(b) Your federal income tax filing status that you expect to use when you file your taxes for the current tax filing year (such as changing from "married filing separately" to "married filing jointly"); and

(c) The tax dependents you expect to claim when you file your federal income tax return for the current tax filing year.

(6) If you get WAH based on age, blindness, or disability (SSI-related medical), then you must also report changes to the following:

(a) Income; and

(b) Resources.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-504-0105, filed 7/29/14, effective 8/29/14.*

##### **Wash. Admin. Code § 182-504-0110** Washington apple health—When to report changes. {#sec-182-504-0110 omnilex-key=us-wa-regs-official--title-182--182-504-0110}

(1) All changes you report to us (the agency or its designee), as required by WAC 182-504-0105, are used to decide if you can receive or keep receiving Washington apple health (WAH) coverage.

(2) You must report changes during your certification period within thirty days of when the change happened.

(3) You must report all changes during application, renewal, or redetermination of your WAH eligibility, regardless of when the change happened.

(4) For a change in income, the date a change happened is the first date you received income based on the change. For example, the date you receive your first paycheck for a new job or the date you got a paycheck with a wage increase is the date the change happened.

(5) If you do not report a change or you report a change late, we will decide if you can receive or keep receiving WAH coverage based on the date the change was required to be reported.

(6) If you do not report a change or you report a change late, and if it affects the amount you must pay toward your cost of care as described in WAC 182-513-1380 or chapter 182-515 WAC, you may become liable for overpayments we make on your behalf and you may need to pay more to your care provider.

(7) If you do not report a change or you report a change late, it may result in us overpaying you and you having to pay us back for the health care costs we overpaid. See chapter 182-520 WAC.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-504-0110, filed 7/29/14, effective 8/29/14.*

##### **Wash. Admin. Code § 182-504-0120** Washington apple health—Effective dates of changes. {#sec-182-504-0120 omnilex-key=us-wa-regs-official--title-182--182-504-0120}

(1) We (the agency or its designee) determine the date a change affects your Washington apple health (WAH) coverage based on:

(a) The date you report the change to us;

(b) The date you give us the requested verification; and

(c) The type of WAH you or your family is receiving.

(2) When you report a change after you submit your application, but before your application is processed, the change is considered when processing your application.

(3) If another person, agency, or data source reports a change in circumstances, the information may be used in determining your eligibility. We will not rely on information received from a person, agency, or data source to terminate your WAH coverage without requesting additional information from you.

(4) A change in income affects your ongoing eligibility only if it is expected to continue beyond the month when the change is reported, and only if it is expected to last more than two months.

(5) A change that results in termination of your WAH coverage takes effect the first of the month following the advance notice period.

(6) The advance notice period:

(a) Begins on the day we send the letter about the change to you; and

(b) Is determined according to the rules in WAC 182-518-0025.

(7) A change that results in a decreased scope of care takes effect on the first of the month following the advance notice period. Examples of a decreased scope of care are:

(a) Termination of WAH categorically needy (CN) medical and approval for other WAH coverage with a lesser scope of care such as WAH medically needy (MN) medical;

(b) WAH-MN recipient with a change that increases the spenddown liability amount;

(c) WAH-MN recipient with no spenddown liability with a change that results in WAH-MN with a spenddown liability.

(8) A change that results in an increased scope of care takes effect on the first of the month following the date the change was reported, when you provide the required verification:

(a) Within ten days of the date we requested the verification; or

(b) By the end of the month of your change report, whichever is later.

If you are a WAH-MN applicant with a spenddown liability that has not yet been met and you report a change that results in your becoming eligible for WAH-CN medical or WAH for adults, your change report will be treated as a new application for purposes of retroactive WAH coverage as described in WAC 182-504-0005.

(9) If you do not provide the required verification timely under subsection (8) of this section, we make the change effective the first of the month following the month in which you provide the verification. We may terminate your WAH coverage if you do not provide the required verification.

(10) When a law or regulation requires a change in WAH, the date specified by the law or regulation is the effective date of the change.

(11) When a change in income or allowable expenses is reported timely (within thirty days) and changes the amount you pay towards the cost of your care for institutional programs (residing in a medical institution), we calculate your new participation amount based on:

(a) Either actual income received in a month or allowable deductions incurred in a month, or both; or

(b) An estimate of your monthly or allowable expenses in a prospective period of six months or less, based on both actual income received in a preceding period of six months or less and income expected to be received during the prospective period. At the end of the prospective period or when any significant change occurs, we reconcile this estimate for the period with income received during the same period.

(12) When a change in income, or allowable expenses, changes the amount you pay towards the cost of your care for a home and community-based waiver or service, we calculate your new participation amount effective the first of the month following the date the change was reported, except that the new participation amount will be effective the month the change occurs if the change is the loss of an income source that you report within thirty days of the change.

(13) We use the following rules to determine the effective date of change for the health care for workers with disabilities (HWD) program:

(a) HWD coverage begins the month after coverage in another medical program ends and the premium amount has been approved by the eligible person; and

(b) If a change in income increases or decreases the monthly premium, the change is effective the first of the month after the change is reported. For more information on premium requirements for this program, see WAC 182-511-1250.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-504-0120, filed 7/29/14, effective 8/29/14.*

##### **Wash. Admin. Code § 182-504-0125** Washington apple health—Effect of reported changes. {#sec-182-504-0125 omnilex-key=us-wa-regs-official--title-182--182-504-0125}

(1) If you report a change required under WAC 182-504-0105 during a certification period, you continue to be eligible for Washington apple health coverage until we decide if you can keep getting apple health coverage under your current apple health program or a different apple health program.

(2) If your apple health categorically needy (CN) coverage ends due to a reported change and you meet all the eligibility requirements for a different apple health CN program, we will approve your coverage under the new apple health CN program. If you are not eligible for coverage under any apple health CN program but you meet the eligibility requirements for either apple health alternative benefits plan (ABP) coverage or apple health medically needy (MN) coverage, we will approve your coverage under the program you are eligible for. If you are not eligible for coverage under any apple health CN program but you meet the eligibility requirements for both apple health ABP coverage and apple health MN coverage, we will approve the apple health ABP coverage unless you notify us that you prefer apple health MN coverage.

(3) If your apple health coverage ends and you are not eligible for a different apple health program, we stop your apple health coverage after giving you advance and adequate notice unless the exception in subsection (4) of this section applies to you.

(4) If you claim to have a disability and that is the only basis for you to be potentially eligible for apple health coverage, then we refer you to the division of disability determination services (within the department of social and health services) for a disability determination. Pending the outcome of the disability determination, we also determine if you are eligible for apple health coverage under the SSI-related medical program described in chapter 182-512 WAC. If you have countable income in excess of the SSI-related categorically needy income level (CNIL), then we look to see if you can get coverage under apple health MN with spenddown as described in chapter 182-519 WAC pending the final outcome of the disability determination.

(5) If you are eligible for and receive coverage under the apple health parent and caretaker relative program described in WAC 182-505-0240, you may be eligible for the apple health medical extension program described in WAC 182-523-0100, if your coverage ends as a result of an increase in your earned income.

(6) Changes in income during a certification period do not affect eligibility for the following programs:

(a) Apple health for pregnant women;

(b) Apple health for children, except as specified in subsection (7) of this section;

(c) Apple health for SSI recipients;

(d) Apple health refugee program; and

(e) Apple health medical extension program.

(7) We redetermine eligibility for children receiving apple health for kids premium-based coverage described in WAC 182-505-0210 when the:

(a) Household's countable income decreases to a percentage of the federal poverty level (FPL) that would result in either a change in premium for apple health for kids with premiums or the children becoming eligible for apple health for kids (without premiums);

(b) Child becomes pregnant;

(c) Family size changes; or

(d) Child receives SSI.

(8) If you get SSI-related apple health CN coverage and report a change in work or earned income which results in a determination by the division of disability determination services that you no longer meet the definition of a disabled person as described in WAC 182-512-0050 due to work or earnings at the level of substantial gainful activity (SGA), we redetermine your eligibility for coverage under the health care for workers with disabilities (HWD) program. The HWD program is a premium-based program that waives the SGA work or earnings test, and you must approve the premium amount before we can authorize coverage under this program. For HWD program rules, see chapter 182-511 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-18-024, § 182-504-0125, filed 8/28/17, effective 10/1/17. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-504-0125, filed 7/29/14, effective 8/29/14. Statutory Authority: RCW 41.05.021, 74.09.035, and 2011 1st sp.s. c 36. WSR 12-19-051, § 182-504-0125, filed 9/13/12, effective 10/14/12.*

##### **Wash. Admin. Code § 182-504-0130** Washington apple health—Continued coverage pending an appeal. {#sec-182-504-0130 omnilex-key=us-wa-regs-official--title-182--182-504-0130}

(1) Continued coverage is when you continue to receive Washington apple health benefits while appealing a medicaid agency adverse action to terminate, suspend, or reduce your:

(a) Medicaid eligibility; or

(b) Authorization for a covered service.

(2) To qualify for continued coverage, you must request a hearing on the adverse action no later than:

(a) The tenth day after we (the medicaid agency or its designee) sent a notice of the action to you; or

(b) The last day of the month before the action takes effect.

(3) If your last day to request a hearing and still qualify for continued coverage falls on a Saturday, Sunday, or a designated holiday under WAC 357-31-005, you have until 5:00 p.m. on the next business day to request the hearing.

(4) Continued coverage ends when:

(a) You state in writing you no longer wish to receive continued coverage;

(b) You withdraw the appeal;

(c) You default and an order of dismissal is entered;

(d) An administrative law judge or a review judge issues an adverse ruling or written decision:

(i) Terminating your continued coverage; or

(ii) Ruling you do not qualify for benefits.

(5) You cannot receive continued coverage if the adverse action was due solely to a change in statute, federal regulation, or administrative rule, unless there is a question about whether you are in the class of people affected by the change.

(6) If you are receiving medically needy coverage, you cannot receive continued coverage past the end of the certification period described in WAC 182-504-0020.

(7) If you are receiving coverage under an alien medical program, you cannot receive continued coverage past the end of the certification period described in chapter 182-507 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-22-060, § 182-504-0130, filed 10/31/16, effective 12/1/16. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-504-0130, filed 2/28/14, effective 3/31/14.*

## **Chapter 182-505** Family, children, pregnancy and adult medical programs. {#struct-chapter-182-505}

##### **Wash. Admin. Code § 182-505-0100** Monthly income standards for MAGI-based programs. {#sec-182-505-0100 omnilex-key=us-wa-regs-official--title-182--182-505-0100}

(1) Each year, the federal government publishes new federal poverty level (FPL) income standards in the Federal Register found at https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines/prior-hhs-poverty-guidelines-federal-register-references.

(a) The income standards for the following Washington apple health programs change on the first day of April every year based on the new FPL, except for subsections (2) and (3) of this section.

(b) The agency determines income eligibility by comparing countable income of the person's medical assistance unit (MAU), as determined under WAC 182-506-0010 and 182-506-0012, to the applicable income standard. Rules for determining countable income are in chapter 182-509 WAC.

(2) Parents and caretaker relatives under WAC 182-505-0240 must have countable income equal to or below the following standards:

| Medical Assistance Unit Size | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11+ |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Income Standard | $511 | $658 | $820 | $972 | $1,127 | $1,284 | $1,471 | $1,631 | $1,792 | $1,951 | $1,951 |

(3) Parents and caretaker relatives with earned income above the limits in subsection (2) of this section are the only people who may be eligible for the transitional medical program described in WAC 182-523-0100.

(4) Adults described in WAC 182-505-0250 who are not eligible under subsection (2) or (3) of this section must have countable income equal to or below 133 percent of the FPL.

(5) Pregnant people described in WAC 182-505-0115 must have countable income equal to or below 210 percent of the FPL.

(6) Children with countable income:

(a) Equal to or below 210 percent of the FPL as described in WAC 182-505-0210 receive coverage at no cost.

(b) Greater than 210 percent but equal to or less than 312 percent as described in WAC 182-505-0210 receive premium-based coverage. Premium amounts are described in WAC 182-505-0225.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 74.09.830, and 74.09.839. WSR 24-19-037, s 182-505-0100, filed 9/11/24, effective 11/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-11-004, § 182-505-0100, filed 5/5/22, effective 6/5/22*
- *WSR 17-12-018, § 182-505-0100, filed 5/30/17, effective 6/30/17. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-505-0100, filed 7/29/14, effective 8/29/14. WSR 11-23-091, recodified as § 182-505-0100, filed 11/17/11, effective 11/21/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.402, 74.09.470, and 2008 session law. WSR 09-07-086, § 388-478-0075, filed 3/17/09, effective 4/17/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.09.700, and 2007 c 5. WSR 08-05-018, § 388-478-0075, filed 2/12/08, effective 3/14/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500 and 42 U.S.C. 9902(2). WSR 06-16-026, § 388-478-0075, filed 7/24/06, effective 8/24/06. Statutory Authority: RCW 74.08.090, 74.09.415, 74.09.530 and 2005 c 279. WSR 06-03-080, § 388-478-0075, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 42 U.S.C. 9902(2). WSR 05-17-157, § 388-478-0075, filed 8/22/05, effective 9/22/05. Statutory Authority: RCW 74.08.090, 74.04.057, 74.04.050, and 74.09.530. WSR 04-15-092, § 388-478-0075, filed 7/16/04, effective 8/16/04. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 74.09.530, and 42 U.S.C. 9902(2). WSR 03-15-088, § 388-478-0075, filed 7/17/03, effective 7/17/03. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. WSR 02-17-030, § 388-478-0075, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.500, 74.09.510, and Section 1902 (a)(10)(A)(ii)(XV) and (XVI) of the Social Security Act. WSR 02-07-090, § 388-478-0075, filed 3/19/02, effective 4/1/02. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 74.09.530, and Section 673(2) (42 U.S.C. 9902(2)). WSR 01-18-056, § 388-478-0075, filed 8/30/01, effective 9/30/01*
- *WSR 00-17-085, § 388-478-0075, filed 8/14/00, effective 9/14/00*
- *WSR 99-19-005, § 388-478-0075, filed 9/3/99, effective 10/4/99. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-478-0075, filed 7/31/98, effective 9/1/98. Formerly WAC 388-507-0805, 388-508-0810, 388-509-0910, 388-509-0920, 388-509-0940 and 388-509-0960.*

##### **Wash. Admin. Code § 182-505-0115** Washington apple health—Eligibility for pregnancy and after-pregnancy coverage. {#sec-182-505-0115 omnilex-key=us-wa-regs-official--title-182--182-505-0115}

(1) A pregnant person is eligible for Washington apple health pregnancy coverage if the person:

(a) Meets citizenship or immigration status under WAC 182-503-0535;

(b) Meets Social Security number requirements under WAC 182-503-0115;

(c) Meets Washington state residency requirements under WAC 182-503-0520 and 182-503-0525; and

(d) Has countable income at or below the limit described in:

(i) WAC 182-505-0100 to be eligible for categorically needy (CN) coverage; or

(ii) WAC 182-505-0100 to be eligible for medically needy (MN) coverage. MN coverage begins when the pregnant person meets any required spenddown liability as described in WAC 182-519-0110.

(2) A noncitizen pregnant person who does not meet the requirements in subsection (1)(a) or (b) of this section is eligible for apple health pregnancy coverage if they meet countable income standards for CN or MN coverage as described in subsection (1)(d) of this section.

(3) The assignment of medical support rights as described in WAC 182-503-0540 does not apply to pregnant people.

(4) A person who was eligible for and covered under any CN or MN scope of coverage apple health program on the last day of pregnancy remains continuously eligible for after-pregnancy coverage for 12 months, beginning the month after their pregnancy ends. This includes people who meet an MN spenddown liability with expenses incurred no later than the date the pregnancy ends.

(5) Pregnancy coverage has CN scope of care for all people except those enrolled through the MN program who have MN scope of care. A person's after-pregnancy coverage has the same scope of coverage as their pregnancy coverage.

(6) A person who does not meet the requirements in subsection (4) of this section may qualify for after-pregnancy coverage if they:

(a) Apply for and meet all requirements of the apple health pregnancy coverage program other than pregnancy; and

(b) Apply any time during their 12-month postpartum period to receive ongoing medical coverage until the end of the 12th month after their pregnancy ends.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-12-033, § 182-505-0115, filed 5/24/22, effective 6/24/22. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-505-0115, filed 7/29/14, effective 8/29/14. WSR 12-13-056, recodified as § 182-505-0115, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 42 U.S.C. 9902(2). WSR 05-07-032, § 388-462-0015, filed 3/9/05, effective 4/9/05. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. WSR 02-17-030, § 388-462-0015, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-462-0015, filed 7/31/98, effective 9/1/98. Formerly WAC 388-508-0820, 388-508-0830, 388-522-2230 and 388-508-0835.*

##### **Wash. Admin. Code § 182-505-0117** Washington apple health—Eligibility for pregnant minors. {#sec-182-505-0117 omnilex-key=us-wa-regs-official--title-182--182-505-0117}

(1) For the purposes of this rule, "minor" means a person under the age of 19.

(2) A pregnant minor who meets Washington state residency requirements under WAC 182-503-0520 and 182-503-0525 is eligible for the Washington apple health for kids program.

(3) The medical assistance unit (MAU) of a pregnant minor is the pregnant minor.

(4) There are no income standards and no resource tests for a pregnant minor to be eligible for apple health for kids.

(5) To ensure reimbursement from the U.S. Department of Health and Human Services, every pregnant minor applicant for apple health for kids must provide their Social Security number, unless they are exempt under WAC 182-503-0515, and must provide their citizenship or immigration status. The immigration status of a pregnant minor who is an undocumented alien (see WAC 182-503-0530) will not be disclosed to any third party.

(6) The assignment of rights as described in WAC 182-503-0540 does not apply to pregnant minors.

(7) A pregnant minor covered by the apple health for kids program has a one-year certification period. If a minor has their 19th birthday during their pregnancy, they are automatically enrolled in apple health for pregnancy coverage through the end of the month their pregnancy ends. They are eligible for after-pregnancy coverage for 12 months, beginning the first day of the month after their pregnancy ends.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-12-033, § 182-505-0117, filed 5/24/22, effective 6/24/22. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-21-040, § 182-505-0117, filed 10/7/14, effective 11/7/14.*

##### **Wash. Admin. Code § 182-505-0120** Washington apple health breast and cervical cancer treatment program for women—Client eligibility. {#sec-182-505-0120 omnilex-key=us-wa-regs-official--title-182--182-505-0120}

(1) Effective April 1, 2014, a woman is eligible for categorically needy (CN) coverage under the Washington apple health (WAH) breast and cervical cancer treatment program (BCCTP) only when she:

(a) Has been screened for breast or cervical cancer under the department of health's breast, cervical, and colon health program (BCCHP);

(b) Requires treatment for breast cancer, cervical cancer, or a related precancerous condition;

(c) Is under sixty-five years of age;

(d) Is not eligible for other WAH-CN coverage, including coverage under the MAGI-based adult group;

(e) Is uninsured or does not otherwise have creditable coverage;

(f) Meets residency requirements under WAC 182-503-0520;

(g) Meets Social Security number requirements under WAC 182-503-0515;

(h) Is a U.S. citizen, U.S. national, qualifying American Indian born abroad, or qualified alien under WAC 182-503-0535; and

(i) Meets the income standard set by the BCCHP in DOH form 342-031.

(2) The certification period for breast and cervical cancer treatment covered under this section is twelve months, as provided in WAC 182-504-0015. To remain continuously enrolled, the client must renew her eligibility before the certification period ends. Eligibility for BCCTP coverage under subsection (1)(b) of this section continues throughout the course of treatment as certified by the BCCHP. Retroactive coverage may be available under WAC 182-504-0005.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-17-056, § 182-505-0120, filed 8/14/15, effective 9/14/15. Statutory Authority: RCW 41.05.021, 41.05.160, 2014 c 221. WSR 14-21-075, § 182-505-0120, filed 10/10/14, effective 11/10/14. WSR 12-02-034, recodified as § 182-505-0120, filed 12/29/11, effective 1/1/12. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090. WSR 04-15-057, § 388-462-0020, filed 7/13/04, effective 8/13/04. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 74.09.530, 74.09.510, and Public Law 106-354. WSR 02-01-134, § 388-462-0020, filed 12/19/01, effective 1/19/02.*

##### **Wash. Admin. Code § 182-505-0210** Eligibility for children. {#sec-182-505-0210 omnilex-key=us-wa-regs-official--title-182--182-505-0210}

(1) General eligibility. For purposes of this section, a child must:

(a) Be a Washington state resident under WAC 182-503-0520 and 182-503-0525;

(b) Provide a Social Security number under WAC 182-503-0515, unless exempt; and

(c) Meet program-specific requirements.

(2) Deemed eligibility groups. A child is automatically eligible for coverage without an application if the child meets the program-specific requirements in (a) through (c) of this subsection.

(a) Newborn coverage. A child younger than age one is eligible for categorically needy (CN) coverage if the birth parent was eligible for Washington apple health on the date of delivery:

(i) Including a retroactive eligibility determination; or

(ii) By meeting a medically needy (MN) spenddown liability with expenses incurred by the date of the newborn's birth:

(b) Washington apple health for supplemental security income (SSI) recipients. A child who is eligible for SSI is automatically eligible for CN coverage under WAC 182-510-0001.

(c) Foster care coverage. A child age 20 or younger is eligible for CN coverage under WAC 182-505-0211 when the child is in foster care or receives subsidized adoption services. For children who age out of the foster care program, see WAC 182-505-0211(3).

(3) Continuous eligibility for children under age six. A child is eligible for Washington apple health continuous eligibility for children under age six when they:

(a) Have household income at or below 210 percent of the federal poverty level at the time of application; or

(b) On or after January 8, 2025, have household income greater than 210 percent but equal to or less than 312 percent of the federal poverty level at the time of application; or

(c) Received coverage under subsection (5) of this section and are no longer eligible for deemed coverage under subsection (5)(b) or (c) of this section.

(4) MAGI-based eligibility groups. A child age 18 or younger is eligible for CN coverage based on modified adjusted gross income (MAGI):

(a) At no cost when the child's countable income does not exceed the standard in WAC 182-505-0100 (6)(a);

(b) With payment of a premium when the child's countable income does not exceed the standard in WAC 182-505-0100 (6)(b), and the child meets additional eligibility criteria in WAC 182-505-0215;

(c) Under chapter 182-514 WAC, if the child needs long-term care services because the child resides or is expected to reside in an institution, as defined in WAC 182-500-0050, for 30 days or longer. An institutionalized child is eligible for coverage under the medically needy (MN) program if income exceeds the CN income standard for a person in an institution (special income level);

(d) Under WAC 182-505-0117, if a child is pregnant.

(5) Non-MAGI-based children's programs. The agency determines eligibility for the:

(a) MN program according to WAC 182-519-0100. A child age 18 or younger is eligible if the child:

(i) Is not eligible for MAGI-based coverage under subsection (4) of this section;

(ii) Meets citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and

(iii) Meets any spenddown liability required under WAC 182-519-0110.

(b) SSI-related program. A child age 18 or younger is eligible for CN or MN SSI-related coverage if the child meets:

(i) SSI-related eligibility under chapter 182-512 WAC;

(ii) Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and

(iii) Any MN spenddown liability under WAC 182-519-0110.

(c) SSI-related long-term care program.

(i) A child age 18 or younger is eligible for home and community based (HCB) waiver programs under chapter 182-515 WAC if the child meets:

(A) SSI-related eligibility under chapter 182-512 WAC;

(B) Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and

(C) Program-specific age and functional requirements under chapters 388-106 and 388-845 WAC.

(ii) A child age 18 or younger who resides or is expected to reside in a medical institution as defined in WAC 182-500-0050 is eligible for institutional medical under chapter 182-513 WAC if the child meets:

(A) Citizenship or immigration requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d);

(B) Blindness or disability criteria under WAC 182-512-0050; and

(C) Nursing facility level of care under chapter 388-106 WAC.

(6) Alien emergency medical program. A child age 20 or younger who does not meet the eligibility requirements for a program described under subsections (2) through (5) of this section is eligible for the alien emergency medical (AEM) program if the child meets:

(a) The eligibility requirements of WAC 182-507-0110; and

(b) MN spenddown liability, if any, under WAC 182-519-0110.

(7) Other provisions.

(a) A child residing in an institution for mental disease (IMD) as defined in WAC 182-500-0050 is not eligible for inpatient hospital services, unless the child is unconditionally discharged from the IMD before receiving the services.

(b) A child incarcerated in a public institution as defined in WAC 182-500-0050 is only eligible for:

(i) Inpatient hospital services; and

(ii) Pre- and post-release reentry services.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2024 c 376 s 211(87). WSR 25-12-035, s 182-505-0210, filed 5/28/25, effective 7/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, and 2023 c 475 § 211(36). WSR 23-23-057, § 182-505-0210, filed 11/8/23, effective 12/9/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-12-018, § 182-505-0210, filed 5/30/17, effective 6/30/17*
- *WSR 16-01-034, § 182-505-0210, filed 12/8/15, effective 1/8/16*
- *WSR 15-15-153, § 182-505-0210, filed 7/21/15, effective 8/21/15. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-505-0210, filed 7/29/14, effective 8/29/14. WSR 12-13-056, recodified as § 182-505-0210, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 41.05.021, 74.04.050, 74.04.057, 74.09.500, and PPACA, § 2102 (b)(1)(A) of the Social Security Act, and Public Law 111-3 (CHIPRA). WSR 11-23-077, § 388-505-0210, filed 11/15/11, effective 12/16/11. Statutory Authority: RCW 74.04.050, 74.04.057, and 74.08.090, and Apple Health for Kids Act (ESHB 2128)*
- *42 U.S.C. 1305*
- *Public Law 111-3 (Children's Health Insurance Program Reauthorization Act of 2009). WSR 11-03-001, § 388-505-0210, filed 1/5/11, effective 2/5/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.402, 74.09.470, and 2008 session law. WSR 09-07-086, § 388-505-0210, filed 3/17/09, effective 4/17/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.09.700, and 2007 c 5. WSR 08-05-018, § 388-505-0210, filed 2/12/08, effective 3/14/08. Statutory Authority: RCW 74.08.090, 74.09.530, and 74.09.415. WSR 05-23-013, § 388-505-0210, filed 11/4/05, effective 1/1/06. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090. WSR 04-15-057, § 388-505-0210, filed 7/13/04, effective 8/13/04. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 03-14-107, § 388-505-0210, filed 6/30/03, effective 7/31/03. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. WSR 02-17-030, § 388-505-0210, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.08.090, 74.04.050, [74.04.]055, and [74.04.]057. WSR 01-11-110, § 388-505-0210, filed 5/21/01, effective 6/21/01. Statutory Authority: RCW 74.08.090 and 74.08A.100. WSR 99-17-023, § 388-505-0210, filed 8/10/99, effective 9/10/99. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-505-0210, filed 7/31/98, effective 9/1/98. Formerly WAC 388-509-0905, 388-509-0910 and 388-509-0920.*

##### **Wash. Admin. Code § 182-505-0211** Washington apple health—Foster care. {#sec-182-505-0211 omnilex-key=us-wa-regs-official--title-182--182-505-0211}

(1) A client under the age of 18 is eligible for Washington apple health foster care coverage when they:

(a) Are in foster care, as determined by the department of children, youth, and families (DCYF), under the legal responsibility of the state, or a federally recognized tribe located within the state; and

(b) Meet Washington residency requirements as described in WAC 182-503-0520 or 182-503-0525.

(2) A client age 20 or younger is eligible for coverage when the client meets:

(a) Washington residency requirements as described in WAC 182-503-0520 or 182-503-0525;

(b) Citizenship or immigration status requirements as described in WAC 182-503-0535;

(c) Social Security number requirements as described in WAC 182-503-0515; and

(d) One of the following requirements:

(i) Is in foster care, or is eligible for continued foster care services as determined by DCYF, under the legal responsibility of the state, or a federally recognized tribe located within the state; or

(ii) Receives subsidized adoption services through DCYF; or

(iii) Is enrolled in the unaccompanied refugee minor (URM) program as authorized by the office of refugee and immigrant assistance (ORIA); or

(iv) Is living in a community facility (as defined in WAC 110-700-0005) operated or contracted by DCYF's juvenile rehabilitation.

(3) A client age 18 or older but under age 26 is eligible for Washington apple health coverage when the client:

(a) Was in foster care under the legal responsibility of any state or a federally recognized tribe located within any state:

(i) On the client's 18th birthday; or

(ii) At such higher age as to when the state or tribe extends foster care coverage; and

(b) Meets residency, Social Security number, and citizenship requirements as described in subsection (2) of this section.

(4) A client described in subsections (1) through (3) of this section is not eligible for full-scope coverage if the client is confined to a public institution as defined in WAC 182-500-0050, except:

(a) If the client is under age 21;

(b) Resides in an institution for mental disease (IMD); and

(c) Meets the institutional status requirements in WAC 182-513-1320, 182-514-0250, or 182-514-0260.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 115-271, Sec. 1002. WSR 22-20-049, § 182-505-0211, filed 9/28/22, effective 1/1/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-12-017, § 182-505-0211, filed 5/30/17, effective 6/30/17. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-505-0211, filed 12/9/13, effective 1/9/14.*

##### **Wash. Admin. Code § 182-505-0215** Children's Washington apple health with premiums. {#sec-182-505-0215 omnilex-key=us-wa-regs-official--title-182--182-505-0215}

(1) A child is eligible for Washington apple health with premiums if the child:

(a) Meets the requirements in WAC 182-505-0210(1);

(b) Has countable income below the standard in WAC 182-505-0100 (6)(b); and

(c) Pays the required premium under WAC 182-505-0225, unless the child is exempt under WAC 182-505-0225 (2)(c).

(2) A child is not eligible for Washington apple health with premiums if the child:

(a) Is eligible for no-cost Washington apple health; or

(b) Has creditable health insurance coverage as defined in WAC 182-500-0020.

(3) A child with creditable health insurance coverage may be eligible for Washington apple health with premiums if the child:

(a) Is eligible for either:

(i) Public employees benefits board (PEBB) health insurance coverage based on a family member's employment with a Washington state agency, or a Washington state university, community college, or technical college; or

(ii) School employees benefits board (SEBB) health insurance coverage based on a family member's employment with a Washington school district, charter school, or educational service district; and

(b) Meets the requirements in subsection (1) of this section.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-01-207, § 182-505-0215, filed 12/23/20, effective 1/23/21. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05.050, 41.05.065, 34.05.010, 74.09.500 and 42 C.F.R. 457.310. WSR 19-21-103, § 182-505-0215, filed 10/16/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-12-018, § 182-505-0215, filed 5/30/17, effective 6/30/17. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-505-0215, filed 7/29/14, effective 8/29/14. WSR 12-13-056, recodified as § 182-505-0215, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.402, 74.09.470, and 2008 session law. WSR 09-07-086, § 388-542-0010, filed 3/17/09, effective 4/17/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.09.700, and 2007 c 5. WSR 08-05-018, § 388-542-0010, filed 2/12/08, effective 3/14/08. Statutory Authority: RCW 74.08.090, 74.09.050, and Title XXI of the Social Security Act. WSR 06-15-134, § 388-542-0010, filed 7/19/06, effective 8/19/06. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 74.09.450, and 2004 c 276. WSR 04-16-064, § 388-542-0010, filed 7/30/04, effective 8/30/04.*

##### **Wash. Admin. Code § 182-505-0225** Children's Washington apple health with premiums—Calculation and determination of premium amount. {#sec-182-505-0225 omnilex-key=us-wa-regs-official--title-182--182-505-0225}

(1) For the purposes of this chapter, "premium" means an amount paid for health care coverage under WAC 182-505-0215.

(2) Premium requirement. The Washington apple health premium-based program under WAC 182-505-0215 requires payment of a monthly premium.

(a) The first monthly premium is due in the month following the determination of eligibility.

(b) There is no premium requirement for health care coverage received in the month eligibility is determined or in any prior month.

(c) A child who is American Indian or Alaska native is exempt from the monthly premium requirement.

(3) Monthly premium amount.

(a) The premium amount for the medical assistance unit (MAU) is based on countable income under chapter 182-509 WAC and the number of people in the MAU under chapter 182-506 WAC.

(b) The premium amount is as follows:

(i) If the MAU's countable income exceeds 210 percent of the federal poverty level (FPL) but does not exceed 260 percent of the FPL, the monthly premium for each child is $20.

(ii) If the MAU's countable income exceeds 260 percent of the FPL but does not exceed 312 percent of the FPL, the monthly premium for each child is $30.

(iii) The medicaid agency charges a monthly premium for no more than two children per household.

(iv) Payment of the full premium is required. Partial payments cannot be designated for a specific child or month.

(v) Any third party may pay the premium on behalf of the household. Failure of a third party to pay the premium does not eliminate the obligation of the household to pay past due premiums.

(c) A change that affects the premium amount takes effect the month after the change is reported.

(4) Nonpayment of premiums. The agency writes off past-due premiums after 12 months.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-20-052, s 182-505-0225, filed 9/25/24, effective 10/26/24*
- *WSR 17-12-018, § 182-505-0225, filed 5/30/17, effective 6/30/17. WSR 12-13-056, recodified as § 182-505-0225, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 41.05.021, 74.04.050, 74.04.057, 74.09.500, and PPACA, § 2102 (b)(1)(A) of the Social Security Act, and Public Law 111-3 (CHIPRA). WSR 11-23-077, § 388-505-0211, filed 11/15/11, effective 12/16/11. Statutory Authority: RCW 74.04.050, 74.04.057, and 74.08.090, and Apple Health for Kids Act (ESHB 2128)*
- *42 U.S.C. 1305*
- *Public Law 111-3 (Children's Health Insurance Program Reauthorization Act of 2009). WSR 11-03-001, § 388-505-0211, filed 1/5/11, effective 2/5/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.402, 74.09.470, and 2008 session law. WSR 09-07-086, § 388-505-0211, filed 3/17/09, effective 4/17/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.09.700, and 2007 c 5. WSR 08-05-018, § 388-505-0211, filed 2/12/08, effective 3/14/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 74.09.450, and 2004 c 276. WSR 04-16-064, § 388-505-0211, filed 7/30/04, effective 8/30/04. Statutory Authority: RCW 74.08.090, 74.09.055, 2004 c 276. WSR 04-08-125, § 388-505-0211, filed 4/7/04, effective 5/8/04.*

##### **Wash. Admin. Code § 182-505-0240** Parents and caretaker relatives. {#sec-182-505-0240 omnilex-key=us-wa-regs-official--title-182--182-505-0240}

(1) A person is eligible for Washington apple health categorically needy (CN) coverage when the person:

(a) Is a parent or caretaker relative of a dependent child who meets the criteria described in WAC 182-503-0565(2);

(b) Meets citizenship and immigration status requirements described in WAC 182-503-0535;

(c) Meets general eligibility requirements described in WAC 182-503-0505; and

(d) Has countable income below the standard in WAC 182-505-0100(2).

(2) To be eligible for coverage as a caretaker relative, a person must be related to a dependent child who meets the criteria described in WAC 182-503-0565(2).

(3) A person must cooperate with the state of Washington in the identification, use and collection of medical support from responsible third parties as described in WAC 182-503-0540.

(4) A person who does not cooperate with the requirements in subsection (3) of this section is not eligible for coverage.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-12-018, § 182-505-0240, filed 5/30/17, effective 6/30/17. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-505-0240, filed 7/29/14, effective 8/29/14. WSR 12-13-056, recodified as § 182-505-0240, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.04.050, 74.04.057, and 74.08.090. WSR 11-13-031, § 388-505-0220, filed 6/7/11, effective 7/8/11. Statutory Authority: RCW 74.04.050 and 74.08.090. WSR 08-19-099 and 08-20-014, § 388-505-0220, filed 9/17/08 and 9/18/08, effective 10/18/08 and 10/19/08. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.04.510, and 74.08.090. WSR 08-14-105, § 388-505-0220, filed 6/30/08, effective 8/1/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.530. WSR 05-16-127, § 388-505-0220, filed 8/3/05, effective 9/3/05. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. WSR 02-17-030, § 388-505-0220, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.08.090, 74.04.050, [74.04.]055, and [74.04.]057. WSR 01-11-110, § 388-505-0220, filed 5/21/01, effective 6/21/01*
- *WSR 98-16-044, § 388-505-0220, filed 7/31/98, effective 9/1/98. Formerly WAC 388-507-0740 and 388-522-2210.*

##### **Wash. Admin. Code § 182-505-0250** Washington apple health—MAGI-based adult medical. {#sec-182-505-0250 omnilex-key=us-wa-regs-official--title-182--182-505-0250}

(1) Effective on or after January 1, 2014, a person is eligible for Washington apple health (WAH) modified adjusted gross income (MAGI)-based adult coverage when he or she meets the following requirements:

(a) Is age nineteen or older and under the age of sixty-five;

(b) Is not entitled to, or enrolled in, medicare benefits under Part A or B of Title XVIII of the Social Security Act;

(c) Is not otherwise eligible for and enrolled in mandatory coverage under one of the following programs:

(i) WAH SSI-related categorically needy (CN);

(ii) WAH foster care program; or

(iii) WAH adoption support program;

(d) Meets citizenship and immigration status requirements described in WAC 182-503-0535;

(e) Meets general eligibility requirements described in WAC 182-503-0505; and

(f) Has net countable income that is at or below one hundred thirty-three percent of the federal poverty level for a household of the applicable size.

(2) Parents or caretaker relatives of an eligible dependent child as described in WAC 182-503-0565 are first considered for WAH for families as described in WAC 182-505-0240. A person whose countable income exceeds the standard to qualify for family coverage is considered for coverage under this section.

(3) Persons who are eligible under this section are eligible for WAH alternative benefit plan as defined in WAC 182-500-0010 coverage. A person described in this section is not eligible for medically needy WAH.

(4) Other coverage options for adults not eligible under this section are described in WAC 182-508-0001.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-505-0250, filed 7/29/14, effective 8/29/14.*

##### **Wash. Admin. Code § 182-505-0300** Hospital presumptive eligibility. {#sec-182-505-0300 omnilex-key=us-wa-regs-official--title-182--182-505-0300}

(1) Purpose. The hospital presumptive eligibility (HPE) program provides temporary Washington apple health coverage to HPE-eligible persons who enroll through an HPE-qualified hospital.

(2) HPE-eligible persons. To be HPE-eligible:

(a) A person must:

(i) Be younger than age 65; and

(ii) Meet the eligibility requirements for one or more of the following programs:

(A) Washington apple health for pregnant women (chapter 182-505 WAC);

(B) Washington apple health for kids (chapter 182-505 WAC);

(C) Washington apple health for foster care (chapter 182-505 WAC);

(D) Washington apple health for parents and caretaker relatives (chapter 182-505 WAC);

(E) Washington apple health for adults (chapter 182-505 WAC); or

(F) Family planning only services (chapter 182-532 WAC).

(b) A person must not:

(i) Be an apple health beneficiary;

(ii) Be a supplemental security income beneficiary; or

(iii) Have received HPE coverage within the preceding 24 months.

(3) HPE-qualified hospitals. To be HPE-qualified, a hospital must:

(a) Operate in Washington state;

(b) Submit a signed core provider agreement (CPA) to the agency;

(c) Submit a signed HPE agreement to the agency;

(d) Comply with the terms of the CPA and HPE agreements;

(e) Determine HPE eligibility using only those employees who have successfully completed the agency's HPE training;

(f) Agree to provide HPE-application assistance to anyone who requests it; and

(g) Agree to be listed on the agency's website as an HPE-application assistance provider.

(4) Limitations.

(a) An HPE-qualified hospital must attempt to help the person complete a regular apple health application before filing an HPE application. If the person cannot indicate whether they expect to file a federal tax return or be claimed as a tax dependent, the HPE-qualified hospital may treat the person as a nonfiler under WAC 182-506-0010 (5)(c) for HPE purposes.

(b) HPE coverage begins on the earlier of:

(i) The day the HPE-qualified hospital determines the person is eligible; or

(ii) The day the HPE-qualified hospital provides a covered medical service to the person, but only if the hospital determines the person is eligible and submits the decision to the agency no later than five calendar days after the date of service.

(c) HPE coverage ends on the earlier of:

(i) The last day of the month following the month in which HPE coverage began; or

(ii) The day the agency determines the person is eligible for other apple health coverage.

(d) HPE coverage does not qualify a person for continuous eligibility under WAC 182-504-0015.

(e) If HPE coverage is based on pregnancy, the pregnant person is eligible for HPE coverage only once for that pregnancy.

(f) The HPE program covers only those services included in the programs listed in subsection (2)(e) of this section, except that pregnancy-related services are limited to ambulatory prenatal care.

(g) A child born to a person with HPE coverage is ineligible for apple health under WAC 182-505-0210(2). An HPE-qualified hospital must complete a separate HPE determination for the newborn child.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-11-007, § 182-505-0300, filed 5/4/23, effective 6/4/23*
- *WSR 17-12-018, § 182-505-0300, filed 5/30/17, effective 6/30/17. Statutory Authority: RCW 41.05.021, 41.05.160, Patient Protection and Affordable Care Act established under Public Law 111-148. WSR 15-06-039, § 182-505-0300, filed 2/26/15, effective 3/29/15.*

## **Chapter 182-506** Medical financial responsibility. {#struct-chapter-182-506}

##### **Wash. Admin. Code § 182-506-0010** Medical assistance units for MAGI-based programs. {#sec-182-506-0010 omnilex-key=us-wa-regs-official--title-182--182-506-0010}

This section applies to applicants or recipients whose financial eligibility for Washington apple health coverage is based on modified adjusted gross income methodology under WAC 182-503-0510 and 182-509-0300.

(1) General medical assistance unit (MAU) rules.

(a) The rules in this section describe how the medicaid agency must determine who is in an applicant's or recipient's MAU.

(b) Each person will have an individualized MAU and may have different eligibility results than other people on the same application.

(c) The countable income used to determine a person's eligibility is the sum of the countable income of everyone in the person's MAU.

(2) Rules regardless of tax filing status.

(a) If a married couple resides together, the agency must include both people in each other's MAU regardless of tax filing status.

(b) If a member of the MAU is pregnant, the number of people in the MAU increases by one for each unborn child.

(c) A deceased person does not count in the MAU of other applicants or recipients except in the month the person died.

(3) People residing in an institution under chapter 182-514 WAC. An applicant or recipient is the only person in the MAU if the applicant or recipient:

(a) Has resided in a medical institution, institution for mental diseases (IMD), or inpatient psychiatric facility for thirty consecutive days; or

(b) Based on an assessment by the department of social and health services, is likely to reside in a medical institution, IMD, or inpatient psychiatric facility for thirty consecutive days.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-07-006, § 182-506-0010, filed 3/3/16, effective 4/3/16. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-506-0010, filed 12/9/13, effective 1/9/14. WSR 11-24-018, recodified as § 182-506-0010, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, and 74.09.055 as amended by 2006 c 24. WSR 07-11-044, § 388-408-0055, filed 5/9/07, effective 6/9/07. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.530. WSR 06-04-021, § 388-408-0055, filed 1/23/06, effective 2/23/06. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. WSR 02-17-030, § 388-408-0055, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-408-0055, filed 7/31/98, effective 9/1/98. Formerly WAC 388-506-0610, 388-506-0630 and 388-507-0730.*

##### **Wash. Admin. Code § 182-506-0012** Determining a person's medical assistance unit. {#sec-182-506-0012 omnilex-key=us-wa-regs-official--title-182--182-506-0012}

This section applies to people whose financial eligibility for Washington apple health coverage is based on modified adjusted gross income methodology.

(1) Determining a tax filer's medical assistance unit (MAU).

(a) A tax filer is a person who:

(i) Expects to file a federal income tax return; and

(ii) Does not expect to be claimed as a tax dependent on a federal income tax return.

(b) If the applicant or recipient is a tax filer, the following people constitute the applicant's or recipient's MAU:

(i) The tax filer;

(ii) The tax filer's spouse, if residing with the tax filer; and

(iii) Everyone the tax filer expects to claim as a tax dependent.

(2) Determining a tax dependent's MAU.

(a) A tax dependent is a person who expects to be claimed as a tax dependent on a tax filer's federal income tax return.

(b) If the applicant or recipient is a tax dependent:

(i) The following people constitute the tax dependent's MAU unless the tax dependent meets one of the exceptions in (b)(ii) of this subsection:

(A) The tax dependent;

(B) The tax dependent's spouse, if living with the tax dependent;

(C) The tax filer who claims the tax dependent;

(D) The spouse of the tax filer who claims the tax dependent, if living with the tax filer; and

(E) All tax dependents claimed by the tax filer.

(ii) A tax dependent who meets one of the exceptions below is treated as a nonfiler under subsection (3) of this section:

(A) A tax dependent who is neither the spouse nor the child of the tax filer;

(B) A child under age nineteen who resides with both parents and those parents do not file a joint tax return; or

(C) The tax dependent expects to be claimed by a noncustodial parent.

(3) Determining a nonfiler's MAU.

(a) A nonfiler is a person who does not expect to file a federal income tax return and either:

(i) Does not expect to be claimed as a dependent; or

(ii) Meets one of the exceptions listed in subsection (2)(b)(ii) of this section.

(b) If the applicant or recipient is a nonfiler, the nonfiler and the following people constitute the applicant's or recipient's MAU, but only if residing with the nonfiler:

(i) The nonfiler's spouse;

(ii) The nonfiler's children under age nineteen; and

(iii) If the nonfiler is under age nineteen, the nonfiler's parents and the nonfiler's siblings under age nineteen.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-07-006, § 182-506-0012, filed 3/3/16, effective 4/3/16.*

##### **Wash. Admin. Code § 182-506-0015** Medical assistance units for non-MAGI-based Washington apple health programs. {#sec-182-506-0015 omnilex-key=us-wa-regs-official--title-182--182-506-0015}

This section explains how medical assistance units (MAUs) are constructed for programs not based on modified adjusted gross income (MAGI) methodologies. (MAGI-based programs are described in WAC 182-503-0510.)

(1) An MAU is a person or group of people who must be included together when determining eligibility. MAUs are established based on each person's relationship to other family members and the person's financial responsibility for the other family members. MAUs for non-MAGI-based programs include an applicant and persons financially responsible for the applicant as described in subsection (2) of this section (as limited by subsection (3) of this section).

(2) Financial responsibility applies as follows:

(a) Married persons living together are financially responsible for each other;

(b) Natural, adoptive, or step-parents are financially responsible for their unmarried, minor children living in the same household;

(c) Minor children are financially responsible for only themselves;

(d) Married persons not living together are financially responsible for each other to the extent described in WAC 182-512-0960 and chapters 182-513 and 182-515 WAC when one or both are residing in a medical institution, or one or both are applying for or receiving home and community-based services.

(3) The number of persons in the MAU is increased by one for each verified unborn child for each pregnant person already included in the MAU under this section.

(4) A separate SSI-related MAU is required for:

(a) SSI recipients, except for spouses who both receive SSI;

(b) SSI-related persons, except spouses whose eligibility is determined as a couple in chapters 182-511, 182-512, and 182-513 WAC;

(c) Institutionalized persons;

(d) The purpose of applying medical income and resource standards for an:

(i) SSI-related applicant whose spouse is not relatable to SSI or is not applying for SSI-related medical; and

(ii) Ineligible spouse of an SSI recipient.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-21-037, § 182-506-0015, filed 10/12/20, effective 11/12/20. Statutory Authority: RCW 41.05.021, 41.05.160, Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, and 457*
- *and 45 C.F.R. § 155. WSR 14-20-094, § 182-506-0015, filed 9/29/14, effective 10/30/14. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-506-0015, filed 12/9/13, effective 1/9/14.*

## **Chapter 182-507** Medical assistance programs for noncitizens. {#struct-chapter-182-507}

##### **Wash. Admin. Code § 182-507-0110** Washington apple health—Alien medical programs. {#sec-182-507-0110 omnilex-key=us-wa-regs-official--title-182--182-507-0110}

(1) To qualify for an alien medical program (AMP) a person must:

(a) Be ineligible for federally funded Washington apple health (WAH) programs due to the citizenship/alien status requirements described in WAC 182-503-0535;

(b) Meet the requirements described in WAC 182-507-0115, 182-507-0120, or 182-507-0125; and

(c) Meet all categorical and financial eligibility criteria for one of the following programs, except for the Social Security number or citizenship/alien status requirements:

(i) An SSI-related medical program described in chapters 182-511 and 182-512 WAC;

(ii) A MAGI-based program referred to in WAC 182-503-0510; or

(iii) The breast and cervical cancer treatment program for women described in WAC 182-505-0120; or

(iv) A medical extension described in WAC 182-523-0100.

(2) AMP medically needy (MN) health care coverage is available only for children, pregnant women and persons who meet SSI-related criteria. See WAC 182-519-0100 for MN eligibility and WAC 182-519-0110 for spending down excess income under the MN program.

(3) The agency or its designee does not consider a person's date of arrival in the United States when determining eligibility for AMP.

(4) For non-MAGI-based programs, the agency or its designee does not consider a sponsor's income and resources when determining eligibility for AMP, unless the sponsor makes the income or resources available. Sponsor deeming does not apply to MAGI-based programs.

(5) A person is not eligible for AMP if that person entered the state specifically to obtain medical care.

(6) A person who the agency or its designee determines is eligible for AMP may be eligible for retroactive coverage as described in WAC 182-504-0005.

(7) Once the agency or its designee determines financial and categorical eligibility for AMP, the agency or its designee then determines whether a person meets the requirements described in WAC 182-507-0115, 182-507-0120, or 182-507-0125.

**History**
- *Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-507-0110, filed 2/28/14, effective 3/31/14. Statutory Authority: RCW 41.05.021. WSR 12-24-038, § 182-507-0110, filed 11/29/12, effective 12/30/12. WSR 12-13-056, recodified as § 182-507-0110, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.04.050, 74.08.090, and 2009 c 564 §§ 1109, 201, 209. WSR 10-19-085, § 388-438-0110, filed 9/17/10, effective 10/18/10. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530. WSR 07-07-024, § 388-438-0110, filed 3/9/07, effective 4/9/07*
- *WSR 06-04-047, § 388-438-0110, filed 1/26/06, effective 2/26/06. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090. WSR 04-15-057, § 388-438-0110, filed 7/13/04, effective 8/13/04. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 74.09.530, and Section 1903 (v)(2)(c) of the Social Security Act. WSR 03-24-058, § 388-438-0110, filed 12/1/03, effective 1/1/04. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. WSR 02-17-030, § 388-438-0110, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.08.090 and C.F.R. 436.128, 436.406(c) and 440.255. WSR 01-05-041, § 388-438-0110, filed 2/14/01, effective 3/17/01. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 74.09.530, 42 C.F.R. 435.139 and 42 C.F.R. 440.255. WSR 99-23-082, § 388-438-0110, filed 11/16/99, effective 12/17/99. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-438-0110, filed 7/31/98, effective 9/1/98.*

##### **Wash. Admin. Code § 182-507-0115** Alien emergency medical program (AEM). {#sec-182-507-0115 omnilex-key=us-wa-regs-official--title-182--182-507-0115}

(1) A person nineteen years of age or older who is not pregnant and meets the eligibility criteria under WAC 182-507-0110 is eligible for the alien emergency medical program's scope of covered services described in this section if the person meets (a) and (b) or (c) of this subsection:

(a) The medicaid agency determines that the primary condition requiring treatment meets the definition of an emergency medical condition as defined in WAC 182-500-0030, and the condition is confirmed through review of clinical records; and

(b) The person's qualifying emergency medical condition is treated in one of the following hospital settings:

(i) Inpatient;

(ii) Outpatient surgery;

(iii) Emergency room services, which must include an evaluation and management (E&M) visit by a physician; or

(c) Involuntary Treatment Act (ITA) and voluntary inpatient admissions to a hospital psychiatric setting that are authorized by the agency's inpatient mental health designee (see subsection (5) of this section).

(2) If a person meets the criteria in subsection (1) of this section, the agency will cover and pay for all related medically necessary health care services and professional services provided:

(a) By physicians in their office or in a clinic setting immediately prior to the transfer to the hospital, resulting in a direct admission to the hospital; and

(b) During the specific emergency room visit, outpatient surgery or inpatient admission. These services include, but are not limited to:

(i) Medications;

(ii) Laboratory, X-ray, and other diagnostics and the professional interpretations;

(iii) Medical equipment and supplies;

(iv) Anesthesia, surgical, and recovery services;

(v) Physician consultation, treatment, surgery, or evaluation services;

(vi) Therapy services;

(vii) Emergency medical transportation; and

(viii) Nonemergency ambulance transportation to transfer the person from a hospital to a long term acute care (LTAC) or an inpatient physical medicine and rehabilitation (PM&R) unit, if that admission is prior authorized by the agency or its designee as described in subsection (3) of this section.

(3) The agency will cover admissions to an LTAC facility or an inpatient PM&R unit if:

(a) The original admission to the hospital meets the criteria as described in subsection (1) of this section;

(b) The person is transferred directly to this facility from the hospital; and

(c) The admission is prior authorized according to LTAC and PM&R program rules (see WAC 182-550-2590 for LTAC and WAC 182-550-2561 for PM&R).

(4) The agency does not cover any services, regardless of setting, once the person is discharged from the hospital after being treated for a qualifying emergency medical condition authorized by the agency or its designee under this program. Exception: Pharmacy services, drugs, devices, and drug-related supplies listed in WAC 182-530-2000, prescribed on the same day and associated with the qualifying visit or service (as described in subsection (1) of this section) will be covered for a one-time fill and retrospectively reimbursed according to pharmacy program rules.

(5) Medical necessity of inpatient psychiatric care in the hospital setting must be determined, and any admission must be authorized by the agency's inpatient mental health designee according to the requirements in WAC 182-550-2600.

(6) There is no precertification or prior authorization for eligibility under this program. Eligibility for the AEM program does not have to be established before an individual begins receiving emergency treatment.

(7) Under this program, certification is only valid for the period of time the person is receiving services under the criteria described in subsection (1) of this section. The exception for pharmacy services is also applicable as described in subsection (4) of this section.

(a) For inpatient care, the certification is only for the period of time the person is in the hospital, LTAC, or PM&R facility - The admission date through the discharge date. Upon discharge the person is no longer eligible for coverage.

(b) For an outpatient surgery or emergency room service the certification is only for the date of service. If the person is in the hospital overnight, the certification will be the admission date through the discharge date. Upon release from the hospital, the person is no longer eligible for coverage.

(8) Under this program, any visit or service not meeting the criteria described in subsection (1) of this section is considered not within the scope of service categories as described in WAC 182-501-0060. This includes, but is not limited to:

(a) Hospital services, care, surgeries, or inpatient admissions to treat any condition which is not considered by the agency to be a qualifying emergency medical condition, including but not limited to:

(i) Laboratory X-ray, or other diagnostic procedures;

(ii) Physical, occupational, speech therapy, or audiology services;

(iii) Hospital clinic services; or

(iv) Emergency room visits, surgery, or hospital admissions.

(b) Any services provided during a hospital admission or visit (meeting the criteria described in subsection (1) of this section), which are not related to the treatment of the qualifying emergency medical condition;

(c) Organ transplants, including preevaluations, post operative care, and anti-rejection medication;

(d) Services provided outside the hospital settings described in subsection (1) of this section including, but not limited to:

(i) Office or clinic-based services rendered by a physician, an ARNP, or any other licensed practitioner;

(ii) Prenatal care, except labor and delivery;

(iii) Laboratory, radiology, and any other diagnostic testing;

(iv) School-based services;

(v) Personal care services;

(vi) Physical, respiratory, occupational, and speech therapy services;

(vii) Waiver services;

(viii) Nursing facility services;

(ix) Home health services;

(x) Hospice services;

(xi) Vision services;

(xii) Hearing services;

(xiii) Dental services;

(xiv) Durable and nondurable medical supplies;

(xv) Nonemergency medical transportation;

(xvi) Interpreter services; and

(xvii) Pharmacy services, except as described in subsection (4) of this section.

(9) The services listed in subsection (8) of this section are not within the scope of service categories for this program and therefore the exception to rule process is not available.

(10) Providers must not bill the agency for visits or services that do not meet the qualifying criteria described in this section. The agency will identify and recover payment for claims paid in error.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 12-24-038, § 182-507-0115, filed 11/29/12, effective 12/30/12. WSR 12-13-056, recodified as § 182-507-0115, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.04.050, 74.08.090, and 2009 c 564 §§ 1109, 201, 209. WSR 10-19-085, § 388-438-0115, filed 9/17/10, effective 10/18/10.*

##### **Wash. Admin. Code § 182-507-0120** Alien medical for dialysis and cancer treatment, and treatment of life-threatening benign tumors. {#sec-182-507-0120 omnilex-key=us-wa-regs-official--title-182--182-507-0120}

In addition to the provisions for emergency care described in WAC 182-507-0115, the medicaid agency also considers the conditions in this section as an emergency, as defined in WAC 182-500-0030.

(1) A person nineteen years of age or older who is not pregnant and meets the eligibility criteria under WAC 182-507-0110 may be eligible for the scope of service categories under this program if the condition requires:

(a) Surgery, chemotherapy, and/or radiation therapy to treat cancer or life-threatening benign tumors;

(b) Dialysis to treat acute renal failure or end stage renal disease (ESRD); or

(c) Antirejection medication, if the person has had an organ transplant.

(2) When related to treating the qualifying medical condition, covered services include but are not limited to:

(a) Physician and ARNP services, except when providing a service that is not within the scope of this medical program (as described in subsection (7) of this section);

(b) Inpatient and outpatient hospital care;

(c) Dialysis;

(d) Surgical procedures and care;

(e) Office or clinic based care;

(f) Pharmacy services;

(g) Laboratory, X-ray, or other diagnostic studies;

(h) Oxygen services;

(i) Respiratory and intravenous (IV) therapy;

(j) Anesthesia services;

(k) Hospice services;

(l) Home health services, limited to two visits;

(m) Durable and nondurable medical equipment;

(n) Nonemergency transportation; and

(o) Interpreter services.

(3) All hospice, home health, durable and nondurable medical equipment, oxygen and respiratory, IV therapy, and dialysis for acute renal disease services require prior authorization. Any prior authorization requirements applicable to the other services listed above must also be met according to specific program rules.

(4) To be qualified and eligible for coverage for cancer treatment or treatment of life-threatening benign tumors under this program, the diagnosis must be already established or confirmed. There is no coverage for cancer screening or diagnostics for a workup to establish the presence of cancer or life-threatening benign tumors.

(5) Coverage for dialysis under this program starts the date the person begins dialysis treatment, which includes fistula placement and other required access. There is no coverage for diagnostics or predialysis intervention, such as surgery for fistula placement anticipating the need for dialysis, or any services related to preparing for dialysis.

(6) Certification for eligibility will range between one to twelve months depending on the qualifying condition, the proposed treatment plan, and whether the client is required to meet a spenddown liability.

(7) The following are not within the scope of service categories for this program:

(a) Cancer screening or work-ups to detect or diagnose the presence of cancer or life-threatening benign tumors;

(b) Fistula placement while the person waits to see if dialysis will be required;

(c) Services provided by any health care professional to treat a condition not related to, or medically necessary to, treat the qualifying condition;

(d) Organ transplants, including preevaluations and post operative care;

(e) Health department services;

(f) School-based services;

(g) Personal care services;

(h) Physical, occupational, and speech therapy services;

(i) Audiology services;

(j) Neurodevelopmental services;

(k) Waiver services;

(l) Nursing facility services;

(m) Home health services, more than two visits;

(n) Vision services;

(o) Hearing services;

(p) Dental services, unless prior authorized and directly related to dialysis or cancer treatment;

(q) Mental health services;

(r) Podiatry services;

(s) Substance abuse services; and

(t) Smoking cessation services.

(8) The services listed in subsection (7) of this section are not within the scope of service categories for this program. The exception to rule process is not available.

(9) Providers must not bill the agency for visits or services that do not meet the qualifying criteria described in this section.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-05-008, § 182-507-0120, filed 2/5/15, effective 3/8/15. Statutory Authority: RCW 41.05.021. WSR 12-24-038, § 182-507-0120, filed 11/29/12, effective 12/30/12. WSR 12-13-056, recodified as § 182-507-0120, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.04.050, 74.08.090, and 2009 c 564 §§ 1109, 201, 209. WSR 10-19-085, § 388-438-0120, filed 9/17/10, effective 10/18/10.*

##### **Wash. Admin. Code § 182-507-0125** State-funded long-term care services. {#sec-182-507-0125 omnilex-key=us-wa-regs-official--title-182--182-507-0125}

(1) Caseload limits.

(a) The state-funded long-term care services program is subject to caseload limits determined by legislative funding.

(b) The home and community living administration (HCLA) must preauthorize state-funded long-term care service before payments begin.

(c) HCLA cannot authorize a service, under chapter 388-106 WAC or under chapter 388-825 WAC, if doing so would exceed statutory caseload limits.

(2) Location of services. State-funded long-term care services may be provided in:

(a) The person's own home, defined in WAC 388-106-0010;

(b) An adult family home, defined in WAC 182-513-1100;

(c) An assisted living facility, defined in WAC 182-513-1100;

(d) An enhanced adult residential care facility, defined in WAC 182-513-1100;

(e) An adult residential care facility, defined in WAC 182-513-1100;

(f) A nursing facility, defined in WAC 182-500-0050, but only if nursing facility care is necessary to sustain life; or

(g) A residential habilitation center, defined in WAC 388-835-0010, that is an intermediate care facility for individuals with intellectual disabilities (ICF/IID), defined in WAC 182-500-0050.

(3) Client eligibility. To be eligible for the state-funded long-term care services program, a person must meet all of the following conditions:

(a) General eligibility requirements for medical programs under WAC 182-503-0505, except (c) and (d) of this subsection;

(b)

Reside in one of the locations under subsection (2) of this section;

(c) Attain institutional status under WAC 182-513-1320;

(d) Meet the functional eligibility requirements under WAC 388-106-0355 for nursing facility level of care or under WAC 388-845-0030 for ICF/IID level of care;

(e) Meet the financial eligibility requirements under WAC 182-513-1315;

(f) Not have a penalty period due to a transfer of assets under WAC 182-513-1363;

(g) Not have equity interest in a primary residence more than the amount under WAC 182-513-1350; and

(h) Meet the requirements under chapter 182-516 WAC for annuities owned by the person or the person's spouse.

(4) General limitations.

(a) If a person entered Washington only to obtain medical care, the person is ineligible for state-funded long-term care services.

(b) Disability requirements under WAC 182-512-0050 do not apply to state-funded long-term care services.

(c) The certification period for state-funded long-term care services may not exceed 12 months.

(d) People who qualify for state-funded long-term care services receive categorically needy (CN) medical coverage under WAC 182-501-0060.

(e) A person who is not eligible for the state-funded long-term care services program under CN rules may qualify under medically needy (MN) rules under WAC 182-513-1395.

(f) The agency determines how much a person is required to pay toward the cost of care, using:

(i) WAC 182-513-1380, if the person resides in a nursing facility or residential habilitation center.

(ii) WAC 182-515-1505 or 182-515-1510, if the person resides in one of the locations listed in subsection (2)(a) through (e) of this section.

(5) Current resource, income, PNA, and room and board standards are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-19-051, s 182-507-0125, filed 9/10/25, effective 10/11/25*
- *WSR 24-16-023, § 182-507-0125, filed 7/26/24, effective 8/26/24*
- *WSR 23-04-034, § 182-507-0125, filed 1/25/23, effective 2/25/23. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R § 155. WSR 17-03-116, § 182-507-0125, filed 1/17/17, effective 2/17/17. WSR 12-13-056, recodified as § 182-507-0125, filed 6/15/12, effective 7/1/12. Statutory Authority: 2011 c 5, RCW 74.04.057, 74.08.090, and 74.09.510. WSR 11-19-070, § 388-438-0125, filed 9/15/11, effective 10/16/11. Statutory Authority: RCW 74.04.050, 74.08.090, and 2009 c 564 §§ 1109, 201, 209. WSR 10-19-085, § 388-438-0125, filed 9/17/10, effective 10/18/10.*

##### **Wash. Admin. Code § 182-507-0130** Refugee medical assistance (RMA). {#sec-182-507-0130 omnilex-key=us-wa-regs-official--title-182--182-507-0130}

(1) You are eligible for refugee medical assistance (RMA) if all the following conditions are met. You:

(a) Meet immigration status requirements of WAC 182-507-0135;

(b) Have countable resources below $2,000 on the date of application;

(c) Have countable income equal to or below 200 percent of the federal poverty level (FPL) on the date of application. The following income is not considered when determining eligibility for RMA:

(i) Resettlement cash payments made by a resettlement agency;

(ii) Income of a sponsor is not counted unless the sponsor is also part of your assistance unit; and

(iii) Income received after the date of application.

(d) Provide the name of the resettlement agency which helped bring you to the United States so that the department of social and health services (DSHS) can promptly notify the resettlement agency (or sponsor) about the medical application.

(2) If you receive refugee cash assistance (RCA) you are eligible for RMA if you have countable resources below $2,000 on the date of application and you are not otherwise eligible for another medicaid or children's health care program as described in WAC 182-505-0210. You do not have to apply for or receive RCA in order to qualify for RMA.

(3) You are not eligible to receive RMA if you are:

(a) Already eligible for another medicaid or children's health care program as described in WAC 182-505-0210;

(b) A full-time student in an institution of higher education unless the educational activity is part of a DSHS-approved individual responsibility plan (IRP); or

(c) A nonrefugee spouse of a refugee.

(4) If approved for RMA, the agency or its designee issues an approval letter in both English and your primary language. The agency or its designee also sends a notice every time there are any changes or actions taken which affect your eligibility for RMA.

(5) You may be eligible for RMA coverage of medical expenses incurred during the three months prior to the first day of the month of the application. Eligibility determination will be made according to medicaid rules.

(6) If you are a victim of human trafficking you must provide the following documentation and meet the eligibility requirements in subsections (1) and (2) of this section to be eligible for RMA:

(a) Adults, 18 years of age or older, must provide the original certification letter from the United States Department of Health and Human Services (DHHS). No other documentation is needed. The eligibility period will be determined based on the entry date on your certification letter;

(b) A child victim under the age of 18 does not need to be certified. DHHS issues a special letter for children. Children also have to meet income eligibility requirements;

(c) A family member of a certified victim of human trafficking must have a T-2, T-3, T-4, T-5, or T-6 visa (derivative T-Visas), and the family member must meet eligibility requirements in subsections (1) and (2) of this section.

(7) The entry date for an asylee is the date that asylum status is granted. For example, you entered the United States on December 1, 1999, as a tourist, then applied for asylum on April 1, 2000, interviewed with the asylum office on July 1, 2000, and were granted asylum on September 1, 2000. The date of entry is September 1, 2000, and that is the date used to establish eligibility for RMA.

(8) RMA certification period.

(a) RMA ends on either:

(i) The last day of the eighth month from the month the person entered the United States if they entered the United States on or before September 30, 2021. For example, if they entered the United States on September 30, 2021, they are eligible through April 30, 2022;

(ii) The last day of the 12th month from the month the person entered the United States if they entered the United States on or after October 1, 2021, through May 4, 2025. For example, if they entered the United States on October 25, 2021, they are eligible through September 30, 2022; or

(iii) The last day of the fourth month from the month the person entered the United States if they entered the United States on or after May 5, 2025. For example, if they entered the United States on June 20, 2025, they are eligible through September 30, 2025.

(b) The number of months you may receive RMA benefits could change if the federal Office of Refugee Resettlement changes the eligibility period.

(9) If you are approved for RMA you are continuously eligible through the end of the initial RMA certification period, regardless of an increase in income.

(10) The agency, or its designee, determines eligibility for medicaid and other medical programs for your spouse when the spouse arrives in the United States. If the spouse is not eligible for medicaid due to your countable income, the spouse is still eligible for RMA under subsection (8) of this section.

(11) If you disagree with a decision or action taken on the case by the agency, or its designee, you have the right to request a review of the case action(s) or request an administrative hearing (see chapter 182-526 WAC). The request must be received by the agency, or its designee, within 90 days of the date of the decision or action.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 90 Fed. Reg. 13370 (March 21, 2025). WSR 25-16-101, s 182-507-0130, filed 8/6/25, effective 9/6/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-24-057, s 182-507-0130, filed 11/27/24, effective 12/28/24*
- *WSR 22-21-072, § 182-507-0130, filed 10/13/22, effective 11/13/22*
- *WSR 20-21-008, § 182-507-0130, filed 10/8/20, effective 11/8/20. Statutory Authority: RCW 41.05.021 and 2011 1st sp.s. c 15. WSR 12-19-001, § 182-507-0130, filed 9/5/12, effective 10/6/12. WSR 12-02-034, recodified as § 182-507-0130, filed 12/29/11, effective 1/1/12. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090, 74.08A.320, Pub. L. No. 110-181, National Defense Authorization Act for Fiscal Year 2008, Pub. L. No. 111-08, the Omnibus Appropriations Act of 2009, Division F, Title VI, Section 602*
- *Office of Refugee Resettlement State Letter 09-17 from April 9, 2009*
- *and federal guidance issued on May 15, 2009, by the Food and Nutrition Service, United States Department of Agriculture. WSR 09-21-046, § 388-466-0130, filed 10/14/09, effective 11/4/09. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08A.320, 74.08.090, and Public Law 110-161 Section 525*
- *Public Law 110-181 Section 1244*
- *FNS Admin Notice 08-17*
- *State Letter 04-12 from the Office of Refugee Resettlement. WSR 08-14-116, § 388-466-0130, filed 6/30/08, effective 8/1/08. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057. WSR 04-05-010, § 388-466-0130, filed 2/6/04, effective 3/8/04. Statutory Authority: RCW 74.08.090, 74.08A.320. WSR 00-21-065, § 388-466-0130, filed 10/16/00, effective 11/1/00.*

##### **Wash. Admin. Code § 182-507-0135** Immigration status requirement for refugee medical assistance (RMA). {#sec-182-507-0135 omnilex-key=us-wa-regs-official--title-182--182-507-0135}

(1) An individual is eligible for refugee medical assistance (RMA) if the individual provides documentation issued by the United States Citizenship and Immigration Services (USCIS) to show that the individual is:

(a) Admitted as a refugee under section 207 of the Immigration and Nationalities Act (INA);

(b) Paroled into the United States as a refugee or asylee under section 212 (d)(5) of the INA;

(c) Granted conditional entry under section 203 (a)(7) of the INA;

(d) Granted asylum under section 208 of the INA;

(e) Admitted as an Amerasian immigrant from Vietnam through the orderly departure program, under section 584 of the Foreign Operations Appropriations Act, incorporated in the FY88 continuing resolution P.L. 100-212;

(f) A Cuban-Haitian entrant who was admitted as a public interest parolee under section 212 (d)(5) of the INA;

(g) Certified as a victim of human trafficking by the federal Office of Refugee Resettlement (ORR);

(h) An eligible family member of a victim of human trafficking certified by ORR who has a T-2, T-3, T-4, or T-5 visa;

(i) Admitted as special immigrant from Iraq or Afghanistan under one of the following:

(i) Special immigrant status under section 101 (a)(27) of the INA;

(ii) Special immigrant conditional permanent resident; or

(iii) Parole under section 602 (b)(1) of the Afghan Allies Protection Act of 2009 or section 1059(a) of the National Defense Authorization Act of 2006;

(j) An Afghan granted humanitarian parole between July 31, 2021, and September 30, 2023, their spouse or child, or a parent or guardian of an unaccompanied minor who is granted parole after September 30, 2022, under section 2502 of the Extending Government Funding and Delivering Emergency Assistance Act of 2021; or

(k) A citizen or national of Ukraine (or a person who last habitually resided in Ukraine) who, under section 401 of the Additional Ukraine Supplemental Appropriations Act, 2022 (AUSAA) and the Ukraine Security Supplemental Appropriations Act, 2024 (USSAA), is evaluated as a qualified alien when:

(i) Granted parole into the United States between February 24, 2022, and September 30, 2024; or

(ii) Granted parole into the United States after September 30, 2024, and is:

(A) The spouse or child of a person described in (k)(i) of this subsection; or

(B) The parent, legal guardian, or primary caregiver of a person described in (k)(i) of this subsection who is determined to be an unaccompanied child under section 462 (g)(2) of the Homeland Security Act of 2002 or section 412 (d)(2)(B) of the Immigration and Nationality Act.

(2) A permanent resident alien meets the immigration status requirements for RCA and RMA if the individual was previously in one of the statuses described in subsection (1) of this section.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 118-50. WSR 24-22-006, s 182-507-0135, filed 10/23/24, effective 11/23/24. Statutory Authority: RCW 41.05.021, 41.05.160, and Section 1501, Consolidated Appropriations Act, 2023*
- *P.L. 117-328, div. M, Title V, § 1501. WSR 23-20-043, § 182-507-0135, filed 9/27/23, effective 10/28/23. Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 117-128. WSR 22-20-074, § 182-507-0135, filed 9/30/22, effective 10/31/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-08-002, § 182-507-0135, filed 3/23/22, effective 4/23/22. Statutory Authority: RCW 41.05.021 and 2011 1st sp.s. c 15. WSR 12-19-001, § 182-507-0135, filed 9/5/12, effective 10/6/12.*

## **Chapter 182-508** Classic and state-funded Washington apple health eligibility for adults. {#struct-chapter-182-508}

##### **Wash. Admin. Code § 182-508-0001** Washington apple health—Coverage options for adults not eligible under MAGI methodologies. {#sec-182-508-0001 omnilex-key=us-wa-regs-official--title-182--182-508-0001}

(1) This chapter provides information on eligibility determinations for adults who:

(a) Need a determination of eligibility on the basis of being aged, blind, or disabled;

(b) Need a determination of eligibility based on the need for long-term institutional care or home and community-based services;

(c) Are excluded from coverage under a modified adjusted gross income (MAGI)-based program as referenced in WAC 182-503-0510 on the basis of medicare entitlement;

(d) Are not eligible for health care coverage under chapter 182-505 WAC due to citizenship or immigration requirements; or

(e) Are not eligible for health care coverage under chapter 182-505 WAC due to income which exceeds the applicable standard for coverage.

(2) The agency determines eligibility for Washington apple health (WAH) noninstitutional categorically needy (CN) coverage under chapter 182-512 WAC for an adult who is age 65 or older, or who meets the federal blind or disabled criteria of the federal SSI program, and:

(a) Meets citizenship/immigration, residency, and Social Security number requirements as described in chapter 182-503 WAC; and

(b) Has CN countable income and resources that do not exceed the income and resource standards in WAC 182-512-0010.

(3) The agency determines eligibility for WAH health care for workers with disabilities (HWD) CN coverage for adults who meet the requirements described in WAC 182-511-1050, as follows:

(a) Are age 16 or older;

(b) Meet citizenship/immigration, residency, and Social Security number requirements as described in chapter 182-503 WAC;

(c) Meet the federal disability requirements described in WAC 182-511-1150; and

(d) Are employed full- or part-time (including self-employment) as described in WAC 182-511-1200.

(4) The agency determines eligibility for WAH long-term care CN coverage for adults who meet the institutional status requirements defined in WAC 182-513-1320 under the following rules:

(a) When the person receives coverage under a MAGI-based program and needs long-term care services in an institution, the agency follows rules described in chapter 182-514 WAC;

(b) When the person meets aged, blind, or disabled criteria as defined in WAC 182-512-0050 and needs long-term care services, the agency follows rules described in:

(i) Chapter 182-513 WAC, for an adult who resides in an institution; and

(ii) Chapter 182-515 WAC, for an adult who is determined eligible for WAH home and community-based waiver services.

(5) The agency determines eligibility for WAH noninstitutional CN or medically needy (MN) health care coverage for an adult who resides in an alternate living facility under rules described in WAC 182-513-1205.

(6) The agency determines eligibility for WAH-CN coverage under institutional rules described in chapters 182-513 and 182-515 WAC for an adult who:

(a) Has made a voluntary election of hospice services;

(b) Is not otherwise eligible for noninstitutional CN or MN health care coverage or for whom hospice is not included in the benefit service package available to the person; and

(c) Meets the aged, blind, or disabled criteria described in WAC 182-512-0050.

(7) The agency uses the following rules to determine eligibility for an adult under the WAH-MN program:

(a) Noninstitutional WAH-MN is determined under chapter 182-519 WAC for an adult with countable income that exceeds the applicable CN standard; and

(b) Non-SSI-related institutional WAH-MN long-term care coverage is determined under WAC 182-514-0263 for pregnant people and people age 20 and younger who:

(i) Meet institutional status requirements described in WAC 182-513-1320;

(ii) Do not meet blind or disabled criteria described in WAC 182-512-0050; and

(iii) Have countable income that exceeds the applicable CN standard.

(c) WAH-MN long-term care coverage is determined under WAC 182-513-1395 for an aged, blind, or disabled adult who resides in an institution and has countable income that exceeds the special income level (SIL).

(8) An adult is eligible for WAH-MN coverage when he or she:

(a) Meets citizenship/immigration, residency, and Social Security number requirements as described in WAC 182-503-0505;

(b) Has MN countable income that does not exceed the effective MN income standards in WAC 182-519-0050, or meets the excess income spenddown requirements in WAC 182-519-0110;

(c) Meets the countable resource standards in WAC 182-519-0050; and

(d) Is 65 years of age or older or meets the blind or disabled criteria of the federal SSI program.

(9) WAH-MN coverage is available for an aged, blind, or disabled ineligible spouse of an SSI recipient. See WAC 182-519-0100 for additional information.

(10) An adult who does not meet citizenship or alien status requirements described in WAC 182-503-0535 may be eligible for the WAH alien emergency medical program as described in WAC 182-507-0110.

(11) An adult is eligible for the state-funded medical care services (MCS) program when he or she meets the requirements under WAC 182-508-0005.

(12) A person who is entitled to medicare is eligible for coverage under a medicare savings program or the state-funded buy-in program when he or she meets the requirements described in chapter 182-517 WAC.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 74.09.540. WSR 24-06-051, § 182-508-0001, filed 3/1/24, effective 4/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-11-009, § 182-508-0001, filed 5/4/23, effective 6/4/23. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-21-040, § 182-508-0001, filed 10/7/14, effective 11/7/14. Statutory Authority: RCW 41.05.021, 74.09.035, and 2011 1st sp.s. c 36. WSR 12-19-051, § 182-508-0001, filed 9/13/12, effective 10/14/12.*

##### **Wash. Admin. Code § 182-508-0005** Washington apple health medical care services—Eligibility and scope of coverage. {#sec-182-508-0005 omnilex-key=us-wa-regs-official--title-182--182-508-0005}

(1) A person is eligible for state-funded Washington apple health medical care services (MCS) coverage to the extent of available funds if the person is:

(a) Determined by the department of social and health services to be eligible for benefits under:

(i) The aged, blind, or disabled program as described in WAC 388-400-0060;

(ii) The housing and essential needs referral program as described in WAC 388-400-0070; or

(iii) The survivors of certain crimes (SCC) program, as described in WAC 388-424-0035, which includes victims of human trafficking as described in RCW 74.04.005;

(b) Not eligible for another federally funded categorically needy (CN) (as defined in WAC 182-500-0020) or alternative benefits plan (ABP) (as defined in WAC 182-500-0010) Washington apple health program; and

(c) Not residing in a public institution as defined in WAC 182-500-0050.

(2) If an enrollment cap exists under WAC 182-508-0150, a waiting list of people may be established.

(3) A person's period of eligibility for MCS is the same as the person's period of eligibility for:

(a) The aged, blind, or disabled program as described in WAC 388-449-0150;

(b) The person's incapacity authorization period for the housing and essential needs referral program as described in WAC 388-447-0110; or

(c) The person's period of eligibility for the SCC program as described in WAC 388-424-0035.

(4) The MCS program covers only the medically necessary services defined in WAC 182-501-0060.

(5) The MCS program does not cover medical services received outside the state of Washington unless the medical services are provided in a border city listed in WAC 182-501-0175.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2022 c 297 § 205(22). WSR 23-03-064, § 182-508-0005, filed 1/12/23, effective 2/12/23. Statutory Authority: RCW 41.05.021, 41.05.160, and 2020 c 136. WSR 22-02-034, § 182-508-0005, filed 12/29/21, effective 2/1/22. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-019, § 182-508-0005, filed 7/24/14, effective 8/24/14. Statutory Authority: RCW 41.05.021, 74.09.035, and 2011 1st sp.s. c 36. WSR 12-19-051, § 182-508-0005, filed 9/13/12, effective 10/14/12.*

##### **Wash. Admin. Code § 182-508-0150** Enrollment cap for medical care services (MCS). {#sec-182-508-0150 omnilex-key=us-wa-regs-official--title-182--182-508-0150}

(1) Enrollment in medical care services (MCS) coverage is subject to available funds.

(2) The medicaid agency may limit enrollment into MCS coverage by implementing an enrollment cap and waitlist.

(3) If a person is denied MCS coverage due to an enrollment cap:

(a) The person is added to the MCS waitlist based on the date the person applied.

(b) Applicants with the oldest application date will be the first to receive an opportunity for enrollment when MCS coverage is available as long as the person remains on the MCS waitlist.

(4) A person is exempted from the enrollment cap and waitlist rules when:

(a) MCS was terminated due to agency error;

(b) The person is in the 30-day reconsideration period for incapacity reviews under WAC 388-447-0110(4);

(c) The person is being terminated from a categorically needy (CN) medical program and was receiving and eligible for CN coverage prior to the date a waitlist was implemented and at the time their CN coverage ended, the person met eligibility criteria to receive benefits under either the aged, blind, or disabled program as described in WAC 388-400-0060 or the housing and essential needs referral program as described in WAC 388-400-0070; or

(d) The person applied for a determination by the department of social and health services (DSHS) to be eligible for benefits under one of the following programs, but the determination was not completed before the enrollment cap effective date:

(i) The aged, blind, or disabled program as described in WAC 388-400-0060;

(ii) The housing and essential needs referral program as described in WAC 388-400-0070; or

(iii) The survivors of certain crimes (SCC) program, as described in WAC 388-424-0035, which includes victims of human trafficking as described in RCW 74.04.005.

(5) The person is removed from the MCS waitlist if the person:

(a) Is not a Washington resident;

(b) Is deceased;

(c) Requests removal from the waitlist;

(d) Is found eligible for categorically or medically needy coverage; or

(e) Is no longer determined by DSHS to be eligible for benefits under:

(i) The aged, blind, or disabled program as described in WAC 388-400-0060;

(ii) The housing and essential needs referral program as described in WAC 388-400-0070; or

(iii) The SCC program as described in WAC 388-424-0035.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2020 c 136. WSR 22-02-034, § 182-508-0150, filed 12/29/21, effective 2/1/22. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-019, § 182-508-0150, filed 7/24/14, effective 8/24/14. Statutory Authority: RCW 41.05.021, 74.09.035, and 2011 1st sp.s. c 36. WSR 12-19-051, § 182-508-0150, filed 9/13/12, effective 10/14/12.*

##### **Wash. Admin. Code § 182-508-0200** Civil transition program (CTP)—Overview. {#sec-182-508-0200 omnilex-key=us-wa-regs-official--title-182--182-508-0200}

(1) The civil transition program (CTP) is a state-funded, fee-for-service program that requires the department of social and health services (department) to provide wraparound services and supports in community-based settings, which may include residential supports, to persons who have been found not competent to stand trial due to an intellectual or developmental disability, dementia, or traumatic brain injury. This apple health program is for persons who are not eligible for any other federal or state-funded medical coverage.

(2) Definitions. The following definitions and those found in chapter 388-106 WAC apply to this section unless otherwise stated.

"Participation" has the same meaning given in WAC 182-513-1100.

"Room and board" has the same meaning given in WAC 182-513-1100.

"Wraparound services" means coordination of services between the individual and service providers.

(3) General eligibility. Effective December 1, 2023, a person is eligible for the CTP when the person:

(a) Has been referred to the home and community services (HCS) division or the developmental disabilities community services (DDCS) division by the behavioral health and habilitation administration and found not competent to stand trial due to dementia, traumatic brain injury, or an intellectual or developmental disability as described in WAC 388-106-2005;

(b) Applies for apple health coverage as described in WAC 182-503-0005; and

(c) Is not eligible for other federal or state-funded medical coverage.

(4) HCS long-term services and supports (LTSS) for persons 18 years and older are governed by chapter 388-106 WAC when LTSS services are authorized by the department.

(5) DDCS services are governed by chapter 388-825 WAC.

(6) Client participation.

(a) A person who is not otherwise eligible for a noninstitutional medical program must have client participation and room and board. Home and community-based services waiver eligibility and cost of care calculations are under:

(i) WAC 182-515-1508 and 182-515-1509 for HCS services; and

(ii) WAC 182-515-1513 and 182-515-1514 for DDCS services.

(b) Changes in income or deductions may affect the amount a person pays toward LTSS including room and board in an alternate living facility based on chapter 182-515 WAC.

(7) Effective dates.

(a) Eligibility for the CTP begins on the date the person:

(i) Does not meet financial or functional eligibility for LTSS that is covered under another apple health coverage group; or

(ii) Meets the criteria described in WAC 388-106-2000 through 388-106-2040.

(b) Eligibility for the CTP ends the earlier of:

(i) When the person moves out-of-state;

(ii) When the person dies;

(iii) The date the person becomes eligible for federal or state-funded medical coverage;

(iv) Six months after the start date of the first CTP-eligible service; or

(v) When CTP services end.

(c) CTP effective dates are subject to WAC 182-504-0120 and 388-106-2030.

(8) Administrative hearings. A person who disagrees with an agency or the agency's designee action under this section may request an administrative hearing under chapter 182-526 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-508-0200, filed 11/4/25, effective 12/5/25. Statutory Authority: RCW 41.05.021, 41.05.160, and 10.77.202. WSR 24-14-060, § 182-508-0200, filed 6/27/24, effective 7/28/24.*

## **Chapter 182-509** Income and resources. {#struct-chapter-182-509}

##### **Wash. Admin. Code § 182-509-0001** Countable income for Washington apple health programs. {#sec-182-509-0001 omnilex-key=us-wa-regs-official--title-182--182-509-0001}

(1) For purposes of Washington apple health program eligibility, a person's countable income is income which remains when:

(a) The income cannot be specifically excluded; and

(b) All appropriate deductions and disregards allowed by a specific program have been applied.

(2) A person's countable income may not exceed the income standard for the specific Washington apple health program, unless the program allows for those limits to be exceeded. Specific program standards are described below:

(a) For modified adjusted gross income (MAGI)-based programs described in WAC 182-503-0510, see WAC 182-505-0100 for the applicable program standard based on a percentage of the federal poverty level (FPL);

(b) For Washington apple health SSI-related CN coverage, see WAC 182-512-0010;

(c) For Washington apple health MN coverage, see WAC 182-519-0050;

(d) For Washington apple health medicare savings programs, see WAC 182-517-0100;

(e) For Washington apple health noninstitutional medical in an alternative living facility, see WAC 182-513-1205; and

(f) For Washington apple health long-term care programs, see WAC 182-513-1315 and 182-513-1395.

(3) For the MAGI-based programs listed below, the agency or its designee determines eligibility based on the countable MAGI income of the members of the person's medical assistance unit as determined per WAC 182-506-0010:

(a) Washington apple health for parents and caretaker relatives program as described in WAC 182-505-0240;

(b) Washington apple health pregnancy program as described in WAC 182-505-0115;

(c) Washington apple health for kids programs as described in WAC 182-505-0210 with the following exceptions:

(i) Newborn children born to a person who is eligible for Washington apple health on the date of the newborn's birth, including a retroactive eligibility determination;

(ii) Children who are receiving SSI;

(iii) Children who are in foster care or receiving subsidized adoption services.

(d) Washington apple health MAGI-based adult medical as described in WAC 182-505-0250; and

(e) Washington apple health MAGI-based alien emergency medical as described in WAC 182-507-0110.

(4) For the following SSI-related Washington apple health programs, unless the state has adopted more liberal rules, income rules for the SSI program are used to determine a person's countable income:

(a) Washington apple health noninstitutional SSI-related CN or medically needy (MN) coverage described in chapters 182-511 and 182-512 WAC;

(b) Washington apple health institutional SSI-related CN or MN long-term care or hospice coverage described in chapters 182-513 and 182-515 WAC;

(c) Washington apple health alien emergency medical programs based on age 65 or older or disability described in chapter 182-507 WAC; and

(d) Washington apple health medicare savings programs described in chapter 182-517 WAC.

(5) Anticipated nonrecurring lump sum payments received by an applicant or recipient of a Washington apple health SSI-related medical program are counted as income in the month of receipt, subject to reporting requirements, with the exception of retroactive supplemental security income (SSI)/Social Security disability lump sum payments. See WAC 182-512-0300(4) and 182-512-0700 for more information.

(6) Countable income for the Washington apple health refugee medical (RMA) program and Washington apple health MN program for pregnant people and children is determined as follows:

(a) The agency or its designee allows the following deductions from a household's gross earnings:

(i) The first $500 of earnings and 50 percent of the remaining earnings;

(ii) Actual work-related child and dependent care expenses, which are the person's responsibility; and

(iii) Court or administratively ordered current or back support paid to meet the needs of legal dependents.

(b) Only income actually contributed to a person from the person's sponsor is countable unless the sponsor signs the affidavit of support I-864 or I-864A.

(c) Nonrecurring lump sum payments are counted as income in the month of receipt and as a resource if the person retains the payment after the month of receipt (resource limits do not apply to MN coverage for pregnant people and children). For RMA, nonrecurring lump sum payments are counted as income if received in the month of application and not considered if received thereafter per WAC 182-507-0130.

(7) Countable income rules for other Washington apple health programs that are not MAGI-based or SSI-related are described in the specific program rules listed in WAC 182-503-0510 (3)(c).

(8) Some Washington apple health programs are not based on a person's or household's countable income but are based on a specific status or entitlement in federal rule. The rules for these deemed eligible Washington apple health programs are described in WAC 182-503-0510(4).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-24-057, s 182-509-0001, filed 11/27/24, effective 12/28/24*
- *WSR 23-11-009, § 182-509-0001, filed 5/4/23, effective 6/4/23. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-509-0001, filed 12/9/13, effective 1/9/14. WSR 11-23-091, recodified as § 182-509-0001, filed 11/17/11, effective 11/21/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.09.700, and 2007 c 5. WSR 08-05-018, § 388-450-0210, filed 2/12/08, effective 3/14/08. Statutory Authority: RCW 74.08.090, 74.09.530, and 74.09.415. WSR 05-23-013, § 388-450-0210, filed 11/4/05, effective 1/1/06. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. WSR 02-17-030, § 388-450-0210, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.08.090, 74.08A.100, and Title XIX State Plan amendment 00-008. WSR 02-03-009, § 388-450-0210, filed 1/4/02, effective 2/4/02. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-450-0210, filed 7/31/98, effective 9/1/98. Formerly WAC 388-505-0580, 388-505-0590 and 388-519-1910.*

##### **Wash. Admin. Code § 182-509-0220** Washington apple health—How resources are considered. {#sec-182-509-0220 omnilex-key=us-wa-regs-official--title-182--182-509-0220}

(1) A resource is any cash, other personal property, or real property that a person:

(a) Owns;

(b) Has the right, authority, or power to convert to cash (if not already cash); and

(c) Has the legal right to use for his or her support and maintenance.

(2) There is no resource limit for an applicant or recipient of the following Washington apple health (medicaid) programs:

(a) Apple health for workers with disabilities (HWD) program, as described in chapter 182-511 WAC;

(b) Apple health foster care program (see WAC 182-505-0211);

(c) Medicare savings programs (see WAC 182-517-0100);

(d) All programs that are based on modified adjusted gross income (MAGI) methodologies, as described in WAC 182-503-0510. This includes the following:

(i) Apple health for parents and caretaker relatives (see WAC 182-505-0240);

(ii) Apple health pregnancy coverage (see WAC 182-505-0115);

(iii) Apple health for kids (see WAC 182-505-0210);

(iv) Premium-based apple health for kids (see WAC 182-505-0215);

(v) Apple health long-term care for children and adults (see WAC 182-514-0230);

(vi) Apple health for MAGI-based adult coverage (see WAC 182-505-0250); and

(vii) Apple health MAGI-based adult alien emergency medical (see WAC 182-507-0110).

(3) For all other apple health programs, the resource limits and exclusions can be found in the following chapters:

(a) Apple health SSI-related medical (see chapter 182-512 WAC) with the exception of programs listed in subsection (2) of this section;

(b) Apple health long-term care (see chapters 182-513 and 182-515 WAC);

(c) SSI-related apple health alien medical program (see chapter 182-507 WAC);

(d) Apple health for refugees (see WAC 182-507-0130); and

(e) Medical care services (see WAC 182-508-0005).

(4) The agency or its designee determines how trusts, annuities and life estates affect eligibility for apple health coverage for the programs listed in subsection (3)(a) through (e) of this section by following the rules described in chapter 182-516 WAC.

(5) Receipt of money by a member of a federally recognized tribe from exercising federally protected rights or extraction of protected resources, such as fishing, shell-fishing, or selling timber, is considered conversion of an exempt resource during the month of receipt. Any amounts remaining from the conversion of this exempt resource on the first of the month after the month of receipt will remain exempt if the funds were used to purchase another exempt resource. Any amounts remaining in the form of countable resources (such as in checking or savings accounts) on the first of the month after receipt, will be added to other countable resources for eligibility determinations when a resource determination is required by the specific apple health program. If no resource determination is required by the specific apple health program, eligibility is not affected.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-03-050, § 182-509-0220, filed 1/10/24, effective 2/10/24. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-509-0220, filed 12/9/13, effective 1/9/14.*

##### **Wash. Admin. Code § 182-509-0300** Modified adjusted gross income (MAGI). {#sec-182-509-0300 omnilex-key=us-wa-regs-official--title-182--182-509-0300}

(1) The agency uses the modified adjusted gross income (MAGI) methodology to determine eligibility for MAGI-based Washington apple health programs described in WAC 182-509-0305.

(2) MAGI methodology is described in WAC 182-509-0300 through 182-509-0375. Generally, MAGI includes adjusted gross income (as determined by the Internal Revenue Code (IRC)) increased by:

(a) Any amount of foreign income excluded from gross income under Section 911 of the IRC;

(b) Any amount of interest received or accrued by the taxpayer during the taxable year which is exempt from tax; and

(c) Any amount of Title II Social Security income or Tier 1 Railroad Retirement income which is excluded from gross income under Section 86 of the IRC.

(3) When calculating a person's eligibility for the programs listed in WAC 182-509-0305, the agency uses the person's MAGI income with the following exceptions:

(a) Scholarships or fellowship grants described in WAC 182-509-0335 used for education purposes are excluded from income;

(b) Income received by American Indian/Alaskan Native individuals described in WAC 182-509-0340 is excluded from income;

(c) Any income received as a lump sum as described in WAC 182-509-0375 is counted as income only in the month in which it is received; and

(d) Income received by a child age 18 or younger or a tax dependent as described in WAC 182-509-0360 is excluded from income.

(4) Countable MAGI income is reduced by an amount equal to five percentage points of the federal poverty level (FPL) based on household size to determine net income except that there is no such reduction of countable MAGI income for parents or caretaker relatives with an eligible dependent child (as described in WAC 182-509-0305(1)). Net income is compared to the applicable standard described in WAC 182-505-0100.

(5) When calculating a person's eligibility for MAGI-based programs listed in WAC 182-509-0305, the agency determines the medical assistance unit for each person according to WAC 182-506-0010 and 182-506-0012.

(6) When calculating a person's eligibility for the community behavioral health support services (CBHS) benefit described in chapter 182-561 WAC, the agency disregards or deducts the amount of the person's income over 150 percent of the FPL.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-10-083, § 182-509-0300, filed 4/30/24, effective 7/1/24*
- *WSR 20-17-136, § 182-509-0300, filed 8/18/20, effective 9/18/20. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-21-040, § 182-509-0300, filed 10/7/14, effective 11/7/14. Statutory Authority: RCW 41.05.021, P.L. 111-148, 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-509-0300, filed 12/9/13, effective 1/9/14.*

##### **Wash. Admin. Code § 182-509-0305** MAGI income—Persons subject to the modified adjusted gross income (MAGI) methodology. {#sec-182-509-0305 omnilex-key=us-wa-regs-official--title-182--182-509-0305}

(1) Eligibility for Washington apple health for the following people is determined using the modified adjusted gross income (MAGI) methodology described in WAC 182-509-0300:

(a) Parents or caretaker relatives with an eligible dependent child (described in WAC 182-503-0565) whose net countable income is below 54 percent of the federal poverty level (FPL) as described in WAC 182-505-0240.

(b) Parents or caretaker relatives with an eligible dependent child whose net countable income exceeds the standard described in (a) of this subsection but is at or below 133 percent FPL as described in WAC 182-505-0250 and 182-507-0110.

(c) Adults with no eligible dependent child with net countable income at or below 133 percent FPL as described in WAC 182-505-0250 and 182-507-0110.

(d) Pregnant people whose net countable income, based on a household size that includes any unborn children, is equal to or below 210 percent FPL at the time of application, as described in WAC 182-505-0115.

(e) People within the 12-month postpartum period beginning the month after the pregnancy ends whose net countable income is equal to or below 210 percent FPL at the time of application, as described in WAC 182-505-0115.

(f) Children age 18 or younger in households with net countable income which is equal to or below 210 percent FPL, as described in WAC 182-505-0210.

(g) Children age 18 or younger in households with net countable income that is greater than 210 percent but equal to or below 312 percent FPL, as described in WAC 182-505-0215. Children who are eligible under this section are subject to premiums as described in WAC 182-505-0225.

(h) People age 18 and older who have income over 150 percent FPL who are financially and functionally eligible to receive the community behavioral health support services (CBHS) benefit, as described in chapter 182-561 WAC.

(2) Household size for a person who is subject to MAGI income methodologies is determined according to WAC 182-506-0010.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 74.09.830, and 74.09.839. WSR 24-19-037, s 182-509-0305, filed 9/11/24, effective 11/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-10-083, § 182-509-0305, filed 4/30/24, effective 7/1/24*
- *WSR 22-12-033, § 182-509-0305, filed 5/24/22, effective 6/24/22. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-509-0305, filed 12/9/13, effective 1/9/14.*

##### **Wash. Admin. Code § 182-509-0310** MAGI income—Timing of income. {#sec-182-509-0310 omnilex-key=us-wa-regs-official--title-182--182-509-0310}

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (WAH) (see WAC 182-509-0300):

(1) The agency uses a point-in-time estimate to determine a person's countable income.

(2) Point-in-time means that the income is received, or is likely to be received, in the month in which the person submits an application or renewal for WAH, or the month in which the agency completes a redetermination of coverage, with the following provisions:

(a) When a person is paid less frequently than on a monthly basis, (for example, they are self-employed), the agency uses an average to calculate the monthly amount. The average is calculated by:

(i) Adding the total income for representative period of time;

(ii) Dividing by the number of months in the time frame; and

(iii) Using the result as a monthly average.

(b) When a person is paid more frequently than on a monthly basis, the agency uses the following budgeting method to calculate a monthly amount:

(i) If the person is paid weekly, the agency multiplies weekly expected income by 4.3;

(ii) If the person is paid every other week, the agency multiplies expected income by 2.15.

(c) If the person's current income does not represent his or her projected income as evidenced by clear indications of future changes in income, the agency permits the person to estimate a monthly amount by averaging income over a representative period of time.

(3) If the person normally gets the income:

(a) On a specific day, the agency counts it as available on that date.

(b) Monthly or twice monthly and pay dates change due to a reason beyond the person's control, such as a weekend or holiday, it is counted in the month it would normally be received.

(c) Weekly or every other week and pay dates change due to a reason beyond the person's control, it is counted in the month it would normally be received.

(4) For information about how income is verified, see WAC 182-503-0050.

(5) If the person reports a change in income as required under WAC 182-504-0105 and the change is expected to last for two months or longer, the agency updates the estimate of income based on this change, unless the person receives categorically needy WAH coverage as a pregnant woman or child.

**History**
- *Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-509-0310, filed 12/9/13, effective 1/9/14.*

##### **Wash. Admin. Code § 182-509-0315** MAGI income—Ownership of income. {#sec-182-509-0315 omnilex-key=us-wa-regs-official--title-182--182-509-0315}

(1) For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (WAH) (see WAC 182-509-0300) income is considered available to a person if:

(a) An individual in the person's medical assistance unit receives or can reasonably predict that he or she will receive the income.

(b) The income must be counted based on rules under chapter 182-509 WAC.

(c) The person has control over the income, which means the income is available to them. If the person has a representative payee, protective payee, or other individual who manages the income on the person's behalf, it is considered as if the person has control over this income.

(d) The person can use the income to meet current needs.

(2) Income that is included in the person's taxable gross income which is required to be reported to the Internal Revenue Service (IRS) is considered as available even if it is paid to someone else or withheld to pay a garnishment, lien or other obligation. (For example, a person manages a block of apartments and lives in one of the apartments. The employer withholds a portion of the person's monthly wages as rent due for the apartment in which he resides. The income that is counted is the gross amount prior to the deduction for rent.)

(3) The agency may conduct post-eligibility reviews of health care applications as described in WAC 182-503-0050. Upon request by the agency, a person must provide proof about a type of income, including submitting clarification on:

(a) Who owns the income;

(b) Who has legal control of the income;

(c) The amount of the income; or

(d) If the income is available.

**History**
- *Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-509-0315, filed 12/9/13, effective 1/9/14.*

##### **Wash. Admin. Code § 182-509-0320** MAGI income—Noncountable income. {#sec-182-509-0320 omnilex-key=us-wa-regs-official--title-182--182-509-0320}

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (see WAC 182-509-0300):

(1) Some types of income are not counted when determining eligibility for MAGI-based apple health. Under the MAGI income methodology described in WAC 182-509-0300, income is not counted if the Internal Revenue Service (IRS) permits it to be excluded or deducted for purposes of determining the tax liability of a person. (See 26 U.S.C. Sections 62(a) and 101-140.)

(2) Examples of income that are not counted include, but are not limited to:

(a) Bona fide loans, except certain student loans as specified under WAC 182-509-0335;

(b) Federal income tax refunds and earned income tax credit payments for up to 12 months from the date received;

(c) Child support payments received by any person included in household size under WAC 182-506-0010;

(d) Nontaxable time loss benefits or other compensation received for sickness or injury, such as benefits from the department of labor and industries (L&I) or a private insurance company;

(e) Title IV-E and state foster care and adoption support maintenance payments;

(f) Veteran's benefits including, but not limited to, disability compensation and pension payments for disabilities paid to the veteran or family members; education, training and subsistence; benefits under a dependent-care assistance program for veterans, housebound allowance and aid and attendance benefits;

(g) Money withheld from a benefit to repay an overpayment from the same income source;

(h) One-time payments issued under the Department of State or Department of Justice reception and replacement programs, such as Voluntary Agency (VOLAG) payments;

(i) Nontaxable income from employment and training programs;

(j) Any portion of income used to repay the cost of obtaining that income source;

(k) Insurance proceeds or other income received as a result of being a Holocaust survivor;

(l) Federal economic stimulus payments that are excluded for federal and federally assisted state programs;

(m) Income from a sponsor given to a sponsored immigrant;

(n) Fringe benefits provided on a pretax basis by an employer, such as transportation benefits or moving expenses;

(o) Employer contributions to certain pretax benefits funded by an employee's elective salary reduction, such as amounts for a flexible spending account;

(p) Distribution of pension payments paid by the employee (such as premiums or contributions) that were previously subject to tax;

(q) Gifts as described in IRS Publication 559: Survivors, Executors, and Administrators;

(r) Cash or noncash inheritances, except that the agency counts income produced by an inheritance;

(s) Death benefits from life insurance and certain benefits paid for deaths that occur in the line of duty;

(t) Working families' tax credit payments under RCW 82.08.0206; and

(u) Other payments that are excluded from income under state or federal law.

(3) Income received from other agencies or organizations as needs-based assistance is not countable income under this section.

(a) "Needs-based" means eligibility for the program is based on having limited income, or resources, or both. Examples of needs-based assistance are:

(i) Clothing;

(ii) Food;

(iii) Household supplies;

(iv) Medical supplies (nonprescription);

(v) Personal care items;

(vi) Shelter;

(vii) Transportation; and

(viii) Utilities (e.g., lights, cooking fuel, the cost of heating or heating fuel).

(b) Needs-based cash programs include, but are not limited to, the following apple health programs:

(i) Diversion cash assistance (DCA);

(ii) Temporary assistance for needy families (TANF);

(iii) State family assistance (SFA);

(iv) Pregnant women's assistance (PWA);

(v) Refugee cash assistance (RCA);

(vi) Aged, blind, disabled cash assistance (ABD); and

(vii) Supplemental security income (SSI).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-076, § 182-509-0320, filed 6/29/23, effective 7/30/23*
- *WSR 20-17-136, § 182-509-0320, filed 8/18/20, effective 9/18/20. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-509-0320, filed 12/9/13, effective 1/9/14.*

##### **Wash. Admin. Code § 182-509-0325** MAGI income—Unearned income. {#sec-182-509-0325 omnilex-key=us-wa-regs-official--title-182--182-509-0325}

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (WAH) (see WAC 182-509-0300):

(1) Unearned income is income received from a source other than employment or self-employment. Examples of unearned income include, but are not limited to:

(a) Tier 1 Railroad Retirement;

(b) Unemployment compensation, except as described in WAC 182-509-0320;

(c) Title II Social Security benefits (including retirement benefits, disability benefits, and benefits for survivors);

(d) Rental income;

(e) Pensions, IRAs, military retirement and annuity payments, except as described in WAC 182-509-0320;

(f) Dividend payments from stocks or shares held in companies; and

(g) Per capita distributions from gaming made by a tribe (see WAC 182-509-0340).

(2) When the unearned income must be counted, the agency counts the gross amount before any taxes or premiums are taken out.

(3) See WAC 182-509-0320 for examples of unearned income that are not counted.

**History**
- *Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-509-0325, filed 12/9/13, effective 1/9/14.*

##### **Wash. Admin. Code § 182-509-0330** MAGI income—Earned income. {#sec-182-509-0330 omnilex-key=us-wa-regs-official--title-182--182-509-0330}

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (WAH) (see WAC 182-509-0300):

(1) Earned income is income received from working. This includes, but is not limited to:

(a) Wages;

(b) Salaries;

(c) Tips;

(d) Commissions;

(e) Profits from self-employment activities as described in WAC 182-509-0365; and

(f) One-time payments for work done over a period of time, if the income is received in the month of application.

(2) When earned income must be counted, the agency computes the countable amount based on deductions from income allowed by the Internal Revenue Service when determining a person's tax liability.

(3) See WAC 182-509-0370 for information on how self-employment income is counted.

**History**
- *Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-509-0330, filed 12/9/13, effective 1/9/14.*

##### **Wash. Admin. Code § 182-509-0335** MAGI income—Educational benefits. {#sec-182-509-0335 omnilex-key=us-wa-regs-official--title-182--182-509-0335}

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (see WAC 182-509-0300), the agency or its designee does not count educational benefits as income when they are used for education expenses, unless the educational benefits are used for living expenses. Examples include, but are not limited to:

(1) Educational assistance in the form of grants or loans issued under Title IV of the Higher Education Amendments (Title IV - HEA) or through a program administered by the Department of Education (DOE), such as:

(a) Pell grants (Title IV);

(b) Stafford loans (Title IV);

(c) Perkins loan program (Title IV);

(d) State need grant program (Title IV);

(e) Training programs administered by the Department of Education (DOE).

(2) Payments received for education, training, or subsistence under any law administered by the department of Veteran's Affairs (VA).

(3) Student financial assistance provided under the Bureau of Indian Affairs education programs.

(4) Educational assistance in the form of grants or loans under the Carl D. Perkins Vocational and Applied Technology Education Act, P.L. 101-392.

(5) Work study income including:

(a) Federal or state work study income; and

(b) WorkFirst work study income.

(6) Payments to service academy cadets at a military academy.

(7) Payments for the purposes of tuition made on behalf of the individual to an educational organization for the education or training of such individual.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-17-136, § 182-509-0335, filed 8/18/20, effective 9/18/20. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-509-0335, filed 12/9/13, effective 1/9/14.*

##### **Wash. Admin. Code § 182-509-0340** MAGI income—American Indian/Alaska Native excluded income. {#sec-182-509-0340 omnilex-key=us-wa-regs-official--title-182--182-509-0340}

For the purposes of determining eligibility of American Indians/Alaska Natives for modified adjusted gross income (MAGI)-based Washington apple health (WAH) (see WAC 182-509-0300), the agency excludes from MAGI the following:

(1) Distributions from Alaska Native corporations and settlement trusts;

(2) Distributions from any property held in trust, subject to federal restrictions, located within the most recent boundaries of a prior federal reservation, or otherwise under the supervision of the Secretary of the Interior;

(3) Distributions and payments from rents, leases, rights of way, royalties, usage rights, or natural resource extraction and harvest from:

(a) Rights of ownership or possession in any lands described in (b) of this subsection; or

(b) Federally protected rights regarding off-reservation hunting, fishing, gathering, or usage of natural resources.

(4) Distributions resulting from real property ownership interests related to natural resources and improvements that are:

(a) Located on or near a reservation or within the most recent boundaries of a prior federal reservation; or

(b) Resulting from the exercise of federally protected rights relating to such real property ownership interests.

(5) Payments resulting from ownership interests in or usage rights to items that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable tribal law or custom;

(6) Student financial assistance provided under the Bureau of Indian Affairs education programs; and

(7) Any other applicable income exclusion as provided by federal law, regulation, or rule, including the Internal Revenue Code, treasury regulations, and Internal Revenue Service revenue rulings, revenue procedures, notices, and other official tax guidance.

**History**
- *Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-102, § 182-509-0340, filed 12/18/13, effective 1/18/14.*

##### **Wash. Admin. Code § 182-509-0360** MAGI income—How the income of a child age eighteen or younger or a tax dependent is counted. {#sec-182-509-0360 omnilex-key=us-wa-regs-official--title-182--182-509-0360}

The medicaid agency determines what income is counted when determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health under WAC 182-509-0300.

(1) When determining countable income for persons described in subsections (2) through (4) of this section, the countable income of a child age eighteen or younger or of a tax dependent is included only when it meets the threshold required for tax filing under 26 U.S.C. Sec. 6012 (a)(1). For purposes of this section, countable income of a child or tax dependent does not include Social Security dependent benefits.

(2) Determining countable income of a tax filer. The countable income of a tax filer includes the countable income of each member in the tax filer's medical assistance unit (MAU) under WAC 182-506-0012(1).

(3) Determining countable income of a tax dependent. The countable income of a tax dependent includes the countable income of each member in the tax dependent's MAU under WAC 182-506-0012(2).

(4) Determining countable income of a nonfiler. The countable income of a nonfiler, including a person considered a nonfiler under WAC 182-506-0012 (2)(b)(ii), includes the countable income of each member in the nonfiler's MAU under WAC 182-506-0012(3).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-02-001, § 182-509-0360, filed 12/21/16, effective 1/21/17. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-509-0360, filed 12/9/13, effective 1/9/14.*

##### **Wash. Admin. Code § 182-509-0365** MAGI income—Self-employment income. {#sec-182-509-0365 omnilex-key=us-wa-regs-official--title-182--182-509-0365}

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (see WAC 182-509-0300):

(1) Self-employment income is income earned by a person from running a business, performing a service, selling items that are made, or reselling items with the intent to make a profit, after deducting allowable IRS self-employment expenses. This income can be earned if the person is carrying on a trade or business as a sole proprietor or an independent contractor; a member of a partnership that carries on a trade or business; or otherwise in business for themselves (including a part-time business). Examples of self-employment business structures include, but are not limited to:

(a) Sole proprietorship - An unincorporated business owned by one person.

(b) Partnership - A relationship between two or more people who conduct a trade or business.

(c) Corporation - An entity that conducts business, realizes net income or loss, pays taxes, and distributes profits to shareholders.

(d) S corporation - Similar to a corporation, but this structure passes corporate income, losses, deductions, and credits through to the shareholders for federal tax purposes.

(e) Limited liability company (LLC) - An entity formed by one or more people or entities through a special written agreement that details the organization of the LLC.

(2) Self-employment income is counted as earned income as described in WAC 182-509-0330, except when it is earned by a child or tax dependent and the income is below the filing threshold, as described in WAC 182-509-0360(1).

(3) A person is considered to be self-employed if they earn income without having an employer/employee relationship with the individual who pays the income. Self-employed people do not work for a specific employer who pays them a consistent salary or wage. Factors to consider are whether:

(a) The person has primary control or has the right to control what they do and how they do their job;

(b) The business aspects of the person's job are controlled by the person and not the payer (this includes things like how the person is paid, whether expenses are reimbursed, or who provides tools/supplies);

(c) The person has a contract stating that they are an independent contractor; or

(d) The person reports their income using one or more IRS schedules or forms that include, but are not limited to:

(i) Schedule C;

(ii) Schedule C-EZ;

(iii) Schedule E;

(iv) Schedule F;

(v) Schedule K-1;

(vi) Schedule SE;

(vii) Form 940;

(viii) Form 941;

(ix) Form 942;

(x) Form 943;

(xi) Form 1065; or

(xii) Form 1120.

(4) A person is considered to have an employer/employee relationship when:

(a) The individual the person provides services for has primary control of how the work is done; or

(b) The person receives an IRS Form W-2 to report the income that is earned.

(5) Self-employment does not have to be a licensed business for a person's business or activity to qualify as self-employment.

(6) A person must keep records of their self-employment income and deductions and provide this information to the agency upon request.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-17-085, § 182-509-0365, filed 8/13/21, effective 9/13/21. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-509-0365, filed 12/9/13, effective 1/9/14.*

##### **Wash. Admin. Code § 182-509-0370** MAGI income—How self-employment income is counted. {#sec-182-509-0370 omnilex-key=us-wa-regs-official--title-182--182-509-0370}

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health, the medicaid agency counts self-employment income by:

(1) Adding together gross self-employment income and any profit made from selling business property or equipment over a period of time; and

(2) Subtracting business expenses and income deductions allowed by the Internal Revenue Service that the person would be entitled to if they were filing a federal tax return and either:

(a) Averaging the income to come up with a monthly amount based on the period of time the business has been in operation within the last year; or

(b) Averaging the income over a representative period of time if the current income does not represent the person's projected income as shown by clear indications of future changes in income; or

(c) By averaging the self-employed income and deductions claimed on the previous year's tax return over a representative period of time.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-17-085, § 182-509-0370, filed 8/13/21, effective 9/13/21. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-509-0370, filed 12/9/13, effective 1/9/14.*

##### **Wash. Admin. Code § 182-509-0375** MAGI income—Lump sums. {#sec-182-509-0375 omnilex-key=us-wa-regs-official--title-182--182-509-0375}

For purposes of determining eligibility for modified adjusted gross income (MAGI)–based Washington apple health (see WAC 182-509-0300):

(1) A lump sum payment is money that a person receives but does not expect to receive on a continuing basis, such as an insurance settlement.

(2) A lump sum payment is only counted as income if it is received in the month of application, and it otherwise qualifies as countable income under another rule.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-17-085, § 182-509-0375, filed 8/13/21, effective 9/13/21. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-509-0375, filed 12/9/13, effective 1/9/14.*

## **Chapter 182-510** Supplemental security income. {#struct-chapter-182-510}

##### **Wash. Admin. Code § 182-510-0001** Supplemental security income and associated categorically needy coverage. {#sec-182-510-0001 omnilex-key=us-wa-regs-official--title-182--182-510-0001}

(1) Supplemental security income (SSI) is a federal cash benefit administered by the Social Security Administration (SSA) under the Social Security Act, 42 U.S.C. Sec. 1381-1383f. The SSI program replaces state programs for the aged, blind and disabled individuals beginning January 1974. An individual who received state assistance in December 1973 who became eligible for SSI in January 1974 is considered a grandfathered client by the medicaid agency, and a mandatory income level (MIL) client by SSI. The individual must continue to meet the definition of blind or disabled that was in effect under the state plan in December 1973. See chapter 182-500 WAC for additional definitions.

(2) An essential person is someone needed in the home to care for an SSI recipient. An essential person is eligible for categorically needy (CN) coverage as long as he or she has lived continuously with the eligible person since January 1974.

(3) An ineligible spouse is the spouse of an SSI recipient who is not eligible for SSI-related CN coverage. An ineligible spouse must have his or her eligibility for Washington apple health (WAH) determined separately under WAC 182-519-0100.

(4) When an individual receives SSI, the agency accepts the SSA's determination of medicaid entitlement. The individual is eligible for CN coverage without submitting an additional application as long as he or she:

(a) Remains entitled to SSI;

(b) Is no longer entitled to SSI, but the SSA is in the process of determining eligibility under the Social Security Act, 42 U.S.C. Sec. 1619(b); or

(c) Currently has 1619(b) status as described in WAC 182-512-0880(3).

(5) An SSI recipient may be terminated from CN coverage when he or she:

(a) Does not provide the agency with information necessary for the agency to determine if he or she has other medical insurance; or

(b) Does not assign the right to recover insurance funds to the agency as required in WAC 182-503-0540.

(6) CN coverage eligibility continues if the SSA stops an individual's SSI for one of the following reasons:

(a) The individual's countable income exceeds the SSI income standard due solely to the annual cost-of-living adjustment (COLA) under WAC 182-512-0880(1);

(b) The individual is a "deemed" eligible SSI recipient on the basis of eligibility for a special income disregard under WAC 182-512-0880; or

(c) The individual has an appeal of an SSA termination pending which has not yet resulted in a final determination.

(7) If an individual's SSI stops due to an SSA determination that the individual is no longer disabled, and any appeal of this determination has resulted in a final decision, the agency:

(a) Redetermines eligibility for all other WAH programs that are not based on receipt of SSI; and

(b) Continues CN coverage until the agency completes the redetermination process described in WAC 182-504-0125.

(8) If an individual's SSI stops for a reason not addressed elsewhere in this section, the agency considers the individual to meet disability requirements through the SSA's original disability review date. The agency:

(a) Redetermines eligibility for other WAH programs, which may or may not be based on disability; and

(b) Continues CN coverage until the agency completes the redetermination process in WAC 182-504-0125.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-13-053, § 182-510-0001, filed 6/10/15, effective 7/11/15. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 13-14-019, § 182-510-0001, filed 6/24/13, effective 7/25/13.*

##### **Wash. Admin. Code § 182-510-0005** Supplemental security income, essential person, and ineligible spouse. {#sec-182-510-0005 omnilex-key=us-wa-regs-official--title-182--182-510-0005}

(1) If you are a supplemental security income (SSI) recipient, you automatically get categorically needy (CN) coverage (WAC 182-512-0100) unless you:

(a) Refuse to provide private medical insurance information; or

(b) Refuse to assign the right to recover insurance funds to the agency (WAC 182-503-0540).

(2) If you are an essential person as described in WAC 182-510-0001 you get CN coverage as long as you continue to live with the SSI recipient.

(3) If you are an ineligible spouse you are not considered an SSI recipient. You must have your Washington apple health eligibility determined separately.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-13-053, § 182-510-0005, filed 6/10/15, effective 7/11/15. WSR 12-13-056, recodified as § 182-510-0005, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090 and 74.04.630. WSR 02-11-033, § 388-474-0005, filed 5/7/02, effective 6/7/02. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-474-0005, filed 7/31/98, effective 9/1/98.*

##### **Wash. Admin. Code § 182-510-0010** Eligibility after supplemental security income ends. {#sec-182-510-0010 omnilex-key=us-wa-regs-official--title-182--182-510-0010}

(1) Your categorically needy (CN) coverage (WAC 182-512-0100) continues after supplemental security income (SSI) ends if:

(a) Countable income exceeds the SSI income standard due solely to the annual cost-of-living adjustment (COLA); or

(b) A timely request for a hearing has been filed. CN coverage is continued until the Social Security Administration (SSA) makes a final decision on the hearing request and on any subsequent timely appeals.

(2) If your SSI ends, your CN coverage continues for a period of up to one hundred twenty days while the agency reviews your eligibility for other cash or medical programs.

(3) If you are a terminated SSI or SSI-related recipient, the agency will review your disability status when:

(a) You present new medical evidence;

(b) Your medical condition changes significantly; or

(c) Your termination from SSI was not based on a review of current medical evidence.

(4) Children terminated from SSI due to loss of disabled status may be eligible for medical benefits under WAC 182-505-0210.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-13-053, § 182-510-0010, filed 6/10/15, effective 7/11/15. WSR 12-13-056, recodified as § 182-510-0010, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090. WSR 02-20-070, § 388-474-0015, filed 9/30/02, effective 10/31/02. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090 and 74.04.630. WSR 02-11-033, § 388-474-0015, filed 5/7/02, effective 6/7/02. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-474-0015, filed 7/31/98, effective 9/1/98. Formerly WAC 388-524-2405.*

## **Chapter 182-511** Apple health for workers with disabilities (HWD). {#struct-chapter-182-511}

##### **Wash. Admin. Code § 182-511-1000** Apple health for workers with disabilities (HWD)—Program description. {#sec-182-511-1000 omnilex-key=us-wa-regs-official--title-182--182-511-1000}

This section describes the apple health for workers with disabilities (HWD) program.

(1) The HWD program provides categorically needy (CN) scope of care as described in WAC 182-501-0060.

(2) The HWD program also provides long-term services and supports described in chapters 182-513 and 182-515 WAC for a client who meets the functional requirements for those programs, are approved for those services, and choose to enroll in HWD.

(3) The medicaid agency approves HWD coverage for twelve months effective the first of the month in which a person applies and meets program requirements. See WAC 182-511-1100 for retroactive coverage for months before the month of application.

(4) A person who is eligible for another medicaid program may choose not to participate in the HWD program.

(5) A person is not eligible for HWD coverage for a month in which the person received medicaid benefits under the medically needy (MN) program.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 70. WSR 19-23-063, § 182-511-1000, filed 11/15/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-080, § 182-511-1000, filed 6/29/15, effective 7/30/15. WSR 11-24-018, recodified as § 182-511-1000, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-475-1000, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, Section 1902 (a)(10)(A)(ii) of the Social Security Act, and 2001 c 7 § 209(5), Part II. WSR 02-01-073, § 388-475-1000, filed 12/14/01, effective 1/14/02.*

##### **Wash. Admin. Code § 182-511-1050** Apple health for workers with disabilities (HWD)—Program requirements. {#sec-182-511-1050 omnilex-key=us-wa-regs-official--title-182--182-511-1050}

This section describes requirements a person must meet to be eligible for the apple health for workers with disabilities (HWD) program.

(1) To qualify for the HWD program, a person must:

(a) Meet the general requirements for a medical program described in WAC 182-503-0505 (3)(a) through (f);

(b) Be at least age sixteen;

(c) Meet the federal disability requirements described in WAC 182-511-1150; and

(d) Be employed full or part time (including self-employment) as described in WAC 182-511-1200.

(2) The HWD program does not require a resource test.

(3) Once approved for HWD coverage, a person must pay the monthly premium in order to continue to qualify.

(a) The agency calculates the premium for HWD coverage according to WAC 182-511-1250.

(b) If a person does not pay four consecutive monthly premiums, the person is not eligible for HWD coverage for the next four months and must pay all premium amounts owed before HWD coverage can be approved again.

(c) Once approved for HWD coverage, a person who experiences a job loss can choose to continue HWD coverage through the original twelve months of eligibility, if the following requirements are met:

(i) The job loss results from an involuntary dismissal or health crisis; and

(ii) The person continues to pay the monthly premium.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 70. WSR 19-23-063, § 182-511-1050, filed 11/15/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-080, § 182-511-1050, filed 6/29/15, effective 7/30/15. WSR 11-24-018, recodified as § 182-511-1050, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.08.090, 34.05.353 and Section 1902 (a)(10)(A)(ii) of the Social Security Act. WSR 04-15-002, § 388-475-1050, filed 7/7/04, effective 8/7/04. Statutory Authority: RCW 74.08.090, Section 1902 (a)(10)(A)(ii) of the Social Security Act, and 2001 c 7 § 209(5), Part II. WSR 02-01-073, § 388-475-1050, filed 12/14/01, effective 1/14/02.*

##### **Wash. Admin. Code § 182-511-1100** Apple health for workers with disabilities (HWD)—Retroactive coverage. {#sec-182-511-1100 omnilex-key=us-wa-regs-official--title-182--182-511-1100}

This section describes requirements for retroactive coverage provided under the apple health for workers with disabilities (HWD) program.

(1) Retroactive coverage refers to the period of up to three months before the month in which a person applies for the HWD program.

(2) To qualify for retroactive coverage under the HWD program, a person must first:

(a) Meet all program requirements described in WAC 182-511-1050 for each month of the retroactive period; and

(b) Pay the premium amount for each month requested within one hundred twenty days of being billed for such coverage.

(3) Payment must be received for each month requested of retroactive coverage before such coverage is approved.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 70. WSR 19-23-063, § 182-511-1100, filed 11/15/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-080, § 182-511-1100, filed 6/29/15, effective 7/30/15. WSR 11-24-018, recodified as § 182-511-1100, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.08.090, Section 1902 (a)(10)(A)(ii) of the Social Security Act, and 2001 c 7 § 209(5), Part II. WSR 02-01-073, § 388-475-1100, filed 12/14/01, effective 1/14/02.*

##### **Wash. Admin. Code § 182-511-1150** Apple health for workers with disabilities (HWD)—Disability requirements. {#sec-182-511-1150 omnilex-key=us-wa-regs-official--title-182--182-511-1150}

This section describes the disability requirements for the following groups of individuals who may qualify for the apple health for workers with disabilities (HWD) program.

(1) A person age sixteen through age sixty-four must meet the requirements of the Social Security Act in section 1902(a)(10)(A)(ii):

(a) (XV) for the basic coverage group (BCG); or

(b) (XVI) for the medical improvement group (MIG).

(2) The BCG consists of individuals who:

(a) Meet federal disability requirements for the supplemental security income (SSI) or Social Security Disability Insurance (SSDI) program; or

(b) Are determined by the department of social and health services (DSHS), division of disability determination services (DDDS), to meet federal disability requirements for the HWD program.

(3) The MIG consists of individuals who:

(a) Were previously eligible and approved for the HWD program as a member of the BCG; and

(b) Are determined by DDDS to have a medically improved disability. The term "medically improved disability" refers to the particular status granted to persons described in subsection (1)(b). For these people, a continuation of HWD coverage is provided to help them maintain their employment.

(4) A person age sixty-five or older, must meet federal disability requirements as determined by the DSHS DDDS. Coverage under the MIG is not available under federal law for persons age sixty-five or older. Coverage for this age group is authorized under the Balanced Budget Act of 1997 as described under section 1902 (a)(10)(A)(ii)(XIII).

(5) When completing a disability determination for the HWD program, DDDS will not determine a person not disabled based only on earnings or the performance of substantial gainful activity (SGA). (See SSA POMS Section DI 10501.001, https://secure.ssa.gov/apps10/poms.nsf/lnx/0410501001).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 70. WSR 19-23-063, § 182-511-1150, filed 11/15/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-08-025, § 182-511-1150, filed 3/27/19, effective 4/27/19*
- *WSR 15-14-080, § 182-511-1150, filed 6/29/15, effective 7/30/15. WSR 11-24-018, recodified as § 182-511-1150, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.08.090, Section 1902 (a)(10)(A)(ii) of the Social Security Act, and 2001 c 7 § 209(5), Part II. WSR 02-01-073, § 388-475-1150, filed 12/14/01, effective 1/14/02.*

##### **Wash. Admin. Code § 182-511-1200** Apple health for workers with disabilities (HWD)—Employment requirements. {#sec-182-511-1200 omnilex-key=us-wa-regs-official--title-182--182-511-1200}

This section describes the employment requirements for the basic coverage group (BCG) and the medical improvement group (MIG) for the apple health for workers with disabilities (HWD) program.

(1) For the purpose of the HWD program, employment means a person:

(a) Gets paid for working;

(b) Has earnings that are subject to federal income tax; and

(c) Has payroll taxes taken out of earnings received, unless self-employed.

(2) To qualify for HWD coverage as a member of the BCG, a person must be employed full or part time.

(3) To qualify for HWD coverage as a member of the MIG, a person must be:

(a) Working at least forty hours per month; and

(b) Earning at least the local minimum wage as described under section 6 of the Fair Labor Standards Act (29 U.S.C. 206).

(4) For a person who is self-employed, the examples described in the Social Security Administration Program Operations Manual System (POMS) provide guidance when determining whether someone meets the HWD work requirements. (See SSA POMS Section SI 00820.200, http://secure.ssa.gov/poms.nsf/lnx/0500820200). The guidelines described in POMS for determining the existence of a trade or business may also be used when making this determination. (See SSA POMS Section RS 01802.010, https://secure.ssa.gov/apps10/poms.nsf/lnx/0301802010).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 70. WSR 19-23-063, § 182-511-1200, filed 11/15/19, effective 1/1/20. WSR 11-24-018, recodified as § 182-511-1200, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.08.090, Section 1902 (a)(10)(A)(ii) of the Social Security Act, and 2001 c 7 § 209(5), Part II. WSR 02-01-073, § 388-475-1200, filed 12/14/01, effective 1/14/02.*

##### **Wash. Admin. Code § 182-511-1250** Apple health for workers with disabilities (HWD)—Premium payments. {#sec-182-511-1250 omnilex-key=us-wa-regs-official--title-182--182-511-1250}

This section describes how the medicaid agency calculates the premium amount a person must pay for apple health for workers with disabilities (HWD) coverage. This section also describes program requirements regarding the billing and payment of HWD premiums.

(1) When determining the HWD premium amount, the agency counts only the income of the person approved for the program. It does not count the income of another household member.

(2) When determining countable income used to calculate the HWD premium, the agency applies the following rules:

(a) Income is considered available and owned when it is:

(i) Received; and

(ii) Can be used to meet the person's needs for food, clothing, and shelter, except as described in WAC 182-512-0600(5) and 182-512-0650.

(b) Income is considered unavailable when it is:

(i) Described in 20 C.F.R. Sec. 416.1103.

(ii) Used to pay the fee described in WAC 182-512-0800(5).

(3) The HWD premium amount equals the lesser of the two following amounts:

(a) A total of the following (rounded down to the nearest whole dollar):

(i) Fifty percent of unearned income above the medically needy income level (MNIL) described in WAC 182-519-0050; plus

(ii) Five percent of total unearned income; plus

(iii) Two and one-half percent of earned income after first deducting $65; or

(b) Seven and one-half percent of countable income described in subsection (2) of this section, including both earned and unearned income.

(4) When determining the premium amount, the agency will use the currently verified income amount until a change in income is reported and processed, unless good cause for delay in verifying changes exists.

(5) A change in the premium amount is effective the month after the change in income is reported and processed.

(6) For current and ongoing coverage, the agency will bill for HWD premiums during the month following the benefit month.

(7) For retroactive coverage, the agency will bill the HWD premiums during the month following the month in which coverage is requested and necessary information that establishes eligibility is received by the agency.

(8) If initial coverage for the HWD program is approved in a month that follows the month of application, the first monthly premium includes the costs for both the month of application and any following months that have passed during determination of eligibility.

(9) As described in WAC 182-511-1050 (3)(b), the agency will close HWD coverage if premiums are not paid in full for four consecutive months.

(10) The person must pay the monthly premium in full to avoid losing HWD coverage. If a person makes a partial payment, the payment does not count as a full payment toward the premium.

(11) Payments received are applied to premiums owed in the following order:

(a) If retroactive coverage is requested, the retroactive coverage month(s);

(b) Past due months, beginning with the most delinquent month;

(c) The current coverage month that has been invoiced; then

(d) Future coverage months.

(12) A person must pay a premium for any month that HWD coverage is provided. This includes months when a redetermination of coverage is made, and months when continued coverage that is requested, pending the outcome of an administrative hearing.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-15-053, s 182-511-1250, filed 7/10/25, effective 8/10/25*
- *WSR 25-07-046, s 182-511-1250, filed 3/12/25, effective 4/12/25. Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 70. WSR 19-23-063, § 182-511-1250, filed 11/15/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-080, § 182-511-1250, filed 6/29/15, effective 7/30/15. WSR 11-24-018, recodified as § 182-511-1250, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.08.090, 34.05.353 and Section 1902 (a)(10)(A)(ii) of the Social Security Act. WSR 04-15-002, § 388-475-1250, filed 7/7/04, effective 8/7/04. Statutory Authority: RCW 74.08.090, Section 1902 (a)(10)(A)(ii) of the Social Security Act, and 2001 c 7 § 209(5), Part II. WSR 02-01-073, § 388-475-1250, filed 12/14/01, effective 1/14/02.*

## **Chapter 182-512** SSI-related medical. {#struct-chapter-182-512}

##### **Wash. Admin. Code § 182-512-0010** Supplemental security income (SSI) standards, SSI-related categorically needy income level (CNIL), and countable resource standards. {#sec-182-512-0010 omnilex-key=us-wa-regs-official--title-182--182-512-0010}

(1) The SSI payment standards, also known as the federal benefit rate (FBR), change each January 1st.

(2) See WAC 388-478-0055 for the amount of the state supplemental payments (SSP) for SSI recipients.

(3) See WAC 182-513-1205 for standards of clients living in an alternate living facility.

(4) The SSI-related CNIL standards are the same as the SSI payment standards for single persons and couples. Those paying out shelter costs have a higher standard than people who have supplied shelter.

(5) The countable resource standards for SSI and SSI-related CN medical programs are:

| (a) One person | $2,000 |
| --- | --- |
| (b) A legally married couple | $3,000 |

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-02-046, § 182-512-0010, filed 12/27/18, effective 1/27/19. WSR 11-23-091, recodified as § 182-512-0010, filed 11/17/11, effective 11/21/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. WSR 08-11-098, § 388-478-0080, filed 5/20/08, effective 6/20/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, and Section 1924 of the Social Security Act (42 U.S.C. 1396r-5). WSR 06-06-013, § 388-478-0080, filed 2/17/06, effective 3/20/06. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 42 U.S.C. 9902(2). WSR 05-06-090, § 388-478-0080, filed 3/1/05, effective 4/1/05*
- *WSR 04-16-107, § 388-478-0080, filed 8/3/04, effective 9/3/04. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 42 U.S.C. 1396r-5. WSR 02-10-116, § 388-478-0080, filed 4/30/02, effective 5/31/02. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and Section 1924 (42 U.S.C. 1396R-5). WSR 01-12-073, § 388-478-0080, filed 6/4/01, effective 7/5/01. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, and 74.09.575. WSR 00-10-095, § 388-478-0080, filed 5/2/00, effective 5/2/00*
- *WSR 99-11-054, § 388-478-0080, filed 5/17/99, effective 6/17/99. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-478-0080, filed 7/31/98, effective 9/1/98. Formerly WAC 388-511-1110.*

##### **Wash. Admin. Code § 182-512-0050** SSI-related medical—General information. {#sec-182-512-0050 omnilex-key=us-wa-regs-official--title-182--182-512-0050}

(1) The agency (which includes its designee for purposes of this chapter) provides health care coverage under the Washington apple health (WAH) categorically needy (CN) and medically needy (MN) SSI-related programs for SSI-related people, meaning those who meet at least one of the federal SSI program criteria as being:

(a) Age sixty-five or older;

(b) Blind with:

(i) Central visual acuity of 20/200 or less in the better eye with the use of a correcting lens; or

(ii) A field of vision limitation so the widest diameter of the visual field subtends an angle no greater than twenty degrees.

(c) Disabled:

(i) "Disabled" means unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment, which:

(A) Can be expected to result in death; or

(B) Has lasted or can be expected to last for a continuous period of not less than twelve months; or

(C) In the case of a child seventeen years of age or younger, if the child suffers from any medically determinable physical or mental impairment of comparable severity.

(ii) Decisions on SSI-related disability are subject to the authority of:

(A) Federal statutes and regulations codified at 42 U.S.C. Section 1382c and 20 C.F.R., parts 404 and 416, as amended; and

(B) Controlling federal court decisions, which define the OASDI and SSI disability standard and determination process.

(2) A denial of Title II or Title XVI federal benefits by SSA solely due to failure to meet the blindness or disability criteria is binding on the agency unless the applicant's:

(a) Denial is under appeal in the reconsideration stage in SSA's administrative hearing process, or SSA's appeals council; or

(b) Medical condition has changed since the SSA denial was issued.

(3) The agency considers a person who meets the special requirements for SSI status under Sections 1619(a) or 1619(b) of the Social Security Act as an SSI recipient. Such a person is eligible for WAH CN health care coverage under WAC 182-510-0001.

(4) Persons referred to in subsection (1) must also meet appropriate eligibility criteria found in the following WAC and EA-Z Manual sections:

(a) For all programs:

(i) WAC 182-506-0015, Medical assistance units;

(ii) WAC 182-504-0015, Categorically needy and WAC 182-504-0020, Medically needy certification periods;

(iii) Program specific requirements in chapter 182-512 WAC;

(iv) WAC 182-503-0050, Verification;

(v) WAC 182-503-0505, General eligibility requirements for medical programs;

(vi) WAC 182-503-0540, Assignment of rights and cooperation;

(vii) Chapter 182-516 WAC, Trusts, annuities and life estates.

(b) For LTC programs:

(i) Chapter 182-513 WAC, Long-term care services;

(ii) Chapter 182-515 WAC, Waiver services.

(c) For WAH MN, chapter 182-519 WAC, Spenddown;

(d) For WAH HWD, program specific requirements in chapter 182-511 WAC.

(5) Aliens who qualify for medicaid coverage, but are determined ineligible because of alien status may be eligible for programs as specified in WAC 182-507-0110.

(6) The agency pays for a person's medical care outside of Washington according to WAC 182-501-0180.

(7) The agency follows income and resource methodologies of the supplemental security income (SSI) program defined in federal law when determining eligibility for SSI-related medical or medicare savings programs unless the agency adopts rules that are less restrictive than those of the SSI program.

(8) Refer to WAC 182-504-0125 for effects of changes on medical assistance for redetermination of eligibility.

**History**
- *Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0050, filed 3/14/14, effective 4/14/14. WSR 11-24-018, recodified as § 182-512-0050, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-002, § 388-475-0050, filed 4/7/04, effective 6/1/04.*

##### **Wash. Admin. Code § 182-512-0100** SSI-related medical—Categorically needy (CN) medical eligibility. {#sec-182-512-0100 omnilex-key=us-wa-regs-official--title-182--182-512-0100}

(1) Washington apple health (WAH) categorically needy (CN) coverage is available for an SSI-related person who meets the criteria in WAC 182-512-0050, SSI-related medical—General information.

(2) To be eligible for SSI-related WAH CN medical programs, a person must also have:

(a) Countable income and resources at or below the SSI-related WAH CN medical monthly standard (refer to WAC 182-512-0010) or be eligible for an SSI cash grant but choose not to receive it; or

(b) Countable resources at or below the SSI resource standard and income above the SSI-related WAH CN medical monthly standard, but the countable income falls below that standard after applying special income disregards as described in WAC 182-512-0880; or

(c) Met requirements for long-term care (LTC) WAH CN income and resource requirements that are found in chapters 182-513 and 182-515 WAC if wanting LTC or waiver services.

(3) An ineligible spouse of an SSI recipient is not eligible for noninstitutional SSI-related WAH CN health care coverage. If an ineligible spouse of an SSI recipient has dependent children in the home, eligibility may be determined for health care coverage under the WAH medically needy program or for a modified adjusted gross income-based program.

**History**
- *Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0100, filed 3/14/14, effective 4/14/14. WSR 11-24-018, recodified as § 182-512-0100, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-002, § 388-475-0100, filed 4/7/04, effective 6/1/04.*

##### **Wash. Admin. Code § 182-512-0150** SSI-related medical—Medically needy (MN) medical eligibility. {#sec-182-512-0150 omnilex-key=us-wa-regs-official--title-182--182-512-0150}

(1) Washington apple health (WAH) medically needy (MN) health care coverage is available for any of the following:

(a) A person who is SSI-related and not eligible for WAH categorically needy (CN) medical coverage because the person has countable income that is above the WAH CN income level (CNIL) (or for long-term care (LTC) recipients, above the special income limit (SIL)):

(i) The person's countable income is at or below WAH MN standards, leaving no spenddown requirement; or

(ii) The person's countable income is above WAH MN standards requiring the person to spenddown their excess income (see subsection (4) of this section). See WAC 182-512-0500 through 182-512-0800 for rules on determining countable income, and WAC 182-519-0050 for program standards or chapter 182-513 WAC for institutional standards.

(b) An SSI-related ineligible spouse of an SSI recipient;

(c) A person who meets SSI program criteria but is not eligible for the SSI cash grant due to immigration status or sponsor deeming. See WAC 182-503-0535 for limits on eligibility for aliens;

(d) A person who meets the WAH MN LTC services requirements of chapter 182-513 WAC;

(e) A person who lives in an alternate living facility and meets the requirements of WAC 182-513-1205; or

(f) A person who meets resource requirements as described in chapter 182-512 WAC, elects and is certified for hospice services per chapter 182-551 WAC.

(2) A person whose countable resources are above the SSI resource standards is not eligible for WAH MN noninstitutional health care coverage. See WAC 182-512-0200 through 182-512-0550 to determine countable resources.

(3) A person who qualifies for services under WAH long-term care programs has different criteria and may spend down excess resources to become eligible for WAH LTC institutional or waiver health care coverage. Refer to WAC 182-513-1315 and 182-513-1395.

(4) A person with income over the effective WAH MN income limit (MNIL) described in WAC 182-519-0050 may become eligible for WAH MN coverage when the person has incurred medical expenses that are equal to the excess income. This is the process of meeting spenddown. Refer to chapter 182-519 WAC for spenddown information.

(5) A person may be eligible for health care coverage for any or all of the three months immediately prior to the month of application, if the person has:

(a) Met all eligibility requirements for the months being considered; and

(b) Received medical services covered by medicaid during that time.

(6) A person who is eligible for WAH MN without a spenddown is certified for up to 12 months. For a person who must meet a spenddown, refer to WAC 182-519-0110. For a person who is eligible for a WAH long-term care MN program, refer to WAC 182-513-1395 and 182-513-1315.

(7) A person must reapply for each certification period. There is no continuous eligibility for WAH MN.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-12-056, § 182-512-0150, filed 5/26/22, effective 6/26/22. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0150, filed 3/14/14, effective 4/14/14. Statutory Authority: RCW 41.05.021. WSR 12-20-001, § 182-512-0150, filed 9/19/12, effective 10/20/12. WSR 11-24-018, recodified as § 182-512-0150, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-002, § 388-475-0150, filed 4/7/04, effective 6/1/04.*

##### **Wash. Admin. Code § 182-512-0200** SSI-related medical—Definition of resources. {#sec-182-512-0200 omnilex-key=us-wa-regs-official--title-182--182-512-0200}

(1) A resource is any cash, other personal property, or real property that an applicant, recipient or other financially responsible person:

(a) Owns;

(b) Has the right, authority, or power to convert to cash (if not already cash); and

(c) Has the legal right to use for his/her support and maintenance.

(2) The value of a resource may change. However, the property (personal or real) still remains a resource.

(3) Some assets are not resources. Any asset that does not meet the criteria in subsection (1) above is not a resource.

(4) When an SSI-related client owns a bank account or time deposit jointly with others who are also SSI-related clients, we consider the funds as being available to the SSI-related individuals in equal shares, unless sufficient evidence to the contrary is provided.

(5) When an SSI-related client owns a bank account or time deposit jointly with others who are not SSI-related, we consider all funds in the joint account as available to the client unless sufficient evidence to the contrary is provided.

(6) When an SSI-related client jointly owns either real or personal property other than bank accounts or time deposits, the department considers that the client owns and has available only his or her fractional interest in the property unless sufficient evidence to the contrary is provided.

(7) A resource is countable toward the resource limit only if it is available and is not excluded.

**History**
- *WSR 11-24-018, recodified as § 182-512-0200, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-002, § 388-475-0200, filed 4/7/04, effective 6/1/04.*

##### **Wash. Admin. Code § 182-512-0250** SSI-related medical—Ownership and availability of resources. {#sec-182-512-0250 omnilex-key=us-wa-regs-official--title-182--182-512-0250}

(1) The agency considers personal and real property to be available to a Washington apple health applicant or recipient if the applicant or recipient:

(a) Owns the property;

(b) Has the authority to convert the property into cash;

(c) Can expect to convert the property to cash within twenty working days; and

(d) May legally use the property for his or her support.

(2) The agency counts the resources of financially responsible persons (as defined in WAC 182-506-0015) who live in the home even if those persons do not receive Washington apple health coverage.

(3) For long-term care (LTC) services, cash and other resources transferred by a Washington apple health applicant or recipient or his or her spouse to another to pay for the Washington apple health applicant or recipient's LTC services are considered resources available to the applicant or recipient unless otherwise excluded in this chapter, chapter 182-513 WAC, or chapter 182-516 WAC.

(4) A resource is considered available on the first day of the month following the month of receipt unless a rule about a specific type of resource provides for a different time period.

(5) A resource that ordinarily cannot be converted to cash within twenty working days is considered unavailable as long as a reasonable effort is being made to convert the resource to cash.

(6) A person may provide evidence showing that a resource is unavailable. A resource is not counted if the person shows sufficient evidence that the resource is unavailable.

(7) We do not count the resources of victims of family violence, as defined in WAC 388-452-0010, when:

(a) The resource is owned jointly with members of the former household;

(b) Availability of the resource depends on an agreement of the joint owner; or

(c) Making the resource available would place the person at risk of harm.

(8) The value of a resource is its fair market value minus encumbrances.

(9) Refer to WAC 182-512-0260 to consider additional resources when an alien has a sponsor.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-08-079, § 182-512-0250, filed 3/27/20, effective 4/27/20*
- *WSR 15-07-064, § 182-512-0250, filed 3/16/15, effective 4/16/15. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0250, filed 3/14/14, effective 4/14/14. WSR 11-24-018, recodified as WAC 182-512-0250, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-002, § 388-475-0250, filed 4/7/04, effective 6/1/04.*

##### **Wash. Admin. Code § 182-512-0260** SSI-related medical—How to count a sponsor's resources. {#sec-182-512-0260 omnilex-key=us-wa-regs-official--title-182--182-512-0260}

(1) The agency counts part of a sponsor's resources as available to an applicant or recipient of Washington apple health (WAH) SSI-related health care coverage if:

(a) The person is a sponsored immigrant as defined in WAC 182-512-0785; and

(b) The person is not exempt from deeming under WAC 182-512-0790.

(2) The agency determines the amount of the sponsor's resources to count by:

(a) Totaling the countable resources of the sponsor and the sponsor's spouse (if the spouse signed the affidavit of support);

(b) Subtracting fifteen hundred dollars; and

(c) Counting the remaining amount as a resource that is available to the person.

(3) When a sponsor has sponsored other people as well, the agency divides the result by the total number of people sponsored.

(4) A sponsor's resources are counted when determining eligibility for WAH coverage until the person becomes exempt from deeming under WAC 182-512-0790.

**History**
- *Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0260, filed 3/14/14, effective 4/14/14.*

##### **Wash. Admin. Code § 182-512-0300** SSI-related medical—Resources eligibility. {#sec-182-512-0300 omnilex-key=us-wa-regs-official--title-182--182-512-0300}

(1) At 12:00 a.m. on the first day of the month a client's countable resources must be at or below the resource standard to be eligible for noninstitutional medical benefits for that month. If the total of the client's countable resources is above the resource standard at 12:00 a.m. on the first day of the month, the client is ineligible for noninstitutional medical benefits for that entire month regardless of resource status at the time of application during that month. For resource eligibility relating to long-term care eligibility see chapter 182-513 WAC.

(2) An excluded resource converted to another excluded resource remains excluded.

(3) Cash received from the sale of an excluded resource becomes a countable resource the first of the month following conversion unless the cash is:

(a) Used to replace the excluded resource;

(b) Invested in another excluded resource in the same month or within the longer time allowed for home sales under WAC 182-512-0350; or

(c) Spent.

(4) The unspent portion of a nonrecurring lump sum payment is counted as a resource on the first of the month following its receipt with the following exception: The unspent portion of any Title II (SSA) or Title XVI (SSI) retroactive payment is excluded as a resource for nine months following the month of receipt. These exclusions apply to lump sums received by the client, client's spouse or any other person who is financially responsible for the client.

(5) Clients applying for SSI-related medical coverage for long-term care (LTC) services must meet different resource rules. See chapter 182-513 WAC for LTC resource rules.

(6) The transfer of a resource without adequate consideration does not affect medical program eligibility except for LTC services described in chapters 182-513 and 182-515 WAC. In those programs, the transfer may make a client ineligible for medical benefits for a period of time. See WAC 182-513-1363 for LTC rules.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-02-046, § 182-512-0300, filed 12/27/18, effective 1/27/19. WSR 11-24-018, recodified as § 182-512-0300, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.057, 74.08.090, 74.04.050, 74.09.500. WSR 08-23-101, § 388-475-0300, filed 11/19/08, effective 12/20/08*
- *WSR 08-14-048, § 388-475-0300, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-002, § 388-475-0300, filed 4/7/04, effective 6/1/04.*

##### **Wash. Admin. Code § 182-512-0350** SSI-related medical—Property and contracts excluded as resources. {#sec-182-512-0350 omnilex-key=us-wa-regs-official--title-182--182-512-0350}

(1) The agency excludes the following resources when determining eligibility for SSI-related medical assistance:

(a) A client's household goods and personal effects;

(b) One home (which can be any shelter), including the land on which the dwelling is located, and all contiguous property and related out-buildings in which the client has ownership interest for long-term care programs, see WAC 182-513-1350 for home equity limits, when:

(i) The client uses the home as a primary residence;

(ii) The client's spouse lives in the home;

(iii) The client does not currently live in the home, but the client or the client's representative has stated the client intends to return to the home; or

(iv) A relative, who is financially or medically dependent on the client, lives in the home and either the dependency is documented or a written statement of dependency is provided by the client, the client's authorized representative, or by the client's dependent relative.

(c) The value of ownership interest in jointly owned real property is an excluded resource for as long as sale of the property would cause undue hardship to a co-owner due to loss of housing. Undue hardship would result if the co-owner:

(i) Uses the property as the client's principal place of residence;

(ii) Would have to move if the property were sold; and

(iii) Has no other readily available housing.

(2) Proceeds from the sale of an interest described in subsection (1)(b) of this section, are excluded as a resource if the client uses the proceeds to purchase another home by the end of the third month after receiving the proceeds from the sale.

(3) An installment contract from the sale of the home described in subsection (1)(b) above is not a resource as long as the client plans to use the entire down payment and the entire principal portion of a given installment payment to buy another excluded home, and does so within three months after the month of receiving such down payment or installment payment.

(4) The value of sales contracts is excluded when the:

(a) Current market value of the contract is zero;

(b) Contract cannot be sold; or

(c) Current market value of the sales contract combined with other resources does not exceed the resource limits.

(5) Sales contracts executed before December 1, 1993, are excluded resources as long as they are not transferred to someone other than a spouse.

(6) A sales contract for the sale of the client's principal place of residence executed between December 1, 1993, and May 31, 2004, is an excluded resource unless it has been transferred to someone other than a spouse and it:

(a) Provides interest income within the prevailing interest rate at the time of the sale;

(b) Requires the repayment of a principal amount equal to the fair market value of the property; and

(c) The term of the contract does not exceed thirty years.

(7) A sales contract executed on or after June 1, 2004, on a home that was the principal place of residence for the client at the time of institutionalization is an excluded resource as long as it is not transferred to someone other than a spouse and it:

(a) Provides interest income within the prevailing interest rate at the time of the sale;

(b) Requires the repayment of a principal amount equal to the fair market value of the property within the anticipated life expectancy of the client; and

(c) The term of the contract does not exceed thirty years.

(8) Payments received on sales contracts of the home described in subsection (1)(b) of this section are treated as follows:

(a) The interest portion of the payment is treated as unearned income in the month of receipt of the payment;

(b) The principal portion of the payment is treated as an excluded resource if reinvested in the purchase of a new home within three months after the month of receipt;

(c) If the principal portion of the payment is not reinvested in the purchase of a new home within three months after the month of receipt, that portion of the payment is a liquid resource as of the date of receipt.

(9) Payments received on sales contracts described in subsection (4) of this section are treated as follows:

(a) The principal portion of the payment on the contract is treated as a resource and counted toward the resource limit to the extent retained at the first moment of the month following the month of receipt of the payment; and

(b) The interest portion is treated as unearned income the month of receipt of the payment.

(10) For sales contracts that meet the criteria in subsection (5), (6), or (7) of this section but do not meet the criteria in subsection (3) or (4) of this section, both the principal and interest portions of the payment are treated as unearned income in the month of receipt.

(11) Property essential to self-support (PESS) is excluded as a resource within certain limits. There are three categories of PESS:

(a) Real and personal property used in a trade or business:

(i) That is a resource defined under WAC 182-512-0200;

(ii) That is in current use as described under the Social Security Administration's Program Operations Manual System (POMS) SI 01130.504; and

(iii) Where the trade or business is a sole proprietorship or simple partnership.

(b) Nonbusiness income-producing property (i.e., property not used in a trade or business), such as:

(i) Houses or apartments for rent; and

(ii) Land, other than home property.

(c) Property used to produce goods or services essential to a client's daily activities, such as land used to produce vegetables or livestock, which is used only for personal consumption in the client's household. This includes personal property necessary to perform daily functions including vehicles such as boats for subsistence fishing and garden tractors for subsistence farming, but does not include other vehicles such as those that qualify as automobiles (e.g., cars, trucks).

(12) The agency excludes a client's real and personal property used in a trade or business, described under subsection (11)(a) of this section, regardless of value as long as it is in current use (as described under POMS SI 01130.504) in the trade or business and remains used in the trade or business.

(13) The agency excludes up to $6,000 of a client's equity in nonbusiness income-producing property, described under subsection (11)(b) of this section, if it produces a net annual income to the client of at least six percent of the excluded equity.

(a) If a client's equity in the property is over $6,000, only the amount over $6,000 is counted toward the resource limit, as long as the net annual income requirement of six percent is met on the excluded equity.

(b) If the six percent requirement is not met due to circumstances beyond the client's control (e.g., illness), and there is a reasonable expectation that the activities will again meet the six percent rule, the same exclusions as in subsection (13)(a) of this section apply.

(c) If a client has more than one piece of real property in this category, each is independently evaluated to see if it meets the six percent return, and the total equities of all those properties are added to see if the total is over $6,000. If the total is over the $6,000 limit, the amount exceeding the limit is counted toward the resource limit.

(d) The equity in each property that does not meet the six percent annual net income limit is counted toward the resource limit, with the exception of property that represents the authority granted by a governmental agency to engage in an income-producing activity if it is:

(i) Used in a trade or business or nonbusiness income-producing activity; or

(ii) Not used due to circumstances beyond the client's control (e.g., illness), and there is a reasonable expectation that the use will resume.

(14) Property used to produce goods or services essential to a client's daily activities is excluded if the client's equity in the property does not exceed $6,000.

(15) Personal property used by a client as an employee for work is not counted toward the resource limit, regardless of value, while in current use (as described under POMS SI 01130.504), or if the required use for work is reasonably expected to resume.

(16) Interests in trust or in restricted Indian land owned by a client who is of Indian descent from a federally recognized Indian tribe or held by the spouse or widow/er of that client, is not counted toward the resource limit if permission of the other people, the tribe, or an agency of the federal government must be received in order to dispose of the land.

(17) Receipt of money by a member of a federally recognized tribe from exercising federally protected rights or extraction of excluded resources, such as fishing, shell-fishing, or selling timber from protected land, is considered conversion of an excluded resource during the month of receipt. Any amount remaining from the conversion of this excluded resource on the first of the month after the month of receipt will remain excluded if it is used to purchase another excluded resource. Any amount remaining in the form of a countable resource (such as in a checking or savings account) on the first of the month after receipt, will be added to other countable resources for eligibility determinations.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-21-084, § 182-512-0350, filed 10/14/19, effective 11/14/19. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0350, filed 3/14/14, effective 4/14/14. WSR 11-24-018, recodified as § 182-512-0350, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.08.090 and ARRA of 2009, Public Law 111-5, Section 5006(b)*
- *42 C.F.R. 435.601, EEOICPA of 2000, Public Law 106398, Sec. 1, app., Title XXXVI (Oct. 30, 2000) (section 1 adopting as Appendix H.R. 5408), Section 3646 of the Appendix. WSR 10-15-069, § 388-475-0350, filed 7/16/10, effective 8/16/10. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-003, § 388-475-0350, filed 4/7/04, effective 6/1/04.*

##### **Wash. Admin. Code § 182-512-0400** SSI-related medical—Vehicles excluded as resources. {#sec-182-512-0400 omnilex-key=us-wa-regs-official--title-182--182-512-0400}

(1) For SSI-related medical programs, a vehicle is defined as anything used for transportation. In addition to cars and trucks, a vehicle can include boats, snowmobiles, and animal-drawn vehicles.

(2) One vehicle is excluded regardless of its value, if it is used to provide transportation for the SSI-related person or a member of the person's household.

(3) A vehicle used as the person's primary residence is excluded as the home, and does not count as the one excluded vehicle under subsection (2) of this section.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R § 155. WSR 17-03-116, § 182-512-0400, filed 1/17/17, effective 2/17/17. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0400, filed 3/14/14, effective 4/14/14. WSR 11-24-018, recodified as § 182-512-0400, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. WSR 10-13-077, § 388-475-0400, filed 6/15/10, effective 7/16/10. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-003, § 388-475-0400, filed 4/7/04, effective 6/1/04.*

##### **Wash. Admin. Code § 182-512-0450** SSI-related medical—Life insurance excluded as a resource. {#sec-182-512-0450 omnilex-key=us-wa-regs-official--title-182--182-512-0450}

(1) The agency excludes life insurance policies that do not have or cannot accrue a cash surrender value (CSV) in determining whether owned policies exceed the life insurance exclusion limits for resources and in determining burial fund exclusion limits.

(2) Policies owned by each spouse are evaluated and counted separately.

(3) If the total face value of all policies with a CSV potential that a person owns on the same insured is equal to or less than fifteen hundred dollars, the resource is excluded.

(4) If the total face value of all policies with a CSV potential that a person owns on the same insured is more than fifteen hundred dollars, the total CSV of the policies is counted toward the resource limit, unless the person designates such policies as burial funds. If they are designated as burial funds, they must be evaluated under the burial fund exclusion described in WAC 182-512-0500.

**History**
- *Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0450, filed 3/14/14, effective 4/14/14. WSR 11-24-018, recodified as § 182-512-0450, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-003, § 388-475-0450, filed 4/7/04, effective 6/1/04.*

##### **Wash. Admin. Code § 182-512-0500** SSI-related medical—Burial funds, contracts and spaces excluded as resources. {#sec-182-512-0500 omnilex-key=us-wa-regs-official--title-182--182-512-0500}

(1) For the purposes of this section, burial funds are funds set aside and clearly designated solely for burial and related expenses, and kept separate from all other resources not intended for burial. These include:

(a) Revocable burial contracts;

(b) Revocable burial trusts; or

(c) Other revocable burial arrangements. The designation is effective the first day of the month in which the person intended the funds to be set aside for burial.

(2) Burial funds in a revocable burial contract, burial trust, cash accounts, or other financial instruments with a definite cash value are excluded as resources for the person and their spouse, up to $1,500 each, when set aside solely for burial or cremation and related expenses.

(3) Interest earned in burial funds and appreciation in the value of excluded burial arrangements in subsection (2) of this section are excluded from resources and are not counted as income if left to accumulate and become part of the separate burial fund.

(4) An irrevocable burial account, burial trust, or other irrevocable burial arrangement, set aside solely for burial and related expenses, is not considered a resource. To be excluded, the amount set aside must be reasonably related to the anticipated death-related expenses.

(5) The $1,500 exclusion for burial funds described in subsection (2) of this section is reduced by:

(a) The face value of life insurance with CSV excluded in WAC 182-512-0450; and

(b) Amounts that meet the requirements of subsection (4) of this section.

(6) A person's burial funds are no longer excluded when they are mixed with other resources that are not related to burial.

(7) When excluded burial funds are spent for other purposes, the spent amount is added to other countable resources and any amount exceeding the resource limit is considered available income on the first of the month it is used. The amount remaining in the burial fund remains excluded.

(8) Burial space and accessories for the person and any member of the person's immediate family described in subsection (9) of this section are excluded. Burial space and accessories include:

(a) Conventional gravesites;

(b) Crypts, niches, and mausoleums;

(c) Urns, caskets and other repositories customarily used for the remains of deceased persons;

(d) Necessary and reasonable improvements to the burial space including, but not limited to:

(i) Vaults and burial containers;

(ii) Headstones, markers and plaques;

(iii) Arrangements for the opening and closing of the gravesite; and

(iv) Contracts for care and maintenance of the gravesite.

(e) A burial space purchase agreement that is fully or partially paid, and any accrued interest.

(9) Immediate family, for the purposes of subsection (8) of this section includes the person's:

(a) Spouse;

(b) Parents and adoptive parents;

(c) Minor and adult children, including adoptive and stepchildren;

(d) Siblings (brothers and sisters), including adoptive and stepsiblings;

(e) Spouses of any of the above.

None of the family members listed above, need to be dependent on or living with the person, to be considered immediate family members.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-11-038, § 182-512-0500, filed 5/11/23, effective 6/11/23. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0500, filed 3/14/14, effective 4/14/14. WSR 11-24-018, recodified as § 182-512-0500, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-003, § 388-475-0500, filed 4/7/04, effective 6/1/04.*

##### **Wash. Admin. Code § 182-512-0550** SSI-related medical—All other excluded resources. {#sec-182-512-0550 omnilex-key=us-wa-regs-official--title-182--182-512-0550}

All resources described in this section are excluded resources for SSI-related medical programs. Unless otherwise stated, interest earned on the resource amount is counted as unearned income.

(1) Resources necessary for a person who is blind or disabled to fulfill a self-sufficiency plan approved by the agency.

(2) Retroactive payments from SSI or old age, survivors, and disability insurance (OASDI), including benefits a person receives under the interim assistance reimbursement agreement with the Social Security Administration, are excluded for nine months following the month of receipt. This exclusion applies to:

(a) Payments received by the person, the person's spouse, or any other person financially responsible for the person;

(b) SSI payments for benefits due for the month(s) before the month of continuing payment;

(c) OASDI payments for benefits due for a month that is two or more months before the month of continuing payment; and

(d) Proceeds from these payments as long as they are held as cash, or in a checking or savings account. The funds may be commingled with other funds, but must remain identifiable from the other funds for this exclusion to apply. This exclusion does not apply once the payments have been converted to any other type of resource.

(3) All resources specifically excluded by federal law, such as those described in subsections (4) through (11) of this section as long as such funds are identifiable.

(4) Payments made under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970.

(5) The excluded resources described in WAC 182-512-0770 and other resources of American Indians/Alaska Natives that are excluded by federal law.

(6) Restitution payment and any interest earned from this payment to persons of Japanese or Aleut ancestry who were relocated and interned during war time under the Civil Liberties Act of 1988 and the Aleutian and Pribilof Islands Restitution Act.

(7) Funds received from the Agent Orange Settlement Fund or any other funds established to settle Agent Orange liability claims.

(8) Payments or interest accrued on payments received under the Radiation Exposure Compensation Act received by the injured person, the surviving spouse, children, grandchildren, or grandparents.

(9) Payments or interest accrued on payments received under the Energy Employees Occupational Illness Compensation Act of 2000 (EEOICA) received by the injured person, the surviving spouse, children, grandchildren, or grandparents.

(10) Payments from:

(a) The Dutch government under the Netherlands' Act on Benefits for Victims of Persecution (WUV).

(b) The Victims of Nazi Persecution Act of 1994 to survivors of the Holocaust.

(c) Susan Walker vs. Bayer Corporation, et al., 96-C-5024 (N.D. Ill.) (May 8, 1997) settlement funds.

(d) Ricky Ray Hemophilia Relief Fund Act of 1998 P.L. 105-369.

(11) The unspent social insurance payments received due to wage credits granted under sections 500 through 506 of the Austrian General Social Insurance Act.

(12) Tax refunds and earned income tax credit refunds and payments are excluded as resources for twelve months after the month of receipt.

(13) Payments from a state administered victim's compensation program for a period of nine calendar months after the month of receipt.

(14) Cash or in-kind items received as a settlement for the purpose of repairing or replacing a specific excluded resource are excluded:

(a) For nine months. This includes relocation assistance provided by state or local government.

(b) Up to a maximum of thirty months, when:

(i) The person intends to repair or replace the excluded resource; and

(ii) Circumstances beyond the control of the settlement recipient prevented the repair or replacement of the excluded resource within the first or second nine months of receipt of the settlement.

(c) For an indefinite period, if the settlement is from federal relocation assistance.

(d) Permanently, if the settlement is assistance received under the Disaster Relief and Emergency Assistance Act or other assistance provided under a federal statute because of a catastrophe which is declared to be a major disaster by the President of the United States, or is comparable assistance received from a state or local government or from a disaster assistance organization. Interest earned on this assistance is also excluded from resources. Any cash or in-kind items received as a settlement and excluded under this subsection are available resources when not used within the allowable time periods.

(15) Insurance proceeds or other assets recovered by a Holocaust survivor.

(16) Pension funds owned by an ineligible spouse. Pension funds are defined as funds held in a(n):

(a) Individual retirement account (IRA) as described by the IRS code; or

(b) Work-related pension plan (including plans for self-employed persons, known as Keogh plans).

(17) Cash payments received from a medical or social service agency to pay for medical or social services are excluded for one calendar month following the month of receipt.

(18) SSA- or division of vocational rehabilitation (DVR)-approved plans for achieving self-support (PASS) accounts, allowing blind or disabled persons to set aside resources necessary for the achievement of the plan's goals, are excluded.

(19) Food and nutrition programs with federal involvement. This includes Washington Basic Food, school reduced and free meals and milk programs and WIC.

(20) Gifts to, or for the benefit of, a person under eighteen years old who has a life-threatening condition, from an organization described in section 501 (c)(3) of the Internal Revenue Code of 1986 which is exempt from taxation under section 501(a) of that code, as follows:

(a) In-kind gifts that are not converted to cash; or

(b) Cash gifts up to a total of two thousand dollars in a calendar year.

(21) Veteran's payments made to, or on behalf of, natural children of Vietnam veterans regardless of their age or marital status, for any disability resulting from spina bifida suffered by these children.

(22) The following are among assets that are not resources and as such are neither excluded nor counted:

(a) Home energy assistance/support and maintenance assistance;

(b) Retroactive in-home supportive services payments to ineligible spouses and parents; and

(c) Gifts of domestic travel tickets.

(23) Resources accumulated in a separate account, designated by the client, that result from work activity during the client's enrollment in apple health for workers with disabilities (HWD) program under chapter 182-511 WAC.

(24) Limited to clients who have been or continue to be subject to participation as defined in WAC 182-513-1100 during the public health emergency (PHE), resources accumulated due to not increasing participation in response to section 6008(b) of the Families First Coronavirus Response Act (FFCRA) are excluded for:

(a) The duration of the PHE; and

(b) A period of twelve months after the PHE ends.

(25) Resources listed in the program operations manual system (POMS), not otherwise excluded under this section, are excluded (see SSA POMS Section SI 01130.050 http://secure.ssa.gov/apps10/poms.nsf/lnx/0501130050).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. 433.400. WSR 21-10-083, § 182-512-0550, filed 5/3/21, effective 6/3/21. Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 70. WSR 19-23-063, § 182-512-0550, filed 11/15/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-13-010, § 182-512-0550, filed 6/6/19, effective 7/7/19. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0550, filed 3/14/14, effective 4/14/14. WSR 11-24-018, recodified as § 182-512-0550, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090, chapter 74.12 RCW, and The Tax Relief, Unemployment Insurance Reauthorization, and Job Creation Act of 2010. WSR 11-21-025, § 388-475-0550, filed 10/11/11, effective 10/29/11. Statutory Authority: RCW 74.08.090 and ARRA of 2009, Public Law 111-5, Section 5006(b)*
- *42 C.F.R. 435.601, EEOICPA of 2000, Public Law 106398, Sec. 1, app., Title XXXVI (Oct. 30, 2000) (section 1 adopting as Appendix H.R. 5408), Section 3646 of the Appendix. WSR 10-15-069, § 388-475-0550, filed 7/16/10, effective 8/16/10. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500, and Social Security Act as amended by P.L. 108-203. WSR 06-04-046, § 388-475-0550, filed 1/26/06, effective 2/26/06. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-004, § 388-475-0550, filed 4/7/04, effective 6/1/04.*

##### **Wash. Admin. Code § 182-512-0600** SSI-related medical—Definition of income. {#sec-182-512-0600 omnilex-key=us-wa-regs-official--title-182--182-512-0600}

(1) Income is anything a client receives in cash or in-kind that can be used to meet the client's needs for shelter. Income can be earned or unearned.

(2) Some receipts are not income because they do not meet the definition of income above. Some types of receipts that are not income are:

(a) Cash or in-kind assistance from federal, state, or local government programs whose purpose is to provide medical care or services;

(b) Some in-kind payments that are not shelter coming from nongovernmental programs whose purposes are to provide medical care or medical services;

(c) Payments for repair or replacement of an exempt resource;

(d) Refunds or rebates for money already paid;

(e) Receipts from sale of a resource;

(f) Replacement of income already received (see 20 C.F.R. 416.1103 for a more complete list of receipts that are not income); and

(g) Receipts from extraction of exempt resources for a member of a federally recognized tribe.

(3) Earned income includes the following types of payments:

(a) Gross wages and salaries, including garnished amounts;

(b) Commissions and bonuses;

(c) Severance pay;

(d) Other special payments received because of employment;

(e) Net earnings from self-employment (WAC 182-512-0840 describes earnings exclusions);

(f) Self-employment income of tribal members unless the income is specifically exempted by treaty;

(g) Payments for services performed in a sheltered workshop or work activities center;

(h) Royalties earned by a client in connection with any publication of their work and any honoraria received for services rendered; and

(i) In-kind payments made in lieu of cash wages, including the value of shelter.

(4) Unearned income is all income that is not earned income. Some types of unearned income are:

(a) Annuities, pensions, and other periodic payments;

(b) Alimony and support payments;

(c) Voluntary or court-ordered child support payments, including arrears, received from a noncustodial parent for the benefit of a child are the income of the child;

(d) Dividends and interest;

(e) Royalties (except for royalties earned by a client in connection with any publication of their work and any honoraria received for services rendered which would be earned income);

(f) Capital gains;

(g) Rents;

(h) Benefits received as the result of another's death to the extent that the total amount exceeds the expenses of the deceased person's last illness and burial paid by the recipient;

(i) Gifts;

(j) Inheritances;

(k) Prizes and awards; and

(l) Amounts received by tribal members from gaming revenues with the exceptions cited in WAC 182-512-0770(3).

(5) Some items which may be withheld from income, but which the agency considers as received income are:

(a) Federal, state, or local income taxes;

(b) Health or life insurance premiums;

(c) SMI premiums;

(d) Union dues;

(e) Penalty deductions for failure to report changes;

(f) Loan payments;

(g) Garnishments;

(h) Child support payments, court ordered or voluntary (WAC 182-512-0900 has an exception for deemors);

(i) Service fees charged on interest-bearing checking accounts;

(j) Inheritance taxes; and

(k) Guardianship fees if presence of a guardian is not a requirement for receiving the income.

(6) Countable income, for the purposes of this chapter, means all income that is available to the client:

(a) If it cannot be excluded; and

(b) After deducting all allowable disregards and deductions.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 20 C.F.R. Part 416, Subpart K. WSR 24-18-062, § 182-512-0600, filed 8/28/24, effective 9/30/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-11-050, § 182-512-0600, filed 5/10/19, effective 6/10/19. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0600, filed 3/14/14, effective 4/14/14. WSR 11-24-018, recodified as § 182-512-0600, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.08.090 and ARRA of 2009 (Recovery Act), Public Law 111-5, Section 5006(b)*
- *42 C.F.R. 435.601, EEOICPA of 2000, Public Law 106398, Sec. 1, app., Title XXXVI (Oct. 30, 2000) (section 1 adopting as Appendix H.R. 5408), Section 3646 of the Appendix. WSR 10-15-069, § 388-475-0600, filed 7/16/10, effective 8/16/10. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-004, § 388-475-0600, filed 4/7/04, effective 6/1/04.*

##### **Wash. Admin. Code § 182-512-0650** SSI-related medical—Available income. {#sec-182-512-0650 omnilex-key=us-wa-regs-official--title-182--182-512-0650}

(1) Income is considered available to a person at the earliest of when it is:

(a) Received; or

(b) Credited to a person's account; or

(c) Set aside for the person's use; or

(d) Used or can be used to meet the person's needs for shelter.

(2) Anticipated nonrecurring lump sum payments are treated as income in the month received, with the exception of those listed in WAC 182-512-0700(4), and any remainder is considered a resource in the following month.

(3) Reoccurring income is considered available in the month of normal receipt, even if the financial institution posts it before or after the month of normal receipt.

(4) In-kind income received from anyone other than a legally responsible relative is considered available income only if it is earned income.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-15-053, s 182-512-0650, filed 7/10/25, effective 8/10/25. Statutory Authority: RCW 41.05.021, 41.05.160, and 20 C.F.R. Part 416, Subpart K. WSR 24-18-062, § 182-512-0650, filed 8/28/24, effective 9/30/24. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0650, filed 3/14/14, effective 4/14/14. WSR 11-24-018, recodified as § 182-512-0650, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-004, § 388-475-0650, filed 4/7/04, effective 6/1/04.*

##### **Wash. Admin. Code § 182-512-0700** SSI-related medical—Income eligibility. {#sec-182-512-0700 omnilex-key=us-wa-regs-official--title-182--182-512-0700}

(1) The agency does not count income until the person begins to receive it. Income is budgeted prospectively for all Washington apple health health care programs.

(2) Anticipated nonrecurring lump sum payments other than retroactive SSI/SSDI payments are considered income in the month received, subject to reporting requirements in WAC 182-504-0110. Any unspent portion is considered a resource the first of the following month.

(3) The agency follows income and resource methodologies of the supplemental security income (SSI) program defined in federal law when determining eligibility for apple health SSI-related medical or medicare savings programs unless the agency adopts rules that are less restrictive than those of the SSI program.

(4) Exceptions to the SSI income methodology:

(a) Lump sum payments from a retroactive old age, survivors, and disability insurance (OASDI) benefit, when reduced by the amount of SSI received during the period covered by the payment, are not counted as income;

(b) Unspent retroactive lump sum money from SSI or OASDI is excluded as a resource for nine months following receipt of the lump sum; and

(c) Both the principal and interest portions of payments from a sales contract, that meet the definition in WAC 182-512-0350(10), are unearned income.

(5) To be eligible for apple health categorically needy (CN) SSI-related health care coverage, a person's countable income cannot exceed the apple health CN program standard described in:

(a) WAC 182-512-0010 for noninstitutional apple health coverage unless living in an alternate living facility; or

(b) WAC 182-513-1205 for noninstitutional apple health CN coverage while living in an alternate living facility; or

(c) WAC 182-513-1315 for institutional and waiver services coverage.

(6) To be eligible for SSI-related health care coverage provided under the apple health medically needy (MN) program, a person must:

(a) Have countable income at or below the effective apple health MN program standard as described in WAC 182-519-0050;

(b) Satisfy spenddown requirements described in WAC 182-519-0110;

(c) Meet the requirements for noninstitutional apple health MN coverage while living in an alternate living facility (ALF). See WAC 182-513-1205; or

(d) Meet eligibility for institutional apple health MN coverage described in WAC 182-513-1315.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-15-053, s 182-512-0700, filed 7/10/25, effective 8/10/25*
- *WSR 19-13-010, § 182-512-0700, filed 6/6/19, effective 7/7/19. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0700, filed 3/14/14, effective 4/14/14. Statutory Authority: RCW 41.05.021. WSR 12-20-001, § 182-512-0700, filed 9/19/12, effective 10/20/12. WSR 11-24-018, recodified as § 182-512-0700, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500, and Social Security Act as amended by P.L. 108-203. WSR 06-04-046, § 388-475-0700, filed 1/26/06, effective 2/26/06. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-004, § 388-475-0700, filed 4/7/04, effective 6/1/04.*

##### **Wash. Admin. Code § 182-512-0750** SSI-related medical—Countable unearned income. {#sec-182-512-0750 omnilex-key=us-wa-regs-official--title-182--182-512-0750}

The agency counts unearned income for Washington apple health (WAH) SSI-related medical programs as follows:

(1) The total amount of income benefits to which a person is entitled is treated as available unearned income even when the benefits are:

(a) Reduced through the withholding of a portion of the benefit amount to repay a legal obligation;

(b) Garnished to repay a debt, other legal obligation, or make any other payment such as payment of medicare premiums.

(2) Payments received on a loan:

(a) Interest paid on the loan amount is considered unearned income; and

(b) Payments on the loan principal are not considered income. However, any amounts retained on the first of the following month are considered a resource.

(3) Money borrowed by a person, which must be repaid, is not considered income. It is considered a loan. If the money received does not need to be repaid, it is considered a gift.

(4) Rental income received for the use of real or personal property, such as land, housing or machinery is considered unearned income. The countable portion of rental income received is the amount left after deducting necessary expenses of managing and maintaining the property paid in that month or carried over from a previous month. Necessary expenses are those such as:

(a) Advertising for tenants;

(b) Property taxes;

(c) Property insurance;

(d) Repairs and maintenance on the property; and

(e) Interest and escrow portions of a mortgage.

note: When a person is in the business of renting properties and actively works the business (over twenty hours per week), the income is counted as earned income.

**History**
- *Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0750, filed 3/14/14, effective 4/14/14. WSR 11-24-018, recodified as § 182-512-0750, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-004, § 388-475-0750, filed 4/7/04, effective 6/1/04.*

##### **Wash. Admin. Code § 182-512-0760** SSI-related medical—Education assistance. {#sec-182-512-0760 omnilex-key=us-wa-regs-official--title-182--182-512-0760}

(1) The agency does not count:

(a) Educational assistance in the form of grants, loans or work study, issued from Title IV of the Higher Education Amendments (Title IV – HEA) and Bureau of Indian Affairs (BIA) education assistance programs. Examples of Title IV – HEA and BIA educational assistance include, but are not limited to:

(i) College work study (federal and state);

(ii) Pell grants; and

(iii) BIA higher education grants.

(b) Educational assistance in the form of grants, loans or work study made available under any program administered by the department of education (DOE) to an undergraduate student. Examples of programs administered by DOE include, but are not limited to:

(i) Christa McAuliffe Fellowship Program;

(ii) Jacob K. Javits Fellowship Program; and

(iii) Library Career Training Program.

(2) For assistance in the form of grants, loans or work study under the Carl D. Perkins Vocational and Applied Technology Education Act, P.L. 101-391:

(a) If the person attends school half-time or more, the agency subtracts the following expenses:

(i) Tuition;

(ii) Fees;

(iii) Costs for purchase or rental of equipment, materials, or supplies required of all students in the same course of study;

(iv) Books;

(v) Supplies;

(vi) Transportation;

(vii) Dependent care; and

(viii) Miscellaneous personal expenses.

(b) If the person attends school less than half-time, the agency subtracts the following expenses:

(i) Tuition;

(ii) Fees; and

(iii) Costs for purchase or rental of equipment, materials, or supplies required of all students in the same course of study.

(3) WorkFirst work-study income is not counted.

(4) Income received from work study program that is not excluded under subsection (1) of this section is counted as earned income and is subject to earned income disregards as described in WAC 182-512-0840(2).

(5) If the person receives Veteran's Administration Educational Assistance:

(a) All applicable attendance costs are subtracted; and

(b) The remaining income is budgeted as unearned income.

**History**
- *Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0760, filed 3/14/14, effective 4/14/14.*

##### **Wash. Admin. Code § 182-512-0770** SSI-related medical—American Indian or Alaska Native excluded income and resources. {#sec-182-512-0770 omnilex-key=us-wa-regs-official--title-182--182-512-0770}

(1) The agency excludes the following types of income from being considered when determining eligibility for Washington apple health (WAH) categorically needy (CN) and medically needy (MN) SSI-related programs for American Indians or Alaska Natives:

(a) Distributions from Alaska Native corporations and settlement trusts;

(b) Distributions from any property held in trust, subject to federal restrictions, located within the most recent boundaries of a prior federal reservation, or otherwise under the supervision of the Secretary of the Interior;

(c) Distributions and payments from rents, leases, rights of way, royalties, usage rights, or natural resource extraction and harvest from:

(i) Rights of ownership or possession in any lands described in (b) of this subsection; or

(ii) Federally protected rights regarding off-reservation hunting, fishing, gathering, or usage of natural resources.

(d) Distributions resulting from real property ownership interests related to natural resources and improvements that are:

(i) Located on or near a reservation or within the most recent boundaries of a prior federal reservation; or

(ii) Resulting from the exercise of federally protected rights relating to such real property ownership interests.

(e) Payments resulting from:

(i) Ownership interests in or usage rights to items that have unique religious, spiritual, traditional, or cultural significance; or

(ii) Rights that support subsistence or a traditional lifestyle according to applicable tribal law or custom.

(f) Student financial assistance provided under the Bureau of Indian Affairs education programs; and

(g) Any other applicable income exclusion as provided by federal law, regulation, or rule.

(2) The agency excludes the following types of resources from being considered when determining eligibility for WAH-CN and WAH-MN SSI-related programs for American Indians or Alaska Natives:

(a) Property, including real property and improvements, that is:

(i) Held in trust, subject to federal restrictions, or otherwise under the supervision of the Secretary of the Interior; and

(ii) Located on a reservation, including any federally recognized Indian tribe's reservation, pueblo, or colony, including:

(A) Former reservations in Oklahoma;

(B) Alaska Native regions established by the Alaska Native Claims Settlement Act; and

(C) Indian allotments on or near a reservation as designated and approved by the Bureau of Indian Affairs of the Department of the Interior.

(b) Property located within the most recent boundaries of a prior federal reservation for any federally recognized tribe not described in (a) of this subsection;

(c) Ownership interests in rents, leases, royalties, or usage rights related to natural resources (including, but not limited to, extraction of natural resources or harvesting of timber, other plants and plant products, animals, fish and shellfish) resulting from the exercise of federally protected rights; and

(d) Ownership interests in or usage rights to items not covered in (a), (b), or (c) of this subsection that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable tribal law or custom.

(3) When determining eligibility for WAH-CN and WAH-MN SSI-related programs for American Indians or Alaska Natives, the agency counts or excludes amounts received by tribal members from exercise of gaming revenues (per capita distributions) that are retained after the month of receipt based on the type of resource in which the money is retained. If the amounts are retained in a countable resource (for example, cash, checking account, or savings account), the agency treats the amounts as a countable resource. If the amounts are converted to an excluded resource (for example, personal property like a refrigerator), the agency treats the amounts as excluded resources.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155*
- *42 U.S.C. Chapter 157. WSR 15-07-065, § 182-512-0770, filed 3/16/15, effective 4/16/15. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0770, filed 3/14/14, effective 4/14/14.*

##### **Wash. Admin. Code § 182-512-0780** SSI-related medical—Employment and training programs. {#sec-182-512-0780 omnilex-key=us-wa-regs-official--title-182--182-512-0780}

(1) The agency excludes income received from the following programs:

(a) Payments issued under the Workforce Investment Act (WIA);

(b) Payments issued under the National and Community Service Trust Act of 1993. This includes payments made through the AmeriCorps program;

(c) Payments issued under Title I of the Domestic Volunteer Act of 1973, such as VISTA, AmeriCorps VISTA, University Year for Action, and Urban Crime Prevention Program; and

(d) All payments issued under Title II of the Domestic Volunteer Act of 1973. These include:

(i) Retired Senior Volunteer Program (RSVP);

(ii) Foster Grandparents Program; and

(iii) Senior Companion Program.

(2) The agency counts training allowances from vocational and rehabilitative programs as earned income when:

(a) The program is recognized by federal, state, or local governments; and

(b) The allowance is not a reimbursement.

(3) The agency excludes support service payments received by or made on behalf of WorkFirst recipients.

**History**
- *Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0780, filed 3/14/14, effective 4/14/14.*

##### **Wash. Admin. Code § 182-512-0785** SSI-related medical—Effect of a sponsor's income. {#sec-182-512-0785 omnilex-key=us-wa-regs-official--title-182--182-512-0785}

(1) The following definitions apply to this section:

(a) "Sponsor" means a person who agreed to meet the needs of a sponsored immigrant by signing a United States Citizenship and Immigration Services Affidavit of Support form I-864 or I-864A. This includes a sponsor's spouse if the spouse signed the affidavit of support.

(b) "Sponsored immigrant" means a person who must have a sponsor under the Immigration and Nationality Act (INA) to be admitted into the United States for residence.

(c) "Deeming" means the agency counts a part of the sponsor's income and resources as available to the sponsored immigrant.

(d) "Exempt" means the person meets one of the conditions of WAC 182-512-0790.

(2) If the person is a sponsored immigrant and is not exempt from deeming, the person must provide the following information to be eligible for Washington apple health (WAH) SSI-related coverage even if the person is not receiving support from their sponsor:

(a) The name and address of the sponsor;

(b) The income and resources of the sponsor; and

(c) Any additional information needed for the agency to determine if:

(i) Income must be deemed to the person's medical assistance unit (MAU); and

(ii) The amount of income that must be deemed to the MAU.

(3) If the person is not eligible for coverage because the agency does not have the information needed regarding the sponsor, eligibility for other unsponsored household members applying for coverage is not delayed. Although the sponsored immigrant may not be eligible for coverage, the following is counted when determining the eligibility of other household members:

(a) All earned or unearned income of the sponsored immigrant that is not excluded under chapter 182-512 WAC; and

(b) All deductions the sponsored immigrant would be eligible for under chapter 182-512 WAC.

(4) If the person refuses to provide the agency with the information needed regarding the sponsor, the other adult members in the MAU must provide the information. If the same person sponsored everyone in the MAU, the entire MAU is not eligible for WAH coverage until someone provides the information that is needed.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-15-005, § 182-512-0785, filed 7/6/18, effective 8/6/18. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0785, filed 3/14/14, effective 4/14/14.*

##### **Wash. Admin. Code § 182-512-0790** SSI-related medical—Exemption from sponsor deeming. {#sec-182-512-0790 omnilex-key=us-wa-regs-official--title-182--182-512-0790}

(1) A person who meets any of the following conditions is permanently exempt from deeming and the agency does not count the sponsor's income or resources when determining eligibility for Washington apple health (WAH) SSI-related coverage:

(a) The Immigration and Nationality Act (INA) does not require the person to have a sponsor. Immigrants who are not required to have a sponsor include those with the following status with U.S. Citizenship and Immigration Services (USCIS):

(i) Refugee;

(ii) Parolee admitted under Section 212(d)(5) of the Immigration and Nationality Act (INA);

(iii) Asylee;

(iv) Cuban/Haitian entrant under Section 202 of the Immigration Reform and Control Act of 1986 (IRCA);

(v) Amerasians admitted with an I-551 admission code of AM1, AM2, AM3, AM6, AM7, or AM8; and

(vi) Special immigrant from Iraq or Afghanistan.

(b) The person meets the blindness or disability requirements described in WAC 182-512-0050(1);

(c) The person was sponsored by an organization or group as opposed to another person;

(d) The person is a nonqualified or undocumented alien as defined in WAC 182-503-0530 (3) and (4);

(e) The person has worked or can get credit for forty qualifying quarters of work under Title II of the Social Security Act. The agency does not count a quarter of work toward this requirement if the person working received TANF, Basic Food, SSI, CHIP, or nonemergency medicaid coverage. A quarter of work earned by the following people is counted toward the forty qualifying quarters:

(i) The person;

(ii) The person's parents for the time they worked before the person turned eighteen years old (including the time they worked before the person's birth); and

(iii) The person's spouse if still married or if the spouse is deceased.

(f) The person has become a United States (U.S.) citizen;

(g) The sponsor is dead; or

(h) If USCIS or a court decides that the person, their child, or their parent was a victim of domestic violence from the person's sponsor and:

(i) The person no longer lives with the sponsor; and

(ii) Leaving the sponsor caused the need for coverage.

(2) A person is exempt from the deeming process while in the same assistance unit (AU) as the sponsor.

(3) If the person, their child, or their parent was a victim of domestic violence, the person is exempt from the deeming process for twelve months if:

(a) They no longer live with the person who committed the violence; and

(b) Leaving this person caused the need for health coverage.

(4) If the person's medical assistance unit (MAU) has income at or below one hundred thirty percent of the federal poverty level (FPL), the person is exempt from the deeming process for twelve months. This is called the "indigence exemption." A person may choose to use this exemption or not to use this exemption in full knowledge of the possible risks involved. See risks in subsection (5) of this section. For this rule, the agency counts the following as income:

(a) Earned and unearned income received by any member of the MAU from any source; and

(b) The value of any noncash items of value such as free rent, commodities, goods, or services received from another person or organization.

(5) A person who chooses not to use the indigence exemption must provide verification of the sponsor's income and resources and will be subject to the deeming rules described in WAC 182-512-0795.

(6) For federally funded programs, if the person uses the indigence exemption, the agency is required by law to give the U.S. Attorney General the following information:

(a) The names of the sponsored people in the person's AU;

(b) That the person is exempt from deeming due to income;

(c) The sponsor's name; and

(d) The effective date that the twelve-month exemption began.

**History**
- *Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0790, filed 3/14/14, effective 4/14/14.*

##### **Wash. Admin. Code § 182-512-0795** SSI-related medical—Budgeting a sponsor's income. {#sec-182-512-0795 omnilex-key=us-wa-regs-official--title-182--182-512-0795}

(1) The agency counts some of the income of a person's sponsor as unearned income to the medical assistance unit (MAU) if:

(a) The sponsor signed the U.S. Citizenship and Immigration Services (USCIS) Affidavit of Support form I-864 or I-864A; and

(b) The person is not exempt from the deeming process in WAC 182-512-0790.

(2) The agency determines the amount of income that must be deemed from the sponsor by taking the following steps:

(a) Add together all of the sponsor's earned and unearned income that is not excluded under WAC 182-512-0860;

(b) Add all of the spouse's earned and unearned income that is not excluded under WAC 182-512-0860;

(c) Subtract an allocation for the sponsor equal to the one-person federal benefit rate (FBR);

(d) Subtract an allocation for the sponsor's spouse as follows:

(i) If the spouse is also a cosponsor of the noncitizen, allow an allocation equal to the one-person FBR; or

(ii) If the spouse is not a cosponsor but lived in the same household as the sponsor, allow an allocation equal to one-half of the FBR.

(e) Subtract an allocation equal to one-half FBR for each dependent of the sponsor. The dependent's income is not subtracted from the sponsor's dependent's allocation; and

(f) The income remaining is deemed as unearned income to the noncitizen and is added to the noncitizen's own income.

(3) If the sponsor has sponsored other noncitizens, all of the sponsor's income is deemed to each person that they sponsored and is not divided between them.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 14-24-102, § 182-512-0795, filed 12/2/14, effective 1/2/15. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0795, filed 3/14/14, effective 4/14/14.*

##### **Wash. Admin. Code § 182-512-0800** SSI-related medical—General income exclusions. {#sec-182-512-0800 omnilex-key=us-wa-regs-official--title-182--182-512-0800}

The agency excludes, or does not consider, the following when determining a person's eligibility for Washington apple health SSI-related medical programs:

(1) The first $20 per month of unearned income. If there is less than $20 of unearned income in a month, the remainder is excluded from earned income in that month.

(a) The $20 limit is the same, whether applying it for a couple or for a single person.

(b) The disregard does not apply to income paid totally or partially by the federal government or a nongovernmental agency on the basis of an eligible person's needs.

(c) The $20 disregard is applied after all exclusions have been taken from income.

(2) Income that is not reasonably anticipated or is received infrequently or irregularly, whether for a single person or each person in a couple when it is:

(a) Earned and does not exceed a total of $30 per calendar quarter; or

(b) Unearned and does not exceed a total of $60 per calendar quarter;

(c) An increase in a person's burial funds that were established on or after November 1, 1982, if the increase is the result of:

(i) Interest earned on excluded burial funds; or

(ii) Appreciation in the value of an excluded burial arrangement that was left to accumulate and become part of separately identified burial funds.

(3) Essential expenses necessary for a person to receive compensation (e.g., necessary legal fees in order to get a settlement).

(4) Receipts, which are not considered income, when they are for:

(a) Replacement or repair of an exempt resource;

(b) Prepayment or repayment of medical care paid by a health insurance policy or medical service program; or

(c) Payments made under a credit life or credit disability policy.

(5) The fee a guardian or representative payee charges as reimbursement for providing services, when such services are a requirement for the person to receive payment of the income.

(6) Funds representing shared household costs.

(7) Crime victim's compensation.

(8) The value of a common transportation ticket, given as a gift, that is used for transportation and not converted to cash.

(9) Gifts that are not for clothing or shelter.

(10) In-kind payments. The agency does not consider in-kind income received from someone other than a person legally responsible for the person unless it is earned. Therefore, the following in-kind payments are not counted when determining eligibility for apple health SSI-related medical programs:

(a) In-kind payments for services paid by a person's employer if:

(i) The service is not provided in the course of an employer's trade or business; or

(ii) The service is in the form of food that is on the employer's business premises and for the employer's convenience; or

(iii) The service is in the form of shelter that is on the employer's business premises, for the employer's convenience, and required to be accepted by the employee as a condition of employment.

(b) In-kind payments made to people in the following categories:

(i) Agricultural employees;

(ii) Domestic employees;

(iii) Members of the uniformed services; and

(iv) Persons who work from home to produce specific products for the employer from materials supplied by the employer.

(11) Unearned income withheld, before receipt by the person, for mandatory income tax purposes.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 20 C.F.R. Part 416, Subpart K. WSR 24-18-062, § 182-512-0800, filed 8/28/24, effective 9/30/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-08-085, § 182-512-0800, filed 4/7/21, effective 5/8/21. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0800, filed 3/14/14, effective 4/14/14. WSR 11-24-018, recodified as § 182-512-0800, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500, and Social Security Act as amended by P.L. 108-203. WSR 06-04-046, § 388-475-0800, filed 1/26/06, effective 2/26/06. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-005, § 388-475-0800, filed 4/7/04, effective 6/1/04.*

##### **Wash. Admin. Code § 182-512-0820** SSI-related medical—Child-related income exclusions and allocations. {#sec-182-512-0820 omnilex-key=us-wa-regs-official--title-182--182-512-0820}

(1) For the purposes of Washington apple health SSI-related medical eligibility determinations under chapter 182-512 WAC, a child is defined as a person who is:

(a) Unmarried;

(b) Living in the household of the SSI-related applicant;

(c) The natural, adopted or stepchild of the SSI-related applicant or the applicant's spouse;

(d) Not receiving a needs-based cash payment such as TANF or SSI; and

(e) Either:

(i) Age seventeen or younger; or

(ii) Age twenty-one or younger and meets the SSI-related definition of a student described in subsection (6) of this section.

(2) The agency allows an allocation for the support of a child when determining the countable income of an SSI-related applicant. The allocation is calculated as follows:

(a) For apple health categorically needy (CN) health care coverage, the allocation is deducted from the countable income of a nonapplying spouse before determining the amount of the nonapplying spouse's income to be deemed to the SSI-related applicant. Allocations to children are not deducted from the income of an unmarried SSI-related applicant.

(b) For apple health medically needy (MN) medical coverage, the allocation is first deducted from the income of the nonapplying spouse as described in subsection (2)(a) of this section when the SSI-related applicant is married, and from the income of the applicant when the applicant is not married.

(3) The child's countable income, if any, is subtracted from the maximum child's allowance before determining the amount of allocation.

(4) Foster care payments received for a child who is not SSI-eligible and who is living in the household, placed there by a licensed, nonprofit or public child placement or childcare agency are excluded from income regardless of whether the client requesting or receiving SSI-related medical is the adult foster parent or the child who was placed.

(5) Adoption support payments, received by an adult for a child in the household that are designated for the child's needs, are excluded as income. Adoption support payments that are not specifically designated for the child's needs are not excluded and are considered unearned income to the adult.

(6) The agency excludes the earned income of a client age twenty-one or younger if that client is a student. In order to allow the student earned income exclusion, a student must:

(a) Attend a school, college, or university a minimum of eight hours a week; or

(b) Pursue a vocational or technical training program designed to prepare the student for gainful employment a minimum of twelve hours per week; or

(c) Attend school or be home schooled in grades seven through twelve at least twelve hours per week.

(7) Any portion of a grant, scholarship, fellowship, or gift used for tuition, fees and/or other necessary educational expenses at any educational institution is excluded from income and not counted as a resource for nine months after the month of receipt.

(8) One-third of child support payments received for a child who is an applicant for SSI-related medical is excluded from the child's income. Child support payments that are subject to the one-third deduction may be voluntary or court-ordered payments for current support or arrears.

(9) The following gifts to, or for the benefit of, a client under eighteen years old who has a life-threatening condition, from an organization described in section 501 (c)(3) of the Internal Revenue Code of 1986 which is exempt from taxation under section 501(a) of that code, are excluded:

(a) In-kind gifts that are not converted to cash; and

(b) Cash gifts up to a total of two thousand dollars in a calendar year.

(10) Veteran's payments made to, or on behalf of, natural children of Vietnam veterans regardless of their age or marital status, for any disability resulting from spina bifida suffered by these children are excluded from income. Any portion of a veteran's payment that is designed as the dependent's income is countable income to the dependent and not the applicant (assuming the applicant is not the dependent).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-11-050, § 182-512-0820, filed 5/10/19, effective 6/10/19. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0820, filed 3/14/14, effective 4/14/14. WSR 11-24-018, recodified as § 182-512-0820, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. WSR 11-15-023, § 388-475-0820, filed 7/8/11, effective 8/8/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500, and Social Security Act as amended by P.L. 108-203. WSR 06-04-046, § 388-475-0820, filed 1/26/06, effective 2/26/06. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-005, § 388-475-0820, filed 4/7/04, effective 6/1/04.*

##### **Wash. Admin. Code § 182-512-0840** SSI-related medical—Work- and agency-related income exclusions. {#sec-182-512-0840 omnilex-key=us-wa-regs-official--title-182--182-512-0840}

The agency excludes the following when determining eligibility for Washington apple health (WAH) SSI-related medical programs:

(1) Work related expenses:

(a) That enable an SSI-related person to work; or

(b) That allows a blind or disabled person to work and that are directly related to the person's impairment.

(2) First sixty-five dollars plus one-half of the remainder of earned income. This is considered a work allowance/incentive. This deduction does not apply to income already excluded.

(3) Any portion of self-employment income normally allowed as an income deduction by the Internal Revenue Service (IRS).

(4) Earned income of a person age twenty-one or younger if that person meets the definition of a student as defined in WAC 182-512-0820.

(5) Veteran's aid and attendance, housebound allowance, unusual/unreimbursed medical expenses (UME) paid by the VA to some disabled veterans, their spouses, widows or parents. For people receiving WAH long-term care services, see chapter 182-513 WAC.

(6) Department of veterans affairs benefits designated for the veteran's dependent as long as the SSI-related applicant is not the dependent receiving the income. If an SSI-related applicant receives a dependent allowance based on the veteran's or veteran's survivor claim, the income is countable as long as it is not paid due to unusual medical expenses (UME).

(7) Payments provided in cash or in-kind, to an ineligible or nonapplying spouse, under any government program that provides social services provided to the person, such as chore services or attendant care.

(8) SSA refunds for medicare buy-in premiums paid by the person when the state also paid the premiums.

(9) Income that causes a person to lose SSI eligibility, due solely to reduction in the SSP.

(10) Tax rebates or special payments excluded under other statutes.

(11) Any public agency refund of taxes paid on real property or on food.

**History**
- *Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0840, filed 3/14/14, effective 4/14/14. WSR 11-24-018, recodified as § 182-512-0840, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. WSR 11-15-023, § 388-475-0840, filed 7/8/11, effective 8/8/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-005, § 388-475-0840, filed 4/7/04, effective 6/1/04.*

##### **Wash. Admin. Code § 182-512-0860** SSI-related medical—Income exclusions under federal statute or other state laws. {#sec-182-512-0860 omnilex-key=us-wa-regs-official--title-182--182-512-0860}

The Social Security Act and other federal statutes or state laws list income that the agency excludes when determining eligibility for Washington apple health (WAH) SSI-related medical programs. These exclusions include, but are not limited to:

(1) Income tax refunds;

(2) Federal earned income tax credit (EITC) payments for 12 months after the month of receipt;

(3) Compensation provided to volunteers in the Corporation for National and Community Service (CNCS), formerly known as ACTION programs established by the Domestic Volunteer Service Act of 1973. P.L. 93-113;

(4) Assistance to a person (other than wages or salaries) under the Older Americans Act of 1965, as amended by section 102 (h)(1) of Pub. L. 95-478 (92 Stat. 1515, 42 U.S.C. 3020a);

(5) Federal, state and local government payments including assistance provided in cash or in-kind under any government program that provides medical or social services;

(6) Certain cash or in-kind payments a person receives from a governmental or nongovernmental medical or social service agency to pay for medical or social services;

(7) Value of food provided through a federal or nonprofit food program such as WIC, donated food program, school lunch program;

(8) Assistance based on need, including:

(a) Any federal SSI income or state supplement payment (SSP) based on financial need;

(b) Basic Food;

(c) State-funded cash assistance;

(d) CEAP;

(e) TANF; and

(f) Bureau of Indian Affairs (BIA) general assistance.

(9) Housing assistance from a federal program such as HUD if paid under:

(a) United States Housing Act of 1937 (section 1437 et seq. of 42 U.S.C.);

(b) National Housing Act (section 1701 et seq. of 12 U.S.C.);

(c) Section 101 of the Housing and Urban Development Act of 1965 (section 1701s of 12 U.S.C., section 1451 of 42 U.S.C.);

(d) Title V of the Housing Act of 1949 (section 1471 et seq. of 42 U.S.C.);

(e) Section 202(h) of the Housing Act of 1959; or

(f) Weatherization provided to low-income homeowners by programs that consider income in the eligibility determinations.

(10) Energy assistance payments including:

(a) Those to prevent fuel cutoffs; and

(b) Those to promote energy efficiency.

(11) Income from employment and training programs as specified in WAC 182-512-0780.

(12) Foster grandparents program;

(13) Title IV-E and state foster care maintenance payments if the foster child is not included in the assistance unit;

(14) The value of any childcare provided or arranged (or any payment for such care or reimbursement for costs incurred for such care) under the Child Care and Development Block Grant Act, as amended by section 8(b) of P.L. 102-586 (106 Stat. 5035);

(15) Educational assistance as specified in WAC 182-512-0760;

(16) The excluded income described in WAC 182-512-0770 and other income received by American Indians/Alaska Natives that is excluded by federal law;

(17) Payments from Susan Walker v. Bayer Corporation, et al., 96-c-5024 (N.D. Ill) (May 8, 1997) settlement funds;

(18) Payments from Ricky Ray Hemophilia Relief Fund Act of 1998, P.L. 105-369;

(19) Disaster assistance paid under Federal Disaster Relief P.L. 100-387 and Emergency Assistance Act, P.L. 93-288 amended by P.L. 100-707 and for farmers P.L. 100-387;

(20) Payments to certain survivors of the Holocaust as victims of Nazi persecution; payments excluded pursuant to section 1(a) of the Victims of Nazi Persecution Act of 1994, P.L. 103-286 (108 Stat. 1450);

(21) Payments made under section 500 through 506 of the Austrian General Social Insurance Act;

(22) Payments made under the Netherlands' Act on Benefits for Victims of Persecution (WUV);

(23) Restitution payments and interest earned to Japanese Americans or their survivors, and Aleuts interned during World War II, established by P.L. 100-383;

(24) Payments made from the Agent Orange Settlement Funds or any other funds to settle Agent Orange liability claims established by P.L. 101-201;

(25) Payments made under section six of the Radiation Exposure Compensation Act established by P.L. 101-426;

(26) Any interest or dividend is excluded as income, except for the community spouse of an institutionalized person; and

(27) Working families' tax credit payments under RCW 82.08.0206.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-076, § 182-512-0860, filed 6/29/23, effective 7/30/23. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0860, filed 3/14/14, effective 4/14/14. WSR 11-24-018, recodified as § 182-512-0860, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090, chapter 74.12 RCW, and The Tax Relief, Unemployment Insurance Reauthorization, and Job Creation Act of 2010. WSR 11-21-025, § 388-475-0860, filed 10/11/11, effective 10/29/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500, and Social Security Act as amended by P.L. 108-203. WSR 06-04-046, § 388-475-0860, filed 1/26/06, effective 2/26/06. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-005, § 388-475-0860, filed 4/7/04, effective 6/1/04.*

##### **Wash. Admin. Code § 182-512-0880** SSI-related medical—Special income disregards. {#sec-182-512-0880 omnilex-key=us-wa-regs-official--title-182--182-512-0880}

Portions of a person's income the agency otherwise counts are disregarded when determining eligibility for Washington apple health SSI-related medical programs.

(1) The agency disregards cost of living adjustments (COLAs) to Social Security benefits and provides categorically needy (CN) SSI-related medicaid benefits under the Pickle Amendment criteria of 42 C.F.R. 435.135 (1)(a) to a person who:

(a) Is currently receiving Title II Social Security benefits;

(b) Was eligible for and received SSI or State Supplement payments (SSP) but became ineligible for those payments after April, 1977; and

(c) Would still be eligible for SSI or SSP payments if the amount of Social Security COLA increases paid under section 215(i) of the Social Security Act were deducted from the person's current Title II Social Security benefits.

(d) To satisfy this provision, a person must have been eligible for and received SSI or SSP payments and in the same month was entitled to, but did not necessarily receive, a Title II Social Security benefit for at least one month since April 1977. This includes a person who receives a Title II Social Security benefit payment the month after the last SSI or SSP payment is made due to the fact that Social Security is paid the month after entitlement begins.

(e) For purposes of this section, the agency also disregards COLAs received by a person, their financially responsible spouse, and other financially responsible family members, such as a parent.

(2) In determining SSI-related CN-WAH coverage, the agency disregards:

(a) Widow(er)'s benefits for a person who:

(i) Was entitled to SSA title II (widow/widower's) benefits in December 1983;

(ii) Was at least 50 years old, but not yet 60 at that time;

(iii) Received title II benefits and SSI in January 1984;

(iv) Would continue to be eligible for SSI/SSP payments if the title II benefits were disregarded; and

(v) Filed an application for medicaid with the state by July 1, 1988.

(b) Widow, Widower or Surviving Divorced Spouse (title II) benefits for a person who:

(i) Received SSI/SSP benefits the month prior to receipt of title II benefits;

(ii) Would continue to be eligible for SSI/SSP benefits if the title II benefits or the COLA(s) to those benefits were disregarded; and

(iii) Is not eligible for medicare Part A. This person is considered an SSI recipient until becoming entitled to medicare Part A.

(3) A disabled adult child (DAC) who is ineligible for SSI/SSP solely due to receipt of either Social Security benefits as a disabled adult child of a person with a Social Security account or due to receipt of a COLA to the DAC benefits, may be income eligible for Apple Health categorically needy (CN) health care coverage if disregarding the SSA DAC benefits and COLA brings countable income below the CN standards, and the person:

(a) Is 18 years of age or older;

(b) Remains related to the SSI program through disability or blindness;

(c) Lost SSI eligibility on or after July 1, 1988, due solely to the receipt of DAC benefits from SSA or a COLA to those benefits; and

(d) Meets the other SSI-related CN medical requirements.

(4) A person is eligible for CN coverage if:

(a) In August 1972, the person received:

(i) Old age assistance (OAA);

(ii) Aid to blind (AB);

(iii) Aid to families with dependent children (AFDC); or

(iv) Aid to the permanently and totally disabled (APTD).

(b) The person was entitled to or received retirement, survivors, and disability insurance (RSDI) benefits; or

(c) The person was ineligible for OAA, AB, AFDC, SSI, or APTD solely because of the 20 percent increase in Social Security benefits under P.L. 92-336.

(5) People who stop receiving an SSI cash payment due to earnings, but still meet all of the other SSI eligibility rules and have income below the higher limit established by the Social Security Act's Section 1619(b) are eligible for continued WAH CN medicaid.

(6) TANF income methodology is used to determine countable income for children and pregnant people applying for medically needy (MN) coverage unless the SSI methodology would be more beneficial to the person. When using the TANF income methodologies, deduct:

(a) A 50 percent earned income disregard described in WAC 388-450-0170;

(b) Actual child care and dependent care expenses related to employment; and

(c) Child support actually paid.

(7) The agency disregards a person's income over 150 percent of the FPL when determining eligibility for the community behavioral health support services (CBHS) benefit under chapter 182-561 WAC. This disregard only applies to eligibility for the CHBS benefit and does not apply to:

(a) Long-term services and supports eligibility determinations under chapters 182-513 and 182-515 WAC; or

(b) Post-eligibility treatment of income (PETI).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-10-083, § 182-512-0880, filed 4/30/24, effective 7/1/24. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0880, filed 3/14/14, effective 4/14/14. WSR 11-24-018, recodified as § 182-512-0880, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-005, § 388-475-0880, filed 4/7/04, effective 6/1/04.*

##### **Wash. Admin. Code § 182-512-0900** SSI-related medical—Deeming and allocation of income. {#sec-182-512-0900 omnilex-key=us-wa-regs-official--title-182--182-512-0900}

The agency considers income of financially responsible persons to determine if a portion of that income must be regarded as available to other household members.

(1) Deeming is the process of determining how much of another person's income is counted when determining Washington apple health (WAH) eligibility of an SSI-related applicant. When income is deemed to the SSI-related applicant from other household members, that income is considered the applicant's income. Income is deemed only:

(a) From a nonapplying spouse who lives with the SSI-related applicant; or

(b) From a parent(s) residing with an SSI-related applicant child.

(2) An allocation is an amount deducted from income counted in the eligibility determination and considered to be set aside for the support of a person other than the SSI-related applicant. When income is allocated to other household members from the SSI-related applicant(s) or from the applicant's spouse, that income is not counted as income of the SSI-related applicant.

(3) An SSI-related person applying for WAH categorically needy (CN) health care coverage must have countable income at or below the SSI categorically needy income level (CNIL) described in WAC 182-512-0010 unless the person is working and meets all requirements for the health care for workers with disabilities (HWD) program described in WAC 182-511-1000 through 182-511-1250.

(4) For WAH institutional or home and community based waiver programs, use rules described in WAC 182-513-1315.

(5) The agency follows rules described in WAC 182-512-0600 through 182-512-0880 to determine the countable income of an SSI-related applicant or SSI-related couple.

(6) If countable income of the applicant exceeds the one-person SSI CNIL prior to considering the income of a nonapplying spouse or children, the applicant is not eligible for WAH CN health care coverage and the agency determines eligibility for the WAH medically needy (MN) program. If the countable income does not exceed the SSI CNIL, see WAC 182-512-0920 to determine if income is to be deemed to the applicant from the nonapplying spouse.

(7) If countable income (after allowable deductions) of an SSI-related couple both applying for medical coverage exceeds the two-person SSI CNIL, the couple is not eligible for WAH CN health care coverage and the agency determines eligibility for the WAH medically needy (MN) program.

(8) For WAH CN health care coverage, allocations to children are deducted from the nonapplying spouse's unearned income, then from their earned income before income is deemed to the SSI-related applicant. See WAC 182-512-0820.

(9) For MN medical coverage, allocations to children are deducted from the income of the SSI-related applicant or SSI-related applicant couple. See subsection (10) of this section to determine the amount of the allocation.

(10) An SSI-related person or couple applying for WAH MN health care coverage is allowed an allocation to a nonapplying spouse, their SSI recipient spouse or their dependent child(ren) to reduce countable income before comparing income to the effective medically needy income level (MNIL) described in WAC 182-519-0050. The agency allocates income:

(a) Up to the effective one-person MNIL to a nonapplying spouse or SSI recipient spouse minus the spouse's countable income; and

(b) Up to one-half of the federal benefit rate (FBR) to each dependent minus each dependent's countable income. See WAC 182-512-0820 for child exclusions.

(11) A portion of a nonapplying spouse's income may be deemed to the SSI-related applicant:

(a) See WAC 182-512-0920(5) to determine how much income is deemed from a nonapplying spouse to the SSI-related applicant when determining WAH CN eligibility; and

(b) See WAC 182-512-0920(10) to determine how much income is deemed from a nonapplying spouse to the SSI-related applicant when determining WAH MN eligibility.

(12) A portion of the income of an ineligible parent or parents is allocated to the needs of an SSI-related applicant child. See WAC 182-512-0940 (4) through (7) to determine how much income is allocated from ineligible parent(s).

(13) When income must be deemed from the sponsor or sponsors of a noncitizen applicant or recipient, see WAC 182-512-0795 to determine the amount that must be counted as income of the noncitizen applicant or recipient.

**History**
- *Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0900, filed 3/14/14, effective 4/14/14. Statutory Authority: RCW 41.05.021. WSR 12-20-001, § 182-512-0900, filed 9/19/12, effective 10/20/12. WSR 11-24-018, recodified as § 182-512-0900, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. WSR 11-15-023, § 388-475-0900, filed 7/8/11, effective 8/8/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 04-09-005, § 388-475-0900, filed 4/7/04, effective 6/1/04.*

##### **Wash. Admin. Code § 182-512-0920** SSI-related medical—Deeming/allocation of income from nonapplying spouse. {#sec-182-512-0920 omnilex-key=us-wa-regs-official--title-182--182-512-0920}

The agency considers the income of financially responsible persons to determine if a portion of that income is available to other household members.

(1) A portion of the income of a nonapplying spouse is considered available to meet the needs of a Washington apple health SSI-related applicant. A nonapplying spouse is defined as someone who is:

(a) Financially responsible for the SSI-related applicant as described in WAC 182-506-0015 and 182-512-0960. For apple health institutional and home and community based waiver programs, see WAC 182-513-1315;

(b) Living in the same household with the SSI-related applicant;

(c) Not receiving a needs based payment such as temporary assistance to needy families (TANF) or state-funded cash assistance (SFA); or

(d) Not related to SSI, or is not applying for apple health coverage including spouses receiving SSI.

(2) An ineligible spouse is the spouse of an SSI cash recipient and is either not eligible for SSI for themselves or who has elected to not receive SSI cash so that their spouse may be eligible. An SSI-related applicant who is the ineligible spouse of an SSI cash recipient is not eligible for apple health categorically needy (CN) health care coverage and must be considered for health care coverage under the apple health medically needy (MN) program or for a modified adjusted gross income-based program if the person does not receive medicare.

(3) When determining whether a nonapplying spouse's income is countable, the agency:

(a) Follows the income rules described in WAC 182-512-0600 through 182-512-0780;

(b) Excludes income described in WAC 182-512-0800 (2) through (10), and all income excluded under federal statute or state law as described in WAC 182-512-0860;

(c) Excludes work-related expenses described in WAC 182-512-0840, with the exception that the $65 plus one half earned income deduction described in WAC 182-512-0840(2) does not apply;

(d) Deducts any court ordered child support which the nonapplying spouse pays for a child outside of the home (current support or arrears); and

(e) Deducts any applicable child-related income exclusions described in WAC 182-512-0820.

(4) The agency allocates income of the nonapplying spouse to nonapplying children who reside in the home as described in WAC 182-512-0820. Allocations to children are deducted first from the nonapplying spouse's unearned income, then from their earned income.

(a) For apple health CN medical determinations, allocations to children are not allowed out of the income of the SSI-related applicant, only from the income of the nonapplying spouse.

(b) For apple health MN medical determinations, allocations to children are allowed from the income of the SSI-related applicant if the applicant is unmarried.

(5) For apple health SSI-related CN medical determinations, a portion of the countable income of a nonapplying spouse remaining after the deductions and allocations described in subsections (3) and (4) of this section may be deemed to the SSI-related applicant. If the nonapplying spouse's countable income is:

(a) Less than or equal to one-half of the federal benefit rate (FBR), no income is deemed to the applicant. Compare the applicant's countable income to the one-person SSI categorically needy income level (CNIL) described in WAC 182-512-0010.

(b) Greater than one-half of the FBR, then the entire nonapplying spouse's countable income is deemed to the applicant. Compare the applicant's income to the two-person SSI CNIL.

(6) When income is not deemed to the SSI-related applicant from the nonapplying spouse per subsection (5)(a) of this section, allow all allowable income deductions and exclusions as described in chapter 182-512 WAC to the SSI-related applicant's income, and compare the net remaining income to the one-person SSI CNIL.

(7) When income is deemed to the SSI-related applicant from the nonapplying spouse per subsection (5)(b) of this section:

(a) Combine the applicant's unearned income with any unearned income deemed from the nonapplying spouse and allow one $20 general income exclusion to the combined amount. If there is less than $20 of unearned income, the remainder of the $20 general income exclusion is deducted from earned income.

(b) Combine the applicant's earned income with any earned income deemed from the nonapplying spouse and allow the $65 plus one half of the remainder earned income deduction (described in WAC 182-512-0840(2)) to the combined amount.

(c) Add together the net unearned and net earned income amounts and compare the total to the two-person SSI CNIL described in WAC 182-512-0010. If the income is equal to or below the applicable two-person standard, the applicant is eligible for apple health CN health care coverage.

(8) An SSI-related applicant who is working, whose level of work activity and earnings is determined not to be "substantial gainful activity" in accordance with all applicable Social Security disability determination rules and standards, but who is not eligible for apple health CN coverage under the regular apple health SSI-related program, may be considered for eligibility under the HWD program. For HWD program rules, see chapter 182-511 WAC.

(9) If the SSI-related applicant's countable income is above the applicable SSI CNIL standard, the agency or its authorized representative considers eligibility under the apple health MN program or under the HWD program if the person is working. An SSI-related applicant who meets the following criteria is not eligible for apple health MN coverage and eligibility must be determined under HWD or under a MAGI-based apple health program:

(a) The applicant is blind or disabled and, for a MAGI-based apple health program, under the age of 65;

(b) The applicant's level of work activity and earnings is determined to be "substantial gainful activity" in accordance with all applicable Social Security disability determination rules and standards; and

(c) The applicant is not receiving a title II Social Security cash benefit based on blindness or disability.

(10) For SSI-related apple health MN medical determinations, a portion of the countable income of a nonapplying spouse remaining after the deductions and allocations described in subsections (3) and (4) of this section may be deemed to the SSI-related applicant. If the nonapplying spouse's countable income is:

(a) Less than or equal to the effective one-person MNIL described in WAC 182-519-0050, no income is deemed to the applicant and a portion of the applicant's countable income is allocated to the nonapplying spouse's income to raise it to the effective MNIL standard.

(b) Greater than the effective MNIL, then the amount in excess of the effective one-person MNIL is deemed to the applicant. Compare the applicant's income to the effective one-person MNIL.

(11) When income is not deemed to the SSI-related applicant from the nonapplying spouse per subsection (10)(a) of this section:

(a) Allocate income from the applicant to bring the income of the nonapplying spouse up to the effective one-person MNIL standard;

(b) Allow all allowable income deductions and exclusions as described in chapter 182-512 WAC to the SSI-related applicant's remaining income;

(c) Allow a deduction for medical insurance premium expenses (if applicable); and

(d) Compare the net countable income to the effective one-person MNIL.

(12) When income is deemed to the SSI-related applicant from the nonapplying spouse per subsection (10)(b) of this section:

(a) Combine the applicant's unearned income with any unearned income deemed from the nonapplying spouse and allow one $20 general income exclusion to the combined amount (if there is less than $20 of unearned income, the remainder of the $20 general income exclusion is deducted from earned income);

(b) Combine the applicant's earned income with any earned income deemed from the nonapplying spouse and allow the $65 plus one half of the remainder earned income deduction (described in WAC 182-512-0840(2)) to the combined amount;

(c) Add together the net unearned and net earned income amounts;

(d) Allow a deduction for medical insurance premium expenses (if applicable) per WAC 182-519-0100(5); and

(e) Compare the net countable income to the effective one-person MNIL described in WAC 182-519-0050. If the income is:

(i) Equal to or below the effective one-person MNIL, the applicant is eligible for apple health MN health care coverage with no spenddown.

(ii) Greater than the effective MNIL, the applicant is only eligible for apple health MN health care coverage after meeting a spenddown liability as described in WAC 182-519-0110.

(13) The ineligible spouse of an SSI-cash recipient applying for apple health MN coverage is eligible to receive the deductions and allocations described in subsection (10)(a) of this section.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 74.09.540. WSR 24-06-051, § 182-512-0920, filed 3/1/24, effective 4/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-15-014, § 182-512-0920, filed 7/6/17, effective 8/6/17. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0920, filed 3/14/14, effective 4/14/14. Statutory Authority: RCW 41.05.021. WSR 12-20-001, § 182-512-0920, filed 9/19/12, effective 10/20/12. WSR 11-24-018, recodified as § 182-512-0920, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. WSR 11-15-023, § 388-475-0920, filed 7/8/11, effective 8/8/11.*

##### **Wash. Admin. Code § 182-512-0940** SSI-related medical—Deeming income from an ineligible parent(s) to a child applying for SSI-related medical. {#sec-182-512-0940 omnilex-key=us-wa-regs-official--title-182--182-512-0940}

The agency considers income of financially responsible persons to determine if a portion of that income must be regarded as available to other household members.

(1) A portion of the income of a parent(s) is considered available to the SSI-related applicant child when the child is age seventeen or younger and the parent(s) is:

(a) Financially responsible for the SSI-related child as described in WAC 182-506-0015;

(b) The natural, adoptive, or step-parent of the child;

(c) Living in the same household with the child;

(d) Not receiving a needs-based payment such as TANF, SFA or SSI; and

(e) Not related to SSI or not applying for medical assistance.

(2) If an SSI-related applicant between the ages of eighteen to twenty-one lives with their parents, only consider the parent's income available to the applicant if it is actually contributed to the applicant. If income is not contributed, count only the applicant's own separate income.

(3) Income that is deemed to the child is considered as that child's income.

(4) When determining whether a parent's income is countable, the agency:

(a) Follows the income rules described in WAC 182-512-0600 through 182-512-0780; and

(b) Excludes income described in WAC 182-512-0800 and 182-512-0840, and all income excluded under a federal statute or state law as described in WAC 182-512-0860.

(5) When determining the amount of income to be deemed from a parent(s) to an SSI-related minor child for Washington apple health (WAH) categorically needy (CN) and medically needy (MN) coverage, the agency reduces the parent(s) countable income in the following order:

(a) Court ordered child support paid out for a child not in the home;

(b) An amount equal to one half of the federal benefit rate (FBR) for each SSI-eligible sibling living in the household, minus any countable income of that child. See WAC 182-512-0010 for FBR amount;

(c) A twenty dollar general income exclusion;

(d) A deduction equal to sixty-five dollars plus one-half of the remainder from any remaining earned income of the parent(s);

(e) An amount equal to the one-person SSI CNIL for a single parent or the two-person SSI CNIL for a two parent household;

(f) Any income remaining after these deductions is considered countable income to the SSI-related child and is added to the child's own income. If there is more than one child applying for SSI-related health care coverage, the deemed parental income is divided equally between the applicant children; and

(g) The deductions described in this section are deducted first from unearned income then from earned income unless they are specific to earned income.

(6) The SSI-related applicant child is also allowed all applicable income exclusions and disregards described in chapter 182-512 WAC from their own income. After determining the child's nonexcluded income, the agency:

(a) Allows the twenty dollar general income exclusion from any unearned income;

(b) Deducts sixty-five dollars plus one half of the remainder from any earned income which has not already been excluded under the student earned income exclusion (see WAC 182-512-0820); and

(c) Adds the child's countable income to the amount deemed from their parent(s). If the combination of the child's countable income plus deemed parental income is equal to or less than the SSI CNIL, the child is eligible for SSI-related WAH CN health care coverage.

(7) If the combination of the child's countable income plus deemed parental income is greater than the SSI CNIL, the agency considers the child for SSI-related WAH medically needy (MN) coverage. Any amount exceeding the effective medically needy income level (MNIL) is used to calculate the amount of the child's spenddown liability as described in WAC 182-519-0110. See WAC 182-519-0050 for the current MNIL standards.

**History**
- *Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0940, filed 3/14/14, effective 4/14/14. Statutory Authority: RCW 41.05.021. WSR 12-20-001, § 182-512-0940, filed 9/19/12, effective 10/20/12. WSR 11-24-018, recodified as § 182-512-0940, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. WSR 11-15-023, § 388-475-0940, filed 7/8/11, effective 8/8/11.*

##### **Wash. Admin. Code § 182-512-0950** SSI-related medical—Child-related resource exclusions and allocations. {#sec-182-512-0950 omnilex-key=us-wa-regs-official--title-182--182-512-0950}

The agency considers resources of financially responsible people to determine if a portion of the resources must be regarded as available to other household members.

(1) A portion of the resources of a parent or parents is available to the SSI-related child when the child is age seventeen or younger and the parent or parents are:

(a) Financially responsible for the SSI-related child as described in WAC 182-506-0015;

(b) The natural, adoptive, or step-parent of the child;

(c) Living in the same household with the child;

(d) Not receiving a needs-based payment such as temporary assistance to needy families (TANF), state-funded cash assistance (SFA) or SSI; and

(e) Not related to SSI or not applying for medical assistance.

(2) Resources that are deemed to the child are that child's resources.

(3) When determining whether a parent's resources are countable, the agency:

(a) Follows the resource rules described in WAC 182-512-0200 through 182-512-0300; and

(b) Excludes resources described in WAC 182-512-0350 through 182-512-0550, except for WAC 182-512-0550(16), where instead, the pension funds excluded are those owned by either parent.

(4) In determining eligibility of an SSI-related child, the child's resources include the value of the countable resources of the parent or parents that exceed the resource limit in WAC 182-512-0010 for:

(a) A person, if one parent lives in the household; or

(b) A couple, if two parents (or one parent and the spouse of that parent) live in the household.

(5) The SSI-related child is allowed all applicable resource exclusions and disregards described in this chapter from their own resources.

(6) If there is more than one child living in the household, the value of the deemed resources is divided equally among the children.

(7) An SSI-related child's total countable resources are the combination of the value of the deemed resources and the nonexcluded resources of the child.

(8) A child's countable resources are compared with the one-person resource standard under WAC 182-512-0010.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-21-037, § 182-512-0950, filed 10/12/20, effective 11/12/20.*

##### **Wash. Admin. Code § 182-512-0960** SSI-related medical—Allocating income—Determining eligibility for a spouse when the other spouse receives long-term services and supports. {#sec-182-512-0960 omnilex-key=us-wa-regs-official--title-182--182-512-0960}

(1) General information.

(a) This section describes how the agency determines household income and resources when the household contains both institutional and noninstitutional household members.

(b) A separate medical assistance unit is established for people who meet institutional status under WAC 182-513-1320. See WAC 182-506-0015 for rules on how to determine medical assistance units for households that include people related to the supplemental security income (SSI) program.

(c) Throughout this section, "home" means "own home" as defined in WAC 388-106-0010.

(d) The income and resources of each spouse are available to the other through the end of the month in which the spouses stopped living together, unless subsection (3) of this section applies.

(e) The agency determines income and resources separately starting the first day of the month following the month of separation if spouses stop living together in the same home.

(f) When one, or both members of a couple live in an alternative living facility (ALF), the agency considers the couple to be living:

(i) Apart when:

(A) Only one spouse enters the ALF;

(B) Both spouses enter the same ALF but have separate rooms; or

(C) Both spouses enter separate ALFs.

(ii) Together when both spouses share a room in an ALF.

(2) The agency counts income and resources under this chapter when both members of a couple live in the same house and the community spouse or spousal impoverishment protections community (SIPC) spouse applies for coverage and his or her spouse receives:

(a) Home and community-based (HCB) waiver;

(b) Program for all inclusive care to the elderly (PACE);

(c) Roads to community living (RCL);

(d) Hospice; or

(e) Community first choice (CFC).

(3) When one member of a couple lives apart from their spouse and the community spouse or SIPC spouse applies for coverage, and the spouse who receives long-term services and supports lives:

(a) In an institution:

(i) The agency counts income under this chapter, plus any allocation the institutionalized spouse has made available to the community spouse; and

(ii) The agency counts resources under this chapter, plus any resources allocated to the community spouse when eligibility for the institutionalized spouse was determined, that remain in the name of the institutionalized spouse and are available to the community spouse under WAC 182-512-0250.

(b) In an ALF and receives HCB waiver, PACE, RCL, or hospice:

(i) The agency counts income under this chapter, plus any allocation the institutionalized spouse has made available to the community spouse; and

(ii) The agency counts resources under this chapter, plus any resources allocated to the community spouse when eligibility for the institutionalized spouse was determined, that remain in the name of the institutionalized spouse, and are available to the community spouse under WAC 182-512-0250; and

(c) In an ALF and receives CFC:

(i) The agency counts income under this chapter; and

(ii) The agency counts resources under this chapter, plus any resources allocated to the SIPC spouse when eligibility for the spousal impoverishment protections institutionalized (SIPI) spouse was determined, that remain in the name of the SIPI spouse and are available to the community spouse under WAC 182-512-0250.

(4) Determining household income when the spouse of an HCB waiver recipient is not eligible for categorically needy (CN) coverage.

(a) When the community spouse is not eligible for categorically needy (CN) coverage under subsection (2) of this section, the agency determines eligibility under the medically needy program;

(b) The agency counts income and resources as described under subsection (2) of this section;

(c) The agency allocates income to the institutionalized spouse before comparing the community spouse's income to the medically needy income level (MNIL) if:

(i) The community spouse lives in the same household as the institutionalized spouse;

(ii) The institutionalized spouse is receiving home and community-based waiver services under WAC 182-515-1505 or institutional hospice services under WAC 182-513-1240; and

(iii) The institutionalized spouse has gross income under the MNIL.

(d) The allocation in (c) of this subsection cannot exceed the one-person effective MNIL minus the institutionalized spouse's income.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R § 155. WSR 17-03-116, § 182-512-0960, filed 1/17/17, effective 2/17/17. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148), 42 C.F.R. §§ 431, 435, 457 and 45 C.F.R. § 155. WSR 14-07-059, § 182-512-0960, filed 3/14/14, effective 4/14/14. WSR 11-24-018, recodified as § 182-512-0960, filed 11/29/11, effective 12/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. WSR 11-15-023, § 388-475-0960, filed 7/8/11, effective 8/8/11.*

## **Chapter 182-513** Client not in own home—Institutional medical. {#struct-chapter-182-513}

##### **Wash. Admin. Code § 182-513-1100** Definitions related to long-term services and supports (LTSS). {#sec-182-513-1100 omnilex-key=us-wa-regs-official--title-182--182-513-1100}

This section defines the meaning of certain terms used in chapters 182-513 and 182-515 WAC. Within these chapters, institutional, home and community-based services (HCBS) waiver, program of all-inclusive care for the elderly (PACE), and hospice in a medical institution are referred to collectively as long-term care (LTC). Long-term services and supports (LTSS) is a broader definition which includes institutional, HCBS waiver, and other services such as medicaid personal care (MPC), community first choice (CFC), PACE, and hospice in the community.

• See chapter 182-516 WAC for definitions related to trusts, annuities, life estates, and promissory notes.

• See chapter 388-106 WAC for long-term care services definitions.

• See WAC 182-513-1405 for long-term care partnership definitions.

• See chapter 182-500 WAC for additional apple health eligibility definitions.

"Adequate consideration" means that the fair market value (FMV) of the property or services received, in exchange for transferred property, approximates the FMV of the property transferred.

"Administrative costs" or "costs" means necessary costs paid by the guardian or conservator including attorney fees.

"Alternate living facility (ALF)" is not an institution under WAC 182-500-0050; it is one of the following community residential facilities:

(a) Adult family home (AFH) licensed under chapter 70.128 RCW.

(b) Adult residential care facility (ARC) licensed under chapter 18.20 RCW.

(c) Assisted living facility (AL) licensed under chapter 18.20 RCW.

(d) Behavioral health adult residential treatment facility (RTF) licensed under chapter 246-337 WAC.

(e) Intensive behavioral health treatment facility (IBHTF) is an RTF licensed under chapter 246-337 WAC.

(f) Developmental disabilities community services (DDCS) group home (GH) licensed as an adult family home under chapter 70.128 RCW or an assisted living facility under chapter 18.20 RCW.

(g) Enhanced adult residential care facility (EARC) licensed as an assisted living facility under chapter 18.20 RCW.

(h) Enhanced service facility (ESF) licensed under chapter 70.97 RCW.

(i) Facility for children and youth 20 years of age and younger where a state-operated living alternative program, as defined under chapter 71A.10 RCW, is operated.

(j) Group care facility for medically complex children licensed under chapter 74.15 RCW.

(k) Staffed residential facility licensed under chapter 74.15 RCW.

"Assets" means all income and resources of a person and of the person's spouse, including any income or resources which that person or that person's spouse would otherwise currently be entitled to but does not receive because of action:

(a) By that person or that person's spouse;

(b) By another person, including a court or administrative body, with legal authority to act in place of or on behalf of the person or the person's spouse; or

(c) By any other person, including any court or administrative body, acting at the direction or upon the request of the person or the person's spouse.

"Authorization date" means the date payment begins for long-term services and supports (LTSS) under WAC 388-106-0045.

"Clothing and personal incidentals (CPI)" means the cash payment (under WAC 388-478-0090, 388-478-0006, and 388-478-0033) issued by the department for clothing and personal items for people living in an ALF or medical institution.

"Community first choice (CFC)" means a medicaid state plan home and community-based service developed under the authority of section 1915(k) of the Social Security Act under chapter 388-106 WAC.

"Community options program entry system (COPES)" means a medicaid home and community-based services (HCBS) waiver program developed under the authority of section 1915(c) of the Social Security Act under chapter 388-106 WAC.

"Community spouse (CS)" means the spouse of an institutionalized spouse.

"Community spouse resource allocation (CSRA)" means the resource amount that may be transferred without penalty from:

(a) The institutionalized spouse (IS) to the community spouse (CS); or

(b) The spousal impoverishment protections institutionalized (SIPI) spouse to the spousal impoverishment protections community (SIPC) spouse.

"Community spouse resource evaluation" means the calculation of the total value of the resources owned by a married couple on the first day of the first month of the institutionalized spouse's most recent continuous period of institutionalization.

"Comprehensive assessment reporting evaluation (CARE) assessment" means the evaluation process defined under chapter 388-106 WAC used by a department designated social services worker or a case manager to determine a person's need for long-term services and supports (LTSS).

"Conservator" has the same meaning given in RCW 11.130.010.

"Conservatorship" means the process outlined in chapter 11.130 RCW for appointing a conservator and a conservator's carrying out of any duties pursuant to an order entered under RCW 11.130.360 through 11.130.575.

"Conservatorship fees" or "fees" means necessary fees charged by a conservator for services rendered on behalf of a client.

"Continuing care contract" means a contract to provide a person, for the duration of that person's life or for a term in excess of one year, shelter along with nursing, medical, health-related, or personal care services, which is conditioned upon the transfer of property, the payment of an entrance fee to the provider of such services, or the payment of periodic charges for the care and services involved.

"Continuing care retirement community" means an entity which provides shelter and services under continuing care contracts with its members and which sponsors or includes a health care facility or a health service.

"Dependent" means a minor child, or one of the following who meets the definition of a tax dependent under WAC 182-500-0105: Adult child, parent, or sibling.

"Developmental disabilities community services (DDCS)" means a division within the Washington state department of social and health services (DSHS).

"Developmental disabilities community services (DDCS) home and community-based services (HCBS) waiver" means a medicaid HCBS waiver program developed under the authority of section 1915(c) of the Social Security Act under chapter 388-845 WAC authorized by DDCS. There are five DDCS HCBS waivers:

(a) Basic Plus;

(b) Core;

(c) Community protection;

(d) Children's intensive in-home behavioral support (CIIBS); and

(e) Individual and family services (IFS).

"Equity" means the fair market value of real or personal property less any encumbrances (mortgages, liens, or judgments) on the property.

"Fair market value (FMV)" means the price an asset may reasonably be expected to sell for on the open market in an agreement, made by two parties freely and independently of each other, in pursuit of their own self-interest, without pressure or duress, and without some special relationship (arm's length transaction), at the time of transfer or assignment.

"Guardian" has the same meaning given in RCW 11.130.010.

"Guardianship" means the process outlined in chapter 11.130 RCW for appointing a guardian and a guardian's carrying out of any duties pursuant to an order entered under RCW 11.130.265 through 11.130.355.

"Guardianship fees" or "fees" means necessary fees charged by a guardian for services rendered on behalf of a client.

"Home and community living administration (HCLA)" means the administration within the Washington state department of social and health services.

"Home and community-based services (HCBS) waiver programs authorized by home and community services (HCS)" means medicaid HCBS waiver programs developed under the authority of Section 1915(c) of the Social Security Act under chapter 388-106 WAC authorized by HCS. There are three HCS HCBS waivers: Community options program entry system (COPES), new freedom consumer directed services (New Freedom), and residential support waiver (RSW).

"Home and community-based services (HCBS)" means LTSS provided in the home or a residential setting to persons assessed by the department.

"Institutional services" means services paid for by Washington apple health, and provided:

(a) In a medical institution;

(b) Through an HCBS waiver; or

(c) Through programs based on HCBS waiver rules for post-eligibility treatment of income under chapter 182-515 WAC.

"Institutionalized individual" means a person who has attained institutional status under WAC 182-513-1320.

"Institutionalized spouse" means a person who, regardless of legal or physical separation:

(a) Has attained institutional status under WAC 182-513-1320; and

(b) Is legally married to a person who is not in a medical institution.

"Life care community" see continuing care community.

"Likely to reside" means the agency or its designee reasonably expects a person will remain in a medical institution for 30 consecutive days. Once made, the determination stands, even if the person does not actually remain in the facility for that length of time.

"Long-term care services" see "Institutional services."

"Long-term services and supports (LTSS)" includes institutional and noninstitutional services authorized by the department.

"Medicaid alternative care (MAC)" is a Washington apple health benefit authorized under Section 1115 of the Social Security Act. It enables the medicaid agency and the agency's designees to deliver an array of person-centered long-term services and supports (LTSS) to unpaid caregivers caring for a medicaid-eligible person who meets nursing facility level of care under WAC 388-106-0355 and 182-513-1605.

"Medicaid personal care (MPC)" means a medicaid state plan home and community-based service under chapter 388-106 WAC.

"Most recent continuous period of institutionalization (MRCPI)" means the current period an institutionalized spouse has maintained uninterrupted institutional status when the request for a community spouse resource evaluation is made. Institutional status is determined under WAC 182-513-1320.

"Noninstitutional medicaid" means any apple health program not based on HCBS waiver rules under chapter 182-515 WAC, or rules based on a person residing in an institution for 30 days or more under chapter 182-513 WAC.

"Nursing facility level of care (NFLOC)" is described in WAC 388-106-0355.

"Participation" means the amount a person must pay each month toward the cost of long-term care services received each month; it is the amount remaining after the post-eligibility process under WAC 182-513-1380, 182-515-1509, or 182-515-1514. Participation is not room and board.

"Penalty period" or "period of ineligibility" means the period of time during which a person is not eligible to receive services that are subject to transfer of asset penalties.

"Personal needs allowance (PNA)" means an amount set aside from a person's income that is intended for personal needs. The amount a person is allowed to keep as a PNA depends on whether the person lives in a medical institution, ALF, or at home.

"Presumptive eligibility (PE)" for long-term services and supports is described in WAC 182-513-1110.

"Program of all-inclusive care for the elderly (PACE)" provides long-term services and supports (LTSS), medical, mental health, and substance use disorder (SUD) treatment through a department-contracted managed care plan using a personalized plan of care for each enrollee.

"Roads to community living (RCL)" is a demonstration project authorized under Section 6071 of the Deficit Reduction Act of 2005 (P.L. 109-171) and extended through the Patient Protection and Affordable Care Act (P.L. 111-148).

"Room and board" means the amount a person must pay each month for food, shelter, and household maintenance requirements when that person resides in an ALF. Room and board is not participation.

"Short stay" means residing in a medical institution for a period of 29 days or fewer.

"Significant financial duress" means, but is not limited to, threatened loss of, or financial burden from, basic shelter, food, or medically necessary health care. It means that a member of a couple has established to the satisfaction of a hearing officer that the community spouse needs income above the level permitted by the community spouse maintenance standard to provide for medical, remedial, or other support needs of the community spouse to permit the community spouse to remain in the community.

"Special income level (SIL)" means the monthly income standard that is 300 percent of the supplemental security income (SSI) federal benefit rate.

"Spousal impoverishment protections" means the financial provisions within Section 1924 of the Social Security Act that protect income and assets of the community spouse through income and resource allocation. The allocation process is used to discourage the impoverishment of a spouse due to the other spouse's need for LTSS. This includes services provided in a medical institution, HCBS waivers authorized under 1915(c) of the Social Security Act, and through September 30, 2027, services authorized under 1115 and 1915(k) of the Social Security Act.

"Spousal impoverishment protections community (SIPC) spouse" means the spouse of a SIPI spouse.

"Spousal impoverishment protections institutionalized (SIPI) spouse" means a legally married person who qualifies for the noninstitutional categorically needy (CN) Washington apple health SSI-related program only because of the spousal impoverishment protections under WAC 182-513-1220.

"State spousal resource standard" means the minimum CSRA standard for a CS or SIPC spouse.

"Tailored supports for older adults (TSOA)" is a federally funded program approved under Section 1115 of the Social Security Act. It enables the medicaid agency and the agency's designees to deliver person-centered long-term services and supports (LTSS).

"Third-party resource (TPR)" means funds paid to or on behalf of a person by a third party, where the purpose of the funds is for payment of activities of daily living, medical services, or personal care. The agency does not pay for these services if there is a third-party resource available.

"Transfer" means, in the context of long-term care eligibility, the changing of ownership or title of an asset, such as income, real property, or personal property, by one of the following:

(a) An intentional act that changes ownership or title; or

(b) A failure to act that results in a change of ownership or title.

"Uncompensated value" means the fair market value (FMV) of an asset on the date of transfer, minus the FMV of the consideration the person receives in exchange for the asset.

"Undue hardship" means a person is not able to meet shelter, food, clothing, or health needs. A person may apply for an undue hardship waiver based on criteria under WAC 182-513-1367.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-513-1100, filed 11/4/25, effective 12/5/25*
- *WSR 25-04-040, s 182-513-1100, filed 1/29/25, effective 3/1/25*
- *WSR 24-02-036, § 182-513-1100, filed 12/27/23, effective 1/27/24. Statutory Authority: RCW 41.05.021, 41.05.160, and 42 U.S.C. 1396r-5 note. WSR 23-11-039, § 182-513-1100, filed 5/11/23, effective 6/11/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Consolidated Appropriations Act of 2021, H.R. 133, Division CC, Title II, Sec. 204 (b)(1)(A) and Sec. 205. WSR 21-10-051, § 182-513-1100, filed 4/29/21, effective 5/30/21. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-24-065, § 182-513-1100, filed 11/27/19, effective 12/28/19. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1100, filed 1/17/17, effective 2/17/17.*

##### **Wash. Admin. Code § 182-513-1105** Personal needs allowance (PNA) and room and board standards in a medical institution and alternate living facility (ALF). {#sec-182-513-1105 omnilex-key=us-wa-regs-official--title-182--182-513-1105}

(1) This section describes the personal needs allowance (PNA), which is an amount set aside from a client's income that is intended for personal needs, and the room and board standard.

(2) The PNA in a state veteran's nursing facility:

(a) Is indicated on the chart described in subsection (8) of this section as "All other PNA Med Inst.", for a veteran without a spouse or dependent children receiving a needs-based veteran's pension in excess of $90;

(b) Is indicated on the chart described in subsection (8) of this section as "All other PNA Med Inst.", for a veteran's surviving spouse with no dependent children receiving a needs-based veteran's pension in excess of $90; or

(c) Is $160 for a client who does not receive a needs-based veteran's pension.

(3) The PNA in a medical institution for clients receiving aged, blind, or disabled (ABD) cash assistance or temporary assistance for needy families (TANF) cash assistance is the client's personal and incidental (CPI) cash payment, as described in WAC 388-478-0006, based on residing in a medical institution, which is $41.62.

(4) The PNA in an alternate living facility (ALF) for clients receiving ABD cash assistance or TANF cash assistance is the CPI, as described in WAC 388-478-0006, based on residing in an ALF that is not an adult family home, which is $38.84.

(5) The PNA for clients not described in subsections (2), (3), and (4) of this section, who reside in a medical institution or in an ALF, is indicated on the chart described in subsection (8) of this section as "All other PNA Med Inst." and "HCS & DDCS Waivers, CFC & MPC PNA in ALF."

(6) Effective January 1, 2024, and each year thereafter, the amount of the PNA in subsection (5) of this section will be adjusted by the percentage of the cost-of-living adjustment (COLA) for old-age, survivors, and disability social security benefits as published by the federal Social Security Administration, per RCW 74.09.340.

(7) The room and board standard in an ALF used by home and community services (HCS) and developmental disabilities community services (DDCS) is based on the federal benefit rate (FBR) minus the current PNA as described under subsection (5) of this section.

(8) The current PNA and room and board standards used in long-term services and supports are published under the institutional standards on the Washington apple health (medicaid) income and resource standards chart located at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-513-1105, filed 11/4/25, effective 12/5/25. Statutory Authority: RCW 41.05.021, 41.05.160, and 74.09.340. WSR 24-06-088, § 182-513-1105, filed 3/6/24, effective 4/6/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-04-034, § 182-513-1105, filed 1/25/23, effective 2/25/23*
- *WSR 22-08-104, § 182-513-1105, filed 4/6/22, effective 5/7/22. Statutory Authority: RCW 41.05.021, 41.05.160, and 74.09.340. WSR 21-02-086, § 182-513-1105, filed 1/6/21, effective 2/6/21. Statutory Authority: RCW 41.05.021, 41.05.160, 2018 c 137, 2018 c 299 §§ 204 (2)(p) and 207(13), and 2018 c 299. WSR 18-20-047, § 182-513-1105, filed 9/26/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 c 270. WSR 17-23-039, § 182-513-1105, filed 11/8/17, effective 1/1/18.*

##### **Wash. Admin. Code § 182-513-1110** Presumptive eligibility (PE)—Long-term services and supports (LTSS) in a home setting authorized by home and community services (HCS). {#sec-182-513-1110 omnilex-key=us-wa-regs-official--title-182--182-513-1110}

(1) A person may be determined presumptively eligible for long-term services and supports (LTSS) in their own home, as defined in WAC 388-106-0010:

(a) Upon completion of a screening interview; and

(b) When authorized by home and community services (HCS).

(2) The screening interview described in subsection (3) of this section may be conducted by either:

(a) A HCS case manager or social worker;

(b) An area agency on aging (AAA) or their subcontractor; or

(c) A state designated tribal entity.

(3) To be presumptively eligible (PE), the person must:

(a) Be determined to meet nursing facility level of care under WAC 388-106-0355 during the screening interview; and

(b) Attest to information that meets the:

(i) Income limits at or below the average monthly state nursing facility rate;

(ii) Resource limits defined under WAC 182-513-1350;

(iii) Social security requirement under WAC 182-503-0515;

(iv) Residency requirement under WAC 182-503-0520; and

(v) Aged, blind, or disabled requirement under WAC 182-512-0050.

(4) The agency or the agency's designee determines how much client responsibility must be paid to the provider for PE home and community-based services authorized by HCS when living at home as outlined in WAC 182-513-1215, 182-515-1507, and 182-515-1509.

(5) The client or the client's representative must submit an online application through Washington connection or an HCA 18-005 application for aged, blind, disabled/long-term care coverage to HCS within 10 calendar days of PE determination.

(6) The PE period begins on the date the screening interview is completed and:

(a) Ends on the last day of the month following the month of the PE determination if an LTSS application is not completed and submitted within 10 calendar days of PE determination; or

(b) Ends the last day of the month that the final eligibility determination is made if a LTSS application is submitted under subsection (5) of this section within 10 calendar days of PE determination.

(7) For application processing times, refer to WAC 182-503-0060.

(8) If the applicant is determined not financially eligible for LTSS under WAC 182-513-1315, there is no overpayment for services received during the PE period; however, client responsibility applies as described in WAC 182-513-1215, 182-515-1507, and 182-515-1509.

(9) People who qualify for PE under this section receive categorically needy (CN) medical coverage under WAC 182-501-0060 through the PE period. CN medical coverage begins as described in WAC 182-503-0070(1).

(10) When PE services described in WAC 388-106-1810 and 388-106-1820 are approved or denied, the agency or the agency's designee sends written notice as described in WAC 182-518-0010.

(11) A person may receive services under a PE period only once within a consecutive 24-month period.

(12) The applicant does not have a right to an administrative hearing on PE decisions under chapter 182-526 WAC.

(13) Institutional resource and income standards are found at https://www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

(14) This section does not apply to medical assistance programs described in WAC 182-507-0125 or 182-508-0005.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-24-095, § 182-513-1110, filed 12/6/23, effective 1/6/24*
- *WSR 23-14-101, § 182-513-1110, filed 6/30/23, effective 9/1/23.*

##### **Wash. Admin. Code § 182-513-1200** Long-term services and supports (LTSS) authorized under Washington apple health programs. {#sec-182-513-1200 omnilex-key=us-wa-regs-official--title-182--182-513-1200}

(1) Long-term services and supports (LTSS) programs available to people eligible for noninstitutional Washington apple health coverage who meet the functional requirements.

(a) Noninstitutional apple health coverage in an alternate living facility (ALF) under WAC 182-513-1205.

(b) Community first choice (CFC) under WAC 182-513-1210.

(c) Medicaid personal care (MPC) under WAC 182-513-1225.

(d) For people who do not meet institutional status under WAC 182-513-1320, skilled nursing or rehabilitation is available under the CN, medically needy (MN) or alternative benefits plan (ABP) scope of care if enrolled into a managed care plan.

(2) Non-HCB waiver LTSS programs that use institutional rules under WAC 182-513-1315 and 182-513-1380 or HCB waiver rules under chapter 182-515 WAC, depending on the person's living arrangement:

(a) Program of all-inclusive care for the elderly (PACE) under WAC 182-513-1230.

(b) Roads to community living (RCL) under WAC 182-513-1235.

(c) Hospice under WAC 182-513-1240.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1200, filed 1/17/17, effective 2/17/17.*

##### **Wash. Admin. Code § 182-513-1205** Determining eligibility for noninstitutional coverage in an alternate living facility (ALF). {#sec-182-513-1205 omnilex-key=us-wa-regs-official--title-182--182-513-1205}

(1) This section describes the eligibility determination for noninstitutional coverage for a client who lives in an agency-contracted alternate living facility (ALF) defined under WAC 182-513-1100.

(2) The eligibility criteria for noninstitutional Washington apple health (medicaid) coverage in an ALF follows SSI-related rules under WAC 182-512-0050 through 182-512-0960, with the exception of the higher income standard under subsection (3) of this section.

(3) A client is eligible for noninstitutional coverage under the categorically needy (CN) program if the client's monthly income after allowable exclusions under chapter 182-512 WAC:

(a) Does not exceed the special income level (SIL) defined under WAC 182-513-1100; and

(b) Is less than or equal to the client's assessed state rate at an agency-contracted facility. To determine the CN standard: ((y × 31) + $38.84), where "y" is the state daily rate. $38.84 is based on the cash payment standard for a client living in an ALF setting under WAC 388-478-0006.

(4) A client is eligible for noninstitutional coverage under the medically needy (MN) program if the client's monthly income after allowable exclusions under chapter 182-512 WAC is less than or equal to the client's private rate at an agency-contracted facility. To determine the MN standard: ((z × 31) + $38.84), where "z" is the facility's private daily rate. To determine MN spenddown liability, see chapter 182-519 WAC.

(5) For both CN and MN coverage, a client's countable resources cannot exceed the standard under WAC 182-512-0010.

(6) The agency or the agency's designee approves CN noninstitutional coverage for twelve months.

(7) The agency or the agency's designee approves MN noninstitutional coverage for a period of months described in WAC 182-504-0020 for an SSI-related client, provided the client satisfies any spenddown liability under chapter 182-519 WAC.

(8) Clients who receive medicaid personal care (MPC) or community first choice (CFC) pay all of their income to the ALF except a personal needs allowance under WAC 182-513-1105.

(9) A client may have to pay third-party resources as defined under WAC 182-513-1100 in addition to the payment under this subsection.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-03-040, § 182-513-1205, filed 1/8/20, effective 2/8/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 c 270. WSR 17-23-039, § 182-513-1205, filed 11/8/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1205, filed 1/17/17, effective 2/17/17.*

##### **Wash. Admin. Code § 182-513-1210** Community first choice (CFC)—Overview. {#sec-182-513-1210 omnilex-key=us-wa-regs-official--title-182--182-513-1210}

(1) Community first choice (CFC) is a Washington apple health state plan benefit authorized under Section 1915(k) of the Social Security Act.

(2) CFC enables the agency and its contracted entities to deliver person-centered home and community based long-term services and supports (LTSS) to medicaid-eligible people who meet the institutional level of care under WAC 388-106-0355. See:

(a) WAC 388-106-0270 through 388-106-0295 for services included within the CFC benefit package.

(b) WAC 182-513-1215 for financial eligibility for CFC services.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1210, filed 1/17/17, effective 2/17/17.*

##### **Wash. Admin. Code § 182-513-1215** Community first choice (CFC)—Eligibility. {#sec-182-513-1215 omnilex-key=us-wa-regs-official--title-182--182-513-1215}

(1) A client who is determined functionally eligible for community first choice (CFC) services under WAC 388-106-0270 through 388-106-0295 is financially eligible to receive CFC services if the client is:

(a) Eligible for a noninstitutional Washington apple health (medicaid) program which provides categorically needy (CN) or alternative benefits plan (ABP) scope of care;

(b) Through September 30, 2027, a spousal impoverishment protections institutional (SIPI) spouse under WAC 182-513-1220; or

(c) Determined eligible for a home and community based (HCB) waiver program under chapter 182-515 WAC.

(2) A client whose only coverage is through one of the following programs is not eligible for CFC:

(a) Medically needy program under WAC 182-519-0100;

(b) Premium-based children's program under WAC 182-505-0215;

(c) Federal medicare savings programs under WAC 182-517-0100;

(d) State-funded pregnancy and state-funded after-pregnancy coverage program under WAC 182-505-0115;

(e) Family planning only under chapter 182-532 WAC;

(f) Medical care services program under WAC 182-508-0005;

(g) Pregnant minor program under WAC 182-505-0117;

(h) Alien emergency medical program under WAC 182-507-0110 through 182-507-0120;

(i) State-funded long-term care (LTC) for noncitizens program under WAC 182-507-0125;

(j) Kidney disease program under chapter 182-540 WAC; or

(k) State-funded apple health expansion program under chapters 182-525 and 182-512 WAC. This program does not include long-term services and supports in the scope of care.

(3) Transfer of asset penalties under WAC 182-513-1363 do not apply to CFC applicants, unless the client is applying for long-term services and supports (LTSS) that are available only through one of the HCB waivers under chapter 182-515 WAC.

(4) Home equity limits under WAC 182-513-1350 do not apply to CFC applicants, unless the client is applying for LTSS that are available only through one of the HCB waivers under chapter 182-515 WAC.

(5) Post-eligibility treatment of income rules do not apply if the client is eligible under subsection (1)(a) or (b) of this section.

(6) Clients eligible under subsection (1)(a) or (b) of this section, who reside in an alternate living facility (ALF):

(a) Keep a personal needs allowance (PNA) under WAC 182-513-1105; and

(b) Pay up to the room and board standard under WAC 182-513-1105 except when CN eligibility is based on the rules under WAC 182-513-1205.

(7) A client who receives CFC services under the health care for workers with disabilities (HWD) program under chapter 182-511 WAC must pay the HWD premium in addition to room and board under WAC 182-513-1105, if residing in an ALF.

(8) Post-eligibility treatment of income rules do apply if a client is eligible under subsection (1)(c) of this section.

(9) A client may have to pay for third-party resources as defined under WAC 182-513-1100 in addition to the room and board and participation.

(10) PNA, MNIL, and room and board standards are found at: www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-06-050, s 182-513-1215, filed 2/25/26, effective 3/28/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 42 U.S.C. 1396r-5 note. WSR 23-11-039, § 182-513-1215, filed 5/11/23, effective 6/11/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-04-034, § 182-513-1215, filed 1/25/23, effective 2/25/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Consolidated Appropriations Act of 2021, H.R. 133, Division CC, Title II, Sec. 204 (b)(1)(A) and Sec. 205. WSR 21-10-051, § 182-513-1215, filed 4/29/21, effective 5/30/21. Statutory Authority: RCW 41.05.021, 41.05.160 and P.L. 111–148, Title II, § 2404. WSR 18-06-031, § 182-513-1215, filed 2/28/18, effective 3/31/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 c 270. WSR 17-23-039, § 182-513-1215, filed 11/8/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1215, filed 1/17/17, effective 2/17/17.*

##### **Wash. Admin. Code § 182-513-1220** Community first choice (CFC)—Spousal impoverishment protections for noninstitutional Washington apple health clients. {#sec-182-513-1220 omnilex-key=us-wa-regs-official--title-182--182-513-1220}

(1) This section is effective through September 30, 2027.

(2) The agency or its designee determines eligibility for community first choice (CFC) using spousal impoverishment protections under this section, when an applicant:

(a) Is married to, or marries, a person not in a medical institution;

(b) Meets institutional level of care and eligibility for CFC services under WAC 388-106-0270 through 388-106-0295;

(c) Is ineligible for a noninstitutional categorically needy (CN) SSI-related program:

(i) Due to spousal deeming rules under WAC 182-512-0920, or due to exceeding the resource limit in WAC 182-512-0010, or both; or

(ii) In an ALF due to combined spousal resources exceeding the resource limit in WAC 182-512-0010; and

(d) Meets the aged, blindness, or disability criteria under WAC 182-512-0050.

(3) The agency or its designee determines countable income using the SSI-related income rules under chapter 182-512 WAC but uses only the applicant's or recipient's separate income and not the income of the applicant's or recipient's spouse.

(4) The agency or its designee determines countable resources using the SSI-related resource rules under chapter 182-512 WAC, except pension funds owned by the spousal impoverishment protections community (SIPC) spouse are not excluded as described under WAC 182-512-0550:

(a) For the applicant or recipient, the resource standard is $2000.

(b) Before determining countable resources used to establish eligibility for the applicant, the agency allocates the state spousal resource standard to the SIPC spouse.

(c) The resources of the SIPC spouse are unavailable to the spousal impoverishment protections institutionalized (SIPI) spouse the month after eligibility for CFC services is established.

(5) The SIPI spouse has until the end of the month of the first regularly scheduled eligibility review to transfer countable resources in excess of $2000 to the SIPC spouse.

(6) A redetermination of the couple's resources under subsection (4) of this section is required if:

(a) The SIPI spouse has a break in CFC services of at least 30 consecutive days;

(b) The SIPI spouse's countable resources exceed the standard under subsection (4)(a) of this section; or

(c) The SIPI spouse does not transfer the amount under subsection (5) of this section to the SIPC spouse by the end of the month of the first regularly scheduled eligibility review.

(7) If the applicant lives at home and the applicant's separate countable income is at or below the SSI categorically needy income level (CNIL) and the applicant is resource eligible, the applicant is a SIPI spouse and is financially eligible for noninstitutional CN coverage and CFC services.

(8) If the applicant lives in an ALF, has separate countable income at or below the standard under WAC 182-513-1205(2), and is resource eligible, the applicant is a SIPI spouse and is financially eligible for noninstitutional CN coverage and CFC services.

(9) Once a person no longer receives CFC services for 30 consecutive days, the agency redetermines eligibility without using spousal impoverishment protection, under WAC 182-504-0125.

(10) If the applicant's separate countable income is above the standards under subsections (7) and (8) of this section, the applicant is not eligible for CFC services under this section.

(11) The spousal impoverishment protections under this section expire on September 30, 2027.

(12) Standards are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 42 U.S.C. 1396r-5 note. WSR 23-11-039, § 182-513-1220, filed 5/11/23, effective 6/11/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-04-034, § 182-513-1220, filed 1/25/23, effective 2/25/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Consolidated Appropriations Act of 2021, H.R. 133, Division CC, Title II, Sec. 204 (b)(1)(A) and Sec. 205. WSR 21-10-051, § 182-513-1220, filed 4/29/21, effective 5/30/21. Statutory Authority: RCW 41.05.021, 41.05.160 and P.L. 111–148, Title II, § 2404. WSR 18-06-031, § 182-513-1220, filed 2/28/18, effective 3/31/18. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1220, filed 1/17/17, effective 2/17/17.*

##### **Wash. Admin. Code § 182-513-1225** Medicaid personal care (MPC). {#sec-182-513-1225 omnilex-key=us-wa-regs-official--title-182--182-513-1225}

(1) Medicaid personal care (MPC) is a state-plan benefit available to a client who is determined:

(a) Functionally eligible for MPC services under WAC 388-106-0200 through 388-106-0235; and

(b) Financially eligible for a noninstitutional categorically needy (CN) or alternative benefits plan (ABP) Washington apple health (medicaid) program.

(2) MPC services may be provided to a client residing at home, in a department-contracted adult family home (AFH), or in a licensed assisted living facility that is contracted with the department to provide adult residential care services.

(3) A client who resides in an alternate living facility (ALF) listed in subsection (2) of this section:

(a) Keeps a personal needs allowance (PNA) under WAC 182-513-1105; and

(b) Pays room and board up to the room and board standard under WAC 182-513-1105, unless CN eligibility is determined using rules under WAC 182-513-1205.

(4) A client who receives MPC services under the health care for workers with disabilities (HWD) program under chapter 182-511 WAC must pay the HWD premium in addition to room and board under WAC 182-513-1105, if residing in an ALF.

(5) A client may have to pay third-party resources as defined under WAC 182-513-1100 in addition to room and board.

(6) Current PNA and room and board standards are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-04-034, § 182-513-1225, filed 1/25/23, effective 2/25/23. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 c 270. WSR 17-23-039, § 182-513-1225, filed 11/8/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1225, filed 1/17/17, effective 2/17/17.*

##### **Wash. Admin. Code § 182-513-1230** Program of all-inclusive care for the elderly (PACE). {#sec-182-513-1230 omnilex-key=us-wa-regs-official--title-182--182-513-1230}

(1) The program of all-inclusive care for the elderly (PACE) provides long-term services and supports (LTSS), medical, mental health, and substance use disorder (SUD) treatment through a department-contracted managed care plan using a personalized plan of care for each enrollee.

(2) Program rules governing functional eligibility for PACE are listed under WAC 388-106-0700, 388-106-0705, 388-106-0710, and 388-106-0715.

(3) A person is financially eligible for PACE if the person:

(a) Is age:

(i) Fifty-five or older and disabled under WAC 182-512-0050; or

(ii) Sixty-five or older;

(b) Meets nursing facility level of care under WAC 388-106-0355;

(c) Lives in a designated PACE service area;

(d) Meets financial eligibility requirements under this section; and

(e) Agrees to receive services exclusively through the PACE provider and the PACE provider's network of contracted providers.

(4) Although PACE is not a home and community based (HCB) waiver program, financial eligibility is determined using the HCB waiver rules under WAC 182-515-1505 when a person is living at home or in an alternate living facility (ALF), with the following exceptions:

(a) PACE enrollees are not subject to the transfer of asset rules under WAC 182-513-1363; and

(b) PACE enrollees may reside in a medical institution thirty days or longer and still remain eligible for PACE services. The eligibility rules for institutional coverage are under WAC 182-513-1315 and 182-513-1380.

(5) A person may have to pay third-party resources as defined under WAC 182-513-1100 in addition to the room and board and participation.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-18-045, § 182-513-1230, filed 8/25/21, effective 9/25/21. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1230, filed 1/17/17, effective 2/17/17.*

##### **Wash. Admin. Code § 182-513-1235** Roads to community living (RCL). {#sec-182-513-1235 omnilex-key=us-wa-regs-official--title-182--182-513-1235}

(1) Roads to community living (RCL) is a demonstration project authorized under Section 6071 of the Deficit Reduction Act of 2005 (P.L. 109-171) and extended through the Patient Protection and Affordable Care Act (P.L. 111-148).

(2) Program rules governing functional eligibility for RCL are described in WAC 388-106-0250 through 388-106-0265. RCL services are authorized by the department.

(3) A person must have a stay of at least 60 consecutive days in a qualified institutional setting such as a hospital, nursing home, or residential habilitation center, to be eligible for RCL. The 60-day count excludes days paid solely by medicare, must include at least one day of medicaid paid inpatient services immediately prior to discharge, and the person must be eligible to receive any categorically needy (CN), medically needy (MN), or alternate benefit plan (ABP) medicaid program on the day of discharge. In addition to meeting the 60-day criteria, a person who is being discharged from a state psychiatric hospital must be under age 22 or over age 64.

(4) Once a person is discharged to home or to a residential setting under RCL, the person remains continuously eligible for medical coverage for 365 days unless the person:

(a) Returns to an institution for 30 days or longer;

(b) Is incarcerated in a public jail or prison;

(c) No longer wants RCL services;

(d) Moves out-of-state; or

(e) Dies.

(5) Changes in income or resources during the continuous eligibility period do not affect eligibility for RCL services. Changes in income or deductions may affect the amount a person must pay toward the cost of care.

(6) A person approved for RCL is not subject to transfer of asset provisions under WAC 182-513-1363 during the continuous eligibility period, but transfer penalties may apply if the person needs HCB waiver or institutional services once the continuous eligibility period has ended.

(7) A person who is not otherwise eligible for a noninstitutional medical program must have eligibility determined using the same rules used to determine eligibility for HCB waivers. If HCB rules are used to establish eligibility, the person must pay participation toward the cost of RCL services. HCB waiver eligibility and cost of care calculations are under:

(a) WAC 182-515-1508 and 182-515-1509 for home and community services (HCS); and

(b) WAC 182-515-1513 and 182-515-1514 for developmental disabilities community services (DDCS).

(8) At the end of the continuous eligibility period, the agency or its designee redetermines a person's eligibility for other programs under WAC 182-504-0125.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-513-1235, filed 11/4/25, effective 12/5/25. Statutory Authority: RCW 41.05.021, 41.05.160 and Consolidated Appropriations Act of 2021, H.R. 133, Division CC, Title II, Sec. 204 (b)(1)(A) and Sec. 205. WSR 21-10-051, § 182-513-1235, filed 4/29/21, effective 5/30/21. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1235, filed 1/17/17, effective 2/17/17.*

##### **Wash. Admin. Code § 182-513-1240** The hospice program. {#sec-182-513-1240 omnilex-key=us-wa-regs-official--title-182--182-513-1240}

(1) General information.

(a) The hospice program provides palliative care to people who elect to receive hospice services and are certified as terminally ill by their physician.

(b) Program rules governing election of hospice services are under chapter 182-551 WAC.

(c) A person may revoke an election to receive hospice services at any time by signing a revocation statement.

(d) Transfer of asset rules under WAC 182-513-1363 do not apply to the hospice program in any setting, regardless of which apple health program the person is eligible to receive.

(2) When hospice is a covered service.

(a) A person who receives coverage under a categorically needy (CN), medically needy (MN), or alternative benefits plan (ABP) program is eligible for hospice services as part of the program specific benefit package.

(b) A person who receives coverage under the alien emergency medical (AEM) program under WAC 182-507-0110 may be eligible for payment for hospice services if preapproved by the agency.

(c) A person who receives coverage under the medical care services (MCS) program is not eligible for coverage of hospice services.

(3) When HCB waiver rules are used to determine eligibility for hospice.

(a) A person who is not otherwise eligible for a CN, MN, or ABP noninstitutional program who does not reside in a medical institution, may be eligible for CN coverage under the hospice program by using home and community based (HCB) waiver rules under WAC 182-515-1505 to determine financial eligibility.

(b) When HCB waiver rules are used, the following exceptions apply:

(i) A person on the hospice program may reside in a medical institution, including a hospice care center, 30 days or longer and remain eligible for hospice services; and

(ii) A person residing at home on the hospice program who has available income over the special income limit (SIL), defined under WAC 182-513-1100, is not eligible for CN coverage. If available income is over the SIL, the agency or its designee determines eligibility for medically needy coverage under WAC 182-519-0100.

(c) When HCB waiver rules are used, a person may be required to pay income and third-party resources (TPR) as defined under WAC 182-513-1100 toward the cost of hospice services. The cost of care calculation is described under WAC 182-515-1509.

(d) When a person already receives HCB waiver services and elects hospice, the person must pay any required cost of care towards the HCB waiver service provider first.

(4) Eligibility for hospice services in a medical institution:

(a) A person who elects to receive hospice services, resides in a medical institution for 30 days or longer, and has income:

(i) Equal to or less than the SIL is income eligible for CN coverage. Eligibility for institutional hospice is determined under WAC 182-513-1315; or

(ii) Over the SIL may be eligible for MN coverage under WAC 182-513-1245.

(b) A person eligible for hospice services in a medical institution may have to pay toward the cost of nursing facility or hospice care center services. The cost of care calculation is under WAC 182-513-1380.

(5) Changes in coverage. The agency or its designee redetermines a person's eligibility under WAC 182-504-0125 if the person:

(a) Revokes the election of hospice services and is eligible for coverage using HCB waiver rules only, described in subsection (3) of this section; or

(b) Loses CN, MN, or ABP eligibility.

(6) Personal needs allowance and income and resource standards for hospice and home and community based (HCB) waiver programs are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-04-034, § 182-513-1240, filed 1/25/23, effective 2/25/23. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1240, filed 1/17/17, effective 2/17/17.*

##### **Wash. Admin. Code § 182-513-1245** Medically needy hospice program in a medical institution. {#sec-182-513-1245 omnilex-key=us-wa-regs-official--title-182--182-513-1245}

(1) General information.

(a) When living in a medical institution, a person may be eligible for medically needy coverage under the hospice program. A person must:

(i) Meet program requirements under WAC 182-513-1315;

(ii) Have available income that exceeds the special income level (SIL), defined under WAC 182-513-1100, but is below the institution's monthly state-contracted rate;

(iii) Meet the financial requirements of subsection (4) or (5) of this section; and

(b) Elect hospice services under chapter 182-551 WAC.

(2) Financial eligibility.

(a) The agency or its designee determines a person's resource eligibility, excess resources, and medical expense deductions using WAC 182-513-1350.

(b) The agency or its designee determines a person's countable income by:

(i) Excluding income under WAC 182-513-1340;

(ii) Determining available income under WAC 182-513-1325 or 182-513-1330;

(iii) Disregarding income under WAC 182-513-1345; and

(iv) Deducting medical expenses that were not used to reduce excess resources under WAC 182-513-1350.

(3) Determining the state-contracted daily rate in an institution, and the institutional medically needy income level (MNIL).

(a) The agency or its designee determines the state-contracted daily rate in an institution and the institutional MNIL based on the living arrangement, and whether the person is entitled to receive hospice services under medicare.

(b) When the person resides in a hospice care center:

(i) If entitled to medicare, the state-contracted daily rate is the state-contracted daily hospice care center rate. The institutional MNIL is calculated by multiplying the state-contracted daily rate by 30.42.

(ii) If not entitled to medicare, the state-contracted daily rate is the state-contracted daily hospice care center rate, plus the state-contracted daily hospice rate. To calculate the institutional MNIL, multiply the state-contracted daily rate by 30.42.

(c) When the person resides in a nursing facility:

(i) If entitled to medicare, the state-contracted daily rate is ninety-five percent of the nursing facility's state-contracted daily rate. The institutional MNIL is calculated by multiplying the state-contracted daily rate by 30.42.

(ii) If not entitled to medicare, the state-contracted daily rate is ninety-five percent of the nursing facility's state-contracted daily rate, plus the state-contracted daily hospice rate. The institutional MNIL is calculated by multiplying the state-contracted daily rate by 30.42.

(4) Eligibility for agency payment to the facility for institutional hospice services and the MN program.

(a) If a person's countable income plus excess resources is less than or equal to the state-contracted daily rate under subsection (3) of this section times the number of days the person has resided in the medical institution, the person:

(i) Is eligible for agency payment to the facility for institutional hospice services;

(ii) Is approved for MN coverage for a twelve-month certification period;

(b) Pays excess resources under WAC 182-513-1350; and

(c) Pays income towards the cost of care under WAC 182-513-1380.

(5) Eligibility for institutional MN spenddown.

(a) If a person's countable income is more than the state-contracted daily rate times the number of days the person has resided in the medical institution, but less than the institution's private rate for the same period, the person:

(i) Is not eligible for agency payment to the facility for institutional hospice services; and

(ii) Is eligible for the MN spenddown program for a three-month or six-month base period when qualifying medical expenses meet a person's spenddown liability.

(b) Spenddown liability is calculated by subtracting the institutional MNIL from the person's countable income for each month in the base period. The values from each month are added together to determine the spenddown liability.

(c) Qualifying medical expenses used to meet the spenddown liability are described in WAC 182-519-0110, except that only costs for hospice services not included within the state-contracted daily rate are qualifying medical expenses.

(6) Eligibility for MN spenddown.

(a) If a person's countable income is more than the institution's private rate times the number of days the person has resided in the medical institution, the person is not eligible for agency payment to the facility for institutional hospice services and institutional MN spenddown; and

(b) The agency or its designee determines eligibility for MN spenddown under chapter 182-519 WAC.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1245, filed 1/17/17, effective 2/17/17.*

##### **Wash. Admin. Code § 182-513-1315** General eligibility requirements for long-term care (LTC) programs. {#sec-182-513-1315 omnilex-key=us-wa-regs-official--title-182--182-513-1315}

This section lists the sections in this chapter that describe how the agency determines a person's eligibility for long-term care services. These sections are:

(1) WAC 182-513-1316 General eligibility requirements for long-term care (LTC) programs.

(2) WAC 182-513-1317 Income and resource criteria for an institutionalized person.

(3) WAC 182-513-1318 Income and resource criteria for home and community based (HCB) waiver programs and hospice.

(4) WAC 182-513-1319 State-funded programs for noncitizens who are not eligible for a federally funded program.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1315, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as WAC 182-513-1315, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-513-1315, filed 10/22/12, effective 11/22/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530. WSR 10-01-158, § 388-513-1315, filed 12/22/09, effective 1/22/10. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.09.575, and Deficit Reduction Act of 2005, 42 C.F.R. Section 435. WSR 09-07-036, § 388-513-1315, filed 3/10/09, effective 4/10/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.39.010. WSR 07-19-129, § 388-513-1315, filed 9/19/07, effective 10/20/07. Statutory Authority: RCW 74.08.090. WSR 06-07-077, § 388-513-1315, filed 3/13/06, effective 4/13/06. Statutory Authority: RCW 71A.12.030, 71A.10.020, chapters 71A.10 and 71A.12 RCW, 2004 c 276. WSR 04-18-054, § 388-513-1315, filed 8/27/04, effective 9/27/04. Statutory Authority: RCW 11.92.180, 43.20B.460, 48.85.020, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.[09.]575, 74.09.585*
- *20 C.F.R. 416.1110-1112, 1123 and 1160*
- *42 C.F.R. 435.403 (j)(2) and 1005*
- *and Sections 17, 1915(c), and 1924 (42 U.S.C. 1396) of the Social Security Act. WSR 00-01-051, § 388-513-1315, filed 12/8/99, effective 1/8/00. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 99-06-045, § 388-513-1315, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.04.050, 74.08.090 and 42 C.F.R. 435.1005. WSR 98-04-003, § 388-513-1315, filed 1/22/98, effective 2/22/98. Statutory Authority: RCW 74.08.090. WSR 96-11-072 (Order 3980), § 388-513-1315, filed 5/10/96, effective 6/10/96. Statutory Authority: RCW 74.08.090 and 1995 c 312 § 48. WSR 95-19-007 (Order 3895), § 388-513-1315, filed 9/6/95, effective 10/7/95. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-513-1315, filed 5/3/94, effective 6/3/94.*

##### **Wash. Admin. Code § 182-513-1316** General eligibility requirements for long-term care (LTC) programs. {#sec-182-513-1316 omnilex-key=us-wa-regs-official--title-182--182-513-1316}

(1) To be eligible for long-term care (LTC) services, a person must:

(a) Meet the general eligibility requirements for medical programs under WAC 182-503-0505, except:

(i) An adult age 19 or older must meet citizenship and immigration status requirements under WAC 182-503-0535 (2)(a) or (b);

(ii) A person under age 19 must meet citizenship and immigration status requirements under WAC 182-503-0535 (2)(a), (b), (c), or (d); and

(iii) If a person does not meet the requirements in (a)(i) or (ii) of this subsection, the person is not eligible for medicaid and must have eligibility determined under WAC 182-513-1319.

(b) Attain institutional status under WAC 182-513-1320;

(c) Meet the functional eligibility under:

(i) Chapter 388-106 WAC for a home and community services (HCS) home and community based (HCB) waiver or nursing facility coverage; or

(ii) Chapter 388-828 WAC for developmental disabilities community services (DDCS) HCB waiver or institutional services; and

(d) Meet either:

(i) SSI-related criteria under WAC 182-512-0050; or

(ii) MAGI-based criteria under WAC 182-503-0510(2), if residing in a medical institution. A person who is eligible for MAGI-based coverage is not subject to the provisions under subsection (2) of this section.

(2) A supplemental security income (SSI) recipient or a person meeting SSI-related criteria who needs LTC services must also:

(a) Not have a penalty period of ineligibility due to the transfer of assets under WAC 182-513-1363;

(b) Not have equity interest in a primary residence greater than the home equity standard under WAC 182-513-1350; and

(c) Disclose to the agency or its designee any interest the applicant or spouse has in an annuity, which must meet annuity requirements under chapter 182-516 WAC.

(3) A person who receives SSI must submit a signed health care coverage application form attesting to the provisions under subsection (2) of this section. A signed and completed eligibility review for LTC benefits can be accepted for people receiving SSI who are applying for long-term care services.

(4) To be eligible for HCB waiver services, a person must also meet the program requirements under:

(a) WAC 182-515-1505 through 182-515-1509 for HCS HCB waivers; or

(b) WAC 182-515-1510 through 182-515-1514 for DDCS HCB waivers.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-513-1316, filed 11/4/25, effective 12/5/25. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1316, filed 1/17/17, effective 2/17/17.*

##### **Wash. Admin. Code § 182-513-1317** Income and resource criteria for an institutionalized person. {#sec-182-513-1317 omnilex-key=us-wa-regs-official--title-182--182-513-1317}

(1) This section provides an overview of the income and resource eligibility rules for a person who lives in an institutional setting.

(2) To determine income eligibility for an SSI-related long-term care (LTC) applicant under the categorically needy (CN) program, the agency or its designee:

(a) Determines available income under WAC 182-513-1325 and 182-513-1330;

(b) Excludes income under WAC 182-513-1340; and

(c) Compares remaining available income to the special income level (SIL) defined under WAC 182-513-1100. A person's available income must be equal to or less than the SIL to be eligible for CN coverage.

(3) To determine income eligibility for an SSI-related LTC client under the medically needy (MN) program, the agency or its designee follows the income standards and eligibility rules under WAC 182-513-1395.

(4) To be resource eligible under the SSI-related LTC CN or MN program, the person must:

(a) Meet the resource eligibility requirements under WAC 182-513-1350;

(b) Not have a penalty period of ineligibility due to a transfer of assets under WAC 182-513-1363;

(c) Disclose to the state any interest the person or the person's spouse has in an annuity, which must meet the annuity requirements under chapter 182-516 WAC.

(5) A resident of eastern or western state hospital is eligible for medicaid if the person:

(a) Has attained institutional status under WAC 182-513-1320; and

(b) Is under age twenty-one; or

(c) Applies for or receives inpatient psychiatric treatment in the month of the person's twenty-first birthday that will likely continue through the person's twenty-first birthday, and can receive coverage until:

(i) The facility discharges the person; or

(ii) The end of the month in which the person turns age twenty-two, whichever occurs first; or

(d) Is at least age sixty-five.

(6) To determine long-term care CN or MN income eligibility for a person eligible under a MAGI-based program, the agency or its designee follows the rules under chapter 182-514 WAC.

(7) There is no asset test for MAGI-based LTC programs under WAC 182-514-0245.

(8) The agency or its designee determines a person's total responsibility to pay toward the cost of care for LTC services as follows:

(a) For an SSI-related person residing in a medical institution, see WAC 182-513-1380;

(b) For an SSI-related person on a home and community based waiver, see chapter 182-515 WAC.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1317, filed 1/17/17, effective 2/17/17.*

##### **Wash. Admin. Code § 182-513-1318** Income and resource criteria for home and community based (HCB) waiver programs and hospice. {#sec-182-513-1318 omnilex-key=us-wa-regs-official--title-182--182-513-1318}

(1) This section provides an overview of the income and resource eligibility rules for a person to be eligible for a categorically needy (CN) home and community based (HCB) waiver program under chapter 182-515 WAC or the hospice program under WAC 182-513-1240 and 182-513-1245.

(2) To determine income eligibility for an SSI-related long-term care (LTC) HCB waiver, the agency or its designee:

(a) Determines income available under WAC 182-513-1325 and 182-513-1330;

(b) Excludes income under WAC 182-513-1340;

(c) Compares remaining gross nonexcluded income to:

(i) The special income level (SIL) defined under WAC 182-513-1100; or

(ii) For HCB service programs authorized by the home and community living administration (HCLA), a higher standard is determined following the rules under WAC 182-515-1508 if a client's income is above the SIL but net income is below the medically needy income level (MNIL).

(3) A person who receives MAGI-based coverage is not eligible for HCB waiver services unless found eligible based on program rules in chapter 182-515 WAC.

(4) To be resource eligible under the HCB waiver program, the person must:

(a) Meet the resource eligibility requirements and standards under WAC 182-513-1350;

(b) Not be in a period of ineligibility due to a transfer of asset penalty under WAC 182-513-1363;

(c) Disclose to the state any interest the person or that person's spouse has in an annuity and meet the annuity requirements under chapter 182-516 WAC.

(5) The agency or its designee determines a person's responsibility to pay toward the cost of care for LTC services as follows:

(a) For people receiving HCS HCB waiver services, see WAC 182-515-1509;

(b) For people receiving DDCS HCB waiver services, see WAC 182-515-1514.

(6) To be eligible for the CN hospice program, see WAC 182-513-1240.

(7) To be eligible for the MN hospice program in a medical institution, see WAC 182-513-1245.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-513-1318, filed 11/4/25, effective 12/5/25. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1318, filed 1/17/17, effective 2/17/17.*

##### **Wash. Admin. Code § 182-513-1319** State-funded programs for noncitizens who are not eligible for a federally funded program. {#sec-182-513-1319 omnilex-key=us-wa-regs-official--title-182--182-513-1319}

(1) This section describes the state-funded programs available to a person who does not meet the citizenship and immigration status criteria under WAC 182-513-1316 for federally funded coverage.

(2) If a person meets the eligibility and incapacity criteria of the medical care services (MCS) program under WAC 182-508-0005, the person may receive nursing facility care or state-funded residential services in an alternate living facility (ALF).

(3) Noncitizens may be eligible for the state-funded long-term care services program under WAC 182-507-0125. A person must be preapproved by the home and community living administration (HCLA) for this program due to enrollment limits.

(4) Noncitizens who meet citizenship and immigration status under WAC 182-503-0535 (2)(e) are eligible for:

(a) Nursing facility services if the person meets nursing facility level of care; or

(b) State-funded personal care services if functionally eligible based on a department assessment under chapter 388-106 or 388-845 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-19-051, s 182-513-1319, filed 9/10/25, effective 10/11/25. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1319, filed 1/17/17, effective 2/17/17.*

##### **Wash. Admin. Code § 182-513-1320** Determining institutional status for long-term care (LTC) services. {#sec-182-513-1320 omnilex-key=us-wa-regs-official--title-182--182-513-1320}

(1) To attain institutional status outside a medical institution, a person must be approved for and receive:

(a) Home and community based (HCB) waiver services under chapter 182-515 WAC;

(b) Roads to community living (RCL) services under WAC 182-513-1235;

(c) Program of all-inclusive care for the elderly (PACE) under WAC 182-513-1230;

(d) Hospice services under WAC 182-513-1240(3); or

(e) State-funded long-term care service under WAC 182-507-0125.

(2) To attain institutional status in a medical institution, a person must reside in a medical institution thirty consecutive days or more, or based on a department assessment, be likely to reside in a medical institution thirty consecutive days or more.

(3) Once a person meets institutional status, the person's status is not affected if the person:

(a) Transfers between medical facilities; or

(b) Changes between any of the following programs: HCB waiver, RCL, PACE, hospice or services in a medical institution.

(4) A person loses institutional status if the person is absent from a medical institution, or does not receive HCB waiver, RCL, PACE, or hospice services, for more than twenty-nine consecutive days.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1320, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as § 182-513-1320, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-513-1320, filed 10/22/12, effective 11/22/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.09.575, and Deficit Reduction Act of 2005, 42 C.F.R. Section 435. WSR 09-07-036, § 388-513-1320, filed 3/10/09, effective 4/10/09. Statutory Authority: RCW 74.08.090. WSR 06-07-077, § 388-513-1320, filed 3/13/06, effective 4/13/06. Statutory Authority: RCW 11.92.180, 43.20B.460, 48.85.020, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.[09.]575, 74.09.585*
- *20 C.F.R. 416.1110-1112, 1123 and 1160*
- *42 C.F.R. 435.403 (j)(2) and 1005*
- *and Sections 17, 1915(c), and 1924 (42 U.S.C. 1396) of the Social Security Act. WSR 00-01-051, § 388-513-1320, filed 12/8/99, effective 1/8/00. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 99-06-045, § 388-513-1320, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090 and 42 C.F.R. 435.403 (j)(2). WSR 97-15-025, § 388-513-1320, filed 7/8/97, effective 8/8/97. Statutory Authority: RCW 74.08.090. WSR 96-11-072 (Order 3980), § 388-513-1320, filed 5/10/96, effective 6/10/96*
- *WSR 94-10-065 (Order 3732), § 388-513-1320, filed 5/3/94, effective 6/3/94.*

##### **Wash. Admin. Code § 182-513-1325** Determining available income for an SSI-related single client for long-term care (LTC) services. {#sec-182-513-1325 omnilex-key=us-wa-regs-official--title-182--182-513-1325}

This section describes income the agency or its designee determines available when evaluating an SSI-related single client's eligibility for long-term care (LTC) services.

(1) See WAC 182-513-1330 for rules related to available income for legally married couples.

(2) The agency or its designee applies the following rules when determining income eligibility for SSI-related LTC services:

(a) WAC 182-512-0600 SSI-related medical—Definition of income;

(b) WAC 182-512-0650 SSI-related medical—Available income;

(c) WAC 182-512-0700 SSI-related medical—Income eligibility;

(d) WAC 182-512-0750 SSI-related medical—Countable unearned income;

(e) WAC 182-512-0840(3) self-employment income-allowable expenses; and

(f) WAC 182-512-0785, 182-512-0790, and 182-512-0795 for sponsored immigrants and how to determine if sponsors' income counts in determining benefits.

(3) In initial categorically needy income eligibility for LTC, the agency does not allow any deductions listed in 1612(b) of the Social Security Act, for example:

(a) Twenty dollars per month income exclusion under WAC 182-512-0800;

(b) The first $65 and the remaining one-half earned income work incentive under WAC 182-512-0840; and

(c) Impairment related work expense or blind work expense under WAC 182-512-0840.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1325, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as WAC 182-513-1325, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-513-1325, filed 10/22/12, effective 11/22/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530. WSR 07-14-087, § 388-513-1325, filed 6/29/07, effective 7/30/07. Statutory Authority: RCW 11.92.180, 43.20B.460, 48.85.020, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.[09.]575, 74.09.585*
- *20 C.F.R. 416.1110-1112, 1123 and 1160*
- *42 C.F.R. 435.403 (j)(2) and 1005*
- *and Sections 17, 1915(c), and 1924 (42 U.S.C. 1396) of the Social Security Act. WSR 00-01-051, § 388-513-1325, filed 12/8/99, effective 1/8/00.*

##### **Wash. Admin. Code § 182-513-1330** Determining available income for legally married couples for long-term care (LTC) services. {#sec-182-513-1330 omnilex-key=us-wa-regs-official--title-182--182-513-1330}

This section describes income the agency or its designee determines available when evaluating a legally married person's eligibility for long-term care (LTC) services.

(1) The agency or the agency's designee applies the following rules when determining income eligibility for LTC services:

(a) WAC 182-512-0600 SSI-related medical—Definition of income;

(b) WAC 182-512-0650 SSI-related medical—Available income;

(c) WAC 182-512-0700 SSI-related medical—Income eligibility;

(d) WAC 182-512-0750 SSI-related medical—Countable unearned income;

(e) WAC 182-512-0840(3), self-employment income-allowance expenses;

(f) WAC 182-512-0960 SSI-related medical—Allocating income—Determining eligibility for a spouse when the other spouse receives long-term services and supports (LTSS);

(g) WAC 182-512-0785, 182-512-0790, and 182-512-0795 for sponsored immigrants and how to determine if the sponsors' income counts in determining benefits.

(2) In initial categorically needy income eligibility for LTC, the agency does not allow any deductions listed in 1612(b) of the Social Security Act, for example:

(a) Twenty dollars per month income exclusion under WAC 182-512-0800;

(b) The first $65 and the remaining one-half earned income work incentive under WAC 182-512-0840; and

(c) Impairment related work expense or blind work expense under WAC 182-512-0840.

(3) The following income is available to an institutionalized spouse, unless subsections (5) and (6) apply:

(a) Income received in the institutionalized spouse's name;

(b) Income paid to a representative on the institutionalized spouse's behalf; and

(c) One-half of the income received in the names of both spouses.

(4) The following income is unavailable to an institutionalized spouse:

(a) Separate income received in the name of the community spouse; and

(b) Income established as unavailable through a court order.

(5) For the determination of eligibility only, if available income under subsection (3)(a) through (c) of this section, minus income exclusions under WAC 182-513-1340, exceeds the special income level (SIL), defined under WAC 182-513-1100, the agency or its designee:

(a) Follows Washington state community property law when determining ownership of income;

(b) Presumes all income received after the marriage by either spouse to be community income;

(c) Considers one-half of all community income available to the institutionalized spouse.

(6) If the total of subsection (5)(c) of this section plus the institutionalized spouse's separate income is over the SIL, determine available income using subsection (3) of this section.

(7) A stream of income, not generated by a transferred resource, is available to the institutionalized spouse, even if the institutionalized spouse transfers or assigns the rights to the stream of income to one of the following:

(a) The community spouse; or

(b) A trust for the benefit of the community spouse.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-16-058, § 182-513-1330, filed 7/26/18, effective 8/26/18. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1330, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as WAC 182-513-1330, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-513-1330, filed 10/22/12, effective 11/22/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.575, and 2005 federal Deficit Reduction Act (DRA), Public Law 109-171. WSR 07-17-152, § 388-513-1330, filed 8/21/07, effective 10/1/07. Statutory Authority: RCW 74.08.090. WSR 06-07-077, § 388-513-1330, filed 3/13/06, effective 4/13/06. Statutory Authority: RCW 11.92.180, 43.20B.460, 48.85.020, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.[09.]575, 74.09.585*
- *20 C.F.R. 416.1110-1112, 1123 and 1160*
- *42 C.F.R. 435.403 (j)(2) and 1005*
- *and Sections 17, 1915(c), and 1924 (42 U.S.C. 1396) of the Social Security Act. WSR 00-01-051, § 388-513-1330, filed 12/8/99, effective 1/8/00. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 99-06-045, § 388-513-1330, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090, 74.05.040 and 20 C.F.R. 416.1110-1112, 1123 and 1160. WSR 97-10-022, § 388-513-1330, filed 4/28/97, effective 5/29/97. Statutory Authority: RCW 74.08.090 and Title XIX State Agency Letter #94-33. WSR 95-02-028 (Order 3819), § 388-513-1330, filed 12/28/94, effective 1/28/95. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-513-1330, filed 5/3/94, effective 6/3/94. Formerly parts of WAC 388-95-335 and 388-95-340.*

##### **Wash. Admin. Code § 182-513-1340** Determining excluded income for long-term care (LTC) services. {#sec-182-513-1340 omnilex-key=us-wa-regs-official--title-182--182-513-1340}

This section describes income the agency or its designee excludes when determining a client's eligibility and participation in the cost of care for long-term care (LTC) services.

(1) When determining a client's eligibility and participation in the cost of care for LTC services, the agency excludes:

(a) Crime victim's compensation;

(b) Earned income tax credit (EITC) for twelve months after the month of receipt;

(c) American Indian/Alaskan native benefits excluded by federal statute (refer to WAC 182-512-0770);

(d) Tax rebates or special payments excluded by other statutes;

(e) Any public agency's refund of taxes paid on real property and/or on food;

(f) Supplemental security income (SSI) and certain state public assistance based on financial need;

(g) The amount a representative payee charges to provide services when the services are a requirement for the client to receive the income;

(h) The amount of expenses necessary for a client to receive compensation, e.g., legal fees necessary to obtain settlement funds;

(i) Education benefits under WAC 182-512-0760;

(j) Self-employment income allowed as a deduction by the Internal Revenue Service (IRS);

(k) Payments to prevent fuel cut-offs and to promote energy efficiency that are excluded by federal statute;

(l) Assistance (other than wages or salary) received under the Older Americans Act;

(m) Assistance (other than wages or salary) received under the foster grandparent program;

(n) Certain cash payments a client receives from a governmental or nongovernmental medical or social service agency to pay for medical or social services;

(o) Interest earned on excluded burial funds and any appreciation in the value of an excluded burial arrangement that are left to accumulate and become part of the separately identified burial funds set aside;

(p) Tax exempt payments received by Alaska natives under the Alaska Native Settlement Act established by P.L. 100-241;

(q) Compensation provided to volunteers in ACTION programs under the Domestic Volunteer Service Act of 1973 established by P.L. 93-113;

(r) Payments made from the Agent Orange Settlement Fund or any other funds to settle Agent Orange liability claims established by P.L. 101-201;

(s) Payments made under section six of the Radiation Exposure Compensation Act established by P.L. 101-426;

(t) Payments made under the Energy Employees Occupational Illness Compensation Program Act of 2000, (EEOICPA) Pub. L. 106-398;

(u) Restitution payment, and interest earned on such payment to a civilian of Japanese or Aleut ancestry established by P.L. 100-383;

(v) Payments made under sections 500 through 506 of the Austrian General Social Insurance Act;

(w) Payments made from Susan Walker v. Bayer Corporation, et, al., 95-C-5024 (N.D. Ill.) (May 8, 1997) settlement funds;

(x) Payments made from the Ricky Ray Hemophilia Relief Fund Act of 1998 established by P.L. 105-369;

(y) Payments made under the Disaster Relief and Emergency Assistance Act established by P.L. 100-387;

(z) Payments made under the Netherlands' Act on Benefits for Victims of Persecution (WUV);

(aa) Payments made to certain survivors of the Holocaust under the Federal Republic of Germany's Law for Compensation of National Socialist Persecution or German Restitution Act;

(bb) Interest or dividends received by the institutionalized individual is excluded as income. Interest or dividends received by the community spouse of an institutional individual is counted as income of the community spouse. Dividends and interest are returns on capital investments such as stocks, bonds, or savings accounts. Institutional status is defined in WAC 182-513-1320;

(cc) Income received by an ineligible or nonapplying spouse from a governmental agency for services provided to an eligible client, e.g., chore services.

(2) The agency or its designee treats Department of Veterans Affairs (VA) benefits as follows:

(a) Any VA dependent allowance is countable income to the dependent unless it is paid due to unusual medical expenses (UME);

(b) UME, aid and attendance allowance, special monthly compensation (SMC) and housebound allowance are third-party resources;

(c) Benefits in subsection (2)(b) of this section for a client who receives long-term care services are excluded when determining eligibility, but are available as a third-party resource (TPR) as defined under WAC 182-513-1100 when determining the amount the institutionalized client contributes in the cost of care.

(3) Any other income excluded by federal law is excluded.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-11-050, § 182-513-1340, filed 5/10/19, effective 6/10/19. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1340, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as WAC 182-513-1340, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-513-1340, filed 10/22/12, effective 11/22/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, Social Security Act § 1611, 1902, and C.F.R. 435.725. WSR 09-09-101, § 388-513-1340, filed 4/20/09, effective 5/21/09. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 42 C.F.R. 435.601, 42 C.F.R. 435.725-726, and Sections 4715 and 4735 of the Federal Balanced Budget Act of 1997 (P.L. 105-33) (H.R. 2015). WSR 00-01-087, § 388-513-1340, filed 12/14/99, effective 1/14/00. Statutory Authority: RCW 74.08.090 and Title XIX State Agency Letter #94-33. WSR 95-02-028 (Order 3819), § 388-513-1340, filed 12/28/94, effective 1/28/95. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-513-1340, filed 5/3/94, effective 6/3/94. Formerly WAC 388-95-340 (part).*

##### **Wash. Admin. Code § 182-513-1345** Determining disregarded income for institutional or hospice services under the medically needy (MN) program. {#sec-182-513-1345 omnilex-key=us-wa-regs-official--title-182--182-513-1345}

This section describes income the agency or its designee disregards when determining a person's eligibility for institutional or hospice services under the medically needy (MN) program. Disregarded income is available when determining a person's participation in the cost of care.

(1) The agency or its designee disregards the following income amounts in the following order:

(a) Income that is not reasonably anticipated, or is received infrequently or irregularly, when such income does not exceed:

(i) Twenty dollars per month if unearned; or

(ii) Ten dollars per month if earned.

(b) The first $20 per month of earned or unearned income, unless the sole source of income paid to a person is:

(i) Based on need; and

(ii) Totally or partially funded by the federal government or a nongovernmental agency.

(2) For a person who is related to the supplemental security income (SSI) program under WAC 182-512-0050(1), the first $65 per month of earned income not excluded under WAC 182-513-1340, plus one-half of the remainder.

(3) Department of Veterans Affairs benefits designated for:

(a) The veteran's dependent when determining LTC eligibility for the veteran. The VA dependent allowance is considered countable income to the dependent unless it is paid due to unusual medical expenses (UME);

(b) Unusual medical expenses, aid and attendance allowance, special monthly compensation (SMC) and housebound allowance, with the exception under subsection (4) of this section.

(4) Benefits under subsection (3)(b) of this section for a person who receives long-term care services are excluded when determining eligibility, but are considered available as a third-party resource (TPR) defined under WAC 182-513-1100 when determining the amount the person contributes in the cost of care.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1345, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as WAC 182-513-1345, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-513-1345, filed 10/22/12, effective 11/22/12. Statutory Authority: RCW 74.08.090. WSR 06-07-077, § 388-513-1345, filed 3/13/06, effective 4/13/06. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 42 C.F.R. 435.601, 42 C.F.R. 435.725-726, and Sections 4715 and 4735 of the Federal Balanced Budget Act of 1997 (P.L. 105-33) (H.R. 2015). WSR 00-01-087, § 388-513-1345, filed 12/14/99, effective 1/14/00. Statutory Authority: RCW 74.08.090 and Title XIX State Agency Letter #94-33. WSR 95-02-028 (Order 3819), § 388-513-1345, filed 12/28/94, effective 1/28/95. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-513-1345, filed 5/3/94, effective 6/3/94. Formerly WAC 388-95-340 (part).*

##### **Wash. Admin. Code § 182-513-1350** Defining the resource standard and determining resource eligibility for SSI-related long-term care (LTC) services. {#sec-182-513-1350 omnilex-key=us-wa-regs-official--title-182--182-513-1350}

(1) General information.

(a) This section describes how the agency or the agency's designee defines the resource standard and countable or excluded resources when determining a person's eligibility for SSI-related long-term care (LTC) services.

(b) "Resource standard" means the maximum amount of resources a person can have and still be resource eligible for program benefits.

(c) For a person not SSI-related, the agency applies program specific resource rules to determine eligibility.

(2) Resource standards.

(a) The resource standard for the following people is $2000:

(i) A single person; or

(ii) An institutionalized spouse.

(b) The resource standard for a legally married couple is $3000, unless subsection (3)(b)(ii) of this section applies.

(c) The resource standard for a person with a qualified long-term care partnership policy under WAC 182-513-1400 may be higher based on the dollar amount paid out by a partnership policy.

(d) Determining the amount of resources that can be allocated to the community spouse when determining resource eligibility is under WAC 182-513-1355.

(3) Availability of resources.

(a) General. The agency or the agency's designee applies the following rules when determining available resources for LTC services:

(i) WAC 182-512-0300 SSI-related medical—Resources eligibility;

(ii) WAC 182-512-0250 SSI-related medical—Ownership and availability of resources; and

(iii) WAC 182-512-0260 SSI-related medical—How to count a sponsor's resources.

(b) Married couples.

(i) When both spouses apply for LTC services, the resources of both spouses are available to each other through the month in which the spouses stopped living together.

(ii) When both spouses are institutionalized, the agency or the agency's designee determines the eligibility of each spouse as a single person the month following the month of separation.

(iii) If the agency or the agency's designee has already established eligibility and authorized services for one spouse, and the community spouse needs LTC services in the same month, but after eligibility has been established and services authorized for the institutionalized spouse, then the agency applies the standard under subsection (2)(a) of this section to each spouse. If doing this would make one of the spouses ineligible, then the agency applies subsection (2)(b) of this section for the couple.

(iv) The resources of the community spouse are unavailable to the institutionalized spouse the month after eligibility for LTC services is established, unless (v) or (vi) of this subsection applies.

(v) When a single institutionalized individual marries, the agency or the agency's designee redetermines eligibility applying the resource and income rules for a legally married couple.

(vi) A redetermination of the couple's resources under this section is required if:

(A) The institutionalized spouse has a break of at least 30 consecutive days in a period of institutional status;

(B) The institutionalized spouse's countable resources exceed the standard under subsection (2)(a) of this section, and WAC 182-513-1355 (2)(b) applies; or

(C) The institutionalized spouse does not transfer the amount, under WAC 182-513-1355 (3) or (5), to the community spouse by either:

(I) The end of the month of the first regularly scheduled eligibility review; or

(II) A reasonable amount of time necessary to obtain a court order for the support of the community spouse.

(4) Countable resources.

(a) The agency or the agency's designee determines countable resources using the following sections:

(i) WAC 182-512-0200 SSI-related medical—Definition of resources.

(ii) WAC 182-512-0250 SSI-related medical—Ownership and availability of resources.

(iii) WAC 182-512-0260 SSI-related medical—How to count a sponsor's resources.

(iv) WAC 182-512-0300 SSI-related medical—Resources eligibility.

(v) WAC 182-512-0350 SSI-related medical—Property and contracts excluded as resources;

(vi) WAC 182-512-0400 SSI-related medical—Vehicles excluded as resources;

(vii) WAC 182-512-0450 SSI-related medical—Life insurance excluded as a resource; and

(viii) WAC 182-512-0500 SSI-related medical—Burial funds, contracts and spaces excluded as resources.

(ix) Chapter 182-516 WAC, Trusts, annuities, life estates, and promissory notes—Effect on medical programs.

(b) The agency or the agency's designee determines excluded resources based on federal law and WAC 182-512-0550, except:

(i) For institutional and HCB waiver programs, pension funds owned by a nonapplying spouse are counted toward the resource standard.

(ii) For institutional and HCB waiver programs, one home is excluded only if it meets the home equity limits of subsection (8) of this section. See WAC 182-512-0350 (1)(b).

(c) The agency or the agency's designee adds together the countable resources of both spouses if subsections (3)(b)(i) and (iv) apply, but not if subsection (3)(b)(ii) or (iii) apply. For a person with a community spouse, see WAC 182-513-1355.

(5) Excess resources.

(a) For LTC programs, a person may reduce excess resources by deducting incurred medical expenses under subsection (6) of this section;

(b) The amount of excess resources is limited to the following amounts:

(i) For LTC services provided under the categorically needy (CN) program:

(A) In a medical institution, excess resources and available income must be under the state medicaid rate based on the number of days the person spent in the medical institution in the month.

(B) For HCB waiver eligibility, incurred medical expenses must reduce resources within allowable resource standards. The cost of care for the HCB waiver services cannot be allowed as a projected expense.

(ii) For LTC services provided under the medically needy (MN) program, see:

(A) WAC 182-513-1395 for LTC programs; and

(B) WAC 182-513-1245 for hospice.

(c) Excess resources not otherwise applied to medical expenses will be applied to the projected cost of care for services in a medical institution under WAC 182-513-1380.

(6) Allowable medical expenses.

(a) The following incurred medical expenses may be used to reduce excess resources:

(i) Premiums, deductibles, coinsurance, or copayment charges for health insurance and medicare;

(ii) Medically necessary care defined under WAC 182-500-0070, but not covered under the state's medicaid plan. Information regarding covered services is under chapter 182-501 WAC;

(iii) Medically necessary care defined under WAC 182-500-0070 incurred prior to medicaid eligibility. Expenses for nursing facility care are reduced at the state rate for the specific facility that provided the services.

(b) To be allowed, the medical expense must:

(i) Have been incurred no more than three months before the month of the medicaid application;

(ii) Not be subject to third-party payment or reimbursement;

(iii) Not have been used to satisfy a previous spenddown liability;

(iv) Not have been previously used to reduce excess resources;

(v) Not have been used to reduce participation;

(vi) Not have been incurred during a transfer of asset penalty under WAC 182-513-1363; and

(vii) Be an amount for which the person remains liable.

(7) Nonallowable expenses. The following expenses are not allowed to reduce excess resources:

(a) Unpaid adult family home (AFH) or assisted living facility expenses incurred prior to medicaid eligibility;

(b) Personal care cost more than approved hours determined by the CARE assessment under chapter 388-106 WAC; and

(c) Expenses excluded by federal law.

(8) Excess home equity.

(a) A person with an equity interest in a primary residence more than the home equity limit is ineligible for institutional and HCB waiver programs, unless one of the following persons lawfully resides in the home:

(i) That person's spouse; or

(ii) That person's dependent child under age 21, blind child, or disabled child.

(b) The home equity provision applies to all applications for LTSS received on or after May 1, 2006.

(c) The excess home equity limit is the federal maximum allowed. On January 1st of each year, this standard may change by the percentage in the consumer price index for all consumers (CPI-U). The current maximum home equity limit is posted by the Centers for Medicare and Medicaid Services. (See subsection (9) of this section for institutional resource standards.)

(d) A person who is denied or terminated LTC services due to excess home equity may apply for an undue hardship waiver under WAC 182-513-1367.

(9) Institutional resource standards are found at: www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-06-050, s 182-513-1350, filed 2/25/26, effective 3/28/26*
- *WSR 23-04-034, § 182-513-1350, filed 1/25/23, effective 2/25/23*
- *WSR 22-13-058, § 182-513-1350, filed 6/8/22, effective 7/9/22*
- *WSR 17-18-023, § 182-513-1350, filed 8/28/17, effective 9/28/17. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1350, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as § 182-513-1350, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-513-1350, filed 10/22/12, effective 11/22/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, and 74.09.575. WSR 09-12-058, § 388-513-1350, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.530. WSR 08-13-072, § 388-513-1350, filed 6/16/08, effective 7/17/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.575, 74.09.500, and 74.09.530. WSR 07-19-128, § 388-513-1350, filed 9/19/07, effective 10/20/07. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.09.575, 2005 Federal Deficit Reduction Act (DRA) P.L. 109-171, and Section 1924 of the Social Security Act (42 U.S.C. 1396r-5). WSR 07-01-073, § 388-513-1350, filed 12/18/06, effective 1/18/07. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 42 U.S.C. 9902(2). WSR 05-07-033, § 388-513-1350, filed 3/9/05, effective 4/9/05. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.575*
- *2003 1st sp.s. c 28, and section 1924 of the Social Security Act (42 U.S.C. 1396R-5). WSR 04-04-072, § 388-513-1350, filed 2/2/04, effective 3/4/04. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500 and Section 1924 (42 U.S.C. 1396R-5). WSR 01-18-055, § 388-513-1350, filed 8/30/01, effective 9/30/01. Statutory Authority: RCW 11.92.180, 43.20B.460, 48.85.020, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.[09.]575, 74.09.585*
- *20 C.F.R. 416.1110-1112, 1123 and 1160*
- *42 C.F.R. 435.403 (j)(2) and 1005*
- *and Sections 17, 1915(c), and 1924 (42 U.S.C. 1396) of the Social Security Act. WSR 00-01-051, § 388-513-1350, filed 12/8/99, effective 1/8/00. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 99-06-045, § 388-513-1350, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 74.09.575 and Section 1924 (42 U.S.C. 1396r-5). WSR 98-11-033, § 388-513-1350, filed 5/14/98, effective 6/14/98. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090 and 74.09.575. WSR 97-09-112, § 388-513-1350, filed 4/23/97, effective 5/24/97. Statutory Authority: RCW 74.08.090 and Title XIX State Agency Letter 95-44. WSR 96-09-033 (Order 3963), § 388-513-1350, filed 4/10/96, effective 5/11/96. Statutory Authority: RCW 74.08.090 and Title XIX State Agency Letter 94-49, notice of increase in SSI level. WSR 95-05-022 (Order 3832), § 388-513-1350, filed 2/8/95, effective 3/11/95. Statutory Authority: RCW 74.08.090. WSR 94-23-129 (Order 3808), § 388-513-1350, filed 11/23/94, effective 12/24/94*
- *WSR 94-10-065 (Order 3732), § 388-513-1350, filed 5/3/94, effective 6/3/94. Formerly parts of WAC 388-95-337 and 388-95-340.*

##### **Wash. Admin. Code § 182-513-1355** Allocating resources to a community spouse when determining resource eligibility for SSI-related long-term care services. {#sec-182-513-1355 omnilex-key=us-wa-regs-official--title-182--182-513-1355}

(1) The agency or its designee uses this section to calculate the resource allocation from the institutionalized spouse to the community spouse for the determination of the institutionalized spouse's resource eligibility under WAC 182-513-1350 (2)(a)(ii).

(2) If the institutionalized spouse's most recent continuous period of institutionalization (MRCPI) began:

(a) Before October 1, 1989, the agency adds together one-half the total amount of countable resources, as determined under WAC 182-513-1350(4), held in the name of:

(i) The institutionalized spouse; and

(ii) Both spouses.

(b) On or after October 1, 1989, the agency or its designee adds together the total amount of countable resources, as determined under WAC 182-513-1350(4), held in the name of:

(i) Either spouse; and

(ii) Both spouses.

(3) If subsection (2)(b) of this section applies, the agency or its designee determines the amount of resources allocated to the community spouse, before determining the amount of countable resources used to establish eligibility for the institutionalized spouse under WAC 182-513-1350:

(a) If the institutionalized spouse's MRCPI began on or after October 1, 1989, and before August 1, 2003, the agency or its designee allocates the federal spousal resource maximum;

(b) If the institutionalized spouse's MRCPI began on or after August 1, 2003, the agency or its designee allocates the greater of:

(i) A spousal share equal to one-half of the couple's combined countable resources, up to the federal spousal resource maximum; or

(ii) The state spousal resource standard.

(4) Countable resources under subsection (3)(b) of this section determined as of the first day of the month in which MRCPI began.

(5) The agency or its designee uses a community spouse evaluation to determine the amount of the spousal share under subsection (3)(b)(i) of this section.

(6) The agency or its designee completes a community spouse resource evaluation:

(a) Upon request by the institutionalized spouse, or the institutionalized spouse's community spouse;

(b) At any time between the date that the MRCPI began and the date that eligibility for long-term care (LTC) is determined; and

(c) Upon receipt of any verification required to establish the amount of the couple's resources in the month of MRCPI.

(7) The community spouse resource evaluation can be completed prior to an application for LTC or as part of the LTC application if:

(a) The beginning of the MRCPI was prior to the month of application; and

(b) The spousal share exceeds the state spousal resource standard.

(8) The amount of allocated resources under subsection (3) of this section can be increased, but only if:

(a) A court has entered an order against the institutionalized spouse for the support of the community spouse or a dependent of either spouse; or

(b) A final order is entered under chapter 182-526 WAC, ruling that the institutionalized spouse or community spouse established that the income generated by the resources allocated under subsection (3) of this section is insufficient to raise the community spouse's income to the monthly maintenance needs allowance (MMNA) determined under WAC 182-513-1385, but only after the application of the income-first rule under 42 U.S.C. 1396r–5 (d)(6).

(9) If a final order establishes that the conditions identified in subsection (8)(b) of this section have been met, then an amount of allocated resources under subsection (3) of this section will be substituted by an amount adequate to provide such an MMNA.

(10) The institutionalized spouse has until the end of the month of the first regularly scheduled eligibility review to transfer countable resources in excess of $2000 to the community spouse.

(11) Standards in this section are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-04-034, § 182-513-1355, filed 1/25/23, effective 2/25/23. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1355, filed 1/17/17, effective 2/17/17.*

##### **Wash. Admin. Code § 182-513-1363** Evaluating an asset transfer for clients applying for or receiving long-term care (LTC) services. {#sec-182-513-1363 omnilex-key=us-wa-regs-official--title-182--182-513-1363}

(1) When determining a client's eligibility for long-term care (LTC) services, the medicaid agency or the agency's designee evaluates the effect of an asset transfer made within the sixty-month period before the month that the client:

(a) Attained institutional status, or would have attained institutional status but for a period of ineligibility; and

(b) Applied for LTC services.

(2) The agency or the agency's designee evaluates all transfers for recipients of LTC services made during or after the month the recipient attained institutional status.

(3) The agency or the agency's designee establishes a period of ineligibility during which the client is not eligible for LTC services if the client, the client's spouse, or someone acting on behalf of either:

(a) Transfers an asset within the time period under subsection (1) or (2) of this section; and

(b) There is uncompensated value because:

(i) Adequate consideration was not received for the asset, unless the transfer meets one of the conditions in subsection (4) of this section;

(ii) The transfer was compensated, but fails a requirement under subsection (4)(d)(iv) or (f) of this section; or

(iii) The transfer was determined to be an uncompensated asset transfer under chapter 182-516 WAC.

(4) The agency or the agency's designee does not apply a period of ineligibility for uncompensated value if:

(a) The total of all asset transfers in a month does not exceed the statewide average daily private cost for nursing facilities at the time of application or the date of transfer, whichever is later;

(b) The transferred asset was an excluded resource under WAC 182-513-1350 except a home, unless the transfer of the home meets the conditions under (d) of this subsection;

(c) The asset was transferred for less than fair market value (FMV), and the client can establish one of the following:

(i) An intent to transfer the asset at FMV. This intent is established by providing convincing evidence to the agency or the agency's designee;

(ii) The asset was transferred exclusively for a purpose other than to qualify for medicaid, continue to qualify for medicaid, or avoid estate recovery.

(A) An asset transfer is presumed to be for the purpose of establishing or continuing medicaid eligibility, avoiding estate recovery, or both;

(B) A client can rebut this presumption by providing convincing evidence that the transfer of an asset was exclusively for a purpose other than to qualify for medicaid, continue to qualify for medicaid, or avoid estate recovery.

(iii) All assets transferred for less than FMV have been returned to the client or the client's spouse; or

(iv) Denial of eligibility results in an undue hardship under WAC 182-513-1367.

(d) The transferred asset was a home, if the home was transferred to the person's:

(i) Spouse;

(ii) Child who meets the disability criteria under WAC 182-512-0050 (1)(b) or (c);

(iii) Child who was under age twenty-one; or

(iv) Child who lived in the home and provided care, but only if:

(A) The child lived in the person's home for at least two years;

(B) The child provided verifiable care to that person during the time period in (d)(iv)(A) of this subsection for at least two years;

(C) The period of care under (d)(iv)(B) of this subsection was immediately before that person's current period of institutional status;

(D) The care was not paid for by medicaid;

(E) The care enabled that person to remain at home; and

(F) The physician's documentation verifies that the in-home care was necessary to prevent that person's current period of institutional status; or

(v) Sibling, who has lived in and has had an equity interest in the home for at least one year immediately before the date the person attained institutional status.

(e) The asset was transferred to the client's spouse; or to the client's or their spouse's child, if the child meets the disability criteria under WAC 182-512-0050 (1)(b) or (c);

(f) The transfer was to a family member before the current period of institutional status, and all the following conditions are met. If all the following conditions are not met, the transfer is an uncompensated transfer, regardless of consideration received:

(i) The transfer is in exchange for care services the family member provided to the client or their spouse;

(ii) The client or their spouse had a documented need for the care services provided by the family member;

(iii) The care services provided by the family member are allowed under the medicaid state plan or the department's home and community-based waiver services;

(iv) The care services provided by the family member do not duplicate those that another party is being paid to provide;

(v) The FMV of the asset transferred is comparable to the FMV of the care services provided;

(vi) The time for which care services are claimed is reasonable based on the kind of services provided; and

(vii) The assets were transferred as the care services were performed, with no more time delay than one calendar month between the provision of the service and the transfer.

(g) The transfer meets the conditions under subsection (5) of this section, and the asset is transferred:

(i) To another party for the sole benefit of the client's spouse;

(ii) From the client's spouse to another party for the sole benefit of the client's spouse;

(iii) To a trust established for the sole benefit of the client's or their spouse's child who meets the disability criteria under WAC 182-512-0050 (1)(b) or (c); or

(iv) To a trust established for the sole benefit of a person who is under age sixty-five who meets the disability criteria under WAC 182-512-0050 (1)(b) or (c).

(5) An asset transfer or establishment of a trust is for the sole benefit of a person under subsection (4)(g) of this section if the document transferring the asset:

(a) Was made in writing;

(b) Is irrevocable;

(c) States that the client's spouse, their blind or disabled child, or another disabled person can benefit from the transferred assets; and

(d) States that all assets involved must be spent for the sole benefit of the person over an actuarially sound period, based on the life expectancy of that person or the term of the document, whichever is less, unless the document is a trust that meets the conditions of a trust established under Section 42 U.S.C. 1396p (d)(4)(A) or Section 42 U.S.C. 1396 (d)(4)(C) as described under chapter 182-516 WAC.

(6) To calculate the period of ineligibility under subsection (3) of this section:

(a) Add together the total uncompensated value of all transfers under subsection (3) of this section; and

(b) Divide the total in (a) of this subsection by the statewide average daily private cost for nursing facilities at the time of application or the date of transfer, whichever is later. The result is the length, in days rounded down to the nearest whole day, of the period of ineligibility.

(7) The period of ineligibility under subsection (6) of this section begins:

(a) For an LTC services applicant: The date the client would be otherwise eligible for LTC services, but for the transfer, based on an approved application for LTC services or the first day after any previous period of ineligibility has ended; or

(b) For an LTC services recipient: The first of the month following ten-day advance notice of the period of ineligibility, but no later than the first day of the month that follows three full calendar months from the date of the report or discovery of the transfer; or the first day after any previous period of ineligibility has ended.

(8) The period of ineligibility ends after the number of whole days, calculated in subsection (6) of this section, pass from the date the period of ineligibility began in subsection (7) of this section.

(9) If the transfer was to the client's spouse, from the client's spouse to the client, and it included the right to receive an income stream, the agency or the agency's designee determines availability of the income stream under WAC 182-513-1330.

(10) If the transferred asset, for which adequate consideration was not received, included the right to receive a stream of income not generated by a transferred asset, the length of the period of ineligibility is calculated and applied in the following way:

(a) The amount of reasonably anticipated future monthly income, after the transfer, is multiplied by the actuarial life expectancy in months of the previous owner of the income. The actuarial life expectancy is based on age of the previous owner in the month the transfer occurs. If the client and their spouse co-owned the asset, the longer actuarial life expectancy is used. This product is the FMV of the asset;

(b) Any consideration received in return for the FMV of the asset under (a) of this subsection is subtracted to calculate the uncompensated value;

(c) The uncompensated value in (b) of this subsection is divided by the statewide average daily private cost for nursing facilities at the time of application or the date of transfer, whichever is later. The result is the length, in days rounded down to the nearest whole day, of the period of ineligibility; and

(d) The period of ineligibility begins under subsection (7) of this section and ends under subsection (8) of this section.

(11) A period of ineligibility for the transfer of an asset that is applied to one spouse is not applied to the other spouse, unless both spouses have attained institutional status. When both spouses are institutionalized, the agency or the agency's designee divides the penalty equally between the two spouses. If one spouse is no longer subject to a period of ineligibility, the remaining period of ineligibility that applied to both spouses will be applied to the other spouse.

(12) Throughout this section, the date of an asset transfer is:

(a) For real property:

(i) The day the deed is signed by the grantor if the deed is recorded; or

(ii) The day the signed deed is delivered to the grantee.

(b) For all other assets, the day the intentional act or the failure to act resulted in the change of ownership or title.

(13) If a client or their spouse disagrees with the determination or application of a period of ineligibility, a hearing may be requested under chapter 182-526 WAC.

(14) Additional statutes that apply to transfer of asset penalties, real property transfer for inadequate consideration, disposal of realty penalties, and transfers to qualify for assistance can be found at:

(a) RCW 74.08.331 Unlawful practices—Obtaining assistance—Disposal of realty—Penalties;

(b) RCW 74.08.338 Real property transfers for inadequate consideration;

(c) RCW 74.08.335 Transfers of property to qualify for assistance; and

(d) RCW 74.39A.160 Transfer of assets—Penalties.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 74.09.585 and 42 U.S.C. 1396p(c). WSR 20-14-120, § 182-513-1363, filed 7/1/20, effective 8/1/20. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. 1396p(a). WSR 19-12-118, § 182-513-1363, filed 6/5/19, effective 7/6/19. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1363, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as § 182-513-1363, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-513-1363, filed 10/22/12, effective 11/22/12. Statutory Authority: RCW 34.05.353 (2)(d), 74.08.090, and chapters 74.09, 74.04 RCW. WSR 08-11-047, § 388-513-1363, filed 5/15/08, effective 6/15/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.575, and 2005 federal Deficit Reduction Act (DRA), Public Law 109-171. WSR 07-17-152, § 388-513-1363, filed 8/21/07, effective 10/1/07.*

##### **Wash. Admin. Code § 182-513-1367** Hardship waivers. {#sec-182-513-1367 omnilex-key=us-wa-regs-official--title-182--182-513-1367}

(1) This section defines undue hardship for long-term services and supports (LTSS) and specifies the request, approval, denial, and other processes for hardship waivers.

(2) Undue hardship.

(a) Undue hardship exists when, without LTSS benefits, the client is unable to obtain:

(i) Medical care to the extent that health or life is endangered; or

(ii) Food, clothing, shelter or other basic necessities of life.

(b) Undue hardship does not exist when:

(i) The denial or termination of LTSS inconveniences the client or restricts the client's lifestyle but does not seriously deprive the client of the items described under (a) of this subsection;

(ii) The denial or termination of LTSS is because of a period of ineligibility under WAC 182-513-1363, and the asset was transferred by a person or entity handling the financial affairs of the client denied or terminated from LTSS, unless the department has found evidence of financial exploitation; or

(iii) The client's situation meets undue hardship under (a) of this subsection because of restrictions placed in a trust by that client, either personally or through a spouse, guardian, conservator, court, or another person authorized to act on behalf of that client through a power of attorney document (attorney-in-fact).

(3) A hardship waiver may be requested when a client is denied or terminated from LTSS under the following scenarios:

(a) A period of ineligibility under WAC 182-513-1363 was established for a client, and that client, who transferred the assets, or on whose behalf the assets were transferred, either personally or through a spouse, guardian, conservator, or another person authorized to act on behalf of that client through a power of attorney document (attorney-in-fact), has exhausted all reasonable means including legal remedies to recover the assets or the value of the transferred assets that caused the period of ineligibility;

(b) A client was denied or terminated from LTSS due to exceeding the home equity standard under WAC 182-513-1350, and the client cannot legally access the excess equity; or

(c) The client was denied or terminated from LTSS due to the application of rules regarding trusts under chapter 182-516 WAC, except that if the application of rules regarding trusts under chapter 182-516 WAC results in a period of ineligibility under WAC 182-513-1363, then (a) of this subsection applies instead of (c) of this subsection.

(4) Process to request a hardship waiver.

(a) A hardship waiver may be requested by:

(i) The client;

(ii) The client's spouse;

(iii) The client's authorized representative; or

(iv) With the consent of the client, a representative of the medical institution in which the client resides.

(b) The hardship waiver request must:

(i) Be in writing;

(ii) State the reason for requesting the hardship waiver;

(iii) Be signed by the requestor and include the requestor's name, address, and telephone number. If the request is being made on behalf of a client, then that client's name, address, and telephone number must be included;

(iv) Be made within 30 days of the date of denial or termination of LTSS; and

(v) Returned to the originating address on the denial or termination letter.

(c) If additional information is needed to determine whether or not to approve a hardship waiver, then, within 15 days of receipt of the request for the hardship waiver, the agency or the agency's designee sends the client a written notice requesting additional information under WAC 182-503-0050.

(5) Standards to approve a hardship waiver request.

(a) Period of ineligibility: If a client was denied or terminated from LTSS under WAC 182-513-1363 (the scenario described in subsection (3)(a) of this section) and undue hardship under subsection (2) of this section is found to exist, then the agency or the agency's designee approves a hardship waiver.

(b) Excess home equity: If a client was denied or terminated from LTSS under WAC 182-513-1350 (the scenario described in subsection (3)(b) of this section) and undue hardship under subsection (2) of this section is found to exist, then the agency or the agency's designee approves a hardship waiver.

(c) Trusts.

(i) The client's home is in a revocable trust: If a client was denied or terminated from LTSS under chapter 182-516 WAC (the scenario described in subsection (3)(c) of this section), then the agency or the agency's designee approves a hardship waiver for up to 90 days if the following conditions are met:

(A) The client is an institutionalized individual;

(B) The home would otherwise meet the exclusion criteria in WAC 182-512-0350 (1)(b), but it is in a revocable trust; and

(C) The client must submit in writing to the agency or the agency's designee that, in order to exclude the home under WAC 182-512-0350 (1)(b), the home will be retitled out of the revocable trust to the client, the client's spouse, or both, within 90 days.

(ii) All other denials or terminations of LTSS due to trusts: If a client was denied or terminated from LTSS under subsection (3)(c) of this section, and undue hardship under subsection (2) of this section is found to exist, then the agency or the agency's designee approves a hardship waiver.

(6) If the hardship is approved:

(a) The agency or the agency's designee sends a notice within 15 days of receiving all information needed to approve the hardship waiver. The hardship waiver approval notice specifies a time period for which the undue hardship waiver is approved.

(b) Any changes in a client's situation that led to the approval of a hardship waiver must be reported to the agency or the agency's designee within 30 days of the change per WAC 182-504-0110.

(c) If the hardship waiver is approved under subsection (5)(c)(i) of this section, the client must provide verification by the 90th day after the hardship waiver approval that the home has been retitled out of the revocable trust to the client, the client's spouse, or both.

(7) If the hardship waiver is denied:

(a) The agency or the agency's designee sends a denial notice within 15 days of receiving the hardship waiver request or the request for additional information. The notice will state the reason why the hardship waiver was not approved.

(b) The denial notice has instructions on how to request an administrative hearing. The agency or the agency's designee must receive an administrative hearing request within 90 days of the date of the adverse action.

(8) The agency or the agency's designee may revoke approval of an undue hardship waiver if any of the following occur:

(a) A client, or the client's authorized representative, fails to provide timely information or resource verifications as it applies to the hardship waiver when requested by the agency or the agency's designee per WAC 182-503-0050 and 182-504-0105;

(b) The lien or legal impediment that restricted access to home equity in excess of the home equity limit is removed; or

(c) Circumstances for which the undue hardship was approved have changed.

(9) If there is a conflict between this section and chapter 182-526 WAC, this section prevails.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-04-040, s 182-513-1367, filed 1/29/25, effective 3/1/25. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. 1396p. WSR 18-04-037, § 182-513-1367, filed 1/30/18, effective 3/2/18. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1367, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as WAC 182-513-1367, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-513-1367, filed 10/22/12, effective 11/22/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, Section 1917 (c)(2)(D) of the Social Security Act (42 U.S.C. 1396p (c)(2)(D), and Section 6011(d) of the federal Deficit Reduction Act of 2005. WSR 07-17-005, § 388-513-1367, filed 8/2/07, effective 9/2/07.*

##### **Wash. Admin. Code § 182-513-1380** Determining a client's financial participation in the cost of care for long-term care in a medical institution. {#sec-182-513-1380 omnilex-key=us-wa-regs-official--title-182--182-513-1380}

This rule describes how the agency or the agency's designee allocates income and excess resources when determining participation in the cost of care in a medical institution.

(1) The agency or the agency's designee defines which income and resources must be used in this process under WAC 182-513-1315.

(2) The agency or the agency's designee allocates nonexcluded income in the following order, and the combined total of (a), (b), (c), and (d) of this subsection cannot exceed the effective one-person medically needy income level (MNIL):

(a) A personal needs allowance (PNA) under WAC 182-513-1105.

(b) Mandatory federal, state, or local income taxes owed by the client.

(c) Wages for a client who:

(i) Is related to the supplemental security income (SSI) program under WAC 182-512-0050(1); and

(ii) Receives the wages as part of an agency-approved or department-approved training or rehabilitative program designed to prepare the client for a less restrictive placement. When determining this deduction, employment expenses are not deducted.

(d) Guardianship fees, conservatorship fees, and administrative costs, including any attorney fees paid by the guardian or conservator, as allowed under chapter 388-79A WAC.

(3) The agency or the agency's designee allocates nonexcluded income after deducting amounts under subsection (2) of this section in the following order:

(a) Current or back child support garnished or withheld from income according to a child support order in the month of the garnishment if it is:

(i) For the current month;

(ii) For the time period covered by the PNA; and

(iii) Not counted as the dependent member's income when determining the dependent allocation amount under WAC 182-513-1385.

(b) A monthly maintenance needs allowance for the community spouse as determined using the calculation under WAC 182-513-1385. If the community spouse is also receiving long-term care services, the allocation is limited to an amount that brings the community spouse's income up to the PNA.

(c) A dependent allowance for each dependent of the institutionalized client or the client's spouse, as determined using the calculation under WAC 182-513-1385.

(d) Medical expenses incurred by the institutionalized individual and not used to reduce excess resources. Allowable medical expenses and reducing excess resources are described in WAC 182-513-1350.

(e) Maintenance of the home of a single institutionalized client, an institutionalized couple, or a married institutionalized client not sharing the same residence as the community spouse:

(i) Up to 100 percent of the one-person federal poverty level per month;

(ii) Limited to a six-month period;

(iii) When a physician has certified that the client or couple is likely to return to the home within the six-month period; and

(iv) When social services staff documents the need for the income deduction.

(4) A client may have to pay third-party resources as defined under WAC 182-513-1100 in addition to the participation.

(5) A client is responsible to pay only up to the state rate for the cost of care. If long-term care insurance pays a portion of the state rate cost of care, a client pays only the difference up to the state rate cost of care.

(6) When a client lives in multiple living arrangements in a month, the agency allows the highest PNA available based on all the living arrangements and services the client has in a month.

(7) Standards under this section for long-term care are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-10-097, s 182-513-1380, filed 5/7/25, effective 6/7/25*
- *WSR 25-04-040, s 182-513-1380, filed 1/29/25, effective 3/1/25*
- *WSR 23-04-034, § 182-513-1380, filed 1/25/23, effective 2/25/23*
- *WSR 21-09-092, § 182-513-1380, filed 4/21/21, effective 5/22/21*
- *WSR 20-08-082, § 182-513-1380, filed 3/27/20, effective 4/27/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 c 270. WSR 17-23-039, § 182-513-1380, filed 11/8/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1380, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as WAC 182-513-1380, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-513-1380, filed 10/22/12, effective 11/22/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, and Deficit Reduction Act of 2005, 42 C.F.R. Section 435. WSR 09-07-037, § 388-513-1380, filed 3/10/09, effective 4/10/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.530. WSR 08-13-072, § 388-513-1380, filed 6/16/08, effective 7/17/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, and 2006 c 372. WSR 07-19-126, § 388-513-1380, filed 9/19/07, effective 10/20/07*
- *WSR 07-01-072, § 388-513-1380, filed 12/18/06, effective 1/18/07. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530 and 2005 c 518 § 207 and Sec. 1924 Social Security Act (42 U.S.C. 1396r-5). WSR 06-07-144, § 388-513-1380, filed 3/21/06, effective 4/21/06. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 42 U.S.C. 9902(2). WSR 05-07-033, § 388-513-1380, filed 3/9/05, effective 4/9/05. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.575*
- *2003 1st sp.s. c 28, and section 1924 of the Social Security Act (42 U.S.C. 1396R-5). WSR 04-04-072, § 388-513-1380, filed 2/2/04, effective 3/4/04. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500 and Section 1924 (42 U.S.C. 1396R-5). WSR 01-18-055, § 388-513-1380, filed 8/30/01, effective 9/30/01. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and Section 1924(g) of the Social Security Act. WSR 00-17-058, § 388-513-1380, filed 8/9/00, effective 9/9/00. Statutory Authority: RCW 72.36.160, 74.04.050, 74.04.057, 74.08.090, 74.09.500 and Section 1924(g) of the Social Security Act, Section 4715 of the BBA of 1997 (Public Law 105-33, HR 2015). WSR 99-11-017, § 388-513-1380, filed 5/10/99, effective 6/10/99. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 43.20B.460, 11.92.180, and Section 1924 (42 U.S.C. 396r-5). WSR 98-08-077, § 388-513-1380, filed 3/31/98, effective 4/1/98. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530 and Social Security Act, Federal Register, March 10, 1997, pgs. 10856 - 10859, 42 U.S.C. 1396 (a)(l)(m). WSR 97-16-008, § 388-513-1380, filed 7/24/97, effective 7/24/97. Statutory Authority: RCW 74.08.090 and Title XIX State Agency Letter 95-44. WSR 96-09-033 (Order 3963), § 388-513-1380, filed 4/10/96, effective 5/11/96. Statutory Authority: RCW 74.08.090. WSR 95-11-045 (Order 3848), § 388-513-1380, filed 5/10/95, effective 6/10/95. Statutory Authority: RCW 74.08.090 and Title XIX State Agency Letter 94-49, notice of increase in SSI level. WSR 95-05-022 (Order 3832), § 388-513-1380, filed 2/8/95, effective 3/11/95. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-513-1380, filed 5/3/94, effective 6/3/94. Formerly WAC 388-95-360.*

##### **Wash. Admin. Code § 182-513-1385** Determining the community spouse monthly maintenance needs allowance and dependent allowance in post-eligibility treatment of income for long-term care (LTC) programs. {#sec-182-513-1385 omnilex-key=us-wa-regs-official--title-182--182-513-1385}

(1) This section describes how to calculate the monthly maintenance needs allowance (MMNA) in post-eligibility treatment of income for long-term care (LTC) programs for a community spouse or dependent of the institutionalized individual.

(2) The community spouse MMNA standards are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources, unless a greater amount is calculated under subsection (5) of this section. The MMNA standards may change each January and July based on the consumer price index.

(3) The community spouse MMNA is allowed only to the extent that the institutionalized spouse's income is made available to the community spouse, and is calculated as follows:

(a) The minimum MMNA as calculated in subsection (4)(a) of this section plus excess shelter expenses as calculated in subsection (4)(b) of this section;

(i) The total under (a) of this subsection cannot be less than the minimum MMNA; and

(ii) If the total under subsection (4)(a) of this section exceeds the maximum MMNA, the maximum MMNA is the result under subsection (4)(a) of this section; and

(b) The total under subsection (4)(a) of this section is reduced by the community spouse's gross income. The result is the MMNA.

(4) The minimum MMNA and excess shelter expense values are calculated as follows:

(a) The minimum MMNA is 150 percent of the two-person federal poverty level (FPL); and

(b) If excess shelter expenses are less than zero, the result is zero. Excess shelter expenses are calculated as follows:

(i) Add:

(A) Mortgage or rent, which includes space rent for mobile homes;

(B) Real property taxes;

(C) Homeowner's insurance;

(D) Required maintenance fees for a condominium, cooperative, or homeowner's association that are recorded in a covenant; and

(E) The food assistance standard utility allowance (SUA) under WAC 388-450-0195 minus the cost of any utilities that are included in (b)(i)(D) of this subsection.

(ii) Subtract the standard shelter allocation from the total in (b)(i) of this subsection. The standard shelter allocation is 30 percent of 150 percent of the two-person FPL. The result is the value of excess shelter expenses.

(5) The amount allocated to the community spouse may be greater than the amount determined in subsection (3) of this section, but only if:

(a) A court order has been entered against the institutionalized spouse approving a higher MMNA for the support of the community spouse; or

(b) A final order has been entered after an administrative hearing has been held under chapter 182-526 WAC ruling the institutionalized spouse or the community spouse established the community spouse needs income, above the level otherwise provided by the MMNA, due to exceptional circumstances causing significant financial duress.

(6) If a final order establishes that the conditions identified in subsection (5)(b) of this section have been met, then an amount of allocated resources under subsection (3) of this section will be substituted by an amount adequate to provide such an MMNA.

(7) The agency or its designee determines the dependent allowance for dependents of the institutionalized individual or the institutionalized individual's spouse. The amount the agency allows depends on whether the dependent resides with the community spouse.

(a) For each dependent who resides with the community spouse:

(i) Subtract the dependent's income from 150 percent of the two-person FPL;

(ii) Divide the amount determined in (a)(i) of this subsection by three;

(iii) The result is the dependent allowance for that dependent.

(b) For each dependent who does not reside with the community spouse:

(i) The agency determines the effective MNIL standard based on the number of dependent family members in the home;

(ii) Subtracts each dependent's separate income;

(iii) The result is the dependent allowance for the dependents.

(c) Child support received from a noncustodial parent is the child's income.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-04-034, § 182-513-1385, filed 1/25/23, effective 2/25/23. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1385, filed 1/17/17, effective 2/17/17.*

##### **Wash. Admin. Code § 182-513-1395** Determining eligibility for institutional services for people living in a medical institution under the SSI-related medically needy program. {#sec-182-513-1395 omnilex-key=us-wa-regs-official--title-182--182-513-1395}

(1) For the purposes of this section only, "remaining income" means all gross nonexcluded income remaining after the post-eligibility calculation under WAC 182-513-1380.

(2) General information. To be eligible for institutional services when living in a medical institution under the SSI-related medically needy (MN) program, a person must:

(a) Meet program requirements under WAC 182-513-1315;

(b) Have gross nonexcluded income in excess of the special income level (SIL) defined under WAC 182-513-1100; and

(c) Meet the financial requirements of subsection (3) or (4) of this section.

(3) Financial eligibility.

(a) The agency or its designee determines a person's resource eligibility, excess resources, and medical expense deductions using WAC 182-513-1350.

(b) The agency or its designee determines a person's countable income by:

(i) Excluding income under WAC 182-513-1340;

(ii) Determining available income under WAC 182-513-1325 or 182-513-1330;

(iii) Disregarding income under WAC 182-513-1345; and

(iv) Deducting medical expenses that were not used to reduce excess resources under WAC 182-513-1350.

(4) Eligibility for agency payment to the facility for institutional services and the MN program.

(a) If a person's remaining income plus excess resources is less than, or equal to, the state-contracted daily rate times the number of days the person has resided in the facility, the person:

(i) Is eligible for agency payment to the facility for institutional services and the MN program; and

(ii) Is approved for a twelve-month certification period.

(b) The person must pay income and excess resources towards the cost of care under WAC 182-513-1380.

(5) Eligibility for agency payment to the facility for institutional services and MN spenddown. If a person's remaining income is more than the state-contracted daily rate times the number of days the person has resided in the facility, but less than the private nursing facility rate for the same period, the person:

(a) Is eligible to receive institutional services at the state-contracted rate; and

(i) Is approved for a three-month or six-month base period;

(ii) Pays income and excess resources towards the state-contracted cost of care under WAC 182-513-1380; and

(b) Is eligible for the MN program for the same three-month or six-month base period when the total of additional medical expenses incurred during the base period exceeds:

(i) The total remaining income for all months of the base period;

(ii) Minus the total state-contracted rate for all months of the base period.

(6) If a person has excess resources and the person's remaining income is more than the state-contracted daily rate times the number of days the person has resided in the facility, the person is not eligible to receive institutional services and the MN program.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1395, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as § 182-513-1395, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-513-1395, filed 10/22/12, effective 11/22/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.39.010. WSR 07-19-129, § 388-513-1395, filed 9/19/07, effective 10/20/07. Statutory Authority: RCW 11.92.180, 43.20B.460, 48.85.020, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.[09.]575, 74.09.585*
- *20 C.F.R. 416.1110-1112, 1123 and 1160*
- *42 C.F.R. 435.403 (j)(2) and 1005*
- *and Sections 17, 1915(c), and 1924 (42 U.S.C. 1396) of the Social Security Act. WSR 00-01-051, § 388-513-1395, filed 12/8/99, effective 1/8/00. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 99-06-045, § 388-513-1395, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090 and Budget Note 17. WSR 96-16-092, § 388-513-1395, filed 8/7/96, effective 8/29/96. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18 §§ 2095a and 5b. WSR 95-24-017 (Order 3921, #100267), § 388-513-1395, filed 11/22/95, effective 1/1/96. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-513-1395, filed 5/3/94, effective 6/3/94. Formerly WAC 388-95-400.*

##### **Wash. Admin. Code § 182-513-1396** People living in a fraternal, religious, or benevolent nursing facility. {#sec-182-513-1396 omnilex-key=us-wa-regs-official--title-182--182-513-1396}

(1) The agency or its designee determines apple health coverage under noninstitutional rules for a person who meets all other eligibility requirements and lives in a licensed, but nonmedicaid-contracted facility operated by a fraternal, religious, or benevolent organization.

(2) Nothing in subsection (1) of this section prevents the agency or its designee from evaluating contracts with facilities not described in subsection (1) of this section.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1396, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as § 182-513-1396, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 11.92.180, 43.20B.460, 48.85.020, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.[09.]575, 74.09.585*
- *20 C.F.R. 416.1110-1112, 1123 and 1160*
- *42 C.F.R. 435.403 (j)(2) and 1005*
- *and Sections 17, 1915(c), and 1924 (42 U.S.C. 1396) of the Social Security Act. WSR 00-01-051, § 388-513-1396, filed 12/8/99, effective 1/8/00. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-513-1396, filed 5/3/94, effective 6/3/94. Formerly WAC 388-95-310.*

##### **Wash. Admin. Code § 182-513-1397** Treatment of entrance fees for people residing in a continuing care retirement community or a life care community. {#sec-182-513-1397 omnilex-key=us-wa-regs-official--title-182--182-513-1397}

(1) A person's entrance fee in a continuing care retirement community or life care community is an available resource to the person, to the extent that:

(a) The person has the ability to use the entrance fee, or the contract provides that the entrance fee may be used, to pay for care should other resources or income of the person be insufficient to pay for care;

(b) The person is eligible for a refund of any remaining entrance fee when the person dies or when the person terminates the continuing care retirement community or life care community contract and leaves the community; and

(c) The entrance fee does not confer an ownership interest in the continuing care retirement community or life care community.

(2) Nothing in subsection (1) of this section prevents the agency or its designee from evaluating contracts with facilities not described in subsection (1) of this section.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1397, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as § 182-513-1397, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-513-1397, filed 10/22/12, effective 11/22/12.*

##### **Wash. Admin. Code § 182-513-1400** Long-term care (LTC) partnership program (index). {#sec-182-513-1400 omnilex-key=us-wa-regs-official--title-182--182-513-1400}

Under the long-term care (LTC) partnership program, people who purchase qualified long-term care partnership insurance policies can apply for long-term care medicaid under special rules for determining financial eligibility. These special rules generally allow the person to protect assets up to the insurance benefits received from a partnership policy so that such assets will not be taken into account in determining financial eligibility for long-term care medicaid and will not subsequently be subject to estate recovery for medicaid and long-term care services paid. The Washington long-term care partnership program is effective on December 1, 2011.

The following rules govern long-term care eligibility under the long-term care partnership program:

(1) WAC 182-513-1405 Definitions.

(2) WAC 182-513-1410 LTC partnership policy qualifications.

(3) WAC 182-513-1415 Assets that can't be protected under the LTC partnership provisions.

(4) WAC 182-513-1420 Eligibility for asset protection under a partnership policy.

(5) WAC 182-513-1425 Not qualifying for LTC medicaid if an LTC partnership policy is in pay status.

(6) WAC 182-513-1430 Change of circumstances that must be reported when there is an LTC partnership policy paying a portion of care.

(7) WAC 182-513-1435 When Washington recognizes an LTC partnership policy purchased in another state.

(8) WAC 182-513-1440 Determining how many assets can be protected.

(9) WAC 182-513-1445 Designating a protected asset and required proof.

(10) WAC 182-513-1450 How the transfer of assets affects LTC partnership and medicaid eligibility.

(11) WAC 182-513-1455 Protected assets under an LTC partnership policy after death.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1400, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as WAC 182-513-1400, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, section 6014 of the Deficit Reduction Act of 2005, WAC 284-83-140, 284-83-400, 284-83-405, 284-83-410, 284-83-415, 284-83-420, and chapter 48.83 RCW. WSR 11-23-106, § 388-513-1400, filed 11/18/11, effective 12/19/11.*

##### **Wash. Admin. Code § 182-513-1405** Definitions. {#sec-182-513-1405 omnilex-key=us-wa-regs-official--title-182--182-513-1405}

For purposes of WAC 182-513-1400 through 182-513-1455, the following terms have the meanings stated. See chapter 182-500 WAC and WAC 182-513-1100 for additional definitions.

"Issuer" means any entity that delivers, issues for delivery, or provides coverage to, a resident of Washington, any policy that claims to provide asset protection under the Washington long-term care partnership act, chapter 48.85 RCW. As used in this chapter, issuer specifically includes insurance companies, fraternal benefit societies, health care service contractors, and health maintenance organizations.

"Long-term care (LTC) insurance" means a policy under chapter 284-83 or 284-212 WAC.

"Protected assets" means assets that are designated as excluded or not taken into account upon determination of long-term care medicaid eligibility under WAC 182-513-1315. The protected or excluded amount is up to the dollar amount of benefits that have been paid for long-term care services by the qualifying long-term care partnership policy on the medicaid applicant's or client's behalf. The assets are also protected or excluded for the purposes of estate recovery under chapter 182-527 WAC, up to the amount of benefits paid by the qualifying policy for medical and long-term care services.

"Qualified long-term care insurance partnership" means an agreement between the Centers for Medicare and Medicaid Services (CMS), and the health care authority (HCA) which allows for the disregard of any assets or resources in an amount equal to the insurance benefit payments that are made to or on behalf of a person who is a beneficiary under a long-term care insurance policy that has been determined by the Washington state insurance commission to meet the requirements of section 1917 (b)(1)(c)(iii) of the act. These policies are described in chapter 284-83 WAC.

"Reciprocity agreement" means an agreement between states approved under section 6021(b) of the Deficit Reduction Act of 2005, Public Law 109-171 (DRA) under which the states agree to provide the same asset protections for qualified partnership policies purchased by a person while residing in another state and that state has a reciprocity agreement with the state of Washington.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-09-114, s 182-513-1405, filed 4/21/26, effective 5/22/26. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1405, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as WAC 182-513-1405, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, section 6014 of the Deficit Reduction Act of 2005, WAC 284-83-140, 284-83-400, 284-83-405, 284-83-410, 284-83-415, 284-83-420, and chapter 48.83 RCW. WSR 11-23-106, § 388-513-1405, filed 11/18/11, effective 12/19/11.*

##### **Wash. Admin. Code § 182-513-1410** LTC partnership policy qualifications. {#sec-182-513-1410 omnilex-key=us-wa-regs-official--title-182--182-513-1410}

A LTC partnership policy is a LTC policy that has been approved by the office of insurance commissioner as a LTC partnership policy described in chapter 284-83 or 284-212 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-09-114, s 182-513-1410, filed 4/21/26, effective 5/22/26. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1410, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as § 182-513-1410, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, section 6014 of the Deficit Reduction Act of 2005, WAC 284-83-140, 284-83-400, 284-83-405, 284-83-410, 284-83-415, 284-83-420, and chapter 48.83 RCW. WSR 11-23-106, § 388-513-1410, filed 11/18/11, effective 12/19/11.*

##### **Wash. Admin. Code § 182-513-1415** Assets that can't be protected under the LTC partnership provisions. {#sec-182-513-1415 omnilex-key=us-wa-regs-official--title-182--182-513-1415}

The following assets cannot be protected under a LTC partnership policy.

(1) Resources in a trust under WAC 182-516-0100 (6) and (7).

(2) Annuity interests in which Washington must be named as a preferred remainder beneficiary as under WAC 182-516-0201.

(3) Home equity in excess of the standard under WAC 182-513-1350. Individuals who have excess home equity interest are not eligible for long-term care medicaid services.

(4) Any portion of the value of an asset that exceeds the dollar amount paid out by the LTC partnership policy.

(5) The unprotected value of any partially protected asset is subject to estate recovery described in chapter 182-527 WAC.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1415, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as WAC 182-513-1415, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, section 6014 of the Deficit Reduction Act of 2005, WAC 284-83-140, 284-83-400, 284-83-405, 284-83-410, 284-83-415, 284-83-420, and chapter 48.83 RCW. WSR 11-23-106, § 388-513-1415, filed 11/18/11, effective 12/19/11.*

##### **Wash. Admin. Code § 182-513-1420** Eligibility for asset protection under a partnership policy. {#sec-182-513-1420 omnilex-key=us-wa-regs-official--title-182--182-513-1420}

(1) The LTC partnership policy must meet all the requirements in chapter 284-83 or 284-212 WAC. For existing LTC policies which are converted to a LTC partnership policy via an exchange or through the addition of a policy rider or endorsement, the conversion must take place on or after December 1, 2011 unless the policy is paying out benefits at the time the policy is exchanged.

(2) You meet all applicable eligible requirements for LTC medicaid and:

(a) Your LTC partnership policy benefits have been exhausted and you are in need of LTC services.

(b) Your LTC partnership policy is not exhausted and is:

(i) Covering all costs in a medical institution and you are still in need for medicaid; or

(ii) Covering a portion of the LTC costs under your LTC partnership policy but does not meet all of your LTC needs.

(c) At the time of your LTC partnership policy has paid out more benefits than you have designated as protected. In this situation your estate can designate additional assets to be excluded from the estate recovery process up to the dollar amount the LTC partnership policy has paid out.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-09-114, s 182-513-1420, filed 4/21/26, effective 5/22/26. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1420, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as § 182-513-1420, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, section 6014 of the Deficit Reduction Act of 2005, WAC 284-83-140, 284-83-400, 284-83-405, 284-83-410, 284-83-415, 284-83-420, and chapter 48.83 RCW. WSR 11-23-106, § 388-513-1420, filed 11/18/11, effective 12/19/11.*

##### **Wash. Admin. Code § 182-513-1425** Not qualifying for LTC medicaid if an LTC partnership policy is in pay status. {#sec-182-513-1425 omnilex-key=us-wa-regs-official--title-182--182-513-1425}

You are not eligible for long-term care (LTC) medicaid when the following applies:

(1) The income you have available to pay toward your cost of care under WAC 182-513-1380, combined with the amount paid under the qualifying LTC partnership policy, exceeds the monthly private rate at the institution.

(2) The income you have available to pay toward your cost of care on a home and community based (HCB) waiver under chapter 182-515 WAC, combined with the amount paid under the qualifying LTC partnership policy, exceeds the monthly private rate in a home or residential setting.

(3) You fail to meet another applicable eligibility requirement for LTC medicaid.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1425, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as WAC 182-513-1425, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, section 6014 of the Deficit Reduction Act of 2005, WAC 284-83-140, 284-83-400, 284-83-405, 284-83-410, 284-83-415, 284-83-420, and chapter 48.83 RCW. WSR 11-23-106, § 388-513-1425, filed 11/18/11, effective 12/19/11.*

##### **Wash. Admin. Code § 182-513-1430** Change of circumstances that must be reported when there is an LTC partnership policy paying a portion of care. {#sec-182-513-1430 omnilex-key=us-wa-regs-official--title-182--182-513-1430}

You must report changes described in WAC 182-504-0105 plus the following:

(1) You must report and verify the value of the benefits that your issuer has paid on your behalf under the long-term care (LTC) partnership policy upon request by the agency, and at each annual eligibility review.

(2) You must provide proof when you have exhausted the benefits under your LTC partnership policy.

(3) You must provide proof if you have given away or transferred assets that you have previously designated as protected. Although, there is no penalty for the transfer of protected assets once you have been approved for LTC medicaid, the value of transferred assets reduces the total dollar amount that is designated as protected and must be verified.

(4) You must provide proof if you have sold an asset or converted a protected asset into cash or another type of asset. You will need to make changes in the asset designation and verify the type of transaction and new value of the asset.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1430, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as WAC 182-513-1430, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, section 6014 of the Deficit Reduction Act of 2005, WAC 284-83-140, 284-83-400, 284-83-405, 284-83-410, 284-83-415, 284-83-420, and chapter 48.83 RCW. WSR 11-23-106, § 388-513-1430, filed 11/18/11, effective 12/19/11.*

##### **Wash. Admin. Code § 182-513-1435** When Washington recognizes an LTC partnership policy purchased in another state. {#sec-182-513-1435 omnilex-key=us-wa-regs-official--title-182--182-513-1435}

The Washington long-term care partnership program provides reciprocity with respect to qualifying long-term care insurance policies covered under other state long-term care insurance partnerships. This allows you to purchase a partnership policy in one state and move to Washington without losing your asset protection. If your LTC policy is in pay status at the time you move to Washington and you are otherwise eligible for LTC medicaid, Washington will recognize the amount of protection you accumulated in the other state.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1435, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as § 182-513-1435, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, section 6014 of the Deficit Reduction Act of 2005, WAC 284-83-140, 284-83-400, 284-83-405, 284-83-410, 284-83-415, 284-83-420, and chapter 48.83 RCW. WSR 11-23-106, § 388-513-1435, filed 11/18/11, effective 12/19/11.*

##### **Wash. Admin. Code § 182-513-1440** Determining how many of my assets can be protected. {#sec-182-513-1440 omnilex-key=us-wa-regs-official--title-182--182-513-1440}

You can protect assets based on the amount paid by your LTC partnership policy. Assets are protected in both LTC eligibility and estate recovery. If the partnership for long-term care program is discontinued, an individual who purchased an approved plan before the date the program is discontinued remains eligible to receive dollar-for-dollar asset disregard and asset protection under the long-term care (LTC) medicaid program.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1440, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as § 182-513-1440, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, section 6014 of the Deficit Reduction Act of 2005, WAC 284-83-140, 284-83-400, 284-83-405, 284-83-410, 284-83-415, 284-83-420, and chapter 48.83 RCW. WSR 11-23-106, § 388-513-1440, filed 11/18/11, effective 12/19/11.*

##### **Wash. Admin. Code § 182-513-1445** Designating a protected asset and required proof. {#sec-182-513-1445 omnilex-key=us-wa-regs-official--title-182--182-513-1445}

(1) Complete a department of social and health services (DSHS) 10-438 long-term care partnership (LTCP) asset designation form listing assets and the full fair market value that are earmarked as protected at the time of initial application for long-term services and supports under medicaid.

(a) The full fair market value (FMV) of real property or interests in real property will be based on the current assessed value for property tax purposes for real property. A professional appraisal by a licensed appraiser can establish the current value if the assessed value is disputed.

(b) The value of a life estate in real property is determined using the life estate tables found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/determining-value-life-estates.

(c) If you own an asset with others, you can designate the value of your pro rata equity share.

(d) If the dollar amount of the benefits paid under a LTCP policy is greater than the fair market value of all assets protected at the time of the application for long-term care medicaid, you may designate additional assets for protection under this section. The DSHS LTCP asset designation form must be submitted with the updated assets indicated along with proof of the current value of designated assets.

(e) The value of your assets protected for you under your LTC partnership policy do not carry over to your spouse should the spouse need medicaid LTC services during or after your lifetime. If your surviving spouse has an LTC partnership policy the spouse may designate assets based on the dollar amount paid under the spouse's own policy.

(f) Assets designated as protected under this subsection will not be subject to transfer penalties under WAC 182-513-1363.

(2) Proof of the current fair market value of all protected assets is required at the initial application and each annual review.

(3) Submit current verification from the issuer of the LTCP policy of the current dollar value paid toward LTC benefits. This verification is required at application and each annual eligibility review.

(4) Any person or the personal representative of the person's estate who asserts that an asset is protected has the initial burden of:

(a) Documenting and proving by convincing evidence that the asset or source of funds for the asset in question was designated as protected;

(b) Demonstrating the value of the asset and the proceeds of the asset beginning from the time period the LTC partnership has paid out benefits to the present; and

(c) Documenting that the asset or proceeds of the asset remained protected at all times.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-04-035, § 182-513-1445, filed 1/25/23, effective 2/25/23. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1445, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as § 182-513-1445, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, section 6014 of the Deficit Reduction Act of 2005, WAC 284-83-140, 284-83-400, 284-83-405, 284-83-410, 284-83-415, 284-83-420, and chapter 48.83 RCW. WSR 11-23-106, § 388-513-1445, filed 11/18/11, effective 12/19/11.*

##### **Wash. Admin. Code § 182-513-1450** How the transfer of assets affects LTC partnership and medicaid eligibility. {#sec-182-513-1450 omnilex-key=us-wa-regs-official--title-182--182-513-1450}

(1) If you transfer an asset within the sixty months prior to the medicaid application or after medicaid eligibility has been established, the agency will evaluate the transfer based on WAC 182-513-1363 and determine if a penalty period applies unless:

(a) You have already been receiving institutional services;

(b) Your LTC partnership policy has paid toward institutional services for you; and

(c) The value of the transferred assets has been protected under the LTC partnership policy.

(2) The value of the transferred assets that exceed your LTC partnership protection will be evaluated for a transfer penalty.

(3) If you transfer assets with values that are protected, you lose that value as future protection unless all the transferred assets are returned.

(4) The value of your protected assets less the value of transferred assets equals the adjusted value of the assets you are able to protect.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1450, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as WAC 182-513-1450, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, section 6014 of the Deficit Reduction Act of 2005, WAC 284-83-140, 284-83-400, 284-83-405, 284-83-410, 284-83-415, 284-83-420, and chapter 48.83 RCW. WSR 11-23-106, § 388-513-1450, filed 11/18/11, effective 12/19/11.*

##### **Wash. Admin. Code § 182-513-1455** What happens to protected assets under a LTC partnership policy after death. {#sec-182-513-1455 omnilex-key=us-wa-regs-official--title-182--182-513-1455}

Assets designated as protected prior to death are not subject to estate recovery for medical or long-term care (LTC) services paid on your behalf under chapter 182-527 WAC as long as the following requirements are met:

(1) A personal representative who asserts an asset is protected under this section has the initial burden of providing proof under chapter 182-527 WAC.

(2) A personal representative must provide verification from the LTC insurance company of the dollar amount paid out by the LTC partnership policy.

(3) If the LTC partnership policy paid out more than was previously designated, the personal representative has the right to assert that additional assets should be protected based on the increased protection. The personal representative must use the DSHS LTCP asset designation form and send it to the office of financial recovery.

(4) The amount of protection available to you at death through the estate recovery process is decreased by the FMV of any protected assets that were transferred prior to death.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 17-03-116, § 182-513-1455, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as WAC 182-513-1455, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, section 6014 of the Deficit Reduction Act of 2005, WAC 284-83-140, 284-83-400, 284-83-405, 284-83-410, 284-83-415, 284-83-420, and chapter 48.83 RCW. WSR 11-23-106, § 388-513-1455, filed 11/18/11, effective 12/19/11.*

##### **Wash. Admin. Code § 182-513-1530** Maximum guardianship or conservatorship fee and related cost deductions allowed from a client's participation or room and board on or after June 1, 2018. {#sec-182-513-1530 omnilex-key=us-wa-regs-official--title-182--182-513-1530}

(1) General information.

(a) This section sets the maximum guardianship or conservatorship fee and related cost deductions when:

(i) A court order was entered on or after June 1, 2018; or

(ii) The client under guardianship or conservatorship began receiving medicaid-funded long-term services and supports on or after June 1, 2018.

(b) This section only applies to a client who is:

(i) Eligible for and receives institutional services under this chapter or home and community-based waiver services under chapter 182-515 WAC, and who is required to pay participation under WAC 182-513-1380, 182-515-1509, or 182-515-1514; or

(ii) Eligible for long-term services and supports under this chapter or chapter 182-515 WAC, and who is required to pay only room and board.

(c) All requirements of this section remain in full force whether or not the agency appears at a guardianship or conservatorship proceeding.

(d) In this section, the agency does not delegate any authority in determining eligibility or post-eligibility for medicaid clients.

(i) Under the authority granted by chapter 11.130 RCW, the agency does not deduct more than the amounts allowed by this section from participation or room and board.

(ii) The eligibility rules under Title 182 WAC remain in full force and effect.

(e) The agency does not reduce a client's participation or room and board under this section for guardianship or conservatorship fees or related costs accumulated during any month that a client was not required to pay:

(i) Participation under WAC 182-513-1380, 182-515-1509, or 182-515-1514; or

(ii) Room and board under this chapter or chapter 182-515 WAC.

(f) If the client has another fiduciary, payee, or other principal-agency relationship and the agent is allowed compensation, any monthly guardianship or conservatorship fee approved under this section is reduced by the agent's compensation.

(2) Maximum guardianship or conservatorship fee and related cost deductions.

(a) The maximum guardianship or conservatorship fee and related cost deductions under this section include all guardianship or conservatorship services provided to the client, regardless of the number of guardians or conservators appointed to a client during a period of time, or whether the client has multiple guardians or conservators appointed at the same time.

(b) Maximum guardianship or conservatorship fees and related cost deductions are as follows:

(i) The total deduction for costs directly related to establishing a guardianship or conservatorship for a client cannot exceed $1,850;

(ii) The total deduction for all guardianship and conservatorship-related costs cannot exceed $1,200 during any three-year period; and

(iii) The amount of the monthly deduction for all guardianship and conservatorship fees cannot exceed $235 per month.

(3) For people under subsection (1)(b)(i) of this section - Participation deductions.

(a) After receiving the court order, the agency or its designee adjusts the client's current participation to reflect the deductions under WAC 182-513-1380, 182-515-1509, or 182-515-1514.

(b) The amounts of the participation deductions are the amounts under subsection (2) of this section, or the court order, whichever are less.

(c) For clients who pay room and board in addition to participation, if the client's amount of participation is insufficient to allow for the amounts under subsection (2) of this section, then, regardless of any provision of this chapter or chapter 182-515 WAC, the client's room and board will be adjusted to allow the amounts under subsection (2) of this section.

(4) For people under subsection (1)(b)(ii) of this section - Room and board deductions.

(a) The agency adjusts the client's room and board after receiving the court order, regardless of any provision of this chapter or chapter 182-515 WAC.

(b) The amounts of the room and board deductions are the amounts under subsection (2) of this section, or the court order, whichever are less.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-04-040, s 182-513-1530, filed 1/29/25, effective 3/1/25*
- *WSR 18-10-024, § 182-513-1530, filed 4/24/18, effective 6/1/18.*

##### **Wash. Admin. Code § 182-513-1600** Medicaid alternative care (MAC)—Overview. {#sec-182-513-1600 omnilex-key=us-wa-regs-official--title-182--182-513-1600}

Medicaid alternative care (MAC) is a Washington apple health benefit authorized under section 1115 of the Social Security Act. It enables the medicaid agency and the agency's designees to deliver an array of person-centered long-term services and supports (LTSS) to unpaid caregivers caring for a medicaid-eligible person who meets nursing facility level of care under WAC 388-106-0355.

(1) For services included with the MAC benefit package, see WAC 388-106-1900 through 388-106-1990.

(2) For financial eligibility for MAC services, see WAC 182-513-1605.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2016 1st sp.s. c 36 § 213 (1)(e), section 1115 of the Social Security Act, and 42 C.F.R. §§ 431.400 through 431.428. WSR 17-12-019, § 182-513-1600, filed 5/30/17, effective 7/1/17.*

##### **Wash. Admin. Code § 182-513-1605** Medicaid alternative care (MAC)—Eligibility. {#sec-182-513-1605 omnilex-key=us-wa-regs-official--title-182--182-513-1605}

(1) The person receiving care must meet the financial eligibility criteria for medicaid alternative care (MAC).

(2) To be eligible for MAC services, the person receiving care must:

(a) Be age 55 or older;

(b) Be assessed as meeting nursing facility level of care under WAC 388-106-0355, and choose to receive services under the MAC program instead of other long-term services and supports;

(c) Meet residency requirements under WAC 182-503-0520;

(d) Live at home and not in a residential or institutional setting;

(e) Have an eligible unpaid caregiver under WAC 388-106-1905;

(f) Meet citizenship and immigration status requirements under WAC 182-503-0535 (2)(a) or (b); and

(g) Be eligible for either:

(i) A noninstitutional medicaid program, which provides categorically needy (CN) or alternative benefit plan (ABP) scope of care under WAC 182-501-0060; or

(ii) An SSI-related CN program by using spousal impoverishment protections institutionalized (SIPI) spouse rules under WAC 182-513-1660.

(3) An applicant whose eligibility is limited to one or more of the following programs is not eligible for MAC:

(a) The medically needy program under WAC 182-519-0100;

(b) The medicare savings programs under chapter 182-517 WAC;

(c) The Washington apple health pregnancy and after-pregnancy coverage program under WAC 182-505-0115;

(d) The family planning only programs under chapter 182-532 WAC;

(e) The medical care services (MCS) program under WAC 182-508-0005;

(f) The alien emergency medical (AEM) program under WAC 182-507-0110 through 182-507-0120;

(g) The state funded long-term care for noncitizens program under WAC 182-507-0125;

(h) The kidney disease program under chapter 182-540 WAC; or

(i) The tailored supports for older adults (TSOA) program under WAC 182-513-1610.

(4) The following rules do not apply to services provided under the MAC benefit:

(a) Transfer of asset penalties under WAC 182-513-1363;

(b) Excess home equity under WAC 182-513-1350; and

(c) Estate recovery under chapter 182-527 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-12-036, s 182-513-1605, filed 5/28/25, effective 6/28/25*
- *WSR 23-11-007, § 182-513-1605, filed 5/4/23, effective 6/4/23. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 1st sp.s. c 36 § 213 (1)(e), section 1115 of the Social Security Act, and 42 C.F.R. §§ 431.400 through 431.428. WSR 17-12-019, § 182-513-1605, filed 5/30/17, effective 7/1/17.*

##### **Wash. Admin. Code § 182-513-1610** Tailored supports for older adults (TSOA)—Overview. {#sec-182-513-1610 omnilex-key=us-wa-regs-official--title-182--182-513-1610}

(1) The tailored supports for older adults (TSOA) program is a federally funded program approved under section 1115 of the Social Security Act. It enables the medicaid agency and the agency's designees to deliver person-centered long-term services and supports (LTSS) to a person who:

(a) Meets nursing facility level of care described in WAC 388-106-0355; and

(b) Meets the functional requirements under WAC 388-106-1900 through 388-106-1990.

(2) For the purposes of TSOA, the applicant is the person receiving care even though services may be authorized to the person providing care.

(3) TSOA does not provide Washington apple health coverage.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2016 1st sp.s. c 36 § 213 (1)(e), section 1115 of the Social Security Act, and 42 C.F.R. §§ 431.400 through 431.428. WSR 17-12-019, § 182-513-1610, filed 5/30/17, effective 7/1/17.*

##### **Wash. Admin. Code § 182-513-1615** Tailored supports for older adults (TSOA)—General eligibility. {#sec-182-513-1615 omnilex-key=us-wa-regs-official--title-182--182-513-1615}

(1) The person receiving care must meet the financial eligibility criteria for tailored supports for older adults (TSOA).

(2) To be eligible for the TSOA program, the person receiving care must:

(a) Be age 55 or older;

(b) Be assessed as meeting nursing facility level of care under WAC 388-106-0355;

(c) Meet residency requirements under WAC 182-503-0520;

(d) Live at home and not in a residential or institutional setting;

(e) Have an eligible unpaid caregiver under WAC 388-106-1905, or meet the criteria under WAC 388-106-1910 if the person does not have an eligible unpaid caregiver;

(f) Meet citizenship or immigration status requirements under WAC 182-503-0535. To be eligible for TSOA, a person must be a:

(i) U.S. citizen under WAC 182-503-0535 (1)(c);

(ii) U.S. national under WAC 182-503-0535 (1)(d);

(iii) Qualifying American Indian born abroad under WAC 182-503-0535 (1)(f); or

(iv) Qualified alien under WAC 182-503-0535 (1)(b) and have either met or is exempt from the five-year bar requirement for medicaid.

(g) Provide a valid Social Security number under WAC 182-503-0515;

(h) Have countable resources within specific program limits under WAC 182-513-1640; and

(i) Meet income requirements under WAC 182-513-1635.

(3) TSOA applicants who receive coverage under Washington apple health programs are not eligible for TSOA, unless their enrollment is limited to the:

(a) Medically needy program under WAC 182-519-0100;

(b) Medicare savings programs under WAC 182-517-0300;

(c) Family planning program under WAC 182-505-0115;

(d) Family planning only programs under chapter 182-532 WAC; or

(e) Kidney disease program under chapter 182-540 WAC.

(4) A person who receives apple health coverage under a categorically needy (CN) or alternative benefit plan (ABP) program is not eligible for TSOA but may qualify for:

(a) Caregiver supports under medicaid alternative care (MAC) under WAC 182-513-1605; or

(b) Other long-term services and supports under chapter 182-513 or 182-515 WAC.

(5) The following rules do not apply to services provided under the TSOA benefit:

(a) Transfer of asset penalties under WAC 182-513-1363;

(b) Excess home equity under WAC 182-513-1350;

(c) Client financial responsibility under WAC 182-515-1509;

(d) Estate recovery under chapter 182-527 WAC;

(e) Disability requirements under WAC 182-512-0050; and

(f) Assignment of rights and cooperation under WAC 182-503-0540.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-15-053, s 182-513-1615, filed 7/10/25, effective 8/10/25*
- *WSR 23-11-007, § 182-513-1615, filed 5/4/23, effective 6/4/23. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 1st sp.s. c 36 § 213 (1)(e), section 1115 of the Social Security Act, and 42 C.F.R. §§ 431.400 through 431.428. WSR 17-12-019, § 182-513-1615, filed 5/30/17, effective 7/1/17.*

##### **Wash. Admin. Code § 182-513-1620** Tailored supports for older adults (TSOA)—Presumptive eligibility (PE). {#sec-182-513-1620 omnilex-key=us-wa-regs-official--title-182--182-513-1620}

(1) A person may be determined presumptively eligible for tailored supports for older adults (TSOA) services upon completion of a prescreening interview.

(2) The prescreening interview may be conducted by either:

(a) The area agency on aging (AAA); or

(b) A home and community services intake case manager or social worker.

(3) To receive services under presumptive eligibility (PE), the person must meet:

(a) Nursing facility level of care under WAC 388-106-0355;

(b) TSOA income limits under WAC 182-513-1635; and

(c) TSOA resource limits under WAC 182-513-1640.

(4) The PE period begins on the date the determination is made and:

(a) Ends on the last day of the month following the month of the PE determination if a full TSOA application is not completed and submitted by that date; or

(b) Continues through the date the final TSOA eligibility determination is made if a full TSOA application is submitted before the last day of the month following the month of the PE determination.

(5) If the person applies and is not determined financially eligible for TSOA, there is no overpayment or liability on the part of the applicant for services received during the PE period.

(6) The medicaid agency or the agency's designee sends written notice as described in WAC 182-518-0010 when PE for TSOA is approved or denied.

(7) A person may receive services under presumptive eligibility only once within a twenty-four-month period.

(8) If the department of social and health services establishes a waitlist for TSOA services under WAC 388-106-1975, then PE does not apply.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-10-037, § 182-513-1620, filed 4/28/21, effective 5/29/21*
- *WSR 19-11-123, § 182-513-1620, filed 5/22/19, effective 6/22/19. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 1st sp.s. c 36 § 213 (1)(e), section 1115 of the Social Security Act, and 42 C.F.R. §§ 431.400 through 431.428. WSR 17-12-019, § 182-513-1620, filed 5/30/17, effective 7/1/17.*

##### **Wash. Admin. Code § 182-513-1625** Tailored supports for older adults (TSOA)—Applications. {#sec-182-513-1625 omnilex-key=us-wa-regs-official--title-182--182-513-1625}

(1) Applications for tailored supports for older adults (TSOA) are submitted:

(a) Online at Washington Connection at www.washingtonconnection.org;

(b) By sending a completed HCA 18-005 application for TSOA form to P.O. Box 45826, Olympia, WA 98605;

(c) By faxing a completed HCA 18-005 application for TSOA form to 1-855-635-8305;

(d) By contacting the local area agency on aging (AAA) office at 1- 855-567-0252; or

(e) By contacting the local home and community services (HCS) office. To find the local HCS office, see https://www.dshs.wa.gov/ALTSA/resources.

(2) Help filing an application:

(a) The medicaid agency or the agency's designee provides help with the application or renewal process in a manner that is accessible to people with disabilities, limitations, or other impairments as described in WAC 182-503-0120 and to those who are limited-English proficient as described in WAC 182-503-0110;

(b) For help filing an application, a person may:

(i) Contact a local AAA office;

(ii) Contact a local HCS office; or

(iii) Have an authorized representative apply on the person's behalf.

(3) The following people can apply for the TSOA program:

(a) The applicant (the person receiving care);

(b) The applicant's spouse;

(c) The applicant's caregiver (person providing in-home caregiver services);

(d) A legal guardian; or

(e) An authorized representative, as defined in WAC 182-500-0010.

(4) A phone interview is required to establish TSOA financial eligibility, but may be waived if the applicant is unable to comply:

(a) Due to the applicant's medical condition; and

(b) Because the applicant does not have another person that is able to conduct the interview on the applicant's behalf.

(5) The agency or the agency's designee processes TSOA applications using the same timelines under WAC 182-503-0060.

(6) TSOA begins on the date the person is determined presumptively eligible for TSOA under WAC 182-513-1620, or on the date all eligibility requirements are established if the person is not found presumptively eligible.

(7) When the person withdraws an application for TSOA, or is determined ineligible for TSOA services, the agency or the agency's designee denies the application under WAC 182-503-0080.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-19-014, § 182-513-1625, filed 9/8/23, effective 10/9/23. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 1st sp.s. c 36 § 213 (1)(e), section 1115 of the Social Security Act, and 42 C.F.R. §§ 431.400 through 431.428. WSR 17-12-019, § 182-513-1625, filed 5/30/17, effective 7/1/17.*

##### **Wash. Admin. Code § 182-513-1630** Tailored supports for older adults (TSOA)—Rights and responsibilities. {#sec-182-513-1630 omnilex-key=us-wa-regs-official--title-182--182-513-1630}

(1) A person applying for or receiving tailored supports for older adults (TSOA) has the right to:

(a) Have TSOA rights and responsibilities explained and provided in writing;

(b) Be treated politely and fairly without regard to race, color, political beliefs, national origin, religion, age, gender (including gender identity and sex stereotyping), sexual orientation, disability, honorably discharged veteran or military status, or birthplace;

(c) Get help with the TSOA application if requested;

(d) Have an application processed promptly and no later than the timelines described in WAC 182-503-0060;

(e) Have at least ten calendar days to give the medicaid agency or the agency's designee information needed to determine eligibility and be given more time if asked for;

(f) Have personal information kept confidential. The agency or the agency's designee may share information with other state and federal agencies for purposes of eligibility and enrollment in other Washington apple health programs;

(g) Get written notice, in most cases, at least ten calendar days before the agency or the agency's designee denies, terminates, or changes eligibility for TSOA;

(h) Ask for an appeal if the person disagrees with the agency or the agency's designee's decision. A person can also ask a department supervisor or administrator to review the decision or action without affecting the right to a fair hearing;

(i) Ask for and get interpreter or translator services at no cost and without delay;

(j) Ask for voter registration assistance;

(k) Refuse to speak to an investigator if the person's case is audited. If the person does not want to let the investigator enter their home, there is no requirement to do so and the person may ask the investigator to come back at another time. Such a request will not affect a person's eligibility for TSOA; and

(l) Get equal access services under WAC 182-503-0120 if eligible.

(2) An applicant or recipient of TSOA is responsible to:

(a) Report changes in household or family circumstances as required under WAC 182-513-1650;

(b) Provide the agency or the agency's designee with any information or proof needed to determine eligibility. If the person has trouble getting proof, the agency or the agency's designee helps get the proof needed or contacts other persons or agencies for it;

(c) Provide a valid Social Security number or immigration document number in order to verify identity, citizenship, immigration status, date of birth, and whether the person has other health care coverage. This information is not shared with the department of homeland security;

(d) Complete renewals when requested; and

(e) Cooperate with quality assurance when requested.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2016 1st sp.s. c 36 § 213 (1)(e), section 1115 of the Social Security Act, and 42 C.F.R. §§ 431.400 through 431.428. WSR 17-12-019, § 182-513-1630, filed 5/30/17, effective 7/1/17.*

##### **Wash. Admin. Code § 182-513-1635** Tailored supports for older adults (TSOA)—Income eligibility. {#sec-182-513-1635 omnilex-key=us-wa-regs-official--title-182--182-513-1635}

(1) To determine income eligibility for the tailored supports for older adults (TSOA) program, the medicaid agency or the agency's designee uses the following rules depending on whether the person is single or married.

(2) If the TSOA applicant is single, the agency or the agency's designee:

(a) Determines available income under WAC 182-513-1325;

(b) Excludes income under WAC 182-513-1340; and

(c) Compares remaining gross nonexcluded income to 400 percent of the federal benefit rate (FBR) for the supplemental security income (SSI) cash grant program. To be eligible, a person's gross income must be equal to or less than 400 percent of the FBR.

(3) If the TSOA applicant is married, the agency or the agency's designee:

(a) Determines available income under WAC 182-513-1330 with the exception of subsections (5) and (6) of that section;

(b) Excludes income under WAC 182-513-1340; and

(c) Compares the applicant's remaining gross nonexcluded income to 400 percent of the FBR. To be eligible, a person's gross income must be equal to or less than 400 percent of the FBR.

(4) The FBR changes annually on January 1st.

(5) The current TSOA income standard is found on the Washington apple health income and resource standards chart, institutional standards section; see www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-19-014, § 182-513-1635, filed 9/8/23, effective 10/9/23. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 1st sp.s. c 36 § 213 (1)(e), section 1115 of the Social Security Act, and 42 C.F.R. §§ 431.400 through 431.428. WSR 17-12-019, § 182-513-1635, filed 5/30/17, effective 7/1/17.*

##### **Wash. Admin. Code § 182-513-1640** Tailored supports for older adults (TSOA)—Resource eligibility. {#sec-182-513-1640 omnilex-key=us-wa-regs-official--title-182--182-513-1640}

(1) The resource standard for a single applicant for tailored supports for older adults (TSOA) is six times the Washington state average monthly private nursing facility rate, as determined by the department of social and health services under chapter 74.46 RCW.

(2) The resource standard for a married couple is six times the Washington state average monthly private nursing facility rate, as determined by the department of social and health services under chapter 74.46 RCW, for the TSOA applicant plus the state spousal resource standard for the spousal impoverishment protections community (SIPC) spouse. The state spousal resource standard may change annually on July 1st.

(3) The medicaid agency or the agency's designee uses rules in WAC 182-513-1350 (1), (3) and (4) to determine general eligibility relating to resources, availability of resources, and which resources count.

(4) The TSOA recipient has one year from the date of initial eligibility of TSOA to transfer resources in excess of the TSOA standard to the SIPC spouse.

(5) The resource standard for TSOA changes annually on January 1st based on the current average private nursing facility rate, as determined by the department of social and health services under chapter 74.46 RCW.

(6) The current TSOA standards and the current average private nursing facility rate are found on the Washington apple health income and resource standards chart, institutional standards section; see www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-19-014, § 182-513-1640, filed 9/8/23, effective 10/9/23. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 1st sp.s. c 36 § 213 (1)(e), section 1115 of the Social Security Act, and 42 C.F.R. §§ 431.400 through 431.428. WSR 17-12-019, § 182-513-1640, filed 5/30/17, effective 7/1/17.*

##### **Wash. Admin. Code § 182-513-1645** Tailored supports for older adults (TSOA)—Certification periods. {#sec-182-513-1645 omnilex-key=us-wa-regs-official--title-182--182-513-1645}

(1) A certification period is the period of time a person is determined eligible for the tailored supports for older adults (TSOA) program. It begins on the first day of the month that the medicaid agency or the agency's designee determines the person is eligible for TSOA services, and continues through the last day of the month of the certification period.

(2) TSOA is certified for twelve months of continuous coverage regardless of a change in circumstances, unless the person:

(a) Moves out-of-state;

(b) Meets institutional status under WAC 182-513-1320;

(c) Becomes eligible for a categorically needy or alternate benefit plan Washington apple health program; or

(d) Dies.

(3) Financial eligibility for the TSOA program may not be approved prior to the date of a presumptive or full eligibility determination.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2016 1st sp.s. c 36 § 213 (1)(e), section 1115 of the Social Security Act, and 42 C.F.R. §§ 431.400 through 431.428. WSR 17-12-019, § 182-513-1645, filed 5/30/17, effective 7/1/17.*

##### **Wash. Admin. Code § 182-513-1650** Tailored supports for older adults (TSOA)—Changes of circumstances requirements. {#sec-182-513-1650 omnilex-key=us-wa-regs-official--title-182--182-513-1650}

(1) Changes in tailored supports for older adults (TSOA) household and family circumstances described in subsection (2) of this section must be reported to the medicaid agency or the agency's designee within thirty days of the date of the change.

(2) The following changes must be reported:

(a) A change in residential or mailing address, including if the TSOA recipient moves out-of-state;

(b) When the TSOA recipient admits to an institution, as defined in WAC 182-500-0050, and is likely to reside there for thirty days or longer; or

(c) When the TSOA recipient dies.

(3) Effective date of changes.

(a) When TSOA terminates because the recipient dies, the effective date is the date of death.

(b) When TSOA terminates because of one of the following reasons, the effective date is the first day of the month following the advance notice period described in subsection (4) of this section. The TSOA recipient:

(i) Is admitted to an institution as defined in WAC 182-503-0050, and is expected to reside there for thirty days or longer;

(ii) Is approved for coverage under a home and community-based waiver program;

(iii) No longer meets nursing facility level of care under WAC 388-106-0355; or

(iv) Becomes eligible for categorically needy (CN) or alternative benefits plan (ABP) apple health coverage. The recipient may continue to receive authorized services through the medical alternative care (MAC) program under WAC 182-513-1600. The person may also apply for other long-term services and supports available under chapters 182-513 and 182-515 WAC.

(4) The advance notice period:

(a) Begins on the day the letter about the change is mailed; and

(b) Is determined according to the rules in WAC 182-518-0025.

(5) When a law or regulation requires a change in TSOA, the date specified by the law or regulation is the effective date of the change.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2016 1st sp.s. c 36 § 213 (1)(e), section 1115 of the Social Security Act, and 42 C.F.R. §§ 431.400 through 431.428. WSR 17-12-019, § 182-513-1650, filed 5/30/17, effective 7/1/17.*

##### **Wash. Admin. Code § 182-513-1655** Tailored supports for older adults (TSOA)—Renewals. {#sec-182-513-1655 omnilex-key=us-wa-regs-official--title-182--182-513-1655}

(1) A person who receives tailored supports for older adults (TSOA) services must complete a renewal of all eligibility factors for the program at least every twelve months.

(2) Forty-five days prior to the end of the certification period, notice is sent to the recipient with the HCA 18-008 application for TSOA form. The TSOA recipient may complete the TSOA renewal in any of the following ways:

(a) Complete the TSOA application form, sign it, and mail it to P.O. Box 45826, Olympia, WA 98605 by the due date on the letter;

(b) Complete the TSOA application form, sign it, and fax it to 1-855-635-8305 by the due date on the letter;

(c) Renew online at Washington connection at www.washingtonconnection.org by the due date on the letter; or

(d) Call the local home and community services office at the telephone number on the letter by the due date on the letter.

(3) During the renewal process, the medicaid agency or the agency's designee reviews all eligibility factors to determine ongoing eligibility for TSOA, and may request additional verification of eligibility factors under WAC 182-503-0050 if unable to verify information through existing data sources. If additional information is needed, the agency or the agency's designee sends written notice under WAC 182-518-0015.

(4) If the agency or the agency's designee is unable to complete the renewal or determine eligibility for TSOA beyond the certification period, prior to ending eligibility for TSOA, the agency or the agency's designee sends a written termination notice as described in WAC 182-518-0025.

(5) A person who is terminated from TSOA for failure to renew has thirty days from the termination date to submit a completed renewal. If still the person is eligible, TSOA is reopened without a break in eligibility.

(6) Equal access services as described in WAC 182-503-0120 are provided for anyone who needs help meeting the requirements of this section.

(7) A person who disagrees with an action regarding TSOA eligibility may ask for a hearing under chapter 182-526 WAC.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2016 1st sp.s. c 36 § 213 (1)(e), section 1115 of the Social Security Act, and 42 C.F.R. §§ 431.400 through 431.428. WSR 17-12-019, § 182-513-1655, filed 5/30/17, effective 7/1/17.*

##### **Wash. Admin. Code § 182-513-1660** Medicaid alternative care (MAC) and tailored supports for older adults (TSOA)—Spousal impoverishment. {#sec-182-513-1660 omnilex-key=us-wa-regs-official--title-182--182-513-1660}

(1) The medicaid agency or the agency's designee determines financial eligibility for medicaid alternative care (MAC) or tailored supports for older adults (TSOA) using spousal impoverishment protections under this section, when an applicant or recipient:

(a) Is married to, or marries, a person who is not in a medical institution; and

(b) Is ineligible for a noninstitutional categorically needy (CN) SSI-related program or the TSOA program due to:

(i) Spousal deeming rules under WAC 182-512-0920 for MAC;

(ii) Exceeding the resource limit in WAC 182-512-0010 for MAC, or the limit under WAC 182-513-1640 for TSOA; or

(iii) Both (b)(i) and (ii) of this subsection.

(2) When a resource test applies, the agency or the agency's designee determines countable resources using the SSI-related resource rules under chapter 182-512 WAC, except pension funds owned by the spousal impoverishment protections community (SIPC) spouse are not excluded as described under WAC 182-512-0550:

(a) Resource standards:

(i) For MAC, the resource standard is $2,000; or

(ii) For TSOA, the resource standard is:

(A) For an individual, six times the Washington state average monthly private nursing facility rate, as determined by the department of social and health services under chapter 74.46 RCW.

(B) For a married couple, six times the Washington state average monthly private nursing facility rate, as determined by the department of social and health services under chapter 74.46 RCW, for the TSOA applicant, plus the state spousal resource standard for the spousal impoverishment protections community (SIPC) spouse. The state spousal resource standard may change annually on July 1st.

(b) Before determining countable resources used to establish eligibility for the applicant, the agency or the agency's designee allocates the state spousal resource standard to the SIPC spouse.

(c) The resources of the SIPC spouse are unavailable to the spousal impoverishment protections institutionalized (SIPI) spouse the month after eligibility for MAC or TSOA services is established.

(3) The SIPI spouse has until the end of the month of the first regularly scheduled eligibility review to transfer countable resources in excess of $2,000 (for MAC) or six times the Washington state average monthly private nursing facility rate, as determined by the department of social and health services under chapter 74.46 RCW (for TSOA) to the SIPC spouse.

(4) Income eligibility:

(a) For MAC:

(i) The agency or the agency's designee determines countable income using the SSI-related income rules under chapter 182-512 WAC, but uses only the applicant or recipient's income;

(ii) If the applicant's or recipient's countable income is at or below the SSI categorically needy income level (CNIL), the applicant or recipient is considered a SIPI spouse and is income eligible for noninstitutional CN coverage and MAC services.

(b) For TSOA, see WAC 182-513-1635.

(5) Once a person no longer receives MAC services, eligibility is redetermined without using spousal impoverishment protections under WAC 182-504-0125.

(6) If the applicant's separate countable income is above the standards described in subsection (4) of this section, the applicant is not income eligible for MAC or TSOA services.

(7) The spousal impoverishment protections described in this section are time-limited and expire on September 30, 2027.

(8) Standards described in this chapter are located at: www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-06-051, s 182-513-1660, filed 2/25/26, effective 3/28/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 42 U.S.C. 1396r-5 note. WSR 23-11-039, § 182-513-1660, filed 5/11/23, effective 6/11/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-04-034, § 182-513-1660, filed 1/25/23, effective 2/25/23. Statutory Authority: RCW 41.05.021, 41.05.160 and Consolidated Appropriations Act of 2021, H.R. 133, Division CC, Title II, Sec. 204 (b)(1)(A) and Sec. 205. WSR 21-10-051, § 182-513-1660, filed 4/29/21, effective 5/30/21. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 1st sp.s. c 36 § 213 (1)(e), section 1115 of the Social Security Act, and 42 C.F.R. §§ 431.400 through 431.428. WSR 17-12-019, § 182-513-1660, filed 5/30/17, effective 7/1/17.*

## **Chapter 182-514** Long-term care for families and children. {#struct-chapter-182-514}

##### **Wash. Admin. Code § 182-514-0230** Purpose. {#sec-182-514-0230 omnilex-key=us-wa-regs-official--title-182--182-514-0230}

(1) This chapter describes eligibility requirements for the Washington apple health (WAH) modified adjusted gross income (MAGI)-based long-term care program (LTC) for children and adults who have been admitted to an institution as defined in WAC 182-500-0050 for at least 30 days. The rules are stated in the following sections:

(a) WAC 182-514-0240 General eligibility;

(b) WAC 182-514-0245 Resource eligibility;

(c) WAC 182-514-0250 Program for adults age 19 and older;

(d) WAC 182-514-0260 Program for children under age 19;

(e) WAC 182-514-0263 Non-SSI-related institutional medically needy coverage for pregnant women and people age 20 and younger.

(f) WAC 182-514-0270 Involuntary commitment to Eastern or Western State Hospital.

(2) A noninstitutional WAH program recipient does not need to submit a new application for LTC coverage if admitted to an institution under this section. Admission to an institution constitutes a change of circumstances. Eligibility is based on institutional status under WAC 182-513-1320.

(3) In this chapter, "medicaid agency" or "agency" means the Washington state health care authority and includes the agency's designee. See chapter 182-500 WAC for additional definitions.

(4) Income standards used in this chapter are listed at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-04-034, § 182-514-0230, filed 1/25/23, effective 2/25/23*
- *WSR 16-04-087, § 182-514-0230, filed 1/29/16, effective 2/29/16. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-514-0230, filed 2/28/14, effective 3/31/14. WSR 12-02-034, recodified as § 182-514-0230, filed 12/29/11, effective 1/1/12. Statutory Authority: RCW 74.04.055, 74.04.057, 74.08.090, 74.09.530, and 42 C.F.R. 441.151. WSR 09-06-029, § 388-505-0230, filed 2/24/09, effective 3/27/09.*

##### **Wash. Admin. Code § 182-514-0240** General eligibility. {#sec-182-514-0240 omnilex-key=us-wa-regs-official--title-182--182-514-0240}

(1) To be eligible for modified adjusted gross income (MAGI)-based long-term care (LTC) coverage under this section, a person must:

(a) Meet institutional status under WAC 182-513-1320;

(b) Meet the general eligibility requirements under WAC 182-503-0505, unless the applicant is a noncitizen, in which case WAC 182-503-0505 (3)(c) and (d) do not apply;

(c) Have countable income below the applicable standard described in WAC 182-514-0250(2) or 182-514-0260(3), unless the applicant is eligible as medically needy;

(d) Satisfy the program requirements in WAC 182-514-0250 and 182-514-0260; and

(e) Meet the nursing facility level of care under WAC 388-106-0355 if admitted to a nursing facility for nonhospice care. Hospice patients are exempt from this requirement.

(2) A person age nineteen or older who does not meet the citizenship or immigration requirements under WAC 182-503-0535 to qualify for medicaid must meet the criteria in subsection (1) of this section and:

(a) Have a qualifying emergency condition and meet the requirements under WAC 182-507-0115 and 182-507-0120; or

(b) Meet the requirements under WAC 182-507-0125 if the person needs LTC coverage in a nursing facility.

(3) If a person meets institutional status, the medicaid agency counts only income received by the person or on behalf of the person when determining eligibility.

(4) A person who meets the federal aged, blind, or disabled criteria may qualify for coverage under chapter 182-513 WAC.

(5) A person who receives supplemental security income (SSI) is not eligible for the MAGI-based LTC program.

(6) If a person does not meet institutional status, the agency determines the person's eligibility for a noninstitutional medical program.

(7) A person eligible for categorically needy or medically needy coverage under a noninstitutional program who is admitted to a nursing facility for fewer than thirty days is only approved for coverage for the nursing facility room and board costs if the person meets the nursing facility level of care as described under WAC 388-106-0355.

(8) A MAGI-based LTC recipient is not required to pay toward the cost of care.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-04-087, § 182-514-0240, filed 1/29/16, effective 2/29/16. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-514-0240, filed 2/28/14, effective 3/31/14. WSR 12-02-034, recodified as § 182-514-0240, filed 12/29/11, effective 1/1/12. Statutory Authority: RCW 74.04.055, 74.04.057, 74.08.090, 74.09.530, and 42 C.F.R. 441.151. WSR 09-06-029, § 388-505-0240, filed 2/24/09, effective 3/27/09.*

##### **Wash. Admin. Code § 182-514-0245** Resource eligibility. {#sec-182-514-0245 omnilex-key=us-wa-regs-official--title-182--182-514-0245}

Applicants for and recipients of the modified adjusted gross income (MAGI)-based long-term care program are exempt from the transfer-of-asset evaluation under WAC 182-513-1363, and there is no resource test.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-04-087, § 182-514-0245, filed 1/29/16, effective 2/29/16. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-514-0245, filed 2/28/14, effective 3/31/14. WSR 12-02-034, recodified as § 182-514-0245, filed 12/29/11, effective 1/1/12. Statutory Authority: RCW 74.04.055, 74.04.057, 74.08.090, 74.09.530, and 42 C.F.R. 441.151. WSR 09-06-029, § 388-505-0245, filed 2/24/09, effective 3/27/09.*

##### **Wash. Admin. Code § 182-514-0250** Program for adults age nineteen and older. {#sec-182-514-0250 omnilex-key=us-wa-regs-official--title-182--182-514-0250}

(1) To qualify for coverage under the modified adjusted gross income (MAGI)-based long-term care (LTC) program under this section, a person age nineteen or older must be eligible for one of the following Washington apple health (WAH) programs:

(a) WAC 182-505-0240 Washington apple health—Parents and caretaker relatives;

(b) WAC 182-523-0100 Washington apple health—Medical extension;

(c) WAC 182-505-0250 Washington apple health—MAGI-based adult medical;

(d) WAC 182-505-0115 Washington apple health—Eligibility for pregnant women; or

(e) WAC 182-507-0110 Washington apple health—Alien medical programs.

(2) The categorically needy (CN) income level for health care coverage under this section is the applicable standard for the program the person receives after the standard five percentage point income disregard. See WAC 182-505-0100 for standards based on the federal poverty level.

(3) The medicaid agency determines countable income for CN coverage under this section using MAGI methodology under chapter 182-509 WAC.

(4) The agency approves CN coverage under this section for twelve calendar months.

(5) A person is ineligible for medically needy (MN) coverage under this section if the person's income exceeds CN eligibility standards, unless the person is age nineteen, twenty, or pregnant.

(6) If a person who is age nineteen, twenty, or pregnant is not eligible for CN coverage under this section, the agency determines eligibility for MN coverage under WAC 182-514-0263.

(7) A person who applies for or receives MAGI-based LTC coverage at Eastern or Western State Hospital in the month of his or her twenty-first birthday and who receives active inpatient psychiatric treatment that will likely continue through the person's twenty-first birthday is eligible for CN coverage until:

(a) The facility discharges the person; or

(b) The end of the month in which the person turns age twenty-two, whichever occurs first.

(8) Except for a person described in subsection (7) of this section, a person who is admitted to Eastern or Western State Hospital who is older than age twenty but younger than age sixty-five is not eligible for WAH coverage.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-04-087, § 182-514-0250, filed 1/29/16, effective 2/29/16. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-514-0250, filed 2/28/14, effective 3/31/14. WSR 12-02-034, recodified as § 182-514-0250, filed 12/29/11, effective 1/1/12. Statutory Authority: RCW 74.04.055, 74.04.057, 74.08.090, 74.09.530, and 42 C.F.R. 441.151. WSR 09-06-029, § 388-505-0250, filed 2/24/09, effective 3/27/09.*

##### **Wash. Admin. Code § 182-514-0260** Institutional program for children under age nineteen. {#sec-182-514-0260 omnilex-key=us-wa-regs-official--title-182--182-514-0260}

(1) To qualify for the modified adjusted gross income (MAGI)-based long-term care (LTC) program under this section, you (a child under age nineteen) must meet:

(a) The general eligibility requirements in WAC 182-514-0240; and

(b) Program requirements under WAC 182-505-0210 or 182-505-0117.

(2) If you are eligible for the premium-based children's program under WAC 182-505-0215, we redetermine your eligibility under this section so that your family is not required to pay the premium.

(3) The categorically needy (CN) income level for LTC coverage under this section is two hundred ten percent of the federal poverty level after the standard five percentage point income disregard.

(4) To determine countable income for CN coverage under this section, we apply the MAGI methodology under chapter 182-509 WAC.

(5) We approve CN coverage under this section for twelve calendar months (certification period). If you are discharged from the facility before the end of the certification period, you remain continuously eligible for CN coverage through the certification period, unless you age out of the program, move out-of-state, or die.

(6) If you are not eligible for CN coverage under this section, we determine your eligibility for coverage under the institutional medically needy program described in WAC 182-514-0263.

(7) The institution where you reside may submit an application on your behalf and may act as your authorized representative if you are:

(a) In a court-ordered, out-of-home placement under chapter 13.34 RCW; or

(b) Involuntarily committed to an inpatient treatment program by a court order under chapter 71.34 RCW.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-12-017, § 182-514-0260, filed 5/30/17, effective 6/30/17*
- *WSR 16-04-087, § 182-514-0260, filed 1/29/16, effective 2/29/16. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-514-0260, filed 2/28/14, effective 3/31/14. WSR 12-02-034, recodified as § 182-514-0260, filed 12/29/11, effective 1/1/12. Statutory Authority: RCW 74.04.055, 74.04.057, 74.08.090, 74.09.530, and 42 C.F.R. 441.151. WSR 09-06-029, § 388-505-0260, filed 2/24/09, effective 3/27/09.*

##### **Wash. Admin. Code § 182-514-0263** Non-SSI-related institutional medically needy coverage for pregnant people and people age 20 and younger. {#sec-182-514-0263 omnilex-key=us-wa-regs-official--title-182--182-514-0263}

(1) Medically needy (MN) coverage under this section is only available for people age 20 and younger or pregnant people. The medicaid agency determines a client who meets SSI-related criteria under WAC 182-512-0050 eligible for institutional MN coverage under WAC 182-513-1395. If a client meets requirements in both this section and WAC 182-513-1395, the client may choose which program to enroll in for coverage.

(2) A client whose income exceeds the categorically needy (CN) standards under WAC 182-514-0250 and 182-514-0260 is:

(a) Eligible for MN coverage with no spenddown if the client's countable income (CI) is equal to or less than the department-contracted daily rate times the number of days in the institution;

(b) Eligible for MN coverage after a spenddown under WAC 182-519-0110 is met if the client's CI is above the department-contracted daily rate times the number of days in the institution but less than the institution's private rate;

(c) Not eligible for payment of long-term care services provided by the institution if the person's CI exceeds the institution's private rate;

(d) Responsible for paying up to the monthly state rate for the facility as participation in the cost of care; and

(e) Allowed to keep a monthly personal needs allowance (PNA) under WAC 182-513-1105. Current PNA and long-term care standards can be found at the agency's program standard for income and resources web page.

(3) If a client's CI exceeds the institution's private rate, the agency determines eligibility for medical coverage under chapter 182-519 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-12-033, § 182-514-0263, filed 5/24/22, effective 6/24/22. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 c 270. WSR 17-23-039, § 182-514-0263, filed 11/8/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-04-087, § 182-514-0263, filed 1/29/16, effective 2/29/16.*

##### **Wash. Admin. Code § 182-514-0270** Involuntary commitment to Eastern or Western State Hospital. {#sec-182-514-0270 omnilex-key=us-wa-regs-official--title-182--182-514-0270}

(1) A person who is involuntarily committed to Eastern or Western State Hospital under chapter 71.34 RCW is eligible for categorically needy (CN) coverage if the person:

(a) Is under age twenty-one;

(b) Meets institutional status under WAC 182-513-1320; and

(c) Has countable income below:

(i) Two hundred ten percent of the federal poverty level if under age nineteen; or

(ii) One hundred thirty-three percent of the federal poverty level if age nineteen or twenty.

(2) A person who is involuntarily committed or receives MAGI-based long-term care coverage at Eastern or Western State Hospital in the month of the person's twenty-first birthday and receives active inpatient psychiatric treatment that will likely continue through the person's twenty-first birthday, is eligible for CN coverage until:

(a) The facility discharges the person; or

(b) The end of the month in which the person turns twenty-two, whichever occurs first.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-04-087, § 182-514-0270, filed 1/29/16, effective 2/29/16. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-06-068, § 182-514-0270, filed 2/28/14, effective 3/31/14. Statutory Authority: RCW 41.05.021, 74.09.035, and 2011 1st sp.s. c 36. WSR 12-19-051, amended and recodified as § 182-514-0270, filed 9/13/12, effective 10/14/12. Statutory Authority: RCW 74.04.055, 74.04.057, 74.08.090, 74.09.530, and 42 C.F.R. 441.151. WSR 09-06-029, § 388-505-0270, filed 2/24/09, effective 3/27/09.*

## **Chapter 182-515** Alternate living—Institutional medical. {#struct-chapter-182-515}

##### **Wash. Admin. Code § 182-515-1505** Home and community based (HCB) waiver services authorized by home and community services (HCS). {#sec-182-515-1505 omnilex-key=us-wa-regs-official--title-182--182-515-1505}

This chapter describes the general and financial eligibility requirements for categorically needy (CN) home and community based (HCB) waiver services authorized by home and community services (HCS). The definitions in WAC 182-513-1100 and chapter 182-500 WAC apply throughout this chapter.

(1) The HCS waivers are:

(a) Community options program entry system (COPES);

(b) New Freedom consumer-directed services (New Freedom); and

(c) Residential support waiver (RSW).

(2) WAC 182-515-1506 describes the general eligibility requirements for HCB waiver services authorized by HCS.

(3) WAC 182-515-1507 describes financial requirements for eligibility for HCB waiver services authorized by HCS when a person is eligible for a noninstitutional SSI-related categorically needy (CN) medicaid program.

(4) WAC 182-515-1508 describes the financial eligibility requirements for HCB waiver services authorized by HCS when a person is not eligible for SSI-related noninstitutional CN medicaid under WAC 182-515-1507.

(5) WAC 182-515-1509 describes the rules used to determine a person's responsibility for the cost of care and room and board for HCB waiver services if the person is eligible under WAC 182-515-1508.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R § 155. WSR 17-03-116, § 182-515-1505, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as § 182-515-1505, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-515-1505, filed 10/22/12, effective 11/22/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.530 and Washington state 2007-09 operating budget (SHB 1128). WSR 08-22-052, § 388-515-1505, filed 11/3/08, effective 12/4/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.575, 74.09.500, 74.09.530, and 2007 c 522. WSR 07-19-127, § 388-515-1505, filed 9/19/07, effective 10/20/07. Statutory Authority: RCW 74.08.090, 42 C.F.R. 441.302(a), Social Security Act section 1915(c) waiver rules, 42 C.F.R. 438. WSR 06-18-058, § 388-515-1505, filed 8/31/06, effective 10/1/06. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.530. WSR 06-03-079, § 388-515-1505, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.575. WSR 05-03-077, § 388-515-1505, filed 1/17/05, effective 2/17/05*
- *WSR 02-05-003, § 388-515-1505, filed 2/7/02, effective 3/10/02. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. WSR 01-02-052, § 388-515-1505, filed 12/28/00, effective 1/28/01. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 42 C.F.R. 435.601, 42 C.F.R. 435.725-726, and Sections 4715 and 4735 of the Federal Balanced Budget Act of 1997 (P.L. 105-33) (H.R. 2015). WSR 00-01-087, § 388-515-1505, filed 12/14/99, effective 1/14/00. Statutory Authority: RCW 74.08.090. WSR 96-14-058 (Order 100346), § 388-515-1505, filed 6/27/96, effective 7/28/96*
- *WSR 95-20-030 (Order 3899), § 388-515-1505, filed 9/27/95, effective 10/28/95*
- *WSR 94-10-065 (Order 3732), § 388-515-1505, filed 5/3/94, effective 6/3/94. Formerly WAC 388-83-200.*

##### **Wash. Admin. Code § 182-515-1506** Home and community based (HCB) waiver services authorized by home and community services (HCS)—General eligibility. {#sec-182-515-1506 omnilex-key=us-wa-regs-official--title-182--182-515-1506}

(1) To be eligible for home and community based (HCB) waiver services a person must:

(a) Meet the program and age requirements for the specific program:

(i) Community options program entry system (COPES), under WAC 388-106-0310;

(ii) Residential support waiver (RSW), under WAC 388-106-0338; or

(iii) New Freedom, under WAC 388-106-1410.

(b) Meet the disability criteria for the supplemental security income (SSI) program under WAC 182-512-0050;

(c) Require the level of care provided in a nursing facility under WAC 388-106-0355;

(d) Reside in a medical institution as defined in WAC 182-500-0050, or be likely to be placed in one within the next 30 days without HCB waiver services provided under one of the programs listed in (a) of this subsection;

(e) Attain institutional status under WAC 182-513-1320;

(f) Assessed for HCB waiver services, be approved for a plan of care, and receiving an HCB waiver service under (a) of this subsection;

(g) Be able to live at home with community support services and choose to remain at home, or live in a department-contracted alternate living facility under WAC 182-513-1100.

(2) A person is not eligible for home and community based (HCB) waiver services if the person:

(a) Is subject to a penalty period of ineligibility for the transfer of an asset under WAC 182-513-1363; or

(b) Has a home with equity in excess of the requirements under WAC 182-513-1350.

(3) See WAC 182-513-1315 for rules used to determine countable resources, income, and eligibility standards for long-term care (LTC) services.

(4) Current income and resource standards are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-03-037, s 182-515-1506, filed 1/8/25, effective 2/8/25*
- *WSR 23-04-034, § 182-515-1506, filed 1/25/23, effective 2/25/23. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R § 155. WSR 17-03-116, § 182-515-1506, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as WAC 182-515-1506, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-515-1506, filed 10/22/12, effective 11/22/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.530 and Washington state 2007-09 operating budget (SHB 1128). WSR 08-22-052, § 388-515-1506, filed 11/3/08, effective 12/4/08.*

##### **Wash. Admin. Code § 182-515-1507** Home and community based (HCB) waiver services authorized by home and community services (HCS)—Financial eligibility if a client is eligible for an SSI-related noninstitutional categorically needy (CN) medicaid program. {#sec-182-515-1507 omnilex-key=us-wa-regs-official--title-182--182-515-1507}

(1) A client is financially eligible for home and community based (HCB) waiver services if the client:

(a) Is receiving coverage under one of the following categorically needy (CN) medicaid programs:

(i) SSI program under WAC 182-510-0001. This includes SSI clients under Section 1619(b) of the Social Security Act;

(ii) SSI-related noninstitutional CN program under chapter 182-512 WAC; or

(iii) Health care for workers with disabilities program (HWD) under chapter 182-511 WAC.

(b) Does not have a penalty period of ineligibility for the transfer of an asset under WAC 182-513-1363; and

(c) Does not own a home with equity in excess of the requirements under WAC 182-513-1350.

(2) A client eligible under this section does not pay toward the cost of care, but must pay room and board if living in an alternate living facility (ALF) under WAC 182-513-1100.

(3) A client eligible under this section who lives in a department-contracted ALF described under WAC 182-513-1100:

(a) Keeps a personal needs allowance (PNA) under WAC 182-513-1105; and

(b) Pays towards room and board under WAC 182-513-1105.

(4) A client who is eligible under the HWD program must pay the HWD premium under WAC 182-511-1250, in addition to room and board, if residing in an ALF.

(5) Current resource, income, PNA, and room and board standards are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-04-034, § 182-515-1507, filed 1/25/23, effective 2/25/23. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 c 270. WSR 17-23-039, § 182-515-1507, filed 11/8/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R § 155. WSR 17-03-116, § 182-515-1507, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as WAC 182-515-1507, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-515-1507, filed 10/22/12, effective 11/22/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, and section 1915(c) of the Social Security Act. WSR 09-14-043, § 388-515-1507, filed 6/24/09, effective 7/25/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.530 and Washington state 2007-09 operating budget (SHB 1128). WSR 08-22-052, § 388-515-1507, filed 11/3/08, effective 12/4/08.*

##### **Wash. Admin. Code § 182-515-1508** Home and community based (HCB) waiver services authorized by home and community services (HCS)—Financial eligibility using SSI-related institutional rules. {#sec-182-515-1508 omnilex-key=us-wa-regs-official--title-182--182-515-1508}

(1) If a person is not eligible for a categorically needy (CN) program under WAC 182-515-1507, the agency determines eligibility for home and community based (HCB) waiver services authorized by home and community services (HCS) using institutional medicaid rules. This section explains how a person may qualify using institutional rules.

(2) A person must meet:

(a) General eligibility requirements under WAC 182-513-1315 and 182-515-1506;

(b) The resource requirements under WAC 182-513-1350;

(c) The following income requirements:

(i) Available income must be at or below the special income level (SIL), defined under WAC 182-513-1100; or

(ii) If available income is above the SIL, net available income is no greater than the effective one-person medically needy income level (MNIL). Net income is calculated by reducing available income by:

(A) Medically needy (MN) disregards found under WAC 182-513-1345;

(B) The average monthly nursing facility state rate;

(C) Health insurance premiums, other than medicare; and

(D) Outstanding medical bills, prorated monthly over a 12-month certification period, that meet the requirements of WAC 182-513-1350.

(3) The agency determines available income and income exclusions under WAC 182-513-1325, 182-513-1330, and 182-513-1340.

(4) A person eligible under this section is responsible to pay toward the cost of care and room and board, as described under WAC 182-515-1509.

(5) Current resource, income standards, and the average state nursing facility rate for long-term care are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-04-034, § 182-515-1508, filed 1/25/23, effective 2/25/23. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R § 155. WSR 17-03-116, § 182-515-1508, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as WAC 182-515-1508, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-515-1508, filed 10/22/12, effective 11/22/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.530 and Washington state 2007-09 operating budget (SHB 1128). WSR 08-22-052, § 388-515-1508, filed 11/3/08, effective 12/4/08.*

##### **Wash. Admin. Code § 182-515-1509** Home and community based (HCB) waiver services authorized by home and community services (HCS)—Client financial responsibility. {#sec-182-515-1509 omnilex-key=us-wa-regs-official--title-182--182-515-1509}

(1) A client eligible for home and community based (HCB) waiver services authorized by home and community services (HCS) under WAC 182-515-1508 must pay toward the cost of care and room and board under this section.

(a) Post-eligibility treatment of income, participation, and participate are all terms that refer to a client's responsibility towards cost of care.

(b) Room and board is a term that refers to a client's responsibility toward food and shelter in an alternate living facility (ALF).

(2) The agency determines how much a client must pay toward the cost of care for HCB waiver services authorized by HCS when living in their own home:

(a) A single client who lives in their own home (as defined in WAC 388-106-0010) keeps a personal needs allowance (PNA) of up to 300% of the federal benefit rate (FBR) for the supplemental security income (SSI) cash grant program and must pay the remaining available income toward cost of care after allowable deductions described in subsection (4) of this section. The Washington apple health income and resource standards chart identifies 300% of the FBR as the medical special income level (SIL).

(b) A married client who lives with the client's spouse in their own home (as defined in WAC 388-106-0010) keeps a PNA of up to the effective one-person medically needy income level (MNIL) and pays the remainder of the client's available income toward cost of care after allowable deductions under subsection (4) of this section.

(c) A married client who lives in their own home and apart from the client's spouse keeps a PNA of up to the SIL but must pay the remaining available income toward cost of care after allowable deductions under subsection (4) of this section.

(d) A married couple living in their own home where each client receives HCB waiver services is each allowed to keep a PNA of up to the SIL but must pay remaining available income toward cost of care after allowable deductions under subsection (4) of this section.

(e) A married couple living in their own home where each client receives HCB waiver services, one spouse authorized by developmental disabilities community services (DDCS) and the other authorized by HCS, is allowed the following:

(i) The client authorized by DDCS pays toward the cost of care under WAC 182-515-1512 or 182-515-1514; and

(ii) The client authorized by HCS retains the SIL and pays the remainder of the available income toward cost of care after allowable deductions under subsection (4) of this section.

(3) The agency determines how much a client must pay toward the cost of care for HCB waiver services authorized by HCS and room and board when living in a department contracted alternate living facility (ALF) defined under WAC 182-513-1100. A client:

(a) Keeps a PNA of under WAC 182-513-1105;

(b) Pays room and board up to the room and board standard under WAC 182-513-1105; and

(c) Pays the remainder of available income toward the cost of care after allowable deductions under subsection (4) of this section.

(4) If income remains after the PNA and room and board liability under subsection (2) or (3) of this section, the remaining available income must be paid toward the cost of care after it is reduced by deductions in the following order:

(a) An earned income deduction of the first $65 plus one-half of the remaining earned income;

(b) Guardianship fees, conservatorship fees, and administrative costs including any attorney fees paid by the guardian or conservator only as allowed under chapter 388-79A WAC;

(c) Current or back child support garnished or withheld from the client's income according to a child support order in the month of the garnishment if it is for the current month. If the agency allows this as a deduction from income, the agency does not count it as the child's income when determining the family allocation amount in WAC 182-513-1385;

(d) A monthly maintenance-needs allowance for the community spouse as determined under WAC 182-513-1385. If the community spouse is also receiving long-term care services, the allocation is limited to an amount that brings the community spouse's income to the community spouse's PNA, as calculated under WAC 182-513-1385;

(e) A monthly maintenance-needs allowance for each dependent of the institutionalized client, or the client's spouse, as calculated under WAC 182-513-1385;

(f) Incurred medical expenses which have not been used to reduce excess resources. Allowable medical expenses are under WAC 182-513-1350.

(5) The total of the following deductions cannot exceed the special income level (SIL) defined under WAC 182-513-1100:

(a) The PNA allowed in subsection (2) or (3) of this section, including room and board;

(b) The earned income deduction in subsection (4)(a) of this section; and

(c) The guardianship fees, conservatorship fees, and administrative costs in subsection (4)(b) of this section.

(6) A client may have to pay third-party resources defined under WAC 182-513-1100 in addition to the room and board and participation.

(7) A client must pay the client's provider the sum of the room and board amount, and the cost of care after all allowable deductions, and any third-party resources defined under WAC 182-513-1100.

(8) A client on HCB waiver services does not pay more than the state rate for cost of care.

(9) When a client lives in multiple living arrangements in a month, the agency allows the highest PNA available based on all the living arrangements and services the client has received in a month.

(10) Standards described in this section are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-515-1509, filed 11/4/25, effective 12/5/25*
- *WSR 25-04-040, s 182-515-1509, filed 1/29/25, effective 3/1/25*
- *WSR 23-04-034, § 182-515-1509, filed 1/25/23, effective 2/25/23. Statutory Authority: RCW 41.05.021, 41.05.160, and 2022 c 164. WSR 22-16-040, § 182-515-1509, filed 7/27/22, effective 8/27/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-08-082, § 182-515-1509, filed 3/27/20, effective 4/27/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 c 270. WSR 17-23-039, § 182-515-1509, filed 11/8/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R § 155. WSR 17-03-116, § 182-515-1509, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as WAC 182-515-1509, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-515-1509, filed 10/22/12, effective 11/22/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.530 and Washington state 2007-09 operating budget (SHB 1128). WSR 08-22-052, § 388-515-1509, filed 11/3/08, effective 12/4/08.*

##### **Wash. Admin. Code § 182-515-1510** Home and community based (HCB) waiver services authorized by developmental disabilities community services (DDCS). {#sec-182-515-1510 omnilex-key=us-wa-regs-official--title-182--182-515-1510}

This chapter describes the general and financial eligibility requirements for categorically needy (CN) home and community based (HCB) waivers authorized by developmental disabilities community services (DDCS). The definitions in WAC 182-513-1100 and chapter 182-500 WAC apply throughout this chapter.

(1) The DDCS waiver programs are:

(a) Basic Plus;

(b) Core;

(c) Community protection;

(d) Children's intensive in-home behavioral support (CIIBS); and

(e) Individual and family services (IFS).

(2) WAC 182-515-1511 describes the general eligibility requirements for HCB waiver services authorized by DDCS.

(3) WAC 182-515-1512 describes the financial requirements for eligibility for HCB waiver services authorized by DDCS if a person is eligible for a noninstitutional SSI-related CN program.

(4) WAC 182-515-1513 describes the financial eligibility requirements for HCB waiver services authorized by DDCS when a person is not eligible for an SSI-related noninstitutional CN program under WAC 182-515-1512.

(5) WAC 182-515-1514 describes the rules used to determine a person's responsibility in the cost of care and room and board for HCB waiver services authorized by DDCS if the person is eligible under WAC 182-515-1512.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-515-1510, filed 11/4/25, effective 12/5/25. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R § 155. WSR 17-03-116, § 182-515-1510, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as WAC 182-515-1510, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-515-1510, filed 10/22/12, effective 11/22/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, and Washington state 2007-09 operating budget (SHB 1128). WSR 08-11-083, § 388-515-1510, filed 5/20/08, effective 6/20/08. Statutory Authority: RCW 71A.12.030, 71A.10.020, chapters 71A.10 and 71A.12 RCW, 2004 c 276. WSR 04-18-054, § 388-515-1510, filed 8/27/04, effective 9/27/04. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. WSR 01-02-052, § 388-515-1510, filed 12/28/00, effective 1/28/01. Statutory Authority: RCW 11.92.180, 43.20B.460, 48.85.020, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, 74.[09.]575, 74.09.585*
- *20 C.F.R. 416.1110-1112, 1123 and 1160*
- *42 C.F.R. 435.403 (j)(2) and 1005*
- *and Sections 17, 1915(c), and 1924 (42 U.S.C. 1396) of the Social Security Act. WSR 00-01-051, § 388-515-1510, filed 12/8/99, effective 1/8/00. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 99-06-045, § 388-515-1510, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-515-1510, filed 5/3/94, effective 6/3/94. Formerly WAC 388-83-210.*

##### **Wash. Admin. Code § 182-515-1511** Home and community based (HCB) waiver services authorized by developmental disabilities community services (DDCS)—General eligibility. {#sec-182-515-1511 omnilex-key=us-wa-regs-official--title-182--182-515-1511}

(1) To be eligible for home and community based (HCB) waiver services authorized by developmental disabilities community services (DDCS), a person must:

(a) Meet specific program requirements under chapter 388-845 WAC;

(b) Be an eligible client of DDCS;

(c) Meet the disability criteria for the supplemental security income (SSI) program under WAC 182-512-0050;

(d) Need the level of care provided in an intermediate care facility for the intellectually disabled (ICF/ID);

(e) Have attained institutional status under WAC 182-513-1320;

(f) Be able to reside in the community and choose to do so as an alternative to living in an ICF/ID;

(g) Be assessed for HCB waiver services, be approved for a plan of care, and receive HCB waiver services under (a) of this subsection, and:

(i) Be able to live at home with HCB waiver services; or

(ii) Live in a department-contracted facility with HCB waiver services, such as:

(A) A group home;

(B) A group training home;

(C) A child foster home, group home, or staffed residential facility;

(D) An adult family home (AFH); or

(E) An adult residential care (ARC) facility.

(iii) Live in the person's own home with supported living services from a certified residential provider; or

(iv) Live in the home of a contracted companion home provider.

(2) A person is not eligible for home and community based (HCB) waiver services if the person:

(a) Is subject to a penalty period of ineligibility for the transfer of an asset under WAC 182-513-1363; or

(b) Has a home with equity in excess of the requirements under WAC 182-513-1350.

(3) See WAC 182-513-1315 for rules used to determine countable resources, income, and eligibility standards for long-term care (LTC) services.

(4) Current income and resource standard charts are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-515-1511, filed 11/4/25, effective 12/5/25*
- *WSR 23-04-034, § 182-515-1511, filed 1/25/23, effective 2/25/23. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R § 155. WSR 17-03-116, § 182-515-1511, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as WAC 182-515-1511, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-515-1511, filed 10/22/12, effective 11/22/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, and Washington state 2007-09 operating budget (SHB 1128). WSR 08-11-083, § 388-515-1511, filed 5/20/08, effective 6/20/08.*

##### **Wash. Admin. Code § 182-515-1512** Home and community based (HCB) waiver services authorized by developmental disabilities community services (DDCS)—Financial eligibility if a client is eligible for a noninstitutional SSI-related categorically needy (CN) program. {#sec-182-515-1512 omnilex-key=us-wa-regs-official--title-182--182-515-1512}

(1) A client is financially eligible for home and community based (HCB) waiver services authorized by developmental disabilities community services (DDCS) if:

(a) The client is receiving coverage under one of the following categorically needy (CN) medicaid programs:

(i) Supplemental security income (SSI) program under WAC 182-510-0001. This includes SSI clients under 1619(b) status; or

(ii) Health care for workers with disabilities (HWD) under chapter 182-511 WAC; or

(iii) SSI-related noninstitutional (CN) program under chapter 182-512 WAC; or

(iv) The foster care program under WAC 182-505-0211 and the client meets disability requirements under WAC 182-512-0050.

(b) The client does not have a penalty period of ineligibility for the transfer of an asset as under WAC 182-513-1363; and

(c) The client does not own a home with equity in excess of the requirements under WAC 182-513-1350.

(2) A client eligible under this section does not pay toward the cost of care, but must pay room and board if living in an alternate living facility (ALF) under WAC 182-513-1100.

(3) A client eligible under this section who lives in a department-contracted ALF described under WAC 182-513-1100:

(a) Keeps a personal needs allowance (PNA) under WAC 182-513-1105; and

(b) Pays towards room and board up to the room and board standard under WAC 182-513-1105.

(4) A client who is eligible under the HWD program must pay the HWD premium under WAC 182-511-1250, in addition to room and board if residing in an ALF.

(5) Current resource, income, PNA and room and board standards are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-515-1512, filed 11/4/25, effective 12/5/25*
- *WSR 23-04-034, § 182-515-1512, filed 1/25/23, effective 2/25/23. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 c 270. WSR 17-23-039, § 182-515-1512, filed 11/8/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R § 155. WSR 17-03-116, § 182-515-1512, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as WAC 182-515-1512, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-515-1512, filed 10/22/12, effective 11/22/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.575, 74.09.500, 74.09.530. WSR 08-24-069, § 388-515-1512, filed 12/1/08, effective 1/1/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, and Washington state 2007-09 operating budget (SHB 1128). WSR 08-11-083, § 388-515-1512, filed 5/20/08, effective 6/20/08.*

##### **Wash. Admin. Code § 182-515-1513** Home and community based (HCB) waiver services authorized by developmental disabilities community services (DDCS)—Financial eligibility using SSI-related institutional rules. {#sec-182-515-1513 omnilex-key=us-wa-regs-official--title-182--182-515-1513}

(1) If a person is not eligible for a categorically needy (CN) program under WAC 182-515-1512, the agency determines eligibility for home and community based (HCB) waiver services authorized by developmental disabilities community services (DDCS) using institutional medicaid rules. This section explains how a person may qualify using institutional rules.

(2) A person must meet:

(a) General eligibility requirements under WAC 182-513-1315 and 182-515-1511;

(b) Resource requirements under WAC 182-513-1350; and

(c) Have available income at or below the special income level (SIL) defined under WAC 182-513-1100.

(3) The agency determines available income and income exclusions according to WAC 182-513-1325, 182-513-1330, and 182-513-1340.

(4) A person eligible under this section is responsible to pay income toward the cost of care and room and board, as described under WAC 182-515-1514.

(5) Current resource, income standards are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-515-1513, filed 11/4/25, effective 12/5/25*
- *WSR 23-04-034, § 182-515-1513, filed 1/25/23, effective 2/25/23. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R § 155. WSR 17-03-116, § 182-515-1513, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as § 182-515-1513, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-515-1513, filed 10/22/12, effective 11/22/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, and Washington state 2007-09 operating budget (SHB 1128). WSR 08-11-083, § 388-515-1513, filed 5/20/08, effective 6/20/08.*

##### **Wash. Admin. Code § 182-515-1514** Home and community based (HCB) services authorized by developmental disabilities community services (DDCS)—Client financial responsibility. {#sec-182-515-1514 omnilex-key=us-wa-regs-official--title-182--182-515-1514}

(1) A client eligible for home and community based (HCB) waiver services authorized by developmental disabilities community services (DDCS) under WAC 182-515-1513 must pay toward the cost of care and room and board under this section.

(a) Post-eligibility treatment of income, participation, and participate are all terms that refer to a client's responsibility towards cost of care.

(b) Room and board is a term that refers to a client's responsibility toward food and shelter in an alternate living facility (ALF).

(2) The agency determines how much a client must pay toward the cost of care for home and community based (HCB) waiver services authorized by DDCS when the client is living at home, as follows:

(a) A single client who lives at home (as defined in WAC 388-106-0010) keeps a personal needs allowance (PNA) of up to the special income level (SIL) defined under WAC 182-513-1100.

(b) A single client who lives at home on the roads to community living program authorized by DDCS keeps a PNA up to the SIL but must pay any remaining available income toward cost of care after allowable deductions described in subsection (4) of this section.

(c) A married client who lives with the client's spouse at home (as defined in WAC 388-106-0010) keeps a PNA of up to the SIL but must pay any remaining available income toward cost of care after allowable deductions under subsection (4) of this section.

(d) A married couple living at home where each client receives HCB waiver services, one authorized by DDCS and the other authorized by home and community services (HCS) is allowed the following:

(i) The client authorized by DDCS keeps a PNA of up to the SIL but must pay any remaining available income toward the client's cost of care after allowable deductions in subsection (4) of this section; and

(ii) The client authorized by HCS pays toward the cost of care under WAC 182-515-1507 or 182-515-1509.

(3) The agency determines how much a client must pay toward the cost of care for HCB wavier services authorized by DDCS and room and board when the client is living in a department-contracted ALF defined under WAC 182-513-1100. A client:

(a) Keeps a PNA under WAC 182-513-1105;

(b) Pays room and board up to the room and board standard under WAC 182-513-1105; and

(c) Pays the remainder of available income toward the cost of care after allowable deductions under subsection (4) of this section.

(4) If income remains after the PNA and room and board liability under subsection (2) or (3) of this section, the remaining available income must be paid toward the cost of care after it is reduced by allowable deductions in the following order:

(a) An earned income deduction of the first $65, plus one-half of the remaining earned income;

(b) Guardianship fees, conservatorship fees, and administrative costs including any attorney fees paid by the guardian or conservator only as allowed under chapter 388-79A WAC;

(c) Current or back child support garnished or withheld from the client's income according to a child support order in the month of the garnishment if it is for the current month. If the agency allows this as a deduction from income, the agency does not count it as the child's income when determining the family allocation amount in WAC 182-513-1385;

(d) A monthly maintenance-needs allowance for the community spouse under WAC 182-513-1385. If the community spouse is on long-term care services, the allocation is limited to an amount that brings the community spouse's income to the community spouse's PNA;

(e) A monthly maintenance-needs allowance for each dependent of the institutionalized client, or the client's spouse, as calculated under WAC 182-513-1385; and

(f) Incurred medical expenses which have not been used to reduce excess resources. Allowable medical expenses are under WAC 182-513-1350.

(5) The total of the following deductions cannot exceed the SIL defined under WAC 182-513-1100:

(a) The PNA described in subsection (2) or (3) of this section, including room and board;

(b) The earned income deduction in subsection (4)(a) of this section; and

(c) The guardianship fees, conservatorship fees, and administrative costs in subsection (4)(b) of this section.

(6) A client may have to pay third-party resources defined under WAC 182-513-1100 in addition to the room and board and participation.

(7) A client must pay the client's provider the sum of the room and board amount, the cost of care after all allowable deductions, and any third-party resources defined under WAC 182-513-1100.

(8) A client on HCB waiver services does not pay more than the state rate for cost of care.

(9) When a client lives in multiple living arrangements in a month, the agency allows the highest PNA available based on all the living arrangements and services the client has received in a month.

(10) Standards described in this section are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-515-1514, filed 11/4/25, effective 12/5/25*
- *WSR 25-04-040, s 182-515-1514, filed 1/29/25, effective 3/1/25*
- *WSR 23-04-034, § 182-515-1514, filed 1/25/23, effective 2/25/23*
- *WSR 20-08-082, § 182-515-1514, filed 3/27/20, effective 4/27/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 c 270. WSR 17-23-039, § 182-515-1514, filed 11/8/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, P.L. 111-148, 42 C.F.R. §§ 431, 435, and 457, and 45 C.F.R § 155. WSR 17-03-116, § 182-515-1514, filed 1/17/17, effective 2/17/17. WSR 13-01-017, recodified as § 182-515-1514, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, section 6014 of the Deficit Reduction Act of 2005 (DRA), and 2010 1st sp.s. c 37 § 209(1). WSR 12-21-091, § 388-515-1514, filed 10/22/12, effective 11/22/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.575, 74.09.500, 74.09.530. WSR 08-24-069, § 388-515-1514, filed 12/1/08, effective 1/1/09. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, and Washington state 2007-09 operating budget (SHB 1128). WSR 08-11-083, § 388-515-1514, filed 5/20/08, effective 6/20/08.*

## **Chapter 182-516** Trusts, annuities, life estates, and promissory notes—Effect on medical programs. {#struct-chapter-182-516}

##### **Wash. Admin. Code § 182-516-0001** Definitions. {#sec-182-516-0001 omnilex-key=us-wa-regs-official--title-182--182-516-0001}

"Acquire" means, in the context of trusts, to gain title to, or to gain ownership interest in an asset in a trust. Receiving payment or benefit from an asset in a trust is not acquiring the asset.

"Annuitant" means a person or entity that receives the stream of payments from an annuity.

"Annuity" means a policy, certificate, or contract that is an agreement between two parties in which one party pays a lump sum to the other, and the other party agrees to guarantee payment of a set amount of money over a set amount of time.

"Beneficiary" means, in the context of a trust, a person or entity that is entitled to benefit from a trust.

"Grantor" means the person or entity who owned the asset immediately before establishing a trust with that asset.

"Immediate" means, in the context of annuities, an annuity that is fully funded at purchase with no accumulation or deferral to allow accumulation.

"Income" means, in the context of a trust, the undistributed proceeds that a trust principal generates over a period including, but not limited to, interest, dividends, rents and realized gains on the sale or exchange. Any income not disbursed in one period is principal the next period.

"Irrevocable":

(a) For a trust, "irrevocable" means the grantor or someone acting on behalf of the grantor cannot reacquire any portion of the assets in the trust for the benefit of the grantor or unilaterally change the terms of the trust; and the beneficiary or someone acting on behalf of the beneficiary cannot acquire any portion of the assets in the trust for the benefit of the beneficiary or unilaterally change the terms of the trust. A legal instrument that is called irrevocable, but permits acquisition or reacquisition of any portion of the assets if some action is taken by or on behalf of the grantor or the beneficiary, is revocable for the purposes of this chapter.

(b) A trust or annuity that is not irrevocable is revocable.

(c) A trust is still irrevocable if it meets the definition under (a) of this definition, but allows modifications to the trust to con-form with changes in trust law, which occur after the establishment of the trust.

(d) For an annuity, "irrevocable" means the contract cannot be canceled and the terms of the contract cannot be changed.

"Principal" means the assets, other than income, that make up the trust, promissory note, or loan.

"Revocable" means the instrument is not irrevocable. See the definition of "irrevocable."

"Self-settled trust" means any trust established with assets that were originally owned by the beneficiary, or would have been owned by the beneficiary if they had not been diverted into the trust by the beneficiary, the court, or someone acting on the beneficiary's behalf. Depending on the date a trust is established, a trust may be self-settled if the assets were originally owned by the beneficiary's spouse, or would have been owned by the beneficiary's spouse if they had not been diverted into the trust by the beneficiary's spouse, the court, or someone acting on the beneficiary's spouse's behalf.

"Sole benefit" of a beneficiary means a trust benefits no one but that beneficiary, whether at the time the trust is established or at any time during the lifetime of the beneficiary.

"Third-party trust" means a trust established with assets originally owned by someone other than the beneficiary. However, depending on the date a trust is established, a trust may be self-settled if the assets were originally owned by the beneficiary's spouse, or would have been owned by the beneficiary's spouse if they had not been diverted into the trust by the beneficiary's spouse, the court, or someone acting on the beneficiary's spouse's behalf.

"To or for the benefit of" means that a payment or benefit of any sort from a trust is transferred to the beneficiary, another person, or entity such that the beneficiary derives some benefit from the transfer.

"Trust" means:

(a) Any arrangement in which a grantor transfers property to a trustee with the intention that it be held, managed, or administered by the trustee for the benefit of the grantor or another beneficiary; or

(b) Any legal instrument, device, or arrangement similar to a trust in which:

(i) A grantor transfers an asset to another; and

(ii) The grantor transfers the asset intending that it be held, managed, or administered for the benefit of the grantor or another beneficiary.

"Trustee" means a person or entity that manages and administers a trust for the beneficiary.

"Uncompensated asset transfer" means the entirety of the fair market value of the asset transferred was uncompensated, regardless of any consideration received in return for the asset.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. 1396p. WSR 18-04-037, § 182-516-0001, filed 1/30/18, effective 3/2/18. WSR 13-01-017, recodified as § 182-516-0001, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.575. WSR 03-06-048, § 388-561-0001, filed 2/28/03, effective 4/1/03. Statutory Authority: RCW 74.04.050, 74.08.090, and 74.09.500. WSR 01-06-043, § 388-561-0001, filed 3/5/01, effective 5/1/01.*

##### **Wash. Admin. Code § 182-516-0100** Trust index. {#sec-182-516-0100 omnilex-key=us-wa-regs-official--title-182--182-516-0100}

The medicaid agency or the agency's designee applies the following rules to determine how trusts affect eligibility for medicaid:

(1) WAC 182-516-0105 General rules that apply to all trusts.

(2) WAC 182-516-0110 Self-settled trusts overview.

(3) WAC 182-516-0115 Revocable self-settled trusts established on or after August 11, 1993.

(4) WAC 182-516-0120 Irrevocable self-settled trusts for a disabled client under age sixty-five established on or after August 11, 1993.

(5) WAC 182-516-0125 Irrevocable pooled self-settled trusts for a disabled client established on or after August 11, 1993.

(6) WAC 182-516-0130 Irrevocable self-settled trusts established on or after August 11, 1993.

(7) WAC 182-516-0135 Self-settled trusts established before August 11, 1993.

(8) WAC 182-516-0140 Third-party trusts.

(9) WAC 182-516-0145 Trusts containing both assets of the beneficiary and third-party assets.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. 1396p. WSR 18-04-037, § 182-516-0100, filed 1/30/18, effective 3/2/18. WSR 13-01-017, recodified as § 182-516-0100, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 34.05.353 (2)(d), 74.08.090, and chapters 74.09, 74.04 RCW. WSR 08-11-047, § 388-561-0100, filed 5/15/08, effective 6/15/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.575. WSR 03-13-113, § 388-561-0100, filed 6/17/03, effective 8/1/03. Statutory Authority: RCW 74.04.050, 74.08.090, and 74.09.500. WSR 01-06-043, § 388-561-0100, filed 3/5/01, effective 5/1/01.*

##### **Wash. Admin. Code § 182-516-0105** General rules that apply to all trusts. {#sec-182-516-0105 omnilex-key=us-wa-regs-official--title-182--182-516-0105}

(1) Regardless of treatment under this chapter, all trusts remain subject to Title 182 WAC, which include income and resource rules under chapter 182-512 WAC and asset transfer rules under WAC 182-513-1363, unless specified otherwise.

(2) The medicaid agency or the agency's designee treats the trust or a distribution from the trust as a third-party resource under WAC 182-501-0200 if:

(a) The agency or the agency's designee determines the trust is not an available resource or determines the distributions from a trust are not income; and

(b) The terms of the trust or how the trust is being administered meet the third-party resource rules under WAC 182-501-0200.

(3) The agency or the agency's designee applies the rules under WAC 182-516-0100 to both the language of the trust and how the trust is being administered.

(4) Assets in a trust are available resources to the beneficiary if the beneficiary:

(a) Is a trustee; or

(b) Can direct the use of the trust principal or income, or direct the trustee's use of trust principal or income, for that beneficiary's support and maintenance under the terms of the trust.

(5) Cash distributions from a trust to the beneficiary are unearned income to the beneficiary in the month they are received or should have been received under the trust's terms.

(6) For asset transfer dates for trusts, the transfer date of an asset under WAC 182-513-1363 is the latest of:

(a) The date the trust was established;

(b) The date the asset being evaluated was transferred into the trust; or

(c) The date access to the asset was foreclosed by any action, inaction, or language in the trust, which prevents the beneficiary from accessing the asset.

(7) A client who is denied or terminated from medicaid due to the application of any rules under WAC 182-516-0100 may apply for a hardship waiver under WAC 182-513-1367.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. 1396p. WSR 18-04-037, § 182-516-0105, filed 1/30/18, effective 3/2/18.*

##### **Wash. Admin. Code § 182-516-0110** Self-settled trusts overview. {#sec-182-516-0110 omnilex-key=us-wa-regs-official--title-182--182-516-0110}

(1) A trust containing the assets of a beneficiary's spouse may be a self-settled trust based on the date it was established. For specific rules regarding this, see WAC 182-516-0130.

(2) To determine whether the assets of the self-settled trust should be counted as income, a resource, or an asset transfer, the medicaid agency or the agency's designee applies the following rules based on when the trust was established:

(a) For revocable self-settled trusts, see WAC 182-516-0115.

(b) For irrevocable self-settled trusts for a disabled client under age sixty-five established on or after August 11, 1993, see WAC 182-516-0120.

(c) For irrevocable pooled self-settled trusts for a disabled client established on or after August 11, 1993, see WAC 182-516-0125.

(d) For all other irrevocable self-settled trusts:

(i) Established on or after August 11, 1993, see WAC 182-516-0130.

(ii) Established before August 11, 1993, see WAC 182-516-0135.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. 1396p. WSR 18-04-037, § 182-516-0110, filed 1/30/18, effective 3/2/18.*

##### **Wash. Admin. Code § 182-516-0115** Revocable self-settled trusts established on or after August 11, 1993. {#sec-182-516-0115 omnilex-key=us-wa-regs-official--title-182--182-516-0115}

(1) This section applies to revocable trusts that are self-settled and established on or after August 11, 1993.

(2) This section does not apply to assets in a revocable trust established before August 11, 1993.

(3) A revocable trust is a self-settled trust if:

(a) The assets of the trust are at least partially from the beneficiary or the beneficiary's spouse;

(b) The trust is not established by will; and

(c) The trust was established by:

(i) The beneficiary or that beneficiary's spouse;

(ii) A person, including a court or administrative body, with legal authority to act in place or on behalf of the beneficiary or that beneficiary's spouse; or

(iii) A person, including a court or administrative body, acting at the direction or upon the request of the beneficiary or that beneficiary's spouse.

(4) The medicaid agency or the agency's designee treats assets in a revocable self-settled trust under this section as follows:

(a) Assets are subject to the resource exclusions under chapter 182-512 WAC; however, for an institutionalized individual, the resource exclusion for the home under WAC 182-512-0350 does not apply; and

(b) Assets not excluded under chapter 182-512 WAC are available resources.

(5) Payments from assets in the trust under this section to or for the benefit of the beneficiary are unearned income of the beneficiary.

(6) If unearned income under subsection (5) of this section was from an available resource under subsection (4) of this section, then the value of the available resource will be reduced by the amount of unearned income under subsection (5) of this section.

(7) Any payments from the revocable trust, other than payments under subsections (5) and (6) of this section, are uncompensated asset transfers.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. 1396p. WSR 18-04-037, § 182-516-0115, filed 1/30/18, effective 3/2/18.*

##### **Wash. Admin. Code § 182-516-0120** Irrevocable self-settled trusts for a disabled client under age sixty-five established on or after August 11, 1993. {#sec-182-516-0120 omnilex-key=us-wa-regs-official--title-182--182-516-0120}

(1) This section governs how the agency or the agency's designee treats self-settled trusts, for a disabled client under age sixty-five established under 42 U.S.C. 1396p (d)(4)(a) on or after August 11, 1993, for medicaid eligibility purposes.

(2) A self-settled trust established on or after August 11, 1993, is not an available resource if:

(a) The beneficiary is under age sixty-five and disabled under WAC 182-512-0050 (1)(c) when the trust is established;

(b) The trust is irrevocable;

(c) The trust was established for the sole benefit of that beneficiary;

(d) The trust was established by the beneficiary's parent, the beneficiary's grandparent, the beneficiary's legal guardian, by a court, or on or after December 13, 2016, the beneficiary; and

(e) The trust says that the states that have spent medicaid funds for the beneficiary will receive all amounts remaining in the trust up to the amount of medicaid funds spent for the beneficiary.

(i) For trusts established from August 11, 1993, to July 31, 2003, the trust must pay the states when the beneficiary dies.

(ii) For trusts established on or after August 1, 2003, the trust must pay the states when the beneficiary dies, the trust terminates, or the beneficiary's disability ends.

(3) The medicaid agency or the agency's designee does not apply a penalty period to a beneficiary for asset transfers into a trust, described under subsection (2) of this section, when the beneficiary is under age sixty-five as of the date of the transfer.

(4) Assets in trusts under subsection (2) of this section continue to be unavailable resources, even after the beneficiary turns age sixty-five.

(5) Asset transfers to the trust from the beneficiary, after the beneficiary turns age sixty-five, may be subject to a transfer penalty under WAC 182-513-1363.

(6) If a trust does not meet the requirements under subsection (2) of this section, see WAC 182-516-0130.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. 1396p. WSR 18-04-037, § 182-516-0120, filed 1/30/18, effective 3/2/18.*

##### **Wash. Admin. Code § 182-516-0125** Irrevocable pooled self-settled trusts for a disabled client established on or after August 11, 1993. {#sec-182-516-0125 omnilex-key=us-wa-regs-official--title-182--182-516-0125}

(1) This section governs how the agency or the agency's designee treats pooled self-settled trusts, for a disabled client established under 42 U.S.C. 1396p (d)(4)(c) on or after August 11, 1993, for medicaid eligibility purposes.

(2) A pooled self-settled trust established on or after August 11, 1993, is not an available resource if:

(a) The beneficiary is disabled under WAC 182-512-0050 (1)(c) when the trust is established;

(b) The trust is irrevocable;

(c) An account in the trust was established for the sole benefit of that beneficiary;

(d) An account in the trust was established by that beneficiary, the beneficiary's parent, grandparent, legal guardian, or by a court;

(e) The trust was established by and is managed by a nonprofit association;

(f) A separate account is maintained for each beneficiary of the trust, but, for the purposes of the investment and management of funds, the trust pools these accounts; and

(g) The trust says that:

(i) Upon the death of the beneficiary, or, for trust accounts established on or after August 1, 2003, when the trust account terminates or the beneficiary's disability ends, the funds will remain in the trust to benefit other disabled beneficiaries; or

(ii) The states that have spent medicaid funds for the beneficiary will receive all amounts remaining in the trust account for that beneficiary up to the amount of medicaid funds spent for the beneficiary.

(A) For trust accounts established from August 11, 1993, to July 31, 2003, the trust must pay the states when the beneficiary dies.

(B) For trust accounts established on or after August 1, 2003, the trust must pay the states when the beneficiary dies, the trust terminates, or the beneficiary's disability ends.

(3) The medicaid agency or the agency's designee does not apply a penalty period to a beneficiary for asset transfers into a trust, described under subsection (2) of this section, when the beneficiary is under age sixty-five as of the date of the transfer.

(4) Assets in trusts under subsection (2) of this section continue to be unavailable resources, even after the beneficiary turns age sixty-five.

(5) Asset transfers to the trust from the beneficiary, after the beneficiary turns age sixty-five, may be subject to a transfer penalty under WAC 182-513-1363.

(6) If a trust does not meet the requirements under subsection (2) of this section, see WAC 182-516-0130.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. 1396p. WSR 18-04-037, § 182-516-0125, filed 1/30/18, effective 3/2/18.*

##### **Wash. Admin. Code § 182-516-0130** Irrevocable self-settled trusts established on or after August 11, 1993. {#sec-182-516-0130 omnilex-key=us-wa-regs-official--title-182--182-516-0130}

(1) This section governs irrevocable self-settled trusts established on or after August 11, 1993, that do not meet the rules under either WAC 182-516-0120 or 182-516-0125.

(2) A trust established on or after August 1, 2003, is a self-settled trust if:

(a) The assets of the trust are at least partially from the beneficiary or the beneficiary's spouse, or would have been owned by the beneficiary or the beneficiary's spouse unless diverted by the beneficiary, the beneficiary's spouse, the court, or someone acting on behalf of the beneficiary or the beneficiary's spouse;

(b) The trust is not established by will; and

(c) The trust was established by:

(i) The beneficiary or that beneficiary's spouse;

(ii) A person, including a court or administrative body, with legal authority to act in place or on behalf of the beneficiary or that beneficiary's spouse; or

(iii) A person, including a court or administrative body, acting at the direction or upon the request of the beneficiary or that beneficiary's spouse.

(3) A trust established from August 11, 1993, to July 31, 2003, is a self-settled trust if:

(a) The assets of the trust are at least partially from the beneficiary, or would have been owned by the beneficiary unless diverted by the beneficiary, the court, or someone acting on behalf of the beneficiary;

(b) The trust is not established by will; and

(c) The trust was established by:

(i) The beneficiary;

(ii) A person, including a court or administrative body, with legal authority to act in place or on behalf of the beneficiary; or

(iii) A person, including a court or administrative body, acting at the direction or upon the request of the beneficiary.

(4) This section applies only to the assets contributed to a trust:

(a) Under subsection (2) of this section, by either the beneficiary or that beneficiary's spouse; or

(b) Under subsection (3) of this section, by the beneficiary.

(5) The medicaid agency or the agency's designee applies the rules of this section without regard to:

(a) The purpose for establishing a trust;

(b) Whether the trustees have or may exercise any discretion under the terms of the trust;

(c) Restrictions on when or whether distributions may be made from the trust; and

(d) Restrictions on the use of distributions from the trust.

(6) Treatment of payments or benefits from trusts established under this section.

(a) Subject to subsection (7) of this section, if there are any circumstances under which payment or benefit from the trust could be made to or for the benefit of the beneficiary, the portion of the principal from which, or the income on the principal from which, payment to the beneficiary could be made is an available resource to the beneficiary, and the payment or benefit from that portion:

(i) Is unearned income when payment or benefit is to or for the benefit of the beneficiary; and

(ii) Is an uncompensated asset transfer, if payment or benefit is for any other purpose.

(b) If there are no circumstances under which any payment or any benefit from the trust could be made to or for the benefit of the beneficiary, the part of the trust or income of that trust, from which payment or benefit cannot be made, is an uncompensated asset transfer.

(7) For the purposes of subsection (6)(a) of this section, "available resource" means a resource after the resource exclusions under chapter 182-512 WAC are applied; however, for an institutionalized individual, the resource exclusion for the home under WAC 182-512-0350 does not apply.

(8) If unearned income under subsection (6)(a)(i) of this section was from an available resource under subsection (6)(a) of this section, then the value of the available resource will be reduced by the amount of unearned income under subsection (6)(a)(i) of this section.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. 1396p. WSR 18-04-037, § 182-516-0130, filed 1/30/18, effective 3/2/18.*

##### **Wash. Admin. Code § 182-516-0135** Self-settled trusts established before August 11, 1993. {#sec-182-516-0135 omnilex-key=us-wa-regs-official--title-182--182-516-0135}

(1) A revocable or irrevocable self-settled trust established before August 11, 1993, under this section is one:

(a) Established other than by will by a beneficiary or that beneficiary's spouse;

(b) Under which that beneficiary may be the beneficiary of all or part of the payments from the trust; and

(c) Under which the distribution of those payments is determined by one or more trustees who are permitted to exercise any discretion with respect to the distribution to the beneficiary.

(2) For trusts established under subsection (1) of this section, the maximum value the trustee may distribute, under any circumstances, to the beneficiary is unearned income.

(3) If a trust does not meet subsection (1)(c) of this section:

(a) The trust is an available resource to the extent that trust assets can be used for the beneficiary; and

(b) Any asset that cannot be used for the beneficiary is an uncompensated asset transfer.

(4) This section does not apply to any trust or initial trust decree established before April 7, 1986, for the sole benefit of an intellectually disabled client who resides in an intermediate care facility for the intellectually disabled.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. 1396p. WSR 18-04-037, § 182-516-0135, filed 1/30/18, effective 3/2/18.*

##### **Wash. Admin. Code § 182-516-0140** Third-party trusts. {#sec-182-516-0140 omnilex-key=us-wa-regs-official--title-182--182-516-0140}

(1) This section governs third-party trust as defined under WAC 182-516-0001.

(2) A trust containing the assets of a beneficiary's spouse may be a self-settled trust based on the date it was established. For specific rules regarding this, see WAC 182-516-0130.

(3) A testamentary trust is a third-party trust created by a will where the trust is in the will and the estate is the grantor.

(4) There is no requirement for a state to be named as a remainder beneficiary in third-party trusts.

(5) If the beneficiary has the power to acquire the assets from the third-party trust, the trust is an available resource.

(6) If the beneficiary has no power to access or control trust assets or distributions, as described under WAC 182-516-0105(4), a third-party trust is not an available resource.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. 1396p. WSR 18-04-037, § 182-516-0140, filed 1/30/18, effective 3/2/18.*

##### **Wash. Admin. Code § 182-516-0145** Irrevocable trusts containing both assets of the beneficiary and third-party assets. {#sec-182-516-0145 omnilex-key=us-wa-regs-official--title-182--182-516-0145}

(1) For irrevocable trusts that contain both assets of the beneficiary and third-party assets, the medicaid agency or the agency's designee treats the assets of the beneficiary under the self-settled trust rule in effect as of the date of the trust's establishment:

(a) After August 11, 1993:

(i) For irrevocable self-settled trusts for a disabled client under age sixty-five, see WAC 182-516-0120;

(ii) For irrevocable pooled self-settled trusts for a disabled client, see WAC 182-516-0125; and

(iii) For all other trusts, see WAC 182-516-0130.

(b) Before August 11, 1993, see WAC 182-516-0135.

(2) For irrevocable trusts that contain both assets of the beneficiary and third-party assets, the agency or the agency's designee treats third-party assets under the third-party trust rules under WAC 182-516-0140.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-02-047, § 182-516-0145, filed 12/27/18, effective 1/27/19. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. 1396p. WSR 18-04-037, § 182-516-0145, filed 1/30/18, effective 3/2/18.*

##### **Wash. Admin. Code § 182-516-0200** Annuities established prior to April 1, 2009. {#sec-182-516-0200 omnilex-key=us-wa-regs-official--title-182--182-516-0200}

(1) A revocable annuity is an available resource.

(2) An irrevocable annuity established prior to May 1, 2001, is not an available resource when issued by an individual, insurer, or other body licensed and approved to do business in the jurisdiction in which the annuity is established.

(3) The income from an irrevocable annuity that meets the requirements of this section is income for determining eligibility and the amount of participation in the total cost of care. The annuity itself is not a resource.

(4) Subject to subsection (5) of this section, an annuity established on or after May 1, 2001, and before April 1, 2009, is an available resource unless it:

(a) Is irrevocable;

(b) Is paid out in equal monthly amounts within the actuarial life expectancy of the annuitant;

(c) Is issued by an individual, insurer, or other body licensed and approved to do business in the jurisdiction in which the annuity is established; and

(d) Names the state of Washington as the beneficiary of the remaining funds up to the total of medicaid funds spent on the client during the client's lifetime. This subsection only applies if the annuity is in the client's name.

(5) If an irrevocable annuity is an available resource under subsection (4) of this section because it does not pay out in equal monthly amounts, it is an unavailable resource if:

(a) The full pay out is within the actuarial life expectancy of the client; and

(b) The client:

(i) Changes the scheduled pay out into equal monthly payments within the actuarial life expectancy of the annuitant; or

(ii) Requests that the medicaid agency or the agency's designee calculate and budget the payments as equal monthly payments within the actuarial life expectancy of the annuitant. The income from the annuity remains unearned income to the annuitant.

(6) An irrevocable annuity is unearned income when the annuitant is:

(a) The client;

(b) The spouse of the client;

(c) The blind or disabled child, as defined in WAC 182-512-0050 (1)(b) and (c), of the client; or

(d) A person designated to use the annuity for the sole benefit of the client, client's spouse, or a blind or disabled child, as defined in WAC 182-512-0050 (1)(b) and (c), of the client.

(7) An annuity is not an available resource when there is a joint owner, co-annuitant or an irrevocable beneficiary who will not agree to allow the annuity to be cashed, unless the joint owner or irrevocable beneficiary is the community spouse. In the case of a community spouse, the value of the annuity is an available resource and counts toward the maximum community spouse resource allowance.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. 1396p. WSR 18-04-037, § 182-516-0200, filed 1/30/18, effective 3/2/18. WSR 13-01-017, recodified as § 182-516-0200, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530. WSR 09-06-048, § 388-561-0200, filed 2/25/09, effective 4/1/09*
- *WSR 08-20-117 and 08-21-083, § 388-561-0200, filed 9/30/08 and 10/14/08, effective 4/1/09. Statutory Authority: RCW 74.04.050, 74.08.090, and 74.09.500. WSR 01-06-043, § 388-561-0200, filed 3/5/01, effective 5/1/01.*

##### **Wash. Admin. Code § 182-516-0201** Annuities established on or after April 1, 2009. {#sec-182-516-0201 omnilex-key=us-wa-regs-official--title-182--182-516-0201}

(1) The medicaid agency or the agency's designee determines how an annuity, purchased by or on behalf of an annuitant and established on or after April 1, 2009, affects eligibility for medicaid.

(2) General information.

(a) Clients of noninstitutional medicaid must disclose to the agency or the agency's designee any interest that client, or the financially responsible members of that client's assistance unit, has in an annuity.

(b) Clients of institutional or home and community-based (HCB) waiver services must disclose to the agency or the agency's designee any interest that client, or that client's community spouse, has in an annuity.

(c) Subject to (d) of this subsection, this section applies when the annuitant is:

(i) The client of medicaid;

(ii) That client's spouse, if that spouse is financially responsible for that client; or

(iii) That client's community spouse.

(d) If this section does not apply because of (c) of this subsection, but the client of institutional or HCB waiver services, or that client's community spouse, is the owner of the annuity, then the purchase of the annuity is evaluated as an asset transfer under WAC 182-513-1363.

(e) For the definition of "disabled," see WAC 182-512-0050 (1)(b) and (c).

(f) Actuarial life expectancy in this section is rounded up to the nearest whole year.

(3) Annuities as resources.

(a) Subject to (b) of this subsection, a revocable annuity is an available resource.

(b) The following annuities are not available resources, even if revocable:

(i) An annuity described under 26 U.S.C. Sec. 408 (b) or (q); or

(ii) An annuity purchased with proceeds from:

(A) An account or trust described under 26 U.S.C. Sec. 408 (a), (c), or (p);

(B) A simplified employee pension (within the meaning of 26 U.S.C. Sec. 408(k)); or

(C) A Roth IRA described under 26 U.S.C. Sec. 408A.

(c) An annuity not described under (b) of this subsection is an available resource unless the annuity:

(i) Is issued by an entity licensed and approved to issue annuities in the jurisdiction in which the annuity is established;

(ii) Is immediate, irrevocable, nonassignable; and

(iii) Is paid out, in equal monthly amounts with no deferral and no balloon payments, over a term:

(A) Of at least five years, if the actuarial life expectancy of the annuitant is at least five years; or

(B) Not less than the actuarial life expectancy of the annuitant, if the actuarial life expectancy of the annuitant is less than five years.

(d) If an annuity fails either the immediate requirement under (c)(ii) of this subsection or the monthly payout requirement under (c)(iii) of this subsection, the annuity is not a resource if:

(i) The annuity is fully paid out within the actuarial life expectancy of the annuitant; and

(ii) The annuitant:

(A) Changes the scheduled payout to equal monthly payments; or

(B) Asks the agency or the agency's designee to calculate and budget the periodic payments as equal monthly payments beginning the month of eligibility. Periodic payments made before the month of eligibility are not included in the calculation.

(iii) Nothing under (d) of this subsection affects the deferral or balloon payment requirements under (c)(iii) of this subsection, or the payment term requirements under (c)(iii)(A) or (B) of this subsection.

(4) Annuities as income.

(a) If an annuity is not an available resource under subsection (3) of this section, the payments from the annuity are unearned income to the annuitant.

(b) If an annuity is an available resource under subsection (3) of this section, the payments from the annuity are not income to the annuitant.

(5) An annuity as a transfer of assets.

(a) The purchase of an annuity is an uncompensated asset transfer, unless the annuity designates the state of Washington as remainder beneficiary under subsection (6) of this section.

(b) The purchase of an annuity by the client of institutional or HCB waiver services is an uncompensated asset transfer, unless the annuity is an annuity under subsection (3)(b)(i) or (ii) of this section, or the annuity:

(i) Is issued by an entity licensed and approved to issue annuities in the jurisdiction in which the annuity is established;

(ii) Is immediate, irrevocable, nonassignable; and

(iii) Is paid out, in equal periodic amounts with no deferral and no balloon payments, over a term that is actuarially sound (i.e., a term that is not greater than the actuarial life expectancy of that client).

(6) Beneficiary designation requirements.

(a) Subject to (b) of this subsection, to satisfy subsection (5)(a) of this section, when the client of institutional or HCB waiver services, or that client's community spouse, is the annuitant, the annuity must:

(i) Name the states as the remainder beneficiary, for at least the total amount of services covered under medicaid, paid on behalf of the client of institutional or HCB waiver services; and

(ii) The remainder beneficiary must be listed in the annuity in the:

(A) First position;

(B) Next position, after the community spouse, and any minor or disabled children; or

(C) First position, if either the community spouse, or any minor or disabled children, or a representative for such children, named as beneficiary in the first position under (a)(ii)(B) of this subsection, transfers the right to receive payments from the annuity for less than fair market value.

(b) When the community spouse is the annuitant, the community spouse, or the community spouse's estate, cannot be named as remainder beneficiary under (a)(ii)(A) of this subsection.

(c) If a change of circumstance requires a change in beneficiary designation under (a) of this subsection, the agency or the agency's designee reevaluates the annuity's beneficiary designation.

(7) Actuarial life expectancy is determined by tables that are published by the office of the chief actuary of the Social Security Administration.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. 1396p. WSR 18-04-037, § 182-516-0201, filed 1/30/18, effective 3/2/18. WSR 13-01-017, recodified as § 182-516-0201, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530. WSR 09-06-048, § 388-561-0201, filed 2/25/09, effective 4/1/09*
- *WSR 08-20-117 and 08-21-083, § 388-561-0201, filed 9/30/08 and 10/14/08, effective 4/1/09.*

##### **Wash. Admin. Code § 182-516-0300** Life estates. {#sec-182-516-0300 omnilex-key=us-wa-regs-official--title-182--182-516-0300}

(1) "Life estate" means an ownership interest in real property only during the lifetime of a specified person.

(2) Subject to subsection (3) of this section, a life estate is an available resource, unless it is either excluded or unavailable under chapter 182-512 WAC.

(3) For someone applying for or receiving long-term services and supports, a life estate interest is subject to the home equity limits under:

(a) WAC 182-513-1350 for institutional and home and community-based (HCB) waiver programs; and

(b) WAC 182-513-1215 for community first choice.

(4) For clients of institutional or HCB waiver services:

(a) If the remainder interest was transferred for less than fair market value, the medicaid agency or the agency's designee will evaluate the transaction as an asset transfer under WAC 182-513-1363. "Remainder interest" is the fair market value of the property at the time the client transferred it and retained a life estate, minus the value of the life estate at the time of that transfer.

(b) If a client purchased a life estate but has not lived in the property for at least one year after the purchase, the purchase price of the life estate is an uncompensated asset transfer under WAC 182-513-1363.

(c) If a client purchased a life estate and has lived in the property for more than one year, it is not an uncompensated transfer, unless the purchase price for the life estate exceeded the value of the life estate. Any amount paid for a life estate in excess of the value of the life estate is an uncompensated transfer under WAC 182-513-1363.

(5) To calculate the value of a life estate:

(a) Identify the person whose life determines the length of the life estate;

(b) Identify whether uncompensated value or home equity is being calculated:

(i) If calculating uncompensated value under subsection (4)(a) or (c) of this section, identify that person's age on the person's last birthday before the transfer; or

(ii) If determining whether home equity requirements are met under subsection (3) of this section, identify that person's age on the person's most recent birthday; and

(c) Multiply the property's fair market value by the life estate factor corresponding to that person's age in the Life Estate and Remainder Interest Tables maintained by the Social Security Administration.

(6) To calculate the remainder interest, subtract the value in subsection (5) of this section from the property's fair market value at the time of the transaction that created the life estate.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. 1396p. WSR 18-04-037, § 182-516-0300, filed 1/30/18, effective 3/2/18. WSR 13-01-017, recodified as § 182-516-0300, filed 12/7/12, effective 1/1/13. Statutory Authority: RCW 34.05.353 (2)(d), 74.08.090, and chapters 74.09, 74.04 RCW. WSR 08-11-047, § 388-561-0300, filed 5/15/08, effective 6/15/08. Statutory Authority: RCW 74.04.050, 74.08.090, and 74.09.500. WSR 01-06-043, § 388-561-0300, filed 3/5/01, effective 5/1/01.*

##### **Wash. Admin. Code § 182-516-0400** Promissory notes and loans. {#sec-182-516-0400 omnilex-key=us-wa-regs-official--title-182--182-516-0400}

(1) General.

(a) In this section, note includes promissory note, loan or other obligation to pay.

(b) The medicaid agency or the agency's designee determines the value of outstanding principal and interest payments using amortization schedules, unless otherwise stated in this section.

(2) A note as a resource.

(a) A note is a resource. The value of the note is the fair market value (FMV).

(b) The FMV of a note is the outstanding principal of the note, unless convincing evidence to the contrary is provided to the agency or the agency's designee.

(c) If the note owner provides convincing evidence to the agency or the agency's designee of a legal bar to the sale of the note, the note's FMV is zero.

(3) A note as income.

(a) Interest on a note is unearned income.

(b) If the FMV of the note under subsection (2)(c) of this section is zero, the principal portion of recurring payments is unearned income.

(c) The agency or the agency's designee may budget the unearned income in equal monthly amounts at the request of the note owner, or at the agency's or the agency's designee's discretion. The budgeting period will be the note owner's certification period under chapter 182-504 WAC.

(4) A note as an asset transfer under WAC 182-513-1363.

(a) Subject to (b) of this subsection:

(i) The agency or the agency's designee evaluates the purchase of a note as an asset transfer if the purchase price of the note exceeds the FMV of the note;

(ii) The value of the asset transfer is the difference between the purchase price of the note and the FMV of the note at the time of purchase; and

(iii) The agency or the agency's designee determines the FMV of the note at the time of purchase using subsection (2) of this section, but can also determine the FMV of the note at a time after purchase if the agency or the agency's designee determines FMV of the note has changed since the time it was purchased.

(b) The assets used to purchase a note are an uncompensated asset transfer under WAC 182-513-1363, unless the note:

(i) Prohibits the cancellation of the balance of the note upon death of the note owner; and

(ii) Is paid out, in equal periodic amounts with no deferral and no balloon payments, over a term not greater than the actuarial life expectancy of that note owner.

(c) The value of the uncompensated asset transfer under (b) of this subsection is the outstanding balance of the note due as of the date of the client's application for medical assistance for institutional or home and community-based waiver services.

(d) If the purchase of a note results in a period of ineligibility under both (a) and (b) of this subsection, then the period of ineligibility under WAC 182-513-1363 will be the period that is longer.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. 1396p. WSR 18-04-037, § 182-516-0400, filed 1/30/18, effective 3/2/18.*

## **Chapter 182-517** Medicare-related medical eligibility. {#struct-chapter-182-517}

##### **Wash. Admin. Code § 182-517-0100** Federal medicare savings programs. {#sec-182-517-0100 omnilex-key=us-wa-regs-official--title-182--182-517-0100}

(1) Available programs. The medicaid agency offers eligible clients the following medicare savings programs (MSPs):

(a) The qualified medicare beneficiary (QMB) program;

(b) The specified low-income medicare beneficiary (SLMB) program;

(c) The qualified individual (QI-1) program; and

(d) The qualified disabled and working individuals (QDWI) program.

(2) Eligibility requirements.

(a) To be eligible for an MSP, a client must:

(i)(A) Be entitled to medicare Part A; or

(B) Be eligible for and enrolled in the medicare Part D low-income subsidy (LIS) program through the social security administration (SSA); and

(ii) Meet the general eligibility requirements under WAC 182-503-0505.

(b) To be eligible for QDWI, a client must be under age 65.

(c) Income limits.

(i) Income limits for all MSPs are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

(ii) If a client's countable income is less than or equal to 110 percent of the federal poverty level (FPL), the client is income eligible for the QMB program.

(iii) If a client's countable income is over 110 percent of the FPL, but does not exceed 120 percent of the FPL, the client is income eligible for the SLMB program.

(iv) If a client's countable income is over 120 percent of the FPL, but does not exceed 138 percent of the FPL, the client is income eligible for the QI-1 program.

(v) If a client's countable income is over 138 percent of the FPL, but does not exceed 200 percent of the FPL, the client is income eligible for the QDWI program if the client is employed and meets disability requirements described in WAC 182-512-0050.

(d) The federal MSPs do not require a resource test.

(3) MSP income eligibility determinations.

(a) The agency has three methods for determining if a client is eligible for an MSP:

(i) The agency first determines if the client is eligible based on SSI-related methodologies under chapter 182-512 WAC. Under this method, the agency calculates the household's net countable income and compares the result to the one-person standard. However, if the spouse's income is deemed to the client, or if both spouses are applying, the household's net countable income is compared to the two-person standard.

(ii) If the client is not eligible under the methodology described in (a)(i) of this subsection, the agency compares the same countable income, as determined under (a)(i) of this subsection, to the appropriate FPL standard based on family size. The number of individuals that count for family size include:

(A) The client;

(B) The client's spouse who lives with the client;

(C) The client's dependents who live with the client;

(D) The spouse's dependents who live with the spouse, if the spouse lives with the client; and

(E) Any unborn children of the client, or of the spouse if the spouse lives with the client.

(iii) The third method for determining if a client is eligible for an MSP is the SSA LIS methodology. This is based on the client's application for the medicare Part D low-income subsidy program through the SSA, which the agency receives from SSA through the LIS data file. Under this methodology, the agency compares the LIS data file regarding income and household size to the current MSP standards.

(b) Under all eligibility determinations, the agency follows the rules for SSI-related people under chapter 182-512 WAC for determining:

(i) Countable income;

(ii) Availability of income;

(iii) Allowable income deductions and exclusions; and

(iv) Deemed income from and allocated income to a nonapplying spouse and dependents.

(c) The agency uses the eligibility determination that provides the client with the highest level of coverage.

(i) If the MSP applicant is eligible for QMB coverage under (a)(i) of this subsection, the agency approves the coverage.

(ii) If the MSP applicant is not eligible for QMB coverage, the agency determines if the applicant is eligible under (a)(ii) of this subsection.

(iii) If neither eligibility determination results in QMB coverage, the agency uses the same process to determine if the client is eligible under any other MSP.

(d) When calculating income under this section:

(i) The agency subtracts client participation from a long-term care client's countable income under WAC 182-513-1380, 182-515-1509, or 182-515-1514.

(ii) The agency counts the annual Social Security cost-of-living increase beginning April 1st each year.

(4) Covered costs.

(a) The QMB program pays:

(i) Medicare Part A and Part B premiums using the start date in WAC 182-504-0025; and

(ii) Medicare coinsurance, copayments, and deductibles for Part A, Part B, and Part C, subject to the limitations in WAC 182-502-0110.

(b) If the client is eligible for both SLMB and another medicaid program:

(i) The SLMB program pays the Part B premiums using the start date in WAC 182-504-0025; and

(ii) The medicaid program pays medicare coinsurance, copayments, and deductibles for Part A, Part B, and Part C subject to the limitations in WAC 182-502-0110.

(c) If the client is only eligible for SLMB, the SLMB program covers medicare Part B premiums using the start date in WAC 182-504-0025.

(d) The QI-1 program pays medicare Part B premiums using the start date in WAC 182-504-0025 until the agency's federal funding allotment is spent. The agency resumes QI-1 benefit payments the beginning of the next calendar year.

(e) The QDWI program covers medicare Part A premiums using the start date in WAC 182-504-0025.

(5) MSP eligibility. Medicaid eligibility may affect MSP eligibility:

(a) QMB and SLMB clients may receive medicaid and still be eligible to receive QMB or SLMB benefits.

(b) QI-1 and QDWI clients who begin receiving medicaid are no longer eligible for QI-1 or QDWI benefits, but may be eligible for the state-funded medicare buy-in program under WAC 182-517-0300.

(6) Right to request administrative hearing. A person who disagrees with agency action under this section may request an administrative hearing under chapter 182-526 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-01-043, s 182-517-0100, filed 12/10/25, effective 1/19/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 2023 c 475 § 211(84). WSR 24-06-008, § 182-517-0100, filed 2/22/24, effective 4/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-04-034, § 182-517-0100, filed 1/25/23, effective 2/25/23. Statutory Authority: RCW 41.05.021, 41.05.160, and 2022 c 297 § 211(79). WSR 22-21-043, § 182-517-0100, filed 10/11/22, effective 1/1/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-12-085, § 182-517-0100, filed 6/4/19, effective 7/15/19*
- *WSR 16-13-157, § 182-517-0100, filed 6/22/16, effective 7/23/16. WSR 11-23-091, recodified as § 182-517-0100, filed 11/17/11, effective 11/21/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500 and 42 U.S.C. 9902(2). WSR 06-16-026, § 388-478-0085, filed 7/24/06, effective 8/24/06*
- *WSR 05-17-157, § 388-478-0085, filed 8/22/05, effective 9/22/05. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 42 U.S.C. 9902(2). WSR 04-17-076, § 388-478-0085, filed 8/13/04, effective 9/13/04. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 74.09.530, and Section 673(2) (42 U.S.C. 9902(2)). WSR 01-18-056, § 388-478-0085, filed 8/30/01, effective 9/30/01*
- *WSR 00-17-085, § 388-478-0085, filed 8/14/00, effective 9/14/00*
- *WSR 99-19-005, § 388-478-0085, filed 9/3/99, effective 10/4/99. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-478-0085, filed 7/31/98, effective 9/1/98. Formerly WAC 388-517-1715, 388-517-1730, 388-517-1750 and 388-517-1770.*

##### **Wash. Admin. Code § 182-517-0300** State-funded medicare buy-in programs. {#sec-182-517-0300 omnilex-key=us-wa-regs-official--title-182--182-517-0300}

(1) A person is eligible for the state-funded medicare buy-in program (SBIP) if the person:

(a) Is entitled to or receiving medicare;

(b) Is not eligible for a federal medicare savings program under WAC 182-517-0100; and

(c) Is eligible for coverage under:

(i) The categorically needy (CN) program; or

(ii) The medically needy (MN) program;

(2) The SBIP begins the second month after the month a person meets eligibility requirements.

(3) The SBIP pays only medicare Part B premiums.

(4) The agency pays medicare deductibles and coinsurance under WAC 182-502-0110.

(5) A person who disagrees with agency action under this section may request an administrative hearing under chapter 182-526 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-13-157, § 182-517-0300, filed 6/22/16, effective 7/23/16. WSR 12-13-056, recodified as § 182-517-0300, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, and 42 U.S.C. 1396a(a) (Section 1902 (n)(2) of the Social Security Act of 1924). WSR 05-14-125, § 388-517-0300, filed 7/1/05, effective 8/1/05. Statutory Authority: RCW 74.08.090, 74.09.530. WSR 02-11-074, § 388-517-0300, filed 5/13/02, effective 6/13/02. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-517-0300, filed 7/31/98, effective 9/1/98. Formerly WAC 388-517-1710, 388-517-1730, 388-517-1750 and 388-517-1770.*

## **Chapter 182-518** Washington apple health—Letters and notices. {#struct-chapter-182-518}

##### **Wash. Admin. Code § 182-518-0005** Washington apple health—Notice requirements—General. {#sec-182-518-0005 omnilex-key=us-wa-regs-official--title-182--182-518-0005}

(1) For the purposes of this chapter, "we" refers to the agency or its designee and "you" refers to the applicant for, or recipient of, health care coverage.

(2) This section applies only to notices and letters that we send about eligibility for Washington apple health (WAH) programs. WAC 182-501-0165 applies to notices and letters regarding prior authorization or other action on requests to cover specific fee-for-service health care services.

(3) We send you written notices (letters) when we:

(a) Approve you for health care coverage for any program;

(b) Reconsider your application for other types of health care coverage based on new information;

(c) Deny you health care coverage (including because you withdrew your application) for any program (according to rules in WAC 182-503-0080);

(d) Ask you for more information to decide if you can start or renew health care coverage;

(e) Renew your health care coverage; or

(f) Change or terminate your health care coverage, even if we approve you for another kind of coverage.

(4) We send notices to you in your primary language if you ask us to and in English according to the rules in WAC 182-503-0110. If you need help to apply for or access your health care coverage due to a disability, we follow the equal access rules in WAC 182-503-0120.

(5) All WAH notices we send you include the following information:

(a) The date of the notice;

(b) Specific contact information for you if you have questions or need help with the notice;

(c) Your appeal rights, if an appeal is available, and the availability of potentially free legal assistance; and

(d) Other information required by state or federal law.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-518-0005, filed 7/29/14, effective 8/29/14.*

##### **Wash. Admin. Code § 182-518-0010** Washington apple health—Notice requirements approval and denial notices. {#sec-182-518-0010 omnilex-key=us-wa-regs-official--title-182--182-518-0010}

(1) We send written notice when we approve, reopen, reinstate, or deny coverage for any Washington apple health (WAH) program. The notice includes the information described in WAC 182-518-0005(4) and all of the following:

(a) The WAH coverage for each person approved, reopened or reinstated;

(b) The date that each person's coverage begins (the effective date); and

(c) The dates for which we approved each person's coverage (certification period).

(2) Denial and withdrawal notices include:

(a) The date of denial;

(b) Specific facts and reason(s) supporting the decision;

(c) Specific rules or statutes that support or require the decision; and

(d) Information to get help applying for nonmodified adjusted gross income (MAGI)-based WAH.

(3) If we deny your request for health care coverage or consider it withdrawn because you failed to give us requested information, the denial notice also includes:

(a) A list of the information you did not give us;

(b) The date we asked you for the information and the date it was due;

(c) Notice that we will reconsider your eligibility if we receive any information related to determining your eligibility, including any changes to information we have, within thirty days of the date of the notice;

(d) Information described in subsection (1) of this section; and

(e) Notice of administrative hearing rights.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-518-0010, filed 7/29/14, effective 8/29/14.*

##### **Wash. Admin. Code § 182-518-0015** Washington apple health—Notice requirements verification requests. {#sec-182-518-0015 omnilex-key=us-wa-regs-official--title-182--182-518-0015}

(1) We send you written notice when we need more information as described in WAC 182-503-0050 to decide if you are eligible to receive or continue receiving Washington apple health (WAH) coverage. The notice includes:

(a) A description or list of the information that we need;

(b) When we must have the information (see WAC 182-503-0060 for applications and WAC 182-504-0035 for renewals);

(c) What action we will take and on what date, if we do not receive the information; and

(d) Information required in WAC 182-518-0005(4).

(2) If we have received conflicting information about facts we need to determine your coverage, the notice will also include:

(a) The information we received that does not match what you gave us and the source; and

(b) A request that you send us a statement explaining the difference(s) between the information from you and the information from the other source.

(3) We allow you at least ten days to return the information. If you ask, we may allow you more time to get us the information. If the tenth day falls on a weekend or holiday, the due date is the next business day.

(4) If the information we ask for costs money, we will pay for it or help you get the information in another way.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-518-0015, filed 7/29/14, effective 8/29/14.*

##### **Wash. Admin. Code § 182-518-0020** Washington apple health—Notice requirements—Renewals. {#sec-182-518-0020 omnilex-key=us-wa-regs-official--title-182--182-518-0020}

(1) We send you written notice before we stop your WAH coverage at the end of your certification period as described in WAC 182-504-0035.

(2) When we can administratively renew your coverage (as defined in WAC 182-500-0010), the notice includes:

(a) Your new certification period;

(b) The information we used to renew your coverage; and

(c) A request for you to give us updated information, if any of the information we used is inaccurate.

(3) When we cannot administratively renew your coverage, the notice includes:

(a) Information we currently have on record;

(b) How to complete the renewal using any of the methods described in WAC 182-504-0035 (1)(b);

(c) What action we will take on what date if we do not receive your completed renewal application on time; and

(d) That we follow the rules in WAC 182-518-0015.

(4) We send your renewal notice following the timeline in:

(a) WAC 182-504-0035(2) for programs based on modified adjusted gross income (MAGI); or

(b) WAC 182-504-0035(3) for non-MAGI based programs.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-518-0020, filed 7/29/14, effective 8/29/14.*

##### **Wash. Admin. Code § 182-518-0025** Washington apple health—Notice requirements—Actions to terminate, suspend, or reduce eligibility or authorization for a covered service. {#sec-182-518-0025 omnilex-key=us-wa-regs-official--title-182--182-518-0025}

(1) General rule.

(a) We send written notice to you at least ten days before taking adverse action to terminate, suspend, or reduce your:

(i) Medicaid eligibility; or

(ii) Authorization for a covered service.

(b) The ten-day notice period starts on the day we sent the notice.

(2) Exceptions to ten-day notice period. We may send a notice fewer than ten days before the date of the action in the following circumstances.

(a) We send written notice to you at least five days before taking action to terminate, suspend, or reduce your medicaid eligibility or authorization for a covered service if:

(i) We have facts indicating fraud by you or on your behalf; and

(ii) We have verified the facts, if possible, through secondary sources.

(b) We send written notice to you no later than the date we took action to terminate, suspend, or reduce your medicaid eligibility or authorization for a covered service if:

(i) You requested the action;

(ii) A change in statute, federal regulation or administrative rule is the sole cause of the action;

(iii) You are incarcerated and expected to remain incarcerated at least thirty days;

(iv) Mail sent to you has been returned without a forwarding address, and we do not have a more current address for you; or

(v) We are terminating your eligibility because you:

(A) Died; or

(B) Began receiving medicaid from a jurisdiction other than Washington state.

(3) Notice contents. Written notice under this section states:

(a) The nature of the action;

(b) The effective date of the action;

(c) The facts and reason(s) for the action;

(d) The specific regulation on which the action is based;

(e) Your appeal rights, if any;

(f) Your right to continued coverage, if any; and

(g) Information found in WAC 182-518-0005(4).

(4) Reinstated coverage.

(a) If we do not meet the advance notice requirements under this section, we reinstate your coverage back to the date of the action. We may still take action once we meet notice requirements under this section.

(b) If you are receiving medically needy coverage, you cannot receive reinstated coverage past the end of the certification period described in WAC 182-504-0020.

(c) We may end your coverage if a notice we mailed to you is returned with no forwarding address. We reinstate your coverage if we learn your new address and you meet eligibility requirements.

(5) Hearing rights. If you do not agree with agency action under this section, you may request an administrative hearing under chapter 182-526 WAC, and you may be entitled to continued coverage under WAC 182-504-0130.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-22-060, § 182-518-0025, filed 10/31/16, effective 12/1/16. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-518-0025, filed 7/29/14, effective 8/29/14.*

##### **Wash. Admin. Code § 182-518-0030** Washington apple health—Modified adjusted gross income (MAGI) notice requirements—Electronic notices. {#sec-182-518-0030 omnilex-key=us-wa-regs-official--title-182--182-518-0030}

(1) For programs based on modified adjusted gross income (MAGI), you may choose to get notices by regular mail or in an electronic format through Washington Healthplanfinder.

(2) We send you letters (notices) about your eligibility for Washington apple health programs as described in WAC 182-518-0005 through 182-518-0025.

(3) When you select electronic notifications, also referred to as "paperless," we:

(a) Confirm your selection by regular mail;

(b) Notify you by email when a new notice has posted to your account; and

(c) Consider the notice received by you as of the date on the notice as described in WAC 182-518-0005.

(4) To read the notice, you must log in to your Washington Healthplanfinder account, as email messages do not include the content of the notice or other confidential information.

(5) If an email message is returned as undeliverable, we send the message to you by regular mail no later than three business days after the date of the undeliverable email response.

(6) You may ask at any time to stop receiving electronic notices from us.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-10-001, § 182-518-0030, filed 4/19/17, effective 5/20/17. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-052, § 182-518-0030, filed 7/29/14, effective 8/29/14.*

## **Chapter 182-519** Medically needy and spenddown. {#struct-chapter-182-519}

##### **Wash. Admin. Code § 182-519-0050** Monthly income and countable resource standards for medically needy (MN). {#sec-182-519-0050 omnilex-key=us-wa-regs-official--title-182--182-519-0050}

(1) Changes to the medically needy income level (MNIL) occur on January 1st of each calendar year when the Social Security Administration (SSA) issues a cost-of-living adjustment.

(2) Medically needy (MN) standards for people who meet institutional status requirements are in WAC 182-513-1395. The standard for a client who lives in an alternate living facility is in WAC 182-513-1205.

(3) The resource standards for institutional programs are in WAC 182-513-1350. The institutional standard chart is found at: http://www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

(4) Countable resource standards for the noninstitutional MN program are:

| (a) | One person | $2,000 |
| --- | --- | --- |
| (b) | A legally married couple | $3,000 |
| (c) | For each additional family member add | $50 |

(5) People who do not meet institutional status requirements use the "effective" MNIL income standard to determine eligibility for the MN program. The "effective" MNIL is the one-person federal benefit rate (FBR) established by SSA each year, or the MNIL listed in the chart below, whichever amount is higher. The FBR is the supplemental security income (SSI) payment standard. For example, in 2023, the FBR is $914.

| | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| | 914 | 914 | 914 | 914 | 914 | 975 | 1125 | 1242 | 1358 | 1483 | |

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-03-050, § 182-519-0050, filed 1/10/24, effective 2/10/24*
- *WSR 23-11-009, § 182-519-0050, filed 5/4/23, effective 6/4/23*
- *WSR 15-17-012, § 182-519-0050, filed 8/7/15, effective 9/7/15. Statutory Authority: RCW 41.05.021. WSR 12-20-001, § 182-519-0050, filed 9/19/12, effective 10/20/12. WSR 11-23-091, recodified as § 182-519-0050, filed 11/17/11, effective 11/21/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. WSR 08-11-098, § 388-478-0070, filed 5/20/08, effective 6/20/08. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530, and Section 1924 of the Social Security Act (42 U.S.C. 1396r-5). WSR 06-06-013, § 388-478-0070, filed 2/17/06, effective 3/20/06. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 42 U.S.C. 9902(2). WSR 05-06-090, § 388-478-0070, filed 3/1/05, effective 4/1/05. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 42 U.S.C. 1396r-5. WSR 02-10-116, § 388-478-0070, filed 4/30/02, effective 5/31/02. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and Section 1924 (42 U.S.C. 1396R-5). WSR 01-12-073, § 388-478-0070, filed 6/4/01, effective 7/5/01. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, and 74.09.575. WSR 00-10-095, § 388-478-0070, filed 5/2/00, effective 5/2/00*
- *WSR 99-11-054, § 388-478-0070, filed 5/17/99, effective 6/17/99. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-478-0070, filed 7/31/98, effective 9/1/98. Formerly WAC 388-507-0710, 388-507-0720, 388-511-1115, 388-518-1820, 388-518-1830, 388-518-1840 and 388-518-1850.*

##### **Wash. Admin. Code § 182-519-0100** Eligibility for the medically needy program. {#sec-182-519-0100 omnilex-key=us-wa-regs-official--title-182--182-519-0100}

(1) A person who meets the following conditions may be eligible for medically needy (MN) coverage under the special rules in chapters 182-513 and 182-515 WAC:

(a) Meets the institutional status requirements of WAC 182-513-1320; or

(b) Resides in a medical institution as described in WAC 182-513-1395.

(2) A supplemental security income (SSI)-related person who lives in a medicaid agency-contracted alternate living facility may be eligible for MN coverage under WAC 182-513-1205.

(3) A person may be eligible for MN coverage under this chapter when he or she is:

(a) Not covered under subsection (1) and (2) of this section; and

(b) Eligible for categorically needy (CN) medical coverage in all other respects, except that his or her CN countable income is above the CN income standard.

(4) MN coverage may be available if the person is:

(a) A child;

(b) A pregnant woman;

(c) A refugee;

(d) An SSI-related person, including an aged, blind, or disabled person, with countable income under the CN income standard, who is an ineligible spouse of an SSI recipient; or

(e) A hospice client with countable income above the special income level (SIL).

(5) A person who is not eligible for CN medical who applies for MN coverage has the right to income deductions in addition to, or instead of, those used to calculate CN countable income. These deductions to income are applied to each month of the base period to calculate MN countable income:

(a) The agency disregards the difference between the medically needy income level (MNIL) described in WAC 182-519-0050 and the federal benefit rate (FBR) established by the Social Security Administration each year. The FBR is the one-person SSI payment standard;

(b) All health insurance premiums, except for medicare Part A through Part D premiums, expected to be paid by the person or family member during the base period or periods;

(c) Any allocations to a spouse or to dependents for an SSI-related person who is married or who has dependent children. Rules for allocating income are described in WAC 182-512-0900 through 182-512-0960;

(d) For an SSI-related person who is married and lives in the same home as his or her spouse who receives home and community-based waiver services under chapter 182-515 WAC, an income deduction equal to the MNIL, minus the nonapplying spouse's income; and

(e) A child or pregnant woman applying for MN coverage is eligible for income deductions allowed under temporary assistance for needy families (TANF) and state family assistance (SFA) rules and not under the rules for CN programs based on the federal poverty level. See WAC 182-509-0001(4) for exceptions to the TANF and SFA rules that apply to medical programs and not to the cash assistance program.

(6) The MNIL for a person who qualifies for MN coverage under subsection (1) of this section is based on rules in chapters 182-513 and 182-515 WAC.

(7) The MNIL for all other people is described in WAC 182-519-0050. If a person has countable income at or below the MNIL, the person is certified as eligible for up to 12 months of MN medical coverage.

(8) If a person has countable income over the MNIL, the countable income that exceeds the agency's MNIL standards is called "excess income."

(9) A person with "excess income" is not eligible for MN coverage until the person gives the agency or its designee evidence of medical expenses incurred by that person, their spouse, or family members living in the home for whom they are financially responsible. See WAC 182-519-0110(8). An expense is incurred when:

(a) The person receives medical treatment or medical supplies, is financially liable for the medical expense, and has not paid the bill; or

(b) The person pays for the expense within the current or retroactive base period under WAC 182-519-0110.

(10) Incurred medical expenses or obligations may be used to offset any portion of countable income that is over the MNIL. This is the process of meeting "spenddown."

(11) The agency or its designee calculates the amount of a person's spenddown by multiplying the monthly excess income amount by the number of months in the certification period under WAC 182-519-0110. The qualifying medical expenses must be greater than or equal to the total calculated spenddown amount.

(12) A person who is considered for MN coverage under this chapter may not spenddown excess resources to become eligible for the MN program. Under this chapter, a person is ineligible for MN coverage if the person's resources exceed the program standard in WAC 182-519-0050. A person who is considered for MN coverage under WAC 182-513-1395, 182-514-0250 or 182-514-0263 is allowed to spenddown excess resources.

(13) There is no automatic redetermination process for MN coverage. A person must apply for each eligibility period under the MN program.

(14) A person who requests a timely administrative hearing under WAC 182-518-0025(5) is not eligible for continued benefits beyond the end of the original certification date under the MN program.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-11-009, § 182-519-0100, filed 5/4/23, effective 6/4/23*
- *WSR 19-02-046, § 182-519-0100, filed 12/27/18, effective 1/27/19*
- *WSR 15-17-012, § 182-519-0100, filed 8/7/15, effective 9/7/15. Statutory Authority: RCW 41.05.021. WSR 12-20-001, amended and recodified as § 182-519-0100, filed 9/19/12, effective 10/20/12. Statutory Authority: RCW 74.04.055, 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 42 C.F.R. 435.831 (3)(e) and (f). WSR 09-08-003, § 388-519-0100, filed 3/19/09, effective 4/19/09. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-519-0100, filed 7/31/98, effective 9/1/98. Formerly WAC 388-503-0320, 388-518-1840, 388-519-1930 and 388-522-2230.*

##### **Wash. Admin. Code § 182-519-0110** Spenddown of excess income for the medically needy program. {#sec-182-519-0110 omnilex-key=us-wa-regs-official--title-182--182-519-0110}

(1) A person who applies for Washington apple health (WAH) and is eligible for medically needy (MN) coverage with a spenddown may choose a three-month or a six-month base period. A base period is a time period used to compute the spenddown liability amount. The months must be consecutive calendar months, unless a condition in subsection (4) of this section applies.

(2) A base period begins on the first day of the month a person applies for WAH, unless a condition in subsection (4) of this section applies.

(3) A person may request a separate base period to cover up to three calendar months immediately before the month of application. This is called a retroactive base period.

(4) A base period may vary from the terms in subsections (1), (2), or (3) of this section if:

(a) A three-month base period would overlap a previous eligibility period;

(b) The person has countable resources over the applicable standard for any part of the required base period;

(c) The person is not or will not be able to meet the temporary assistance to needy families (TANF)-related or supplemental security income (SSI)-related requirement for the required base period;

(d) The person is eligible for categorically needy (CN) coverage for part of the required base period; or

(e) The person was not otherwise eligible for MN coverage for each month of the retroactive base period.

(5) The medicaid agency or its designee calculates a person's spenddown liability. The MN countable income from each month of the base period is compared to the effective medically needy income level (MNIL) under WAC 182-519-0050. Income over the effective MNIL standard (based on the person's household size) in each month in the base period is added together to determine the total spenddown amount.

(6) If household income varies and a person's MN countable income falls below the effective MNIL for one or more months, the difference offsets the excess income in other months of the base period. See WAC 182-519-0100(7) if a spenddown amount results in zero dollars and cents.

(7) If a person's income decreases, the agency or its designee approves CN coverage for each month in the base period when the person's countable income and resources are equal to or below the applicable CN standards. Children age eighteen and younger and pregnant women who become CN eligible in any month of the base period are continuously eligible for CN coverage for the remainder of the certification, even if there is a subsequent increase in income.

(8) Once a person's spenddown amount is determined, qualifying medical expenses are deducted. A qualifying medical expense must:

(a) Be an expense for which the person is financially liable;

(b) Not have been used to meet another spenddown;

(c) Not be the confirmed responsibility of a third party. The agency or its designee allows the entire expense if a third party has not confirmed its coverage of the expense within:

(i) Forty-five days of the date of service; or

(ii) Thirty days after the base period ends.

(d) Be an incurred expense for the person:

(i) The person's spouse;

(ii) A family member residing in the person's home for whom the person is financially responsible; or

(iii) A relative residing in the person's home who is financially responsible for the person.

(e) Meet one of the following conditions:

(i) Be an unpaid liability at the beginning of the base period;

(ii) Be for paid or unpaid medical services incurred during the base period;

(iii) Be for medical services incurred and paid during the three-month retroactive base period if eligibility for WAH was not established in that base period. Paid expenses that meet this requirement may be applied towards the current base period; or

(iv) Be for medical services incurred during a previous base period, either unpaid or paid, if it was necessary for the person to make a payment due to delays in the certification for that base period.

(9) An exception to subsection (8) of this section exists for qualifying medical expenses paid on the person's behalf by a publicly administered program during the current or the retroactive base period. The agency or its designee uses the qualifying medical expenses to meet the spenddown liability. To qualify for this exception, the program must:

(a) Not be federally funded or make payments from federally matched funds;

(b) Not pay the expenses before the first day of the retroactive base period; and

(c) Provide proof of the expenses paid on the person's behalf.

(10) Once the agency or its designee determines the expenses are a qualified medical expense under subsection (8) or (9) of this section, the expenses are subtracted from the spenddown liability to determine the date the person's eligibility for medical coverage begins. Qualifying medical expenses are deducted in the following order:

(a) First, medicare and other health insurance deductibles, coinsurance charges, enrollment fees, copayments, and premiums that are the person's responsibility under medicare Part A through Part D. (Health insurance premiums are income deductions under WAC 182-519-0100(5));

(b) Second, medical expenses incurred and paid by the person during the three-month retroactive base period if eligibility for WAH was not established in that base period;

(c) Third, current payments on, or unpaid balance of, medical expenses incurred before the current base period that were not used to establish eligibility for medical coverage in another base period. The agency or its designee sets no limit on the age of an unpaid expense; however, the expense must be a current liability and be unpaid at the beginning of the base period;

(d) Fourth, other medical expenses that are not covered by the agency's or its designee's medical programs, minus any third-party payments that apply to the charges. A licensed health care provider must provide or prescribe the items or services allowed as a medical expense;

(e) Fifth, other medical expenses incurred by the person during the base period that are potentially payable by the MN program (minus any confirmed third-party payments that apply to the charges). This deduction is allowed even if payment is denied for these services because they exceed the agency's or its designee's limits on amount, duration, or scope of care. Scope of care is described in WAC 182-501-0060 and 182-501-0065; and

(f) Sixth, other medical expenses incurred by the person during the base period that are potentially payable by the MN program (minus any confirmed third-party payments that apply to the charges) and that are within the agency's or its designee's limits on amount, duration, or scope of care.

(11) If a person submits verification of qualifying medical expenses with his or her application that meet or exceed the spenddown liability, the person is eligible for MN medical coverage for the remainder of the base period unless their circumstances change. See WAC 182-504-0105 to determine which changes must be reported to the agency or its designee. The beginning of eligibility is determined under WAC 182-504-0020.

(12) If a person cannot meet the spenddown amount when the application is submitted, the person is not eligible until he or she provides proof of additional qualifying expenses that meet the spenddown liability.

(13) Each dollar of a qualifying medical expense may count once against a spenddown period that leads to eligibility for MN coverage. However, medical expenses may be used more than once if:

(a) The person did not meet his or her total spenddown liability and become eligible in a previous base period and the bill remains unpaid; or

(b) The medical expense was incurred and paid within three months of the current application, and the agency or its designee could not establish WAH eligibility for the person in the retroactive base period.

(14) The person must provide the proof of qualifying medical expense information to the agency or its designee within thirty days after the base period ends, unless there is a good reason for delay.

(15) Once a person meets the spenddown requirement and the certification begin date is established, newly identified expenses are not considered toward that spenddown unless:

(a) There is a good reason for the delay in submitting the expense; or

(b) The agency or its designee made an error when determining the correct begin date.

(16) Good reasons for delay in providing medical expense information to the agency or its designee include, but are not limited to:

(a) The person did not receive a timely bill from his or her medical provider or insurance company;

(b) The person has medical issues that prevent him or her from submitting proof on time; or

(c) The person meets the criteria for needing equal access under WAC 182-503-0120.

(17) The agency or its designee does not pay for any expense or portion of an expense used to meet a person's spenddown liability.

(18) If an expense is potentially payable under the MN program, and only a portion of the medical expense is assigned to meet spenddown, the medical provider must not:

(a) Bill the person for more than the amount assigned to the remaining spenddown liability; or

(b) Accept or retain any additional amount for the covered service from the person. Any additional amount may be billed to the agency or its designee. See WAC 182-502-0160, Billing a client.

(19) The agency or its designee determines whether any payment is due to the medical provider on medical expenses partially assigned to meet a spenddown liability under WAC 182-502-0100.

(20) If the medical expense assigned to spenddown was incurred outside of a period of MN eligibility, or if the expense is not covered by WAH, the agency or its designee does not pay any portion of the bill.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-02-046, § 182-519-0110, filed 12/27/18, effective 1/27/19*
- *WSR 15-17-012, § 182-519-0110, filed 8/7/15, effective 9/7/15. Statutory Authority: RCW 41.05.021. WSR 12-20-001, amended and recodified as § 182-519-0110, filed 9/19/12, effective 10/20/12. Statutory Authority: RCW 74.04.055, 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 42 C.F.R. 435.831 (3)(e) and (f). WSR 09-08-003, § 388-519-0110, filed 3/19/09, effective 4/19/09. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-519-0110, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 71.05.560, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530. WSR 06-13-042, § 388-519-0110, filed 6/15/06, effective 7/16/06. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, and 74.08.090. WSR 05-08-093, § 388-519-0110, filed 4/1/05, effective 5/2/05*
- *WSR 98-16-044, § 388-519-0110, filed 7/31/98, effective 9/1/98. Formerly WAC 388-518-1830, 388-518-1840, 388-519-1905, 388-519-1910, 388-519-1930 and 388-522-2230.*

## **Chapter 182-520** Fraud referrals and overpayments. {#struct-chapter-182-520}

##### **Wash. Admin. Code § 182-520-0005** Washington apple health fraud referrals and overpayments. {#sec-182-520-0005 omnilex-key=us-wa-regs-official--title-182--182-520-0005}

(1) The agency or the agency's designee may refer a case to the office of fraud and accountability for a fraud investigation when it has reliable information that the person purposely misrepresented their circumstances in order to qualify for Washington apple health.

(2) When a fraud investigation reveals substantial evidence to support a finding of fraud, the case is referred for prosecution. The prosecuting attorney's office decides which cases will be prosecuted.

(3) When a referral results in a conviction, an overpayment amount for the cost of the apple health coverage is established.

(4) The person is responsible to pay the agency for the amount of overpayment established as a result of a fraud conviction.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05A.005, 41.05.010, and 74.09.741. WSR 16-13-059, § 182-520-0005, filed 6/13/16, effective 7/14/16. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-520-0005, filed 12/9/13, effective 1/9/14.*

##### **Wash. Admin. Code § 182-520-0010** Washington apple health overpayments resulting from an administrative hearing. {#sec-182-520-0010 omnilex-key=us-wa-regs-official--title-182--182-520-0010}

(1) If a person asks for Washington apple health coverage to continue during an appeal, he or she must pay the agency for the cost of that coverage if both (a) and (b) of this subsection occur:

(a) The administrative law judge, or review judge if applicable, enters an order:

(i) That the person was not eligible for apple health coverage during the appeal;

(ii) Dismissing the hearing under WAC 182-526-0285(3) because the person defaulted (did not attend or refused to participate) and the agency's action that was appealed included a finding that the person was not eligible for apple health coverage; or

(iii) Dismissing the hearing under WAC 182-526-0285(4) due to a written agreement between all the parties that the person will pay for an overpayment of the cost of apple health coverage.

(b) The agency decides to collect the overpayment.

(2) The overpayment amount is limited to payments for apple health coverage that were spent:

(a) During the sixty days following receipt of the hearing request; and

(b) For a person who was not eligible for apple health coverage.

(3) The agency will not attempt to recover an apple health overpayment from a nonneedy caretaker relative or guardian except in the case of fraud by the caretaker relative or guardian as described in WAC 182-520-0005.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 41.05A.005, 41.05.010, and 74.09.741. WSR 16-13-059, § 182-520-0010, filed 6/13/16, effective 7/14/16. Statutory Authority: RCW 41.05.021, Patient Protection and Affordable Care Act (P.L. 111-148), 42 C.F.R. §§ 431, 435, 457, and 45 C.F.R. § 155. WSR 14-01-021, § 182-520-0010, filed 12/9/13, effective 1/9/14.*

##### **Wash. Admin. Code § 182-520-0015** Long-term services and supports client overpayments. {#sec-182-520-0015 omnilex-key=us-wa-regs-official--title-182--182-520-0015}

(1) General right to recover.

(a) A long-term services and supports (LTSS) client overpayment is any payment for LTSS made by the agency or the agency's designee on a client's behalf in excess of that to which the client is legally entitled.

(b) An LTSS client overpayment may be caused by:

(i) A client or a client's authorized representative misstating or failing to reveal a fact affecting eligibility under WAC 182-503-0505;

(ii) A client or a client's authorized representative failing to timely report a change required under WAC 182-504-0105; or

(iii) The agency or the agency's designee's error.

(c) The agency or the agency's designee may recoup an LTSS client overpayment:

(i) Up to six years after the date of the notice in subsection (2) of this section; and

(ii) Regardless of whether the program is state-funded, federally funded, or both.

(d) The amount of the LTSS client overpayment equals the amount the agency or the agency's designee paid on the client's behalf minus the amount to which the client was legally entitled.

(e) When the agency or the agency's designee determines it caused the overpayment, the agency or the agency's designee may grant exceptions to client recovery.

(2) Notice.

(a) The agency notifies the client or the client's authorized representative by:

(i) Personal service under RCW 4.28.080; or

(ii) Certified mail, return receipt requested.

(b) The agency or the agency's designee may prove that it notified the client by providing:

(i) A sworn statement;

(ii) An affidavit or certificate of mailing; or

(iii) The certified mail receipt signed by the client or the client's authorized representative.

(c) The notice states:

(i) The client's name;

(ii) The client's address;

(iii) The date the agency or the agency's designee issued the notice;

(iv) The amount of the LTSS client overpayment;

(v) How the agency calculated the LTSS client overpayment;

(vi) How the client may request an administrative hearing; and

(vii) How the client may make a payment.

(3) Response.

(a) The client must respond to the notice within 90 days of the date the agency or the agency's designee served the client with the notice of the LTSS client overpayment by:

(i) Paying the agency or the agency's designee;

(ii) Establishing a payment plan with the agency or the agency's designee; or

(iii) Requesting an administrative hearing.

(b) If the client does not respond to the notice within 90 days of the date the agency or the agency's designee served the client with the notice, the agency or the agency's designee may initiate collection action.

(4) Hearings. A person who disagrees with agency or the agency's designee's action under this section may request an administrative hearing under chapter 182-526 WAC.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 43.20B.030. WSR 25-23-025, s 182-520-0015, filed 11/10/25, effective 12/11/25. Statutory Authority: RCW 41.05.021, 41.05.160, 41.05A.005, 41.05.010, and 74.09.741. WSR 16-13-059, § 182-520-0015, filed 6/13/16, effective 7/14/16.*

## **Chapter 182-521** Public health emergency rules. {#struct-chapter-182-521}

##### **Wash. Admin. Code § 182-521-0100** Noncountable income and resources during the COVID-19 public health emergency. {#sec-182-521-0100 omnilex-key=us-wa-regs-official--title-182--182-521-0100}

(1) This section describes certain types of income and resources received as a result of the COVID-19 public health emergency that the health care authority (agency) does not count as income or resources when determining apple health eligibility. This includes certain unemployment income; any Federal Pandemic Unemployment Compensation (FPUC) or Recovery Rebates authorized under the Coronavirus Aid, Relief, and Economic Security (CARES) Act; and other needs-based and disaster-related benefits authorized as a result of the COVID-19 public health emergency. The noncountable income and resources in this section are in addition to other noncountable income and resources in this title, such as those described in WAC 182-509-0320, 182-512-0860, and 182-513-1340.

(2) For all apple health programs, including both modified adjusted gross income-based (MAGI) and nonmodified adjusted gross income-based (non-MAGI) programs, the agency does not count as income for Apple Health determinations of eligibility or cost-sharing calculations any of the following:

(a) Federal pandemic unemployment compensation benefits of six hundred dollars per week issued for the period of March 18, 2020, through July 31, 2020;

(b) Federal pandemic unemployment compensation benefits of three hundred dollars per week issued for the period of December 26, 2020, through September 6, 2021;

(c) Lost wages assistance unemployment compensation benefits of three hundred dollars per week issued for the period of weeks ending August 1, 2020, through September 6, 2021, due to the federal Disaster Relief Fund authorized for states to offset lost wages due to the COVID-19 pandemic, known as Lost Wage Assistance (LWA);

(d) Payments from the pandemic relief payment program as authorized by Governor Jay Inslee on December 27, 2020;

(e) Pandemic Recovery Rebates (also known as stimulus checks or economic impact payments);

(f) Needs-based and disaster-related benefits from other agencies, organizations, or tribal entities including, but not limited to:

(i) Federal Emergency Management Agency (FEMA) programs, such as FEMA COVID-19 Funeral Assistance;

(ii) State programs, such as disaster cash assistance and the Washington immigrant relief fund; and

(iii) Local/municipal programs, such as the city of Seattle hospitality workers relief fund and disaster relief fund for immigrants; and

(g) Pandemic-related changes to federal refundable tax credits including, but not limited to, the child tax credit, the earned income tax credit, and the child and dependent tax care credit.

(3) For non-MAGI programs, the agency does not count as income any unemployment compensation received during the public health emergency.

(4) The agency does not count for apple health premium calculations all income not counted for eligibility determinations for apple health programs. The agency waives monthly premiums until the first of the month following the calendar quarter in which the COVID-19 public health emergency ends.

(5) All income the agency does not count for eligibility determinations for non-MAGI programs, the agency also does not count in post-eligibility treatment of income (PETI) calculations for long-term services and supports. The agency does not count such income whether it is paid to the community spouse or to the spouse seeking or receiving long-term services and supports. The agency does not count such income when determining the spousal allowance or in any other part of the post-eligibility calculation process.

(6) For non-MAGI programs, the agency does not count as a resource:

(a) The value of property essential for self-support (PESS) described in 20 C.F.R. 416.1222 that is subject to the requirement of producing net annual income of at least six percent of the PESS value during the period of the presidential and secretarial emergency declarations related to the COVID-19 outbreak;

(b) Pandemic recovery rebates and all other assistance described in Social Security Administration guidance; and

(c) Assistance including, but not limited to, the Temporary Expansion of the Child Tax Credit of 2021 that is not counted as income and treated under Social Security Administration guidance as not counted as resources for a period of 12 months after receipt.

(7) The agency reviews cases on an individual basis and does not count as resources any disaster assistance identified as excludable under federal law for an indefinite period.

(8) The agency does not count as income or resources any other payments for pandemic assistance not described in this section to the fullest extent provided for under state or federal law.

(9) Any income received as unemployment compensation not described within this section is otherwise countable and the agency counts it when determining MAGI-based apple health eligibility, unless otherwise specified under state or federal law.

(10) The agency does not terminate an enrollee's eligibility due to changes to an enrollee's income or resources.

(11) These rules are in effect until the later of:

(a) The date the client is receiving any benefits described in this rule; or

(b) The end of the month the Secretary of the U.S. Department of Health and Human Services declares the COVID-19 public health emergency to be over.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. § 247d. WSR 21-22-094, § 182-521-0100, filed 11/2/21, effective 12/3/21.*

##### **Wash. Admin. Code § 182-521-0200** Coverage after the public health emergency (PHE) ends. {#sec-182-521-0200 omnilex-key=us-wa-regs-official--title-182--182-521-0200}

(1) In response to the coronavirus (COVID-19) public health emergency (PHE) declared by the Secretary of the U.S. Department of Health and Human Services (HHS) and in response to Section 6008 of the Families First Coronavirus Response Act (Public Law 116-127), the medicaid agency:

(a) Continues your Washington apple health coverage unless your eligibility determination was made incorrectly, or you:

(i) Are deceased;

(ii) Move out-of-state;

(iii) Request termination of your coverage; or

(iv) No longer meet citizenship or immigration requirements as described in WAC 182-503-0535.

(b) Waives and suspends the collection of premiums through the last day of the calendar quarter in which the PHE ends for:

(i) Apple health for kids with premiums (CHIP), as described in WAC 182-505-0215; and

(ii) Health care for workers with disabilities (HWD) program, as described in WAC 182-511-1250.

(c) As required by Social Security Administration guidance, excludes permanently from resources federal, state, and local pandemic-related disaster assistance that has been retained.

(d) Excludes, for the duration of the PHE and a period of 12 months after the PHE ends, any resources not permanently excluded under (c) of this subsection and which accumulated from participation that did not increase in response to Section 6008(b) of the Families First Coronavirus Response Act (FFCRA), as described in WAC 182-512-0550(24).

(2) Based on Section 5131 of the Consolidated Appropriations Act, 2023 (Public Law 117-328), effective April 1, 2023, if you receive continued apple health due to the suspension of certain eligibility rules during the PHE, the agency will, after April 1, 2023:

(a) Redetermine your eligibility for ongoing coverage using the process and timelines described in WAC 182-504-0035 and notify you as required under chapter 182-518 WAC. You may update any information needed to complete a redetermination of eligibility, as described in WAC 182-504-0035.

(i) If you are no longer eligible for apple health, or you do not respond to our renewal request notice, you will receive at least 10 calendar days' advance notice before your coverage is terminated, as described in WAC 182-518-0025.

(ii) If your modified adjusted gross income (MAGI)-based coverage ends because you did not renew it, you have 90 calendar days from the termination date to complete your renewal. If you are still eligible for apple health, your benefits will be restored without a gap in coverage.

(iii) If your coverage is terminated, you have a right to an administrative hearing, as described in chapter 182-526 WAC.

(b) Begin collecting premiums for CHIP and HWD clients prospectively, beginning with the month following the quarter in which the PHE ends, based upon reported circumstances, and without collecting arrears.

(c) Resume eligibility verification based on the factors described in WAC 182-503-0050.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 42 U.S.C. § 1396d note. WSR 23-16-105, § 182-521-0200, filed 7/31/23, effective 8/31/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-12-004, § 182-521-0200, filed 5/19/22, effective 7/1/22.*

## **Chapter 182-523** Medical extensions. {#struct-chapter-182-523}

##### **Wash. Admin. Code § 182-523-0100** Washington apple health—Medical extension. {#sec-182-523-0100 omnilex-key=us-wa-regs-official--title-182--182-523-0100}

(1) A parent or caretaker relative who was eligible for and who received coverage under Washington apple health for parents and caretaker relatives, described in WAC 182-505-0240, in any three of the last six months is eligible, along with all dependent children living in the household, for twelve months' extended health care coverage if the person becomes ineligible for coverage due to increased earnings or hours of employment.

(2) A person remains eligible for apple health medical extension unless:

(a) The person:

(i) Moves out of state;

(ii) Dies; or

(iii) Leaves the household.

(b) The family:

(i) Moves out of state;

(ii) Loses contact with the agency or its designee or the whereabouts of the family are unknown; or

(iii) No longer includes an eligible dependent child as defined in WAC 182-503-0565(2).

(3) When a person or family is determined ineligible for apple health coverage under subsection (2)(a)(i) through (iii) or (b)(i) or (ii) of this section during the medical extension period, the agency or its designee redetermines eligibility for the remaining household members as described in WAC 182-504-0125 and sends written notice as described in chapter 182-518 WAC before apple health medical extension is terminated.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2016 c 154. WSR 19-24-060, § 182-523-0100, filed 11/27/19, effective 12/28/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-18-024, § 182-523-0100, filed 8/28/17, effective 10/1/17. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-019, § 182-523-0100, filed 7/24/14, effective 8/24/14. WSR 12-13-056, recodified as § 182-523-0100, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.08.090, 74.08A.100, 74.09.080, and 74.09.415. WSR 02-17-030, § 388-523-0100, filed 8/12/02, effective 9/12/02. Statutory Authority: RCW 74.08.090 and 2001 c 7 § 209. WSR 02-10-018, § 388-523-0100, filed 4/22/02, effective 5/23/02. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-523-0100, filed 7/31/98, effective 9/1/98. Formerly WAC 388-522-2210, 388-523-2305 and 388-523-2320.*

##### **Wash. Admin. Code § 182-523-0130** Medical extension—Redetermination. {#sec-182-523-0130 omnilex-key=us-wa-regs-official--title-182--182-523-0130}

(1) When the agency or its designee determines the family or an individual family member is ineligible during the medical extension period, the agency or its designee must determine if they are eligible for another medical program.

(2) Children are eligible for twelve month continuous eligibility beginning with the first month of the medical extension period.

(3) When a family reports a reduction of income, the family may be eligible for the Washington apple health for parents and caretaker relatives program (described in WAC 182-505-0240) instead of medical extension benefits.

(4) When a medical extension period is ending, the family is required to complete a renewal of eligibility as described in WAC 182-504-0035.

(5) Postpartum and family planning extensions are described in WAC 182-505-0115.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-019, § 182-523-0130, filed 7/24/14, effective 8/24/14. WSR 12-13-056, recodified as § 182-523-0130, filed 6/15/12, effective 7/1/12. Statutory Authority: RCW 74.08.090, 74.09.530, and 74.09.415. WSR 05-23-013, § 388-523-0130, filed 11/4/05, effective 1/1/06. Statutory Authority: RCW 74.08.090 and 2001 c 7 § 209. WSR 02-10-018, § 388-523-0130, filed 4/22/02, effective 5/23/02.*

## **Chapter 182-524** COFA islander health care. {#struct-chapter-182-524}

##### **Wash. Admin. Code § 182-524-0100** General. {#sec-182-524-0100 omnilex-key=us-wa-regs-official--title-182--182-524-0100}

(1) Compact of Free Association (COFA) islander health care and COFA islander dental care are state-funded programs administered by the health care authority (the agency) to pay the monthly premiums and out-of-pocket expenses for silver level qualified health plans or qualified dental plans for eligible COFA islanders.

(2) For the purpose of this chapter, "our," "us," and "we" refer to the agency or the agency's designee and "you" refers to the applicant for, or recipient of, COFA islander health care.

(3) You have the right to appeal any adverse agency action regarding COFA islander health care or COFA islander dental care as described in chapter 182-526 WAC. For coordinated appeals with the Washington health benefit exchange, as described under WAC 182-526-0102, we treat appeals made to either the Washington health benefit exchange or us as filed on the same day. You will not have to submit any information that you have previously submitted to either the Washington health benefit exchange or us.

**History**
- *Statutory Authority: RCW 74.09.719, 41.05.021, and 41.05.160. WSR 20-19-014, § 182-524-0100, filed 9/3/20, effective 10/4/20. Statutory Authority: 2018 c 161, 2018 c 299 § 213 (1)(hhh) and (4)(d), RCW 41.05.021 and 41.05.160. WSR 19-11-082, § 182-524-0100, filed 5/17/19, effective 6/17/19.*

##### **Wash. Admin. Code § 182-524-0200** Definitions. {#sec-182-524-0200 omnilex-key=us-wa-regs-official--title-182--182-524-0200}

This section defines terms used in this chapter. See chapter 182-500 WAC for additional definitions.

"Advance premium tax credit (APTC)" - A tax credit taken in advance to lower a monthly health insurance payment (or premium).

"COFA islander" – A person who is a citizen of the Federated States of Micronesia, the Republic of the Marshall Islands, or the Republic of Palau.

"COFA islander dental care" - An agency-administered program that pays the premium and out-of-pocket costs for a stand-alone dental plan for eligible COFA islanders.

"COFA islander health care" - An agency-administered program that pays the premium and out-of-pocket costs for a silver level qualified health plan for eligible COFA islanders.

"Compact of Free Association (COFA)" - A legal agreement between the government of the United States and the governments of the Federated States of Micronesia (U.S. Pub. L. 108-188); the Republic of the Marshall Islands (U.S. Pub. L. 108-188); and the Republic of Palau (U.S. Pub. L. 99-658).

"Cost-sharing funds" - Agency-provided funds for out-of-pocket costs.

"Out-of-pocket costs" - Copayments, coinsurance, deductibles, and other cost-sharing requirements imposed under a qualified health plan for services, pharmaceuticals, devices, and other health benefits covered by the plan and rendered as in-network. Excludes premiums, balance billing amounts for out-of-network providers, and spending for noncovered services.

"Premium cost" – A person's premium for a qualified health plan, minus the amount of the person's advanced premium tax credit.

"Qualified dental plan (QDP)" – A stand-alone dental plan offered by the Washington health benefit exchange (HBE). For a definition of stand-alone dental plan, see WAC 284-43-6020.

"Qualified dental plan - Noncovered services" - In-network services that are not covered by the QDP, and are consistent with but do not exceed benefits covered under the agency's adult dental program described in chapter 182-535 WAC.

"Silver level qualified health plan (QHP)" - Silver level indicates the category of a qualified health plan (QHP) offered by the Washington health benefit exchange (HBE). For a definition of QHP, see WAC 182-500-0090.

**History**
- *Statutory Authority: RCW 74.09.719, 41.05.021, and 41.05.160. WSR 20-19-014, § 182-524-0200, filed 9/3/20, effective 10/4/20. Statutory Authority: 2018 c 161, 2018 c 299 § 213 (1)(hhh) and (4)(d), RCW 41.05.021 and 41.05.160. WSR 19-11-082, § 182-524-0200, filed 5/17/19, effective 6/17/19.*

##### **Wash. Admin. Code § 182-524-0250** How to apply. {#sec-182-524-0250 omnilex-key=us-wa-regs-official--title-182--182-524-0250}

(1) COFA islanders age nineteen and older may apply for a qualified health plan (QHP) by:

(a) Completing the application via the Washington Healthplanfinder website at www.wahealthplanfinder.org;

(b) Calling the Washington health benefit exchange (HBE) customer support center and completing an application by telephone;

(c) Calling the COFA islander health care support line and completing an application by telephone; or

(d) Completing the application for health care coverage (HCA 18-001P), and mailing or faxing to the HBE.

(2) When you submit an application for a QHP through HBE using any of the methods listed in subsection (1) of this section, you are automatically considered for COFA islander health care.

**History**
- *Statutory Authority: 2018 c 161, 2018 c 299 § 213 (1)(hhh) and (4)(d), RCW 41.05.021 and 41.05.160. WSR 19-11-082, § 182-524-0250, filed 5/17/19, effective 6/17/19.*

##### **Wash. Admin. Code § 182-524-0275** Eligibility—COFA islander dental care coverage. {#sec-182-524-0275 omnilex-key=us-wa-regs-official--title-182--182-524-0275}

You apply for COFA islander dental care the same way you would apply for COFA islander health care as described in WAC 182-524-0250.

(1) To be eligible for state-funded COFA islander dental care, you must enroll in a qualified dental plan (QDP) through the Washington health benefit exchange (HBE) during open enrollment or when you qualify for a special enrollment period as described in 45 C.F.R. 155.410 and 45 C.F.R. 420.

(2) You are eligible for COFA islander dental care administered by us no earlier than January 1, 2021, if you enroll in a QDP and:

(a) Meet the requirements of COFA islander health care as described in WAC 182-524-0300 (1)(a) through (f); or

(b) Are enrolled in medicare, meet the requirements as described in WAC 182-524-0300 (1)(a) and (c) and:

(i) Are a resident as described in WAC 182-524-0400 (1) through (3).

(ii) You can be temporarily out-of-state and remain on COFA islander dental care if you:

(A) Intend to return once the purpose of your absence concludes; and

(B) Meet the eligibility requirements described in this section.

(3) Eligibility for COFA islander dental care under subsection (2) of this section is subject to the availability of amounts appropriated for the program as described in WAC 182-524-0300(2).

(4) Your COFA islander dental care begins the first day of the month your QDP coverage begins and you meet the other eligibility requirements described in subsection (2) of this section.

(5) We will pay for your premiums, QDP out-of-pocket costs and QDP-noncovered services the same way we pay your premiums and out-of-pocket costs for COFA islander health care as described in WAC 182-524-0600. We may require authorization for payment for QDP-noncovered services.

(6) We will not pay for expenses incurred by people not covered under COFA islander dental care or services excluded under the medicaid dental program as described in WAC 182-535-1100.

(7) We will send you notices and letters according to the same provisions and requirements as the letters we send regarding COFA islander health care as described in WAC 182-524-0500.

(8) We will terminate your COFA islander dental care if you:

(a) No longer meet the eligibility criteria described in subsection (2) of this section;

(b) Request termination;

(c) Perform an act, practice, or omission that constitutes fraud and your insurer rescinds your policy;

(d) Use your COFA islander dental care cost-sharing funds to pay for anything other than:

(i) Out-of-pocket costs for dental coverage under your QDP; or

(ii) Authorized QDP-noncovered services.

(9) We will reinstate your COFA islander dental care if you are:

(a) Terminated in error; or

(b) Successful in your appeal of a termination.

(10) If you report a change that makes you eligible for COFA islander dental care, your sponsorship begins either:

(a) The first day of the following month, if the change was reported on or before the fifteenth of the month; or

(b) The first day of the month after the following month, if the change was reported after the fifteenth of the month.

(11) Your COFA islander dental care ends the day your enrollment in a silver level QHP ends or the last day of the month your COFA islander dental care eligibility ends, whichever is earlier.

**History**
- *Statutory Authority: RCW 74.09.719, 41.05.021, and 41.05.160. WSR 20-19-014, § 182-524-0275, filed 9/3/20, effective 10/4/20.*

##### **Wash. Admin. Code § 182-524-0300** Eligibility. {#sec-182-524-0300 omnilex-key=us-wa-regs-official--title-182--182-524-0300}

In order to be eligible for state-funded COFA islander health care, you must enroll in a silver level qualified health plan (QHP) through the Washington health benefit exchange (HBE) during open enrollment or when you qualify for a special enrollment period as described in 45 C.F.R. 155.410 and 45 C.F.R. 155.420.

(1) You are eligible for state-funded COFA islander health care administered by us no earlier than January 1, 2019, if you:

(a) Are a COFA islander;

(b) Meet the residency requirements as described under WAC 182-524-0400;

(c) Have household income, as defined under 26 C.F.R. 1.36B-1(e), under one hundred thirty-three percent of the federal poverty level (FPL);

(d) Do not qualify for another federal or state medical assistance programs under chapter 74.09 RCW, that provides minimum essential coverage;

(e) Qualify for, and accept, the maximum advance premium tax credit available under 45 C.F.R. 155.305(f); and

(f) Are enrolled in a silver level QHP.

(2) Eligibility for COFA islander health care is subject to the availability of amounts appropriated for the program.

(3) You will be terminated from COFA islander health care if you:

(a) Do not meet the eligibility criteria under subsection (1) of this section; or

(b) Request termination.

(4) You may be terminated from COFA islander health care if you:

(a) Perform an act, practice, or omission that constitutes fraud, and an insurer rescinds your QHP policy; or

(b) Use your COFA islander health care cost-sharing funds to pay for anything other than out-of-pocket costs.

(5) We will reinstate your COFA islander health care if you were:

(a) Terminated in error; or

(b) Successful in your appeal of a termination.

(6) Your COFA islander health care begins the first day of the month your silver level QHP coverage begins and you meet the other eligibility requirements as described in subsection (1) of this section.

(7) If you report a change that makes you eligible for COFA islander health care, your sponsorship begins either:

(a) The first day of the following month if the change was reported before the fifteenth of the month; or

(b) The first day of the second month if the change was reported after the fifteenth of the month.

(8) Your COFA islander health care ends the day your enrollment in a silver level QHP ends or the last day of the month your COFA islander health care eligibility ends, whichever is earlier.

**History**
- *Statutory Authority: 2018 c 161, 2018 c 299 § 213 (1)(hhh) and (4)(d), RCW 41.05.021 and 41.05.160. WSR 19-11-082, § 182-524-0300, filed 5/17/19, effective 6/17/19.*

##### **Wash. Admin. Code § 182-524-0400** Residency requirements. {#sec-182-524-0400 omnilex-key=us-wa-regs-official--title-182--182-524-0400}

(1) This section applies only to residency requirement for COFA islander health care.

(2) A resident is a person who currently lives in Washington and:

(a) Intends to reside here, including people without a fixed address; or

(b) Entered the state looking for a job; or

(c) Entered the state with a job commitment.

(3) You do not need to live in the state for a specific period of time to meet the requirements in subsection (2) of this section.

(4) You can be temporarily out-of-state and remain on COFA islander health care if you:

(a) Intend to return once the purpose of your absence concludes; and

(b) Meet the eligibility requirements as described under WAC 182-524-0300.

**History**
- *Statutory Authority: 2018 c 161, 2018 c 299 § 213 (1)(hhh) and (4)(d), RCW 41.05.021 and 41.05.160. WSR 19-11-082, § 182-524-0400, filed 5/17/19, effective 6/17/19.*

##### **Wash. Admin. Code § 182-524-0500** Notice requirements. {#sec-182-524-0500 omnilex-key=us-wa-regs-official--title-182--182-524-0500}

(1) The provisions in chapter 182-518 WAC apply to COFA islander health care, where applicable. This section applies only to notices and letters that we send regarding COFA islander health care.

(2) We send you written notices (letters) when we:

(a) Approve you for COFA islander health care;

(b) Deny you for COFA islander health care;

(c) Change or terminate your eligibility from COFA islander health care;

(d) Ask you for more information; and

(e) Reimburse you for premium costs, as determined by WAC 182-524-0600.

(3) All written notices we send to you include:

(a) The date of the notice;

(b) Specific contact information for you to use if you have questions or need help with the notice;

(c) The nature of the action;

(d) The effective date of the action;

(e) The facts and reasons for the action;

(f) The specific regulation on which the action is based;

(g) Your appeal rights, if an appeal is available; and

(h) Other information required by the state.

(4) If we request information from you, we allow at least ten calendar days for you to submit requested information. If you ask, we may allow you more time to get us the information.

(a) If the due date falls on a weekend or a legal holiday as described in RCW 1.16.050, the due date is the next business day.

(b) We do not deny or terminate your eligibility when we ask you to provide information.

(c) If we do not receive your information by the due date, we make a determination based on all the information available.

(5) We send a written notice to you at least ten days before taking any adverse action. The ten-day notice period starts on the day we send the notice.

(6) We may send a notice fewer than ten days before the date of the adverse action if:

(a) You request the action;

(b) You request termination;

(c) A change in statute, federal regulation, or administrative rule is the sole cause of the action;

(d) You are incarcerated and expect to remain incarcerated at least thirty days;

(e) Mail sent to you is returned without a forwarding address and we do not have a more current address for you;

(f) You move out-of-state;

(g) Your plan ends because you move to a county where your current silver level qualified health plan (QHP) is not available and you fail to select a new plan;

(h) You die;

(i) You begin receiving other state or federal medical assistance that provides minimum essential coverage; or

(j) Your silver level QHP is closed and you do not enroll in another silver level QHP.

**History**
- *Statutory Authority: 2018 c 161, 2018 c 299 § 213 (1)(hhh) and (4)(d), RCW 41.05.021 and 41.05.160. WSR 19-11-082, § 182-524-0500, filed 5/17/19, effective 6/17/19.*

##### **Wash. Admin. Code § 182-524-0600** Payments. {#sec-182-524-0600 omnilex-key=us-wa-regs-official--title-182--182-524-0600}

(1) We pay your silver level qualified health plan (QHP) premium costs directly to the QHP carrier unless we determine good cause exists to reimburse you for the premium costs.

(2) We pay your mandatory out-of-pocket costs separate from your premium costs through cost-sharing funds.

(3) Cost-sharing funds are only for your out-of-pocket costs.

(4) We will not pay for, or reimburse you for, costs not considered as out-of-pocket costs or expenses incurred by people not covered under COFA islander health care.

(5) You are responsible for ensuring the services you receive are covered under your QHP and rendered as in-network.

(6) We may stop payments of your silver level QHP premium costs and your cost-sharing funds when you:

(a) Fail to provide verification of payments through us or an agency-contracted vendor;

(b) Fail to respond to a request for information from us or an agency-contracted vendor;

(c) Misuse your cost-sharing funds by:

(i) Purchasing anything not considered an out-of-pocket cost; or

(ii) Allowing another person access to your cost-sharing funds.

(d) Are no longer eligible for COFA islander health care as described under WAC 182-524-0300.

(7) You must follow the requirements of any agency-contracted vendor that provides services enabling you to access your cost-sharing funds.

(8) We monitor payments and cost-sharing transactions under COFA islander health care.

**History**
- *Statutory Authority: 2018 c 161, 2018 c 299 § 213 (1)(hhh) and (4)(d), RCW 41.05.021 and 41.05.160. WSR 19-11-082, § 182-524-0600, filed 5/17/19, effective 6/17/19.*

## **Chapter 182-526** Administrative hearing rules for medical services programs. {#struct-chapter-182-526}

##### **Wash. Admin. Code § 182-526-0005** Purpose and scope. {#sec-182-526-0005 omnilex-key=us-wa-regs-official--title-182--182-526-0005}

(1) This chapter:

(a) Describes the general hearing rules and procedures that apply to:

(i) The resolution of disputes between an appellant and medical services programs established under chapter 74.09 RCW including, but not limited to, managed care in chapters 182-538, 182-538A, and 182-538B WAC, and crisis and noncrisis services in chapter 182-538C WAC; and

(ii) The resolution of disputes between an appellant and the health care authority (HCA) arising from the prescription drug pricing transparency program in chapter 182-51 WAC and the all payer health care claims database rules in chapter 182-70 WAC.

(b) Supplements the Administrative Procedure Act (APA), chapter 34.05 RCW, and the model rules, chapter 10-08 WAC, adopted by the office of administrative hearings (OAH).

(c) Establishes rules encouraging informal dispute resolution between HCA, its authorized agents, or an HCA-contracted managed care organization (MCO), and people or entities who disagree with its actions.

(d) Regulates all hearings involving medical services programs established under chapter 74.09 RCW including, but not limited to, managed care in chapters 182-538, 182-538A, and 182-538B WAC, and crisis and noncrisis services in chapter 182-538C WAC, unless specifically excluded by this chapter or program rules.

(2) Nothing in this chapter is intended to affect the constitutional rights of any person or to limit or change additional requirements imposed by statute or other rule. Other laws or rules determine if a hearing right exists, including the APA and program rules or laws.

(3) If there is a conflict between this chapter and specific program rules, the specific program rules prevail. HCA's hearing rules and program rules prevail over the model hearing rules in chapter 10-08 WAC.

(4) The hearing rules in this chapter do not apply to the public employees benefits board or the school employees benefits board programs (see chapters 182-16 and 182-32 WAC).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 43.71C.110, and 2019 c 334. WSR 21-11-039, § 182-526-0005, filed 5/12/21, effective 6/12/21. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0005, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0005, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0010** Definitions. {#sec-182-526-0010 omnilex-key=us-wa-regs-official--title-182--182-526-0010}

The following definitions and those found in RCW 34.05.010 apply to this chapter:

"Administrative law judge (ALJ)" - An impartial decision-maker who is an attorney and presides at an administrative hearing. ALJs are employed by the office of administrative hearings (OAH), which is a separate state agency, as defined in RCW 34.05.010. ALJs are not department of social and health services or health care authority (HCA) employees or representatives.

"Agency" - See WAC 182-500-0010.

"Appellant" - A person or entity who requests a hearing about an action of HCA or its designee.

"Applicant" - Any person who has made a request, or on whose behalf a request has been made, to HCA, or HCA's authorized agent on HCA's behalf, for assistance through a medical service program administered by HCA.

"Authorized agent" - A person or agency, as defined in RCW 34.05.010, acting on HCA's behalf under an agreement authorized by RCW 41.05.021 to act as an HCA hearing representative. An authorized agent may be an employee of the department of social and health services or its contractors but may not be an employee of an HCA-contracted managed care organization.

"Board of appeals" or "BOA" - The HCA's board of appeals.

"Business days" - All days except Saturdays, Sundays, and designated holidays under WAC 357-31-005.

"Calendar days" - All days including Saturdays, Sundays, and designated holidays under WAC 357-31-005.

"Continuance" - A change in the date or time of a prehearing conference, hearing, or the deadline for other action.

"Date of the health care authority (HCA) action" - The date when the HCA's decision is effective.

"Deliver" - Giving a document to a person or entity in person or placing the document into the person or entity's possession as authorized by the rules in this chapter or chapter 34.05 RCW.

"Department" - The department of social and health services.

"Documents" - Papers, letters, writings, emails, or other printed or written items.

"Electronic service" - The service of documents sent or received through electronic communications, cloud services, or other electronic means established by the agency. For the purpose of effectuating service, as defined below, on HCA or OAH (but not BOA), service via OAH's PRISM participant portal is an acceptable method of "electronic service."

"Filing" - The act of delivering documents to the office of administrative hearings (OAH) or the board of appeals (BOA).

"Final order" - An order that is the final HCA decision.

"HCA" - The health care authority.

"Health care authority (HCA) hearing representative" - An employee of HCA, an authorized agent of HCA, HCA contractor or a contractor of HCA's authorized agent, or an assistant attorney general authorized to represent HCA in an administrative hearing. The HCA hearing representative may or may not be an attorney. An employee of an HCA contracted managed care organization is not an HCA hearing representative.

"Hearing" - Unless context clearly requires a different meaning, a proceeding before an ALJ, HCA-employed presiding officer, or a review judge that gives a party an opportunity to be heard in disputes about medical services programs administered by HCA. For purposes of this chapter, hearings include administrative hearings, adjudicative proceedings, and any other similar term referenced under chapter 34.05 RCW, the Administrative Procedure Act, Titles 182 and 388 WAC, chapter 10-08 WAC, or other law.

"Initial order" - A hearing decision entered (made) by an ALJ that may be reviewed by a review judge at any party's request.

"Intermediary interpreter" - An interpreter who:

(1) Is a certified deaf interpreter (CDI); and

(2) Is able to assist in providing an accurate interpretation between spoken and sign language or between types of sign language by acting as an intermediary between a person with hearing loss and a qualified interpreter.

"Judicial review" - Review of a final order as provided under RCW 34.05.510 through 34.05.598.

"Limited-English proficient (LEP)" - Includes limited-English-speaking persons or other persons unable to communicate in spoken English because of hearing loss.

"Limited-English-speaking (LES) person" - A person who, because of non-English-speaking cultural background or disability, cannot readily speak or understand the English language.

"Mail" - Placing a document in the United States Postal system, or commercial delivery service, properly addressed and with the proper postage.

"Managed care organization" or "MCO" - An organization having a certificate of authority or certificate of registration from the office of insurance commissioner that contracts with HCA under a comprehensive risk contract to provide prepaid health care services to eligible recipients under HCA's managed care programs.

"OAH" - The office of administrative hearings.

"Order of default" - An order entered by an administrative law judge (ALJ) or review judge when the appellant fails to appear in a prehearing conference or a hearing. Once the order of default becomes a final order, it terminates the appellant's request for a hearing and ends the hearing process.

"Order of dismissal" - An order from the administrative law judge (ALJ) or review judge ending the hearing process.

"Party":

(1) The health care authority (HCA);

(2) HCA-contracted managed care organization (MCO) (if applicable); and

(3) A person or entity:

(a) Named in the action;

(b) To whom the action is directed; or

(c) Is allowed to participate in a hearing to protect an interest as authorized by law or rule.

"Person with hearing loss" - A person who, because of a loss of hearing, cannot readily speak, understand, or communicate in spoken language.

"Prehearing conference" - A formal proceeding scheduled and conducted by an ALJ or other reviewing officer on the record for the purposes identified in WAC 182-526-0195.

"Prehearing meeting" - An informal, voluntary meeting that may be held before any prehearing conference or hearing.

"Program" - An organizational unit and the services that it provides, including services provided by HCA staff, its authorized agents, and through contracts with providers and HCA-contracted managed care organizations.

"Qualified interpreter" - Includes qualified interpreters for a limited-English-speaking person or a person with hearing loss.

"Qualified interpreter for a limited-English-speaking person" - A person who is readily able to interpret or translate spoken and written English communications to and from a limited-English-speaking person effectively, accurately, and impartially. If an interpreter is court certified, the interpreter is considered qualified.

"Qualified interpreter for a person with hearing loss" - A visual language interpreter who is certified by the Registry of Interpreters for the Deaf (RID) or National Association of the Deaf (NAD) and is readily able to interpret or translate spoken communications to and from a person with hearing loss effectively, accurately, and impartially.

"Recipient" - Any person receiving assistance through a medical service program administered by HCA.

"Reconsideration" - Asking a review judge to reconsider a final order entered because the party believes the review judge made a mistake.

"Record" - The official documentation of the hearing process. The record includes recordings or transcripts, admitted exhibits, decisions, briefs, notices, orders, and other filed documents.

"Review" - A review judge evaluating initial orders entered by an ALJ and making the final HCA decision as provided by RCW 34.05.464, or issuing final orders.

"Review judge" - A decision maker with expertise in program rules who serves as the reviewing officer under RCW 34.05.464. The review judge reviews initial orders and the hearing record exercising decision-making power as if hearing the case as a presiding officer. In some cases, review judges conduct hearings under RCW 34.05.425 as a presiding officer. After reviewing initial orders or conducting hearings, review judges enter final orders. Review judges are employed by HCA but may be physically located at the board of appeals (BOA). The review judge must not have been involved in the initial HCA action.

"Rule" - A regulation adopted by a state agency. Rules are found in the Washington Administrative Code (WAC).

"Service" - The delivery of documents as explained in WAC 182-526-0040.

"Should" - That an action is recommended but not required.

"Stay" - An order temporarily halting the HCA decision or action.

"Witness" - For the purposes of this chapter, means any person who makes statements or gives testimony that becomes evidence in a hearing. One type of witness is an expert witness. An expert witness is qualified by knowledge, skill, experience, training, and education to give opinions or evidence in a specialized area.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-04-009, s 182-526-0010, filed 1/23/25, effective 2/23/25*
- *WSR 21-18-063, § 182-526-0010, filed 8/26/21, effective 9/26/21*
- *WSR 17-05-066, § 182-526-0010, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0010, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0015** Terms in the Administrative Procedure Act compared to this chapter. {#sec-182-526-0015 omnilex-key=us-wa-regs-official--title-182--182-526-0015}

To improve clarity and understanding, the rules in this chapter may use different words than the Administrative Procedure Act (APA) or the model rules. Following is a list of terms used in those laws and the terms as used in these rules:

| Chapter 34.05 RCW Chapter 10-08 WAC | Chapter 182-526 WAC |
| --- | --- |
| Adjudicative proceeding. | Different terms are used to refer to different stages of the hearing process and may include prehearing meeting, prehearing conference, hearing, review, reconsideration, and the entire hearing process. |
| Application for adjudicative proceeding. | Request a hearing. |
| Presiding officer. | Administrative law judge, review judge, or designated HCA employee. |
| Reviewing officer. | Review judge. |

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0015, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0020** Good cause. {#sec-182-526-0020 omnilex-key=us-wa-regs-official--title-182--182-526-0020}

(1) Good cause is a substantial reason or legal justification allowing the administrative law judge (ALJ) to grant a party's request or to excuse their action or inaction, including granting a continuance or excusing a failure to appear at an administrative proceeding.

(2) To determine if there is good cause, the administrative law judge may consider the provisions of Superior Court Civil Rule 60 as a guideline. Good cause may include, but is not limited to, the following examples:

(a) The party who requested the hearing ignored a notice because the party was in the hospital or was otherwise prevented from responding; or

(b) The party who requested the hearing could not respond to the notice because it was written in a language that the party did not understand.

(3) For applicants and recipients with rights to adjudicative proceedings, good cause for failing to meet a hearing deadline is further addressed in RCW 74.09.741.

(4) The requestor bears the burden to show why a request should be granted or an action excused.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 74.09.741. WSR 24-21-046, s 182-526-0020, filed 10/9/24, effective 11/9/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0020, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0020, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0025** Use and location of the office of administrative hearings. {#sec-182-526-0025 omnilex-key=us-wa-regs-official--title-182--182-526-0025}

(1) The health care authority (HCA) may use administrative law judges employed by the office of administrative hearings (OAH) to conduct administrative hearings and issue initial orders in accordance with RCW 34.05.425 (1)(c).

(2) In some situations, HCA may use presiding officers employed by HCA to conduct administrative hearings and issue final orders in accordance with RCW 34.05.425 (1)(a) and (b). When HCA uses HCA-employed presiding officers to conduct administrative hearings, HCA's presiding officer has all the duties and responsibilities set forth in this chapter relating to administrative law judges and the office of administrative hearings. The notice of hearing will identify whether the case is to be heard by OAH or an HCA-employed presiding officer.

(3) OAH headquarters location is:

Office of Administrative Hearings

2420 Bristol Court S.W.

P.O. Box 42488

Olympia, WA 98504-2488

360-407-2700 or 800-583-8271

fax: 360-664-8721

(4) OAH field offices are at the following locations:

Olympia

Office of Administrative Hearings

2420 Bristol Court S.W.

P.O. Box 42489

Olympia, WA 98504-2489

360-407-2700

1-800-583-8271

fax: 360-586-6563

Tacoma

Office of Administrative Hearings

4301 S. Pine Street, Suite 200

Tacoma, WA 98409

253-476-6888

fax: 253-593-2200

Spokane

Office of Administrative Hearings

16201 E. Indiana Avenue, Suite 3000

Spokane Valley, WA 99216

509-742-5747

fax: 509-456-3980

(5) All OAH facilities are closed to the public. Access is by appointment only. Contact OAH at the telephone numbers listed in subsection (4) of this section or by visiting OAH's website: oah.wa.gov/contact-us/offices-appointment-only.

(6) Contact the Olympia field office, under subsection (3) of this section, if unable to identify the correct field office.

(7) Further hearing information can be obtained at the OAH website: oah.wa.gov.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-06-049, s 182-526-0025, filed 2/25/26, effective 3/28/26*
- *WSR 17-05-066, § 182-526-0025, filed 2/13/17, effective 3/16/17*
- *WSR 14-17-031, § 182-526-0025, filed 8/13/14, effective 9/13/14. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0025, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0030** Contacting the board of appeals. {#sec-182-526-0030 omnilex-key=us-wa-regs-official--title-182--182-526-0030}

The information included in this section is current at the time of rule adoption, but may change. Current information and additional contact information are available on the health care authority's internet site, in person at the board of appeals (BOA) office, or by a telephone call to the BOA's main public number.

| Board of Appeals | |
| --- | --- |
| Location | 626 8th Avenue S.E. Olympia, Washington |
| Mailing address | P.O. Box 42700 Olympia, WA 98504-2700 |
| Toll free telephone | 1-844-728-5212 |
| Fax | 360-507-9018 |
| Electronic service | HCABoardofAppeals@hca.wa.gov |
| Internet website | https://www.hca.wa.gov/about-hca/board-appeals |

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-20-046, § 182-526-0030, filed 9/28/22, effective 10/29/22*
- *WSR 21-18-063, § 182-526-0030, filed 8/26/21, effective 9/26/21*
- *WSR 15-04-102, § 182-526-0030, filed 2/3/15, effective 3/6/15. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0030, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0035** Calculating when a hearing deadline ends. {#sec-182-526-0035 omnilex-key=us-wa-regs-official--title-182--182-526-0035}

(1) When counting days to calculate when a hearing deadline ends under program rules or statutes:

(a) Do not include the day of the action, notice, or order. For example, if a hearing decision is mailed on Tuesday and the party has twenty-one days to request a review, start counting the days with Wednesday.

(b) If the last day of the period is a Saturday, Sunday, or a designated holiday under WAC 357-31-005, the deadline is the next business day.

(c) For periods of seven days or less, count only business days. For example, if the party has seven days to respond to a review request that was mailed on Friday, May 10th, the response period ends on Tuesday, May 21st.

(d) For periods over seven days, count every calendar day, including Saturdays, Sundays, and designated holidays under WAC 357-31-005.

(2) The deadline is 5:00 p.m. on the last day.

(3) If the party who requested the hearing misses a deadline, that party may lose the right to a hearing or appeal of a decision.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0035, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0035, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0040** Service of documents on another party. {#sec-182-526-0040 omnilex-key=us-wa-regs-official--title-182--182-526-0040}

(1) When the rules in this chapter or in other program rules or statutes require a party to serve copies of documents on other parties, the party must send copies of the documents to all other parties or their representatives.

(2) When sending documents to the office of administrative hearings (OAH) or the board of appeals (BOA), the party must file the documents at one of the locations listed in WAC 182-526-0025(2) for OAH or in WAC 182-526-0030 for BOA.

(3) When sending documents to the assigned OAH field office, the parties should use the address of the assigned OAH listed on the notice of hearing. If a field office has not been assigned, all written communication about the hearing must be sent to the OAH Olympia field office, which sends the communication to the correct office. Documents may be sent only as described in this section to accomplish service.

(4) Unless otherwise stated in law, a party may serve someone by:

(a) Personal service (hand delivery);

(b) First class, registered, or certified mail;

(c) Fax;

(d) Electronic service;

(e) Commercial delivery service;

(f) Legal messenger service; or

(g) Department of enterprise services consolidated mail services if the serving party is a state agency, including the agency and OAH. See RCW 43.19.710.

(5) A party must serve all other parties or their representatives whenever the party files a pleading, brief, or other document with OAH or BOA, or when required by law.

(6) Service is complete when:

(a) Personal service is made;

(b) Mail is properly stamped, addressed, and deposited in the United States mail;

(c) Mail is placed in consolidated mail services to be mailed by United States mail first class, postage prepaid, by a state agency for outgoing mail delivery;

(d) A fax produces proof of transmission;

(e) Electronic service is sent;

(f) A parcel is delivered to a commercial delivery service with charges prepaid; or

(g) A parcel is delivered to a legal messenger service with charges prepaid.

(7) A party may prove service by providing any of the following:

(a) A sworn statement;

(b) The certified mail receipt signed by the person who received the envelope;

(c) An affidavit or certificate of mailing;

(d) A signed receipt from the person who accepted the commercial delivery service or legal messenger service package; or

(e) Proof of fax or electronic service transmission.

(8) The OAH or BOA may serve documents, including notices, initial orders, and final orders, by email only if the other parties have agreed to accept electronically served documents.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 43.19.710, and 43.19.715. WSR 24-13-116, § 182-526-0040, filed 6/20/24, effective 7/21/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-18-063, § 182-526-0040, filed 8/26/21, effective 9/26/21*
- *WSR 17-05-066, § 182-526-0040, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0040, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0070** Filing documents. {#sec-182-526-0070 omnilex-key=us-wa-regs-official--title-182--182-526-0070}

(1) Filing is the act of delivering documents to the office of administrative hearings (OAH) or the board of appeals (BOA).

(2) The date of filing is the date documents are received by OAH or BOA.

(3) Filing is complete when the documents are received by OAH or BOA during business days between 8:00 a.m. to 5:00 p.m. If the documents are received after 5:00 p.m. on a business day, the filing is effective the next business day.

(4) A party may file documents by delivering them to OAH or BOA by:

(a) Personal service (e.g., hand delivery);

(b) First class, registered, or certified mail;

(c) Fax transmission;

(d) Electronic service;

(e) Other secure electronic means established by the agency or OAH;

(f) Electronic cloud sharing service approved by the agency;

(g) Commercial delivery service; or

(h) Legal messenger service.

(5) A party may obtain confirmation of receipt of the filing from the OAH or BOA staff to prove that the documents were successfully filed electronically.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-18-063, § 182-526-0070, filed 8/26/21, effective 9/26/21. Statutory Authority: RCW 41.05.021, 41.05.160, 74.09.741, chapter 34.05 RCW. WSR 17-23-201, § 182-526-0070, filed 11/22/17, effective 12/23/17. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0070, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0070, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0080** Resolving a dispute with the health care authority. {#sec-182-526-0080 omnilex-key=us-wa-regs-official--title-182--182-526-0080}

(1) If a person or entity disagrees with a decision or action of the health care authority (HCA) or one of its authorized agents, the person or entity may request a hearing.

(2) A notice of an action or decision by HCA or its authorized agent sent to a person's or entity's correct address is presumed to be received by the person or entity on the fourth business day after it was sent by first class mail. This presumption does not apply to certified or registered mail.

(3) A hearing must be requested in the manner and within the deadlines established in statute or rule.

(4) After a person or entity requests a hearing the dispute may be resolved through:

(a) Any prehearing alternative or administrative process offered by the program, HCA's authorized agent, or the HCA hearing representative;

(b) A prehearing meeting;

(c) A prehearing conference; or

(d) A hearing.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0080, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0080, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0085** Determining if a hearing right exists. {#sec-182-526-0085 omnilex-key=us-wa-regs-official--title-182--182-526-0085}

(1) A person or entity has a right to a hearing only if a law or program rule gives that right.

(2) Some programs may require a person or entity to go through an informal administrative process before requesting or having a hearing. The notice of the agency's action includes information about this requirement if it applies.

(3) Program rules and statutes may limit the time a person or entity has to request a hearing. The deadline for filing the request for hearing varies by the program involved. Hearing requests should be submitted right away to protect the right to a hearing, even if the parties are also trying to resolve the dispute informally. The notice of the agency's action contains information about this requirement.

(4) If the health care authority (HCA) hearing representative or the administrative law judge (ALJ) questions the person's or entity's right to a hearing, the ALJ or review judge (RJ) must address whether the hearing right exists.

(5) If on appeal of the initial order the HCA hearing representative or the review judge questions the right to a hearing, the review judge decides whether the hearing right exists.

(6) If the ALJ or RJ decides that the person or entity does not have a right to a hearing, the ALJ or RJ enters an order dismissing the hearing.

(7) If the ALJ or RJ decides that a person or entity has a right to a hearing, the hearing proceeds.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0085, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0085, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0095** Requesting a hearing. {#sec-182-526-0095 omnilex-key=us-wa-regs-official--title-182--182-526-0095}

(1) A hearing request may be made orally or in writing, unless a rule requires otherwise. If an oral request is allowed by rule, an oral request for hearing can be made to a health care authority (HCA) employee, HCA's authorized agent, or to the office of administrative hearings (OAH) employee in person, by telephone, or by voice mail.

(2) Program rules may require a specific method and location for sending a written request for hearing. A written request for hearing should be sent to the location specified in the notice.

(3) A hearing request should contain:

(a) The requestor's name;

(b) The requestor's address;

(c) The requestor's telephone number;

(d) The applicant's, recipient's, or provider's identification number;

(e) A description of each agency action being contested;

(f) A brief explanation of why the person or entity disagrees with HCA's action; and

(g) Any accommodation to help the requestor fully participate in the hearing, including a foreign or sign language interpreter or any other accommodation for an individual with a disability.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0095, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0095, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0100** Expedited administrative hearings for urgent health care needs. {#sec-182-526-0100 omnilex-key=us-wa-regs-official--title-182--182-526-0100}

(1) Requesting an expedited hearing.

(a) An expedited hearing may be requested only in matters involving applicants or recipients.

(b) An applicant or recipient may request an expedited administrative hearing when the applicant or recipient believes there is an urgent health care need as defined in subsection (3) of this section.

(c) The applicant or recipient bears the burden of proof to establish an urgent health care need and must submit evidence or arrange for evidence to be submitted to the office of administrative hearings (OAH) with the expedited hearing request to support the need for an expedited hearing. Agency staff may help an applicant or recipient who asks for assistance in obtaining information that the agency has pursuant to WAC 182-503-0120.

(d) A recipient may be eligible for continued coverage according to WAC 182-504-0130.

(2) Exception to notice requirements. The notice requirements in this section prevail over notice requirements in WAC 182-526-0250.

(3) Standard for granting an expedited hearing request.

(a) For the purposes of this section, an urgent health care need means that waiting for an otherwise timely final order could jeopardize the applicant's or recipient's life, health or ability to attain, maintain, or regain maximum function.

(b) The administrative law judge (ALJ) grants a request for an expedited hearing only if the ALJ finds by a preponderance of the evidence submitted with the applicant's or recipient's expedited hearing request and the information listed below that the applicant or recipient has an urgent health care need.

(c) Information the ALJ may consider when determining whether the applicant or recipient has an urgent health care need and whether to subsequently grant or deny an expedited hearing request includes, but is not limited to:

(i) The documentation submitted with the expedited hearing request to show an urgent health care need;

(ii) Whether the recipient is eligible for continued coverage of the benefits denied, reduced, or terminated by the agency or the agency's designee pending resolution of the appeal as an expedited hearing request may not be granted for individuals receiving continued coverage;

(iii) The length of time between the applicant's or recipient's receipt of the agency's or the agency designee's adverse notice and the applicant's or recipient's request for an expedited hearing; and

(iv) Whether the documentation submitted with the expedited hearing request shows that an appointment with a provider for a health care procedure or treatment to address the applicant's or recipient's stated urgent health care need:

(A) Is scheduled; or

(B) Cannot be scheduled due to a lack of coverage.

(4) Time frame and notice requirements for expedited hearing request determination. The ALJ must grant or deny the expedited hearing request and issue the determination within four business days of receipt of the request by OAH or as expeditiously as possible. OAH must immediately notify the parties orally and in writing of the ALJ's determination, unless the parties waive written notification. The oral and written notice must clearly state:

(a) Whether the expedited hearing request was approved or denied;

(b) That a hearing has been or will be scheduled; and

(c) The information listed in subsection (3)(c) of this section that the ALJ relied upon.

(5) Scheduling an expedited hearing. If the ALJ grants a request for an expedited hearing, OAH will schedule a hearing and provide notice as expeditiously as possible, allowing for a reasonable amount of notice and time for the parties to prepare for hearing. The notice rules in WAC 182-526-0250 do not apply.

(6) Denial of expedited hearing. If the ALJ denies an expedited hearing request, OAH will schedule the hearing based on standard scheduling practices and the notice rules in WAC 182-526-0250.

(7) Appeal right. There is no right to appeal an ALJ's determination to grant or deny an expedited hearing request.

(8) Expedited hearing initial order. If an expedited hearing request is granted and an expedited hearing is held, the ALJ must issue an initial order as expeditiously as possible.

(9) Expedited final order. Any party may request administrative review of the initial order with the health care authority board of appeals according to WAC 182-526-0560 through 182-526-0600. The board of appeals will issue a final order as expeditiously as possible.

(10) Delayed expedited hearing request determination or expedited hearing initial order. The ALJ has a duty to determine whether to grant or deny an expedited hearing request and, if granted, to issue an expedited hearing initial order as expeditiously as possible, except in unusual circumstances when:

(a) An ALJ is unable to reach a decision because the applicant or recipient requests a delay or does not take a required action; or

(b) There is an administrative or other emergency beyond OAH's or the agency's control.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 42 C.F.R. Part 431, Subpart E. WSR 17-24-103, § 182-526-0100, filed 12/5/17, effective 1/5/18.*

##### **Wash. Admin. Code § 182-526-0102** Coordinated appeals process with the Washington health benefits exchange. {#sec-182-526-0102 omnilex-key=us-wa-regs-official--title-182--182-526-0102}

(1) The health care authority (HCA) coordinates with the Washington state health benefits exchange (HBE) to ensure a seamless appeal process for determinations related to eligibility for Washington apple health when the modified adjusted gross income (MAGI) methodology is used as described in WAC 182-509-0305.

(2) An applicant, recipient, or an authorized representative of an applicant or recipient may request an apple health hearing:

(a) By telephone;

(b) By mail (which should be sent to Health Care Authority, P.O. Box 45504, Olympia, WA 98504-5504);

(c) In person;

(d) By facsimile transmission;

(e) By email; or

(f) By any other commonly available electronic means.

(3) When an applicant or recipient appeals an HBE determination of eligibility for health insurance premium tax credits (HIPTC) or cost-sharing reductions with HBE and also requests a hearing with HCA related to apple health eligibility, the ALJ will not require the applicant or recipient to submit information to the ALJ that the applicant or recipient previously submitted to HBE.

(4) If an applicant or recipient submits to HBE a request for a hearing related to apple health eligibility, the ALJ will accept the date HBE received the request for the hearing as the date filed for the purposes of timeliness standards and will treat it as a valid hearing request.

(5) If the applicant or recipient appeals only the determination related to apple health eligibility, subsection (3) of this section does not apply.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0102, filed 2/13/17, effective 3/16/17. Statutory Authority: RCW 41.05.021, 42 C.F.R. § 431, 435, and 457, 45 C.F.R. § 155, and Patient Protection and Affordable Care Act (Public Law 111-148). WSR 13-22-094, § 182-526-0102, filed 11/6/13, effective 12/7/13.*

##### **Wash. Admin. Code § 182-526-0110** Process after a hearing is requested. {#sec-182-526-0110 omnilex-key=us-wa-regs-official--title-182--182-526-0110}

(1) After a hearing is requested, in accordance with WAC 182-526-0025, the office of administrative hearings (OAH) must send a copy of the hearing request to the health care authority (HCA) or HCA's authorized agent who made the decision on HCA's behalf, unless OAH received the hearing request from HCA or HCA's authorized agent.

(2) OAH sends the hearing request to HCA or HCA's authorized agent within four business days of OAH receiving the request.

(3) OAH must serve all parties with a notice of hearing, which advises the parties of the hearing date, time, and location. This document is called the notice of hearing. In appropriate cases, OAH also serves a written notice of a prehearing conference.

(4) If HCA, in its sole discretion, chooses to use presiding officers employed by HCA to conduct the administrative hearing and issue the final order in a particular case, the notice of hearing will identify that the case is to be heard by an HCA-employed presiding officer and advise the parties of the hearing date and time.

(5) Before the hearing or prehearing conference is held by OAH or by an HCA-employed presiding officer:

(a) The HCA hearing representative may contact any other party to try to resolve the dispute or gather information; and

(b) The party who requested the hearing may contact the HCA hearing representative to try to resolve the dispute or gather information.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-06-049, s 182-526-0110, filed 2/25/26, effective 3/28/26*
- *WSR 17-05-066, § 182-526-0110, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0110, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0115** Withdrawing a request for hearing. {#sec-182-526-0115 omnilex-key=us-wa-regs-official--title-182--182-526-0115}

(1) The appellant may withdraw the hearing request for any reason and at any time by contacting the health care authority hearing representative or the office of administrative hearings (OAH). The request for withdrawal must be made orally on the record with the administrative law judge or in writing.

(2) After the request for withdrawal is received, the hearing is canceled and the administrative law judge (ALJ) enters an order dismissing the hearing. If a hearing request is withdrawn, the appellant may not be able to request another hearing on the same action.

(3) If an appellant withdraws the hearing request, the order of dismissal may only be set aside according to WAC 182-526-0290.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0115, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0115, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0120** Interpreter services for hearings. {#sec-182-526-0120 omnilex-key=us-wa-regs-official--title-182--182-526-0120}

If the party requesting the hearing needs an interpreter because the party or its witness is a person with limited-English-proficiency, the office of administrative hearings will provide an interpreter at no cost to that party.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0120, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0130** Limited-English-proficient parties—Notice requirements. {#sec-182-526-0130 omnilex-key=us-wa-regs-official--title-182--182-526-0130}

If the office of administrative hearings is notified that the party who has requested the hearing is a limited-English-proficient (LEP) person, all hearing notices, decisions and orders must:

(1) Be written in that party's primary language; or

(2) Include a statement in the party's primary language:

(a) Indicating the importance of the notice; and

(b) Providing information about how to get help in understanding the notice and responding to it.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0130, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0135** Interpreters. {#sec-182-526-0135 omnilex-key=us-wa-regs-official--title-182--182-526-0135}

(1) The office of administrative hearings (OAH) must provide a qualified interpreter to assist any person at no charge who:

(a) Has limited-English-proficiency; and

(b) Is a party or witness in a hearing.

(2) OAH may hire or contract with persons to interpret at hearings.

(3) The following persons may not be used as interpreters at a hearing:

(a) A relative of any party;

(b) Health care authority (HCA) employees; or

(c) HCA authorized agents.

(4) The administrative law judge (ALJ) must determine, at the beginning of the hearing, if an interpreter can accurately interpret all communication for the person requesting the service. To do so, the ALJ considers the interpreter's:

(a) Ability to meet the needs of the person with hearing loss or limited-English-speaking person;

(b) Education, certification, and experience;

(c) Understanding of the basic vocabulary and procedures involved in the hearing; and

(d) Ability to be impartial.

(5) The parties or their representatives may question the interpreter's qualifications and ability to be impartial.

(6) If at any time before or during the hearing the interpreter does not provide accurate and effective communication, OAH must provide another interpreter.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0135, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0135, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0140** Waiving interpreter services. {#sec-182-526-0140 omnilex-key=us-wa-regs-official--title-182--182-526-0140}

(1) If one of the parties is limited-English-proficient (LEP), that party may ask to waive interpreter services.

(2) The request must be in writing or through a qualified interpreter on the record.

(3) The administrative law judge must determine if the waiver has been knowingly and voluntarily made.

(4) The party may withdraw their waiver at any time before or during the hearing.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0140, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0145** Interpreter requirements. {#sec-182-526-0145 omnilex-key=us-wa-regs-official--title-182--182-526-0145}

(1) Interpreters must:

(a) Use the interpretive mode that the parties, the person with hearing loss, the interpreter, and the administrative law judge (ALJ) consider the most accurate and effective;

(b) Interpret statements made by the parties and the ALJ;

(c) Not disclose information about the hearing without the written consent of the parties; and

(d) Not comment on the hearing or give legal advice.

(2) The ALJ must allow enough time for all interpretations to be made and understood.

(3) The ALJ may make a video recording of a hearing and use it as the official transcript for hearings involving a person with hearing loss.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0145, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0150** Hearing decisions involving limited-English-proficient parties. {#sec-182-526-0150 omnilex-key=us-wa-regs-official--title-182--182-526-0150}

(1) When an interpreter is used at a hearing, the administrative law judge must explain that the decision is written in English and that the office of administrative hearings (OAH) will provide an interpreter for a sight translation of the decision at no cost to that party.

(2) OAH must provide the party needing sight translation services information about how to obtain those services. Information about how to access sight translation must be attached to the decision or order.

(3) OAH or the board of appeals must send a copy of a decision or order to an interpreter for use in sight translation.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0150, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0155** Appellant's representation in the hearing. {#sec-182-526-0155 omnilex-key=us-wa-regs-official--title-182--182-526-0155}

(1) Appellants may act as their own representative or may choose to have someone represent them including, but not limited to, a friend, relative, community advocate, attorney or paralegal.

(2) All parties, including the health care authority (HCA) and their representatives, must provide their name, address, and telephone number to the office of administrative hearings (OAH) and all other parties prior to the hearing.

(3) The administrative law judge (ALJ) may require an appellant's representative to file a written notice of appearance, limited notice of appearance, or other documentation authorizing the representative to appear on behalf of the appellant.

(4) In cases involving confidential information, the representative must file a legally sufficient signed written consent or release of information document with HCA or HCA's authorized agent.

(5) If an appellant is represented by an attorney admitted to practice law in Washington state, the attorney must file a notice of appearance or limited notice of appearance and a notice of withdrawal if the attorney stops representing the appellant before the hearing process ends.

(6) HCA allows an exception to the requirement to file a notice of appearance in subsection (5) of this section when an appellant is represented by an attorney admitted to practice law in Washington state, and that attorney originally requested the appellant's hearing under WAC 182-526-0095. If the attorney stops representing the appellant before the hearing process ends, the requirement to file a notice of withdrawal still applies.

(7) The following restrictions apply to an appellant's representative:

(a) HCA and HCA's authorized agents do not pay for an appellant's representation.

(b) OAH does not pay for an appellant's representation.

(c) The following people may not act as an appellant's representative in a hearing under this chapter:

(i) An employee of HCA;

(ii) HCA's authorized agent;

(iii) An employee of the department of social and health services (DSHS);

(iv) An employee of the department of children, youth, and families (DCYF);

(v) An employee of OAH; or

(vi) Anyone under eighteen years of age.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-14-048, § 182-526-0155, filed 6/27/19, effective 7/28/19. Statutory Authority: RCW 41.05.021, 41.05.160, 74.09.741, chapter 34.05 RCW. WSR 17-23-201, § 182-526-0155, filed 11/22/17, effective 12/23/17. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0155, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0155, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0156** Legal assistance in the hearing process. {#sec-182-526-0156 omnilex-key=us-wa-regs-official--title-182--182-526-0156}

(1) The health care authority (HCA), HCA's authorized agents, and the office of administrative hearings (OAH) will not pay for an attorney for another party.

(2) If a party wants an attorney to represent him or her and cannot afford one, community resources may be available to assist that party. These legal services may be free or available at a reduced cost. HCA, HCA's authorized agent, or OAH can provide information about who to contact for legal assistance.

(3) Information about legal assistance can also be found at www.oah.wa.gov.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0156, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0175** Prehearing meetings. {#sec-182-526-0175 omnilex-key=us-wa-regs-official--title-182--182-526-0175}

(1) A prehearing meeting is an informal meeting with a health care authority (HCA) hearing representative that may be held before any prehearing conference or hearing.

(2) The HCA hearing representative may contact the party who requested the hearing before the hearing date to arrange a prehearing meeting. Any party may also contact the HCA hearing representative to request a prehearing meeting.

(3) A prehearing meeting is voluntary, but strongly encouraged. A party is not required to request a prehearing meeting and is not required to participate in one. A party's refusal to participate in a prehearing meeting does not affect the party's right to a hearing.

(4) The prehearing meeting may include all or some of the parties, but does not include an administrative law judge (ALJ).

(5) The prehearing meeting gives the parties an opportunity to:

(a) Clarify issues;

(b) Exchange documents and witness statements;

(c) Resolve issues through agreement or withdrawal; and

(d) Ask questions about the hearing process and the laws and rules that apply.

(6) During a prehearing meeting:

(a) The HCA hearing representative may:

(i) Explain the role of the HCA hearing representative in the hearing process;

(ii) Explain how a hearing is conducted and the relevant laws and rules that apply;

(iii) Explain the right to representation during the hearing;

(iv) Respond to questions about the hearing process;

(v) Identify accommodation and safety issues;

(vi) Distribute copies of the documents to be presented during the hearing;

(vii) Provide, upon request, copies of relevant laws and rules;

(viii) Identify additional documents or evidence a party may want or be required to present during the hearing;

(ix) Provide information about how to obtain relevant documents;

(x) Clarify the issues; and

(xi) Attempt to settle the dispute, if possible.

(b) Parties should explain their position and provide documents that relate to the case. Parties may consult legal resources.

(c) Parties may enter into written agreements or stipulations, including agreements that settle the dispute.

(7) A prehearing meeting may be held or information exchanged:

(a) In person;

(b) By telephone conference call;

(c) Through correspondence; or

(d) Any combination of the above that is agreeable to the parties.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0175, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0175, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0185** Settlement agreements. {#sec-182-526-0185 omnilex-key=us-wa-regs-official--title-182--182-526-0185}

(1) If the parties resolve the dispute during the prehearing meeting and put it in writing or present the agreement to an administrative law judge (ALJ), the agreement may be legally enforceable.

(2) If the parties want the ALJ to consider any agreements or stipulations made at the prehearing meeting, the parties must present them to the ALJ either before or during the hearing.

(3) If all the issues are not resolved in the prehearing meeting, the parties may request a prehearing conference before an ALJ or go to the scheduled hearing. The ALJ may also order a prehearing conference.

(4) If all the issues are resolved and the settlement agreement is in writing and signed by both parties, or presented orally by both parties to the ALJ, the ALJ enters the settlement agreement into the record and the agreement constitutes a withdrawal of the appellant's hearing request.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0185, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0185, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0195** Prehearing conferences. {#sec-182-526-0195 omnilex-key=us-wa-regs-official--title-182--182-526-0195}

(1) A prehearing conference is a formal proceeding conducted on the record by an administrative law judge (ALJ) to address issues and prepare for a hearing.

(a) The ALJ must make an audio record of the prehearing conference.

(b) An ALJ may conduct the prehearing conference in person, by telephone, or in any other manner acceptable to the parties.

(2) All parties must attend the prehearing conference. If the party who requested the hearing does not attend the prehearing conference, the ALJ may enter an order of default and an order dismissing the hearing.

(3) The ALJ may require a prehearing conference. Any party may request a prehearing conference.

(4) The ALJ must grant the appellant's, and may grant the managed care organization's or the agency representative's, first request for a prehearing conference if it is filed with the office of administrative hearings (OAH) at least seven business days before the scheduled hearing date.

(5) When the ALJ grants a party's request for a prehearing conference, the ALJ must continue the previously scheduled hearing when necessary to comply with notice requirements in this section.

(6) The ALJ may grant additional requests for prehearing conferences.

(7) The office of administrative hearings (OAH) must schedule prehearing conferences for all cases which concern:

(a) Provider and vendor overpayment hearings.

(b) Estate recovery and predeath liens.

(c) Notice of violation disputes under chapter 182-51 WAC.

(d) Notice of violation disputes under chapter 182-70 WAC.

(e) Provider termination disputes under WAC 182-502-0030.

(8) During a prehearing conference the parties and the ALJ may:

(a) Simplify or clarify the issues to be decided during the hearing;

(b) Agree to the date, time, and place of the hearing;

(c) Identify any accommodation or safety issues;

(d) Agree to postpone the hearing;

(e) Allow the parties to make changes in their own documents, including the notice or the hearing request;

(f) Agree to facts and documents to be entered during the hearing;

(g) Set a deadline to exchange names and phone numbers of witnesses and documents before the hearing;

(h) Schedule additional prehearing conferences;

(i) Resolve the dispute;

(j) Consider granting a stay if authorized by law or program rule; or

(k) Rule on any procedural issues and substantive motions raised by any party.

(9) After the prehearing conference, the ALJ must enter a written order describing:

(a) The actions taken at the prehearing conference;

(b) Any changes to the documents;

(c) A statement of the issue or issues identified for the hearing;

(d) Any agreements reached; and

(e) Any ruling of the ALJ.

(10) OAH must serve the prehearing order on the parties at least 14 calendar days before the scheduled hearing.

(11) A party may object to the prehearing order by notifying OAH in writing within 10 calendar days after the mailing date of the order. The ALJ must issue a ruling on the objection within five days from the date a party files an objection.

(12) If no objection is made to the prehearing order, the order determines how the hearing is conducted, including whether the hearing will be in person or held by telephone conference or other means, unless the ALJ changes the order for good cause.

(13) The ALJ may take further appropriate actions to address other concerns raised by the parties.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-21-061, § 182-526-0195, filed 10/12/23, effective 11/12/23*
- *WSR 21-18-077, § 182-526-0195, filed 8/27/21, effective 9/27/21. Statutory Authority: RCW 41.05.021, 41.05.160, 43.71C.110, and 2019 c 334. WSR 21-11-039, § 182-526-0195, filed 5/12/21, effective 6/12/21. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0195, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0195, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0200** Enrollee appeals of a managed care organization action. {#sec-182-526-0200 omnilex-key=us-wa-regs-official--title-182--182-526-0200}

(1) The hearing process described in this chapter applies to enrollee appeals of a health care authority (HCA)-contracted managed care organization (MCO) action. Where a conflict exists, the requirements in this section prevail.

(2) An MCO enrollee must exhaust all levels of resolution and appeal within the MCO's grievance system prior to requesting a hearing with HCA. See WAC 182-538-110.

(3) If an MCO enrollee does not agree with the MCO's resolution of the enrollee's appeal, the enrollee may request a hearing orally or in writing to the contact information on the written notice. The enrollee must request the hearing within one hundred twenty calendar days of the date of receipt of the MCO's notice of resolution of the MCO's appeal process.

(a) An enrollee may request continuation of services pending the outcome of a hearing related to the termination, suspension, or reduction of a previously authorized service.

(b) To receive continuation of services pending the outcome of the hearing, the enrollee must request a hearing and request to continue services within ten days of the date of the MCO's notice of the resolution of the appeal. See WAC 182-538-110 for additional requirements related to continuation of services.

(4) The entire appeal and hearing process, including the MCO appeal process, must be completed within ninety calendar days of the date the MCO enrollee filed the appeal with the MCO, not including the number of days the enrollee took to subsequently file for a hearing.

(5) Expedited hearing process.

(a) The office of administrative hearings (OAH) must establish and maintain an expedited hearing process when the enrollee or the enrollee's representative requests an expedited hearing and OAH determines that the time taken for a standard resolution of the claim could seriously jeopardize the enrollee's life or health and ability to attain, maintain, or regain maximum function.

(b) When approving an expedited hearing, OAH must issue a hearing decision as expeditiously as the enrollee's health condition requires, but not later than three business days after receiving the case file and information from the MCO regarding the action and MCO appeal.

(c) When denying an expedited hearing, OAH must give prompt oral notice to the enrollee followed by written notice within two calendar days of the request and change the hearing to the standard time frame.

(6) Parties to the hearing include HCA, the MCO, the enrollee and the enrollee's representative or the representative of a deceased enrollee's estate.

(7) Any party that disagrees with the initial order may request a review by an HCA review judge in accordance with WAC 182-526-0560 through 182-526-0600.

(8) If an enrollee disagrees with the initial order, the enrollee may request review in accordance with subsection (7) of this section, or an independent review (IR) by an independent review organization (IRO) in accordance with RCW 48.43.535. The enrollee must request the IR within twenty-one calendar days of the date of mailing the initial order. A timely submitted request for an IR stays any review requested pursuant to subsection (7) of this section.

(9) Any party that disagrees with the IR decision may request a review by an HCA review judge in accordance with WAC 182-526-0560 through 182-526-0600 within twenty-one calendar days of the date of mailing of the IR decision.

(10) When an initial order or an IR decision is appealed to an HCA review judge, the review judge issues the final order.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 74.09.741, chapter 34.05 RCW. WSR 17-23-201, § 182-526-0200, filed 11/22/17, effective 12/23/17. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0200, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0200, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0203** Administrative reviews requested by a reporting entity to the prescription drug pricing transparency program. {#sec-182-526-0203 omnilex-key=us-wa-regs-official--title-182--182-526-0203}

(1)(a) A reporting entity as defined in WAC 182-51-0100, seeking administrative review of a fine or other appealable action of the authority taken under chapter 182-51 WAC or chapter 43.71C RCW, must file a written request for administrative review at the address provided in the authority's notice within twenty-eight calendar days after receiving the notice.

(b) When the authority has sent written notice by United States mail, it considers the reporting entity to have received the notice five calendar days after the date of the notification letter, unless actual proof of the date of receipt of the authority's notification letter exists. If such proof exists, the authority uses the actual date of receipt to determine timeliness of the reporting entity's request for administrative review. When the authority has electronically mailed (email) written notice, the date the authority's notification email was sent is considered to be the date of receipt by the reporting entity, irrespective of when the reporting entity reads the email.

(c) The reporting entity's request for administrative review must:

(i) Be signed by a partner, officer, or authorized employee of the reporting entity;

(ii) State the particular issues raised; and

(iii) Include supporting documentation or other information.

(2) After receiving a request for administrative review, the authority either directly schedules the requested administrative hearing or causes the scheduling of the hearing with the office of administrative hearings (OAH). The hearing may be conducted by telephone.

(3) At least five calendar days before the scheduled date of the administrative hearing, the reporting entity must supply to the authority or OAH any additional or supporting documentation or information upon which they intend to rely in presenting its case. In addition, at any time before issuing the initial order, the authority or OAH may request any documentation or information needed to decide the issue raised, and the reporting entity must comply with such a request within five calendar days after it is received. The authority or OAH may extend this period up to fourteen additional calendar days for good cause shown if the reporting entity requests an extension in writing and it is received by the authority or OAH before the initial five-day period expires. The authority or OAH may dismiss issues that cannot be decided or resolved due to a reporting entity's failure to provide requested documentation or information within the required period.

(4) Within sixty calendar days after conclusion of the hearing conducted as part of the administrative review, the authority or OAH renders an initial order in writing, addressing the issues raised. If the authority or OAH is waiting for additional documentation or information promised by or requested from the reporting entity, the sixty-day period does not begin until the authority or OAH receives the documentation or information or until expiration of the time allowed to provide it. The initial order includes a notice of dismissal of all issues which cannot be decided due to a reporting entity's failure to provide documentation or information promised or requested.

(5) Additional review of a determination.

(a) A reporting entity seeking further review of an initial order issued according to subsection (4) of this section, must file a written application for an adjudicative proceeding signed by one of the individuals authorized by subsection (1) of this section with the authority's board of appeals within twenty-one calendar days after receiving the authority's initial order.

(b) When the authority or OAH has sent the initial order by United States mail, the authority considers the reporting entity to have received the initial order five calendar days after the date of the order, unless proof of the date of receipt of the letter exists. If such proof exists, the authority or OAH uses the actual date of receipt to determine timeliness of the reporting entity's application for an adjudicative proceeding. When the authority or OAH has electronically mailed (email) the initial order, the date of authority's email containing the initial order was sent is considered to be the date of receipt by the reporting entity, irrespective of when the contractor reads the email.

(c) The reporting entity must attach the authority's or OAH's initial order to its application for an adjudicative proceeding. When the authority or OAH delivered the initial order by email, either in the body of the email or as an attachment to the email, the reporting entity must include a copy of the email with the application for an adjudicative proceeding. The application for an adjudicative proceeding must be addressed to the authority's board of appeals. The authority uses the board of appeals date received stamp on the application for an administrative proceeding to determine whether the application is timely. When the application for adjudicative proceeding is filed by fax, the authority uses the date stamped on the application received by fax to determine timeliness.

(6) A review judge employed by the authority's board of appeals conducts a review of any appealed initial order. The scope of any review is generally limited to the issues specifically raised by the reporting entity at the initial hearing and addressed on the merits in the authority's or OAH's initial order. The authority or OAH considers the reporting entity to have waived all issues or claims that could have been raised to challenge the authority's or OAH's action, but which were not previously pursued at the hearing and not addressed in the initial order. The reporting entity must specify its issues in its request for an adjudicative proceeding, or as soon as practicable.

(7) Any party dissatisfied with an order of the board of appeals may file a petition for reconsideration within ten calendar days after the order is served on the party. The petition must state the specific grounds upon which relief is sought. The review judge may extend the time for seeking reconsideration for good cause upon motion of either party if the extension request is made within ten calendar days after the order was entered. The review judge rules on a petition for reconsideration and may seek additional argument, briefing, testimony, or other evidence as considered necessary. Filing a petition for reconsideration is not a requisite for seeking judicial review; however, if either party files a reconsideration petition, the authority's order is not considered final until the review judge makes a ruling.

(8) The authority's board of appeals assigns a review judge to conduct the review and render the final agency order. A reporting entity dissatisfied with a board of appeals' order may file a petition for judicial review under RCW 34.05.570(3) or other applicable authority.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 43.71C.110, and 2019 c 334. WSR 21-11-039, § 182-526-0203, filed 5/12/21, effective 6/12/21.*

##### **Wash. Admin. Code § 182-526-0205** Appeals requested by a data supplier to the Washington all payer health care claims database (WA-APCD). {#sec-182-526-0205 omnilex-key=us-wa-regs-official--title-182--182-526-0205}

(1) Appeal. A data supplier may request an appeal of a denial of its administrative review conducted in accordance with WAC 182-70-100.

(a) Request for an appeal must be submitted in writing to the health care authority (HCA) within fifteen calendar days after receipt of written notification of denial of its administrative review.

(b) An appeal request must contain:

(i) The requestor's name;

(ii) The requestor's mailing address;

(iii) The requestor's telephone number;

(iv) A description of HCA's action being contested;

(v) A brief explanation of why the person or entity disagrees with HCA's action; and

(vi) Any accommodation to help the requestor fully participate in the hearing, if applicable.

(c) Within ten business days of receipt of a written notice of appeal, HCA transmits the request to the office of administrative hearings (OAH).

(2) Scheduling.

(a) OAH will assign an administrative law judge (ALJ) to handle the appeal.

(b) The ALJ will notify parties of the time when any additional documents or arguments must be submitted.

(c) If a party fails to comply with a scheduling letter or established timelines, the ALJ may decline to consider arguments or documents submitted after the scheduled timelines.

(d) A status conference in complex cases may be scheduled to provide for the orderly resolution of the case and to narrow issues and arguments for hearing.

(3) Hearings.

(a) The hearing must be conducted in accordance with the Administrative Procedure Act, chapter 34.05 RCW, and this chapter. To the extent that there may be a conflict between the general provisions contained in this chapter and this section, the more specific provisions in this section apply.

(b) Hearings may be by telephone or in person.

(c) The ALJ may decide the case without a hearing if legal or factual issues are not in dispute, the appellant does not request a hearing, or the appellant fails to appear at a scheduled hearing or otherwise fails to respond to inquiries.

(d) The ALJ will notify the appellant by mail whether a hearing will be held, whether the hearing will be in person or by telephone, the location of any in-person hearing, and the date and time for any hearing in the case.

(e) The date and time for a hearing may be continued at the ALJ's discretion.

(f) Other authority employees may attend a hearing, and the ALJ notifies the appellant when other authority employees are attending. The appellant may appear in person or may be represented by an attorney.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 43.71C.110, and 2019 c 334. WSR 21-11-039, § 182-526-0205, filed 5/12/21, effective 6/12/21.*

##### **Wash. Admin. Code § 182-526-0206** Hearing and final order for penalties imposed under WAC 182-70-600. {#sec-182-526-0206 omnilex-key=us-wa-regs-official--title-182--182-526-0206}

(1) For penalties imposed under WAC 182-70-600, the Washington all payer health care claims database (WA-APCD) program director or the director's designee conducts a hearing and prepares a final order.

(2) The hearing must be conducted in accordance with this chapter and the Administrative Procedure Act, chapter 34.05 RCW.

(3) The WA-APCD program director, on behalf of the health care authority, must be the petitioner in the hearing, and the requestor must be the respondent.

(4) The WA-APCD program director has the burden of proving the basis for the finding of a violation and the penalty as set forth in the notice of violation and recommended penalty.

(5) The WA-APCD program director or the director's delegate issues a final written order that includes findings of fact, conclusions of law, and if appropriate, the penalty.

(6) If the order finds a violation and assesses monetary penalties, the order must include notice that payment must be made no later than forty-five days after service of the order or the period to appeal has expired, whichever is later.

(7) The WA-APCD program director must cause service of the final order on all parties.

(8) Any party to whom a violation is found may file a petition for review of the final order to superior court.

(9) If an appeal is not filed within the period set by RCW 34.05.542, the WA-APCD program director's order is conclusive and binding on all parties.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 43.71C.110, and 2019 c 334. WSR 21-11-039, § 182-526-0206, filed 5/12/21, effective 6/12/21.*

##### **Wash. Admin. Code § 182-526-0210** Appeals requested by intermediate care facilities for individuals with intellectual disabilities (ICF/IID). {#sec-182-526-0210 omnilex-key=us-wa-regs-official--title-182--182-526-0210}

The hearing process described in this section applies to requests for an appeal made by an intermediate care facility for individuals with intellectual disabilities (ICF/IID), as defined in WAC 388-825-020.

(1) Right to hearing. An ICF/IID may request a hearing when it is dissatisfied with the medicaid agency's finding of noncompliance resulting in the termination of medicaid funding and any related provider agreements under 42 C.F.R. Sec. 431.151 through 431.154.

(a) An agency review judge conducts the hearing and enters the agency's final order for cases held under this subsection.

(b) An ICF/IID cannot appeal:

(i) The choice of sanction or remedy;

(ii) The monitoring remedy;

(iii) The level of noncompliance found, except when a favorable review decision would affect the range of civil money penalty amounts the agency could collect; or

(iv) The decision about when to conduct an initial survey of a prospective provider.

(2) Notice of adverse action. The agency gives the ICF/IID a written notice of adverse action that includes:

(a) The basis for the finding of noncompliance that resulted in the agency's decision to terminate medicaid funding and any related provider agreements;

(b) A statement of the deficiencies resulting in the decision;

(c) The effective date of the adverse action; and

(d) The ICF/IID's appeal rights and procedures, including deadlines, for filing a hearing request.

(3) Request for hearing. The ICF/IID, its legal representative, or other authorized official must file a written request for a hearing with the agency's board of appeals at P.O. Box 42700, Olympia, Washington, or by facsimile at 360-507-9018 within 60 calendar days of receiving the notice of adverse action.

(4) Hearing. If an ICF/IID requests a hearing on the termination of medicaid funding and any related provider agreements, the hearing is completed and the agency issues the final order on the hearing within 120 calendar days of the effective date of the adverse action.

(a) If the agency is unable to hold the hearing until after the effective date of the adverse action, the agency offers the ICF/IID an informal reconsideration that meets the requirements of subsection (5) of this section.

(b) The informal reconsideration process described in subsection (5) of this section is not the same reconsideration process defined in WAC 182-526-0010 or described in WAC 182-526-0605 through 182-526-0635.

(5) Informal reconsideration for ICF/IID. The informal reconsideration includes:

(a) Written notice to the ICF/IID of the agency's findings resulting in the termination of medicaid funding and any related provider agreements;

(b) A reasonable opportunity for the ICF/IID to dispute those findings in writing; and

(c) A written affirmation or reversal of the agency's action.

(6) Termination of medicaid funding and related provider agreements.

(a) The medicaid funding and any related provider agreements end on the effective date of the termination, unless:

(i) A hearing is timely requested and not provided by the agency until after the effective date of the termination; and

(ii) The termination is based on a survey agency certification stating that there is no jeopardy to beneficiaries' health and safety.

(b) If medicaid funding extends past the termination date, funding will be available only through the earlier of:

(i) The issuance date of a hearing decision that upholds the agency's action; or

(ii) One hundred twenty calendar days after the effective date of termination, as required by 42 C.F.R. Sec. 442.40.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 42 C.F.R. § 431, Subpart D and § 498.5. WSR 24-05-078, § 182-526-0210, filed 2/21/24, effective 3/23/24. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. §§ 431.151, 431.153, 431.154, and 498.5. WSR 19-18-025, § 182-526-0210, filed 8/28/19, effective 9/28/19.*

##### **Wash. Admin. Code § 182-526-0215** Authority of the administrative law judge when conducting a hearing. {#sec-182-526-0215 omnilex-key=us-wa-regs-official--title-182--182-526-0215}

(1) The administrative law judge (ALJ) must hear and decide the issues de novo (anew) based on the evidence presented and admitted into the record during the hearing.

(2) As needed, the ALJ may:

(a) Determine the order for presenting evidence;

(b) Issue subpoenas or orders directing witnesses to appear or bring documents;

(c) Rule on objections, motions, and procedural matters;

(d) Rule on an offer of proof made to admit evidence;

(e) Admit relevant evidence;

(f) Impartially question witnesses to develop the record;

(g) Call additional witnesses and request exhibits to complete the record;

(h) Give the parties an opportunity to cross-examine witnesses or present more evidence against the witnesses or exhibits;

(i) Keep order during the hearing;

(j) Allow or require oral or written argument and set the deadlines for the parties to submit argument or evidence;

(k) Permit others to attend, photograph, or electronically record hearings, but may place conditions to preserve confidentiality or prevent disruption;

(l) Allow a party to waive rights given by chapters 34.05 RCW or 182-526 WAC, unless another law prevents it;

(m) Decide whether a party has a right to a hearing;

(n) Issue protective orders;

(o) Consider granting a stay if authorized by law or HCA rule; and

(p) Take any other action necessary and authorized under these or other rules.

(3) The ALJ administers oaths or affirmations and takes testimony.

(4) The ALJ enters an initial order after the hearing. Initial orders become final orders under WAC 182-526-0525.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0215, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0215, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0216** The authority of the administrative law judge and the review judge is limited. {#sec-182-526-0216 omnilex-key=us-wa-regs-official--title-182--182-526-0216}

(1) The authority of the administrative law judge and the review judge is limited to those powers granted by statute or rule. The ALJ and the review judge do not have any inherent or common law powers.

(2) Neither an administrative law judge nor a review judge may decide that a rule is invalid or unenforceable. Only a court may decide this issue.

(3) If the validity of a rule is raised during the hearing, the ALJ or review judge may allow only argument for court review.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0216, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0218** The authority of a review judge when conducting a hearing as a presiding officer. {#sec-182-526-0218 omnilex-key=us-wa-regs-official--title-182--182-526-0218}

(1) A review judge has the same authority and responsibilities as an administrative law judge, as described in WAC 182-526-0215, when conducting a hearing.

(2) A review judge conducts the hearing and enters the final order in cases where a contractor for the delivery of nursing facility services requests an administrative hearing under WAC 388-96-904(5).

(3) The review judge enters final HCA decisions on all cases in the form of a final order.

(4) Following a review judge's final order:

(a) Any party may request reconsideration of the final order as provided in this chapter and WAC 388-96-904(12); and

(b) The party who requested the hearing, but not the health care authority or any of its authorized agents, may file a petition for judicial review as provided in this chapter.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0218, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0220** Rules and laws an administrative law judge and review judge must apply when conducting a hearing and making a decision. {#sec-182-526-0220 omnilex-key=us-wa-regs-official--title-182--182-526-0220}

(1) Administrative law judges (ALJs) and review judges must first apply the applicable program rules adopted in the Washington Administrative Code (WAC).

(2) If no program rule applies, the ALJ and review judge must decide the issue according to the best legal authority and reasoning available, including federal and Washington state constitutions, statutes, regulations, and court decisions.

(3) When applying program rules regarding the substantive rights and responsibilities of the parties (such as eligibility for services, benefits, or a license), the ALJ and review judge must apply the program rules in effect on the date of the health care authority (HCA) action, unless otherwise required by other rule or law. If HCA amends its notice of action, the ALJ or review judge must apply the rules in effect on the date the action was taken, unless otherwise required by other rule or law.

(4) When applying procedural rules, the ALJ and review judge must apply the rules that are in effect on the date the procedure is followed.

(5) Program rules determine the amount of time HCA or HCA's authorized agent has to process an application for services, benefits, or a license.

(6) The ALJ and review judge must apply the rules in this chapter beginning on the date each rule is effective.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0220, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0221** HCA index of significant decisions. {#sec-182-526-0221 omnilex-key=us-wa-regs-official--title-182--182-526-0221}

(1) A final order may be relied on, used, or cited as precedent by a party if the final order has been indexed in the index of significant decisions maintained by the health care authority (HCA).

(2) The index of significant decisions is available to the public at http://www.hca.wa.gov/about-hca/significant-decisions. For information on how to obtain a copy of the index, contact the HCA hearing representative.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0221, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0221, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0230** Assigning an administrative law judge to a hearing. {#sec-182-526-0230 omnilex-key=us-wa-regs-official--title-182--182-526-0230}

(1) The office of administrative hearings (OAH) assigns an administrative law judge (ALJ) at least five business days before the hearing, except when the hearing is expedited.

(2) A party may ask which ALJ is assigned to the hearing by calling or writing to the OAH field office listed on the notice of hearing.

(3) If requested by a party, OAH must send the name of the assigned ALJ to the party by email or in writing at least five business days before the party's scheduled hearing date.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0230, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0230, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0240** Filing a motion of prejudice. {#sec-182-526-0240 omnilex-key=us-wa-regs-official--title-182--182-526-0240}

(1) A party requesting a different administrative law judge (ALJ) may do so by filing a written motion of prejudice consistent with RCW 34.12.050. A party must file the motion with the office of administrative hearings (OAH) before the ALJ rules on a discretionary issue in the case, admits evidence, or takes testimony. The motion must include an affidavit or sworn statement under penalty of perjury supporting the party's claim that the ALJ cannot hear the case fairly.

(2) Rulings that are not considered discretionary rulings for purposes of this section include, but are not limited to rulings that:

(a) Grant or deny a request for a continuance; or

(b) Grant or deny a request for a prehearing conference.

(3) A party must send the motion of prejudice to the chief ALJ at OAH headquarters and must send a copy to the OAH field office where the ALJ is assigned. The address of OAH headquarters is provided in WAC 182-526-0025(1).

(4) A party may make an oral motion of prejudice at the beginning of the hearing or prehearing conference before the ALJ rules on a discretionary issue in the case, admits evidence, or takes testimony if:

(a) OAH did not assign an ALJ at least five business days before the date of the hearing or prehearing conference; or

(b) OAH changed the assigned ALJ within five business days of the date of the hearing or prehearing conference.

(5) The first request by each party for a different ALJ is automatically granted. The chief ALJ or a designee grants or denies any later requests.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0240, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0240, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0245** Disqualifying an administrative law judge or review judge. {#sec-182-526-0245 omnilex-key=us-wa-regs-official--title-182--182-526-0245}

(1) An administrative law judge (ALJ) or review judge may be disqualified for bias, prejudice, or conflict of interest, or if one of the parties or a party's representative has ex parte contact with the ALJ or review judge.

(2) Ex parte contact means any written or oral communication with the ALJ or review judge about something related to the hearing when the other parties are not present. Procedural questions are not considered an ex parte contact. Examples of procedural questions include clarifying the hearing date, time, or location, or asking for directions to the hearing location.

(3) To request disqualification of an ALJ or review judge, a party must file a written petition for disqualification consistent with RCW 34.05.425 explaining why the ALJ or review judge should be disqualified. A party must promptly file the petition upon discovery of possible bias, conflict of interest, or ex parte contact.

(4) A party must deliver the petition to the ALJ or review judge assigned to the case. That ALJ or review judge must decide whether to grant or deny the petition and must state the facts and reasons for the decision.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0245, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0245, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0250** Time requirements for notices issued by the office of administrative hearings. {#sec-182-526-0250 omnilex-key=us-wa-regs-official--title-182--182-526-0250}

(1) The office of administrative hearings (OAH) must serve a notice of hearing on all parties and their representatives at least fourteen calendar days before the hearing date.

(2) If OAH schedules a prehearing conference, OAH must serve a notice of prehearing conference to the parties and their representatives at least seven business days before the date of the prehearing conference except:

(a) OAH or an administrative law judge (ALJ) may change a scheduled hearing into a prehearing conference and provide less than seven business days' notice of the prehearing conference; and

(b) OAH may give less than seven business days' notice if the only purpose of the prehearing conference is to consider whether to grant a continuance under WAC 182-526-0280 or 182-526-0282, as applicable.

(3) OAH must reschedule the hearing if necessary to comply with the notice requirements in this section, unless the parties agree to waive notice requirements.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0250, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0250, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0255** Notice of hearing or notice of prehearing conference. {#sec-182-526-0255 omnilex-key=us-wa-regs-official--title-182--182-526-0255}

(1)(a) A notice of hearing or a notice of prehearing conference is a written notice issued by the office of administrative hearings (OAH) that must include the:

(i) Names of all parties to whom the notice is sent and, if known, the names and addresses of their representatives;

(ii) Name, mailing address, and telephone number of the administrative law judge (ALJ), if known;

(iii) Date, time, place, and nature of the hearing or prehearing conference;

(iv) Legal authority and jurisdiction for the hearing; and

(v) Date of the hearing request.

(b) A notice of hearing or prehearing conference must include a statement that the appellant's failure to attend the prehearing conference or hearing may result in the loss of the right to a hearing.

(c) If the appellant fails to appear, the ALJ may enter an order of default.

(2) Limited-English proficiency. The notice must include a statement that, if the appellant needs a qualified interpreter because they or any of their witnesses are people with limited-English proficiency, OAH will provide an interpreter at no cost to that party.

(3) The notice must state whether the hearing or prehearing conference is to be held by telephone or in person, and how to request a change in the way it is held.

(4) The notice of hearing or prehearing conference informs the appellant:

(a) How to indicate any special needs for the appellant or their witnesses, including the need for an interpreter in a primary language or for sensory impairments;

(b) How to contact OAH if a party has a safety concern; and

(c) That the appellant may request a qualified interpreter if the appellant or any of the appellant's witnesses are people with limited-English proficiency, and that OAH provides such interpreters at no cost to the appellant.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0255, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0255, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0260** Amending the health care authority or managed care organization notice. {#sec-182-526-0260 omnilex-key=us-wa-regs-official--title-182--182-526-0260}

(1) The administrative law judge (ALJ) must allow the health care authority (HCA), HCA's authorized agent, or a managed care organization (MCO) to amend (change) the notice of an action before or during the hearing to match the evidence and facts.

(2) HCA, HCA's authorized agent, or MCO must put the change in writing and deliver a copy to the ALJ and all parties.

(3) The ALJ must offer to continue (postpone) the hearing to give the parties more time to prepare or present evidence or argument if there is a substantive change from the earlier notice.

(4) If the ALJ grants a continuance, the office of administrative hearings must serve a new hearing notice at least fourteen calendar days before the hearing date.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0260, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0265** Amending hearing requests. {#sec-182-526-0265 omnilex-key=us-wa-regs-official--title-182--182-526-0265}

(1) The administrative law judge (ALJ) may allow the party that requested the hearing to amend its hearing request before or during the hearing.

(2) The ALJ must offer to continue (postpone) the hearing to give the other parties more time to prepare or present evidence or argument if there is a substantive change in the hearing request.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0265, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0270** Mailing address changes. {#sec-182-526-0270 omnilex-key=us-wa-regs-official--title-182--182-526-0270}

(1) The appellant must tell the health care authority (HCA) hearing representative and the office of administrative hearings (OAH) as soon as possible, when the party's mailing address changes.

(2) If a party does not notify the HCA hearing representative and OAH of a change of mailing address, OAH continues to send notices and other important papers to the last known mailing address. If this happens, the administrative law judge may find that the party received the documents or waived the right to receive those documents.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0270, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0270, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0280** Continuing a hearing when an appellant is an applicant or recipient. {#sec-182-526-0280 omnilex-key=us-wa-regs-official--title-182--182-526-0280}

(1) Any party may request a continuance under this section either orally or in writing.

(2) Before contacting the office of administrative hearings (OAH) to request a continuance, the party seeking the continuance must make a good faith effort to contact the other parties to find out if they agree to a continuance. The party making the request for a continuance must let OAH know whether the other parties agreed to the continuance.

(3) Standard when less than sixty days. When a continuance request is made less than sixty days from the date OAH received the hearing request:

(a) If all parties agree to the continuance, the ALJ must grant the request unless the ALJ holds a prehearing conference and finds that good cause for a continuance does not exist under WAC 182-526-0020.

(b) If the parties do not agree to the continuance, the ALJ must schedule a prehearing conference and determine if good cause for a continuance exists under WAC 182-526-0020 and under the following factors:

(i) Why the party is requesting a continuance;

(ii) Why the other party or parties are objecting to the request;

(iii) Whether a continuance in the case has previously been granted at the request of the same party who is now requesting the continuance and, if so, whether it was for the same reason;

(iv) The extent to which the requesting or objecting parties could have prevented the need for delay;

(v) The number and duration of previous continuances in the case and who requested them;

(vi) The legal or factual complexity of the case;

(vii) The relative harm to the parties if the continuance is granted or denied, including the risk of harm to the appellant if he or she is not receiving continued benefits;

(viii) The impact of a continuance on the parties' ability to adequately prepare and present their cases;

(ix) Any need to provide accommodation, translation, or interpreter services; and

(x) The impact of a continuance on the ability of OAH to issue a timely initial decision; or

(xi) Other relevant factors.

(4) Standard when sixty days or greater. When a continuance request is made sixty days or more from the date OAH received the hearing request:

(a) The ALJ must not only consider whether there is good cause to continue the hearing but also must find a compelling reason for the continuance.

(b) Compelling reasons include:

(i) Medical evidence is required;

(ii) Extraordinary circumstances exist, such as the sudden unforeseen onset of an illness or adverse event that was beyond the party's ability to prevent;

(iii) The hearing format changes or the ALJ finds a compelling reason to change the way a witness appears at the hearing according to WAC 182-526-0360;

(iv) The appellant needs more time to prepare or present evidence or argument because the agency issued an amended notice under WAC 182-526-0260;

(v) The need for more time was caused by another party's action or inaction, considering the relative capacity and resources of the parties;

(vi) The need to provide accommodation, translation, or interpreter services;

(vii) A party received notice of the date or deadline thirty days or more after OAH received the hearing request;

(viii) Whether the continuance is needed to allow for effective assistance of counsel of record; or

(ix) Other compelling reasons.

(5) The ALJ must notify all parties whether a continuance was granted or denied orally on the record, or must do so in writing within five business days of the prehearing conference.

(6) If the ALJ grants a continuance, OAH must serve a new notice of hearing on the parties at least fourteen calendar days before the new hearing date, unless the parties agree to a shorter time period.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 42 C.F.R. Part 431, Subpart E. WSR 17-24-103, § 182-526-0280, filed 12/5/17, effective 1/5/18. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0280, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0280, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0282** Continuance requests in provider hearing, estate recovery hearing, or nursing home rate hearing under WAC 388-96-904. {#sec-182-526-0282 omnilex-key=us-wa-regs-official--title-182--182-526-0282}

This section applies to continuance requests made in provider hearings, estate recovery hearings, or nursing home rate hearings.

(1) A request for continuance under this section may be made either orally or in writing.

(2) Before contacting the office of administrative hearings (OAH) to request a continuance, the party seeking the continuance must make a good faith effort to contact the other parties to find out if they agree to a continuance.

(3) The party making the request for a continuance must let OAH know whether the other parties agreed to the continuance. If all parties agree to a continuance, the administrative law judge (ALJ) must grant the request unless the ALJ requires a showing of good cause for a continuance.

(4) If the parties do not agree to a continuance, the ALJ must schedule and hold a prehearing conference to decide whether there is good cause to grant the continuance.

(5) If the ALJ grants a continuance, OAH must serve a new notice of hearing on the parties at least fourteen calendar days before the new hearing date.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0282, filed 2/13/17, effective 3/16/17.*

##### **Wash. Admin. Code § 182-526-0284** Orders of default. {#sec-182-526-0284 omnilex-key=us-wa-regs-official--title-182--182-526-0284}

(1) An order of default may be entered when the appellant fails to attend a scheduled prehearing conference or hearing. The order of default will include a notice of inquiry as to whether the appellant wants to petition to reinstate the hearing.

(2) The appellant may file a petition to vacate an order of default under WAC 182-526-0290.

(3) An order of default becomes a final order by operation of law, disposing of the appellant's request for a hearing under RCW 34.05.440 if:

(a) The appellant does not file a petition to vacate within twenty-one calendar days of the order being served (mailed) on the parties under WAC 182-526-0290 (2) and (5)(b); or

(b) If the appellant fails to appear at a prehearing conference scheduled to address the petition to vacate under WAC 182-526-0290 (3) and (4)(a).

(4) The health care authority or managed care organization action stands after an order of default becomes a final order.

(5) The appellant may seek judicial review of a final order of default to the superior court under WAC 182-526-0640.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-15-088, § 182-526-0284, filed 7/18/18, effective 8/18/18*
- *WSR 17-05-066, § 182-526-0284, filed 2/13/17, effective 3/16/17.*

##### **Wash. Admin. Code § 182-526-0285** Orders of dismissal. {#sec-182-526-0285 omnilex-key=us-wa-regs-official--title-182--182-526-0285}

(1) An order of dismissal may be entered when the appellant withdraws the request for hearing under WAC 182-526-0115.

(2) An appellant may file a petition (request) to vacate an order of dismissal under WAC 182-526-0290.

(3) An order of dismissal becomes a final order by operation of law, disposing of the appellant's request for a hearing under RCW 34.05.440 if:

(a) The appellant does not file a petition to vacate the order within twenty-one calendar days of the order being served (mailed) on the parties under WAC 182-526-0290 (2) and (5)(b); or

(b) The appellant fails to appear at a prehearing conference scheduled to address the petition to vacate under WAC 182-526-0290 (3) and (4)(a).

(4) The health care authority or managed care organization action stands after an order of dismissal becomes a final order.

(5) The appellant may seek judicial review of a final order of dismissal to the superior court under WAC 182-526-0640.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-15-088, § 182-526-0285, filed 7/18/18, effective 8/18/18*
- *WSR 17-05-066, § 182-526-0285, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0285, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0290** Reinstating a hearing after an order of default or an order of dismissal. {#sec-182-526-0290 omnilex-key=us-wa-regs-official--title-182--182-526-0290}

(1) If an order of default was entered under WAC 182-526-0284, or an order of dismissal was entered under WAC 182-526-0285, the appellant may file a petition (request) to vacate (set aside) the order.

(a) If the order was issued by the office of administrative hearings (OAH), the petition to vacate must be filed with OAH.

(b) If the order was issued by the health care authority (HCA), the petition to vacate must be filed with HCA or the board of appeals (BOA).

(c) The appellant must specify in the petition to vacate the reason why the order should be vacated.

(2) The petition to vacate must be filed within 21 calendar days of service (mailing) of the order to the parties. If the petition to vacate is not filed by the deadline, the order of default or order of dismissal becomes a final order by operation of law.

(3) If OAH or HCA receives a petition to vacate, OAH or HCA schedules a prehearing conference and serves all parties with a notice of a prehearing conference under WAC 182-526-0250.

(4) If the appellant fails to appear at the scheduled prehearing conference to address the petition to vacate:

(a) The order of default or order of dismissal becomes a final order by operation of law;

(b) OAH or HCA will issue an order disposing of the appellant's hearing request, stating that the order of default or order of dismissal became a final order by operation of law under RCW 34.05.440 (2) and (3) because the appellant failed to appear at the prehearing conference to address the petition to vacate, and including information about judicial review under WAC 182-526-0640;

(c) The appellant may seek judicial review of the final order of default or final order of dismissal to the superior court under WAC 182-526-0640.

(5) If the appellant appears for the scheduled prehearing conference:

(a) The ALJ or review judge will receive evidence and argument from the parties regarding whether:

(i) The petition to vacate was timely filed; and

(ii) The appellant has established good cause to excuse any default or dismissal and to reinstate the matter for hearing.

(b) If the petition to vacate was not filed timely, the ALJ or the review judge will issue an order disposing of the appellant's hearing request, stating that the order of default or order of dismissal became a final order by operation of law under RCW 34.05.440(1) because the appellant failed to timely file the petition to vacate, and including information about judicial review under WAC 182-526-0640. The appellant may seek judicial review of the final order of default or final order of dismissal to the superior court under WAC 182-526-0640.

(c) If the petition to vacate was timely filed, but the appellant does not establish good cause to excuse any default or dismissal, the ALJ must issue an initial order, including information about how to petition for review to the BOA, or the review judge must issue a final order dismissing the appeal.

(d) If the petition to vacate was timely filed and the appellant establishes good cause to excuse any default or dismissal, the ALJ or review judge vacates the order of default or order of dismissal and the matter may proceed to hearing on the issues identified in the original request for hearing. The hearing may occur:

(i) Immediately following the prehearing conference if the parties agree; or

(ii) At a hearing date scheduled by OAH or BOA under WAC 182-526-0250 if the ALJ or review judge continues the hearing to a later date.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-06-049, s 182-526-0290, filed 2/25/26, effective 3/28/26. Statutory Authority: RCW 41.05.021, 41.05.160, 42 C.F.R. Part 431, Subpart E. WSR 17-24-103, § 182-526-0290, filed 12/5/17, effective 1/5/18. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0290, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0290, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0300** Order of dismissal based on subject matter. {#sec-182-526-0300 omnilex-key=us-wa-regs-official--title-182--182-526-0300}

An order of dismissal issued based on lack of subject matter jurisdiction must be entered as an initial order subject to the requirements of WAC 182-526-0520.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0300, filed 2/13/17, effective 3/16/17.*

##### **Wash. Admin. Code § 182-526-0310** Requesting a stay of the health care authority action. {#sec-182-526-0310 omnilex-key=us-wa-regs-official--title-182--182-526-0310}

A party may request that an administrative law judge (ALJ) or review judge stay (stop) a health care authority action until there is a decision entered by the ALJ or review judge. The ALJ or review judge decides whether to grant or deny the stay and enters a written order.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0310, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0320** Subpoenas. {#sec-182-526-0320 omnilex-key=us-wa-regs-official--title-182--182-526-0320}

(1) An administrative law judge (ALJ), the health care authority hearing representative, and an attorney for a party may issue subpoenas. If a party is not represented by an attorney, that party may ask the ALJ to issue a subpoena on the party's behalf. The ALJ may schedule a prehearing conference to decide whether to issue a subpoena.

(2) An ALJ may deny a party's request for a subpoena. For example, an ALJ may deny a request for a subpoena when the ALJ determines that a witness has no actual knowledge regarding the facts or that the documents are not relevant.

(3) There is no cost when OAH issues a subpoena on behalf of a party, but the party may have to pay for:

(a) Serving the subpoena;

(b) Complying with the subpoena; and

(c) Witness fees according to RCW 34.05.446(7).

(4) Any person who is at least eighteen years old and not a party to the hearing may serve a subpoena.

(5) Service of a subpoena is complete when the server:

(a) Gives the witness a copy of the subpoena; or

(b) Leaves a copy at the residence of the witness with a person over the age of eighteen.

(6) To prove that a subpoena was served on a witness, the person serving the subpoena must sign a written, dated statement including:

(a) Who was served with the subpoena;

(b) When the subpoena was served;

(c) The address where the subpoena was served; and

(d) The name, age, and address of the person who served the subpoena.

(7) A party may request that an ALJ quash (set aside) or change the requirements of a subpoena at any time before the deadline given in the subpoena.

(8) An ALJ may set aside or change a subpoena if it is unreasonable.

(9) Witnesses with safety or accommodation concerns should contact the office of administrative hearings (OAH) upon receipt of a subpoena.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0320, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0320, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0340** Hearing location. {#sec-182-526-0340 omnilex-key=us-wa-regs-official--title-182--182-526-0340}

(1) The office of administrative hearings (OAH) may schedule a hearing to be conducted in-person, by telephone, or by video.

(2) A telephonic or video hearing is where the appellant appears by telephone, video, or other electronic means.

(3) An in-person hearing is where the appellant appears face-to-face with the ALJ. The other parties may choose to appear either in person, by telephone, or by video.

(4) Whether a hearing is held in-person, by video, or telephonically, each party has the right to see all documents, hear all testimony, and question all witnesses.

(5) If a hearing is originally scheduled as an in-person hearing, the appellant may ask that the ALJ change it to a telephonic or video hearing. Once a telephonic or video hearing begins, the ALJ may stop, reschedule, and change the hearing to an in-person hearing if any party makes such a request.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-18-063, § 182-526-0340, filed 8/26/21, effective 9/26/21*
- *WSR 17-05-066, § 182-526-0340, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0340, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0345** Administrative law judge present at the hearing. {#sec-182-526-0345 omnilex-key=us-wa-regs-official--title-182--182-526-0345}

(1) If the hearing is scheduled as an in-person hearing, an administrative law judge (ALJ) is physically present.

(2) If the hearing is scheduled as a telephonic hearing, an ALJ is present by telephone.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0345, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0350** Recording the hearing. {#sec-182-526-0350 omnilex-key=us-wa-regs-official--title-182--182-526-0350}

The administrative law judge must make an audio record of the entire hearing.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0350, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0350, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0355** People who may attend the hearing. {#sec-182-526-0355 omnilex-key=us-wa-regs-official--title-182--182-526-0355}

(1) All parties and their representatives may attend a hearing under this chapter.

(2) Witnesses may be excluded from the hearing if the administrative law judge (ALJ) finds good cause to do so.

(3) The ALJ may also exclude other people from all or part of the hearing.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0355, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0355, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0360** Changing how a hearing is held or how a witness appears at a hearing. {#sec-182-526-0360 omnilex-key=us-wa-regs-official--title-182--182-526-0360}

(1) For cases in which the party who requested a hearing is an applicant or recipient of a medical services program administered by the agency, the hearing must be held according to RCW 74.09.741 (5)(c).

(2) An applicant or recipient may agree to have one or more prehearing conferences conducted telephonically without waiving the right to have any subsequent prehearing conference or other hearings held in person.

(3) Any party to the hearing has the right to request that:

(a) The hearing be changed from an in-person hearing to a telephonic hearing or from a telephonic hearing to an in-person hearing; or

(b) A witness be allowed to appear telephonically even for an in-person hearing.

(4) A party must show a compelling reason to change the way a witness appears (in person or by telephone). Some examples of compelling reasons are:

(a) A party does not speak or understand English well.

(b) A party wants to present a significant number of documents during the hearing.

(c) A party does not believe that one of the witnesses or another party is credible and wants the administrative law judge (ALJ) to have the opportunity to see the testimony.

(d) A party has a disability or communication barrier that affects its ability to present its case.

(e) A party believes that the personal safety of someone involved in the hearing process is at risk.

(5) A compelling reason to change the way a witness appears at a hearing can be overcome by a more compelling reason not to change how a witness appears for a hearing.

(6) If a party wants to change how a hearing is held or change how their witnesses or other parties appear, the party must contact the office of administrative hearings (OAH) to request the change.

(7) The ALJ may schedule a prehearing conference to determine if the request should be granted.

(8) If the ALJ grants the request, the ALJ may orally advise the parties of the change in how the witness or party appears.

(9) If the ALJ denies the request, the ALJ must issue a written order that includes findings of fact supporting why the request was denied.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-04-009, s 182-526-0360, filed 1/23/25, effective 2/23/25*
- *WSR 17-05-066, § 182-526-0360, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0360, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0370** Submitting documents for a telephonic hearing. {#sec-182-526-0370 omnilex-key=us-wa-regs-official--title-182--182-526-0370}

(1) When a hearing is conducted by telephone, an administrative law judge (ALJ) may order the parties to file and serve any documents or proposed exhibits at least five days before the hearing.

(2) The health care authority hearing representative may be able to help a party copy and file their documents with the office of administrative hearings (OAH) and send them to any other party.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0370, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0370, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0375** Summary of the hearing process. {#sec-182-526-0375 omnilex-key=us-wa-regs-official--title-182--182-526-0375}

At a hearing under this chapter:

(1) The administrative law judge (ALJ):

(a) Explains the hearing rights of the parties;

(b) Marks and admits or rejects exhibits;

(c) Ensures that a record is made;

(d) Explains that a decision is mailed after the hearing;

(e) Notifies the parties of appeal rights;

(f) May keep the record open for a time after the hearing if needed to receive more evidence or argument; and

(g) May take actions as authorized under this chapter.

(2) The parties may:

(a) Make opening statements to explain the issues;

(b) Offer evidence to prove their positions, including oral or written statements of witnesses;

(c) Question the witnesses presented by the other parties; and

(d) Give closing arguments about what the evidence shows and what laws apply.

(3) At the end of the hearing, the record is closed unless the ALJ allows more time to file additional evidence. See WAC 182-526-0390.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0375, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0375, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0380** Group hearing requests. {#sec-182-526-0380 omnilex-key=us-wa-regs-official--title-182--182-526-0380}

(1) A group hearing may be held when two or more parties request a hearing about similar issues.

(2) Hearings may be combined at the request of the parties or the administrative law judge (ALJ).

(3) All parties participating in a group hearing may have their own representative present.

(4) A party may withdraw from a group hearing by asking the ALJ for a separate hearing.

(5) If a party asks to withdraw from a group hearing before the ALJ makes a discretionary ruling or the hearing begins, the ALJ must give the party a separate hearing.

(6) If a party later shows good cause, the ALJ may give the party a separate hearing at any time during the hearing process.

(7) The ALJ must grant a party's request to withdraw from a group hearing when participation in the group hearing could require the release of confidential or protected health care information and the party does not consent to the release of such information.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0380, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0380, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0387** Requesting that a hearing be consolidated or severed when multiple agencies are parties to the proceeding. {#sec-182-526-0387 omnilex-key=us-wa-regs-official--title-182--182-526-0387}

(1) The following requirements apply only to hearings in which an applicant or recipient of medical services programs administered by the agency seeks review of decisions made by more than one agency, as defined in RCW 34.05.010. For example: A medical services program recipient appeals a termination of medical assistance by the health care authority and in the same request for hearing the recipient appeals a termination of cash assistance issued by the department of social and health services.

(2) When the applicant or recipient of a medical services program files a single request for hearing objecting to decisions made by more than one agency, as defined in RCW 34.05.010, the office of administrative hearings (OAH) schedules one hearing. The administrative law judge (ALJ) may sever the proceeding into multiple hearings on the motion of any of the parties, when:

(a) All parties consent to the severance; or

(b) Any party requests severance without another party's consent, and the ALJ finds there is good cause for severing the hearing and that the proposed severance is not likely to prejudice the rights of the applicant or recipient in accordance with RCW 74.09.741(5).

(3) If there are multiple hearings involving common issues or parties where there is one appellant and both the health care authority and the department are parties, upon motion of any party or upon the ALJ's motion, the ALJ may consolidate the hearings if the ALJ finds that the consolidation is not likely to prejudice the rights of the applicant or recipient who is a party to any of the consolidated hearings in accordance with RCW 74.09.741(5).

(4) If the ALJ grants the motion to sever the hearing into multiple hearings or consolidate multiple hearings into a single hearing, the ALJ enters an order and OAH sends a new notice of hearing to the appropriate parties in accordance with WAC 182-526-0250, unless service of notice is waived by the parties.

(5) Petitions for judicial review must be served on all agencies involved in the hearing.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-04-009, s 182-526-0387, filed 1/23/25, effective 2/23/25*
- *WSR 17-05-066, § 182-526-0387, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0387, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0390** Evidence. {#sec-182-526-0390 omnilex-key=us-wa-regs-official--title-182--182-526-0390}

(1) Evidence includes documents, objects, and testimony of witnesses that parties offer during the hearing to help prove their positions.

(2) Evidence may be all or parts of original documents and may be copies of the originals.

(3) Parties may offer statements signed by a witness under oath or affirmation as evidence, if the witness cannot appear.

(4) Testimony subject to cross examination by the other parties may be given more importance by the administrative law judge (ALJ).

(5) The parties may bring evidence to any prehearing meeting, prehearing conference, or hearing, or may file evidence before these events with the office of administrative hearings (OAH).

(6) The ALJ may set a deadline before the hearing for the parties to file proposed exhibits and the names of witnesses. If a party misses the deadline, the ALJ may refuse to admit the evidence unless:

(a) The ALJ finds that the offering party has good cause.

(b) The other parties agree that party has good cause for missing the deadline; or

(c) The other parties agree the ALJ may consider the evidence.

(7) Parties may bring any documents and witnesses to the hearing to support their position. However, the other parties may object to any evidence that is offered and may cross-examine witnesses.

(8) The ALJ determines whether the evidence is admitted and what importance to give it.

(a) If the ALJ does not admit the evidence, the parties may make an offer of proof to show why the ALJ should admit it.

(b) To make an offer of proof, a party presents evidence and argument on the record to show why the ALJ should consider the evidence.

(c) The offer of proof preserves the argument for appeal.

(9) The ALJ may only consider admitted evidence and matters officially noticed in the proceeding (judicial notice) to decide the case.

(10) Admission of evidence is based upon the reasonable person standard. This standard means evidence that a reasonable person would rely on in making a decision.

(11) The ALJ may admit and consider hearsay evidence in accordance with RCW 34.05.452.

(12) The ALJ may reject evidence using the Washington rules of evidence as guidelines.

(13) The ALJ must reject evidence if required by law.

(14) The ALJ decides:

(a) What evidence is more credible if evidence conflicts; and

(b) The importance given to the evidence.

(15) The ALJ uses the Washington rules of evidence as guidelines when those rules do not conflict with the rules of this chapter or the Washington Administrative Procedure Act, chapter 34.05 RCW.

(16) The ALJ may permit a party or parties to submit additional evidence after the date of the hearing. The ALJ also may allow an appropriate amount of time for the other parties to respond and object to any evidence submitted after the hearing.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0390, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0390, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0405** Stipulations. {#sec-182-526-0405 omnilex-key=us-wa-regs-official--title-182--182-526-0405}

(1) A stipulation is an agreement among two or more parties that certain facts or evidence is correct or authentic.

(2) If an administrative law judge (ALJ) accepts a stipulation, the ALJ must enter it into the record.

(3) A stipulation may be made before or during the hearing.

(4) A party may change or reject a stipulation after it has been made.

(5) To change or reject a stipulation, a party must show the administrative law judge that:

(a) The party did not intend to make the stipulation or was mistaken when making it; and

(b) Changing or rejecting the stipulation does not harm the other parties.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0405, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0415** Exhibits. {#sec-182-526-0415 omnilex-key=us-wa-regs-official--title-182--182-526-0415}

(1) Proposed exhibits.

(a) Proposed exhibits are documents or other objects that a party wants the administrative law judge (ALJ) to consider when reaching a decision.

(b) After the document or object is accepted by the ALJ, it is admitted and becomes an exhibit.

(2) Marking and numbering proposed exhibits and providing copies.

(a) All parties should mark and number their proposed exhibits before the hearing.

(b) All parties should send their proposed exhibits to the office of administrative hearings (OAH) and to all other parties in advance of the hearing.

(c) Parties should bring to the hearing enough copies of their proposed exhibits for all parties if those exhibits were not provided prior to the hearing.

(d) If the party who requested the hearing cannot afford to provide copies of its exhibits for all parties, the requesting party must make its proposed exhibits available for copying. The ALJ may require proof that the requesting party is unable to afford copies.

(3) Admitting proposed exhibits into the record.

(a) The ALJ decides whether to admit a proposed exhibit into the record and also determines the importance of the evidence.

(b) The ALJ admits proposed exhibits into the record by marking, listing, identifying, and admitting the proposed exhibits.

(c) The ALJ must make rulings on the record to admit or exclude exhibits.

(4) Disagreeing with an exhibit proposed by another party.

(a) A party may object to the authenticity or admissibility of any exhibit, or offer argument about how much importance the ALJ should give the exhibit.

(b) Even if a party agrees that a proposed exhibit is a true and authentic copy of a document, the agreement does not mean that a party agrees with:

(i) Everything in the exhibit or agrees that it should apply to the hearing;

(ii) What the exhibit says; or

(iii) How the ALJ should use the exhibit to make a decision.

(c) The ALJ may also exclude proposed exhibits from the record.

(5) The following rules apply to filing proposed exhibits with OAH and serving them on the other parties for a telephonic hearing:

(a) Parties should file their proposed exhibits with OAH and serve them on the other parties at least five days before the telephonic hearing. In some cases, the ALJ may require that the parties file and serve them earlier.

(b) The health care authority hearing representative may help the appellant file copies of proposed exhibits with OAH and serve the other parties if the appellant cannot afford to do so. The ALJ may require the appellant to provide proof that they are unable to afford to do so.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0415, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0415, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0440** Judicial notice. {#sec-182-526-0440 omnilex-key=us-wa-regs-official--title-182--182-526-0440}

(1) The administrative law judge (ALJ) may consider and admit evidence by taking judicial notice.

(2) Judicial notice is evidence that includes facts or standards that are generally recognized and accepted by judges, government agencies, or national associations. For example, an administrative law judge may take judicial notice of a calendar, a building code, or a standard or practice.

(3) If a party requests judicial notice, or if the ALJ intends to take judicial notice, the ALJ may ask the party to provide a copy of the document that contains the information.

(4) If judicial notice has been requested, or if the ALJ intends to take judicial notice, the ALJ must tell the parties before or during the hearing.

(5) The ALJ must give the parties time to object to judicial notice evidence.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0440, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0450** Witness. {#sec-182-526-0450 omnilex-key=us-wa-regs-official--title-182--182-526-0450}

(1) The following persons may be witnesses in a hearing:

(a) The appellant or the health care authority (HCA) hearing representative; or

(b) Anyone the parties or the administrative law judge (ALJ) asks to be a witness.

(2) The ALJ decides who may testify as a witness.

(3) An expert witness may not be a former HCA employee, a former HCA authorized agent, or a former employee of the department in the proceeding against HCA or the department if that employee was actively involved in the HCA action while working for HCA or the department, unless the HCA hearing representative agrees.

(4) All witnesses:

(a) Must affirm or take an oath to testify truthfully during the hearing.

(b) May testify in person or by telephone.

(c) May request interpreters from the office of administrative hearings (OAH) at no cost to the party offering the witness.

(d) May be subpoenaed and ordered to appear according to WAC 182-526-0320.

(5) Cross-examining a witness.

(a) Each party has the right to cross-examine (question) each witness.

(b) If a party has a representative, only the representative, and not the party, may question the witness.

(c) The ALJ may also question witnesses.

(6) Witnesses may refuse to answer questions. However, if a witness refuses to answer a question, the ALJ may reject all of the related testimony of that witness.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0450, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0450, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0480** Burden of proof. {#sec-182-526-0480 omnilex-key=us-wa-regs-official--title-182--182-526-0480}

(1) Burden of proof is a party's responsibility to:

(a) Provide evidence regarding disputed facts; and

(b) Persuade the administrative law judge (ALJ) that a position is correct.

(2) To persuade the ALJ, the party who has the burden of proof must provide the amount of evidence required by WAC 182-526-0485. The ALJ decides if a party has met the burden of proof.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0480, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0485** Standard of proof. {#sec-182-526-0485 omnilex-key=us-wa-regs-official--title-182--182-526-0485}

Standard of proof refers to the amount of evidence needed to prove a party's position. Unless the rules or law states otherwise, the standard of proof in a hearing is a preponderance of the evidence. This standard means that it is more likely than not that something happened or exists.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0485, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0495** Equitable estoppel. {#sec-182-526-0495 omnilex-key=us-wa-regs-official--title-182--182-526-0495}

(1) Equitable estoppel is a legal doctrine that may be used only as an affirmative defense to prevent the health care authority (HCA) from collecting an overpayment. Equitable estoppel may not be used to require HCA to continue to provide something or to require HCA to take action contrary to a statute.

(2) There are five elements of equitable estoppel. A party asserting the doctrine of equitable estoppel must prove all of the following five elements by clear and convincing evidence:

(a) HCA made a statement or took an action or failed to take an action, which is inconsistent with a later claim or position by HCA.

(b) The party reasonably relied on HCA's original statement, action or failure to act.

(c) The party will be injured to its detriment if HCA is allowed to contradict the original statement, action or failure to act.

(d) Equitable estoppel is needed to prevent a manifest injustice. Factors to be considered in determining whether a manifest injustice would occur include, but are not limited to, whether:

(i) The party cannot afford to repay the money to HCA;

(ii) The party gave HCA timely and accurate information when required;

(iii) The party did not know that HCA made a mistake;

(iv) The party is free from fault; and

(v) The overpayment was caused solely by an HCA mistake.

(e) The exercise of government functions is not impaired.

(3) If the administrative law judge (ALJ) concludes that the party has proven all of the elements of equitable estoppel by clear and convincing evidence, HCA is estopped or prevented from taking action or enforcing a claim of overpayment against that party.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0495, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0495, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0500** Hearing record. {#sec-182-526-0500 omnilex-key=us-wa-regs-official--title-182--182-526-0500}

(1) Before the record is closed, the administrative law judge (ALJ) may:

(a) Set another hearing date;

(b) If needed, enter orders addressing limited issues before issuing a hearing decision resolving all issues in the proceeding; or

(c) Give the parties more time to file exhibits or written argument.

(2) The record is closed:

(a) At the end of the hearing if the ALJ does not allow more time to file evidence or argument; or

(b) After the deadline for filing evidence or argument is over.

(3) After the record is closed:

(a) No more evidence may be admitted without good cause;

(b) The ALJ must enter an initial order and the office of administrative hearings (OAH) must serve copies on all of the parties; and

(c) OAH must send the official record of the proceedings to the board of appeals. The record must be complete when it is sent, and include all parts required by WAC 182-526-0512.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0500, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0500, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0512** Contents of the hearing record. {#sec-182-526-0512 omnilex-key=us-wa-regs-official--title-182--182-526-0512}

(1) The administrative law judge must produce a complete official record of the proceedings.

(2) The official record must include, if applicable:

(a) Notice of all proceedings;

(b) Any prehearing order;

(c) Any motions, pleadings, briefs, petitions requests, and intermediate rulings;

(d) Evidence received or considered;

(e) A statement of matters officially noticed;

(f) Offers of proof, objections, and any resulting rulings;

(g) Proposed findings, requested orders and exceptions;

(h) A complete audio recording of the entire hearing, together with any transcript of the hearing;

(i) Any final order, initial order, or order on reconsideration; and

(j) Matters placed on the record after an ex parte communication.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0512, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0520** Information which must be included in the ALJ's initial order. {#sec-182-526-0520 omnilex-key=us-wa-regs-official--title-182--182-526-0520}

In an initial order, the administrative law judge (ALJ) must:

(1) Identify the matter as a health care authority appeal;

(2) List the name and docket number of the case and the names of all parties and representatives;

(3) Make findings concerning the facts used to resolve the dispute based on the hearing record;

(4) Explain how the ALJ determined that evidence is credible or not credible when the facts or conduct of a witness is questioned;

(5) State the law that applies to the dispute;

(6) Apply the law to the facts of the case in the conclusions of law;

(7) Discuss the reasons for the decision based on the facts and the law;

(8) State the result and remedy ordered;

(9) Explain how to request corrections to the initial order or petition for review by the board of appeals (BOA) and provide the deadlines for such requests;

(10) State the date the initial order becomes final according to WAC 182-526-0525; and

(11) Include any other information required by law or program rules.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0520, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0520, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0525** When initial orders become final. {#sec-182-526-0525 omnilex-key=us-wa-regs-official--title-182--182-526-0525}

An initial order becomes a final order at 5:00 p.m. on the twenty-first calendar day after the office of administrative hearings (OAH) serves the initial order, unless:

(1) Any party files a request for review of the initial order within twenty-one calendar days of the serving (mailing) of the initial order in accordance with WAC 182-526-0580(1);

(2) Any party files a request for extension of the deadline for filing a request for review which is granted by the review judge under WAC 182-526-0580(2); or

(3) Any party files a late request for review which is accepted by a review judge in accordance with WAC 182-526-0580(3);

(4) A managed care enrollee requests review by an independent review (IR) organization in accordance with RCW 48.43.535 prior to the initial order becoming final or a final order being entered by a review judge. See WAC 182-526-0200 for enrollee appeals.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0525, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0525, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0530** How to correct or appeal an initial order. {#sec-182-526-0530 omnilex-key=us-wa-regs-official--title-182--182-526-0530}

(1) If a party disagrees with an administrative law judge's (ALJ) initial order because of a clerical error, the party may ask for a corrected initial order from the ALJ as provided in WAC 182-526-0540 through 182-526-0555.

(2) If a party disagrees with an initial order for a reason other than a clerical error and wants the initial order changed, the party must request review by a review judge as provided in WAC 182-526-0560 through 182-526-0595.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0530, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0540** Correction of clerical errors in an initial order. {#sec-182-526-0540 omnilex-key=us-wa-regs-official--title-182--182-526-0540}

(1) A clerical error is a mistake that does not change the intent of the initial order.

(2) The administrative law judge (ALJ) may correct clerical errors in the initial order by entering a corrected initial order. The ALJ may correct clerical errors in response to a request by one of the parties.

(3) Some examples of clerical error are:

(a) Missing or incorrect words or numbers;

(b) Dates inconsistent with the decision or evidence in the record such as using May 3, 2004, instead of May 3, 2014; or

(c) Math errors when adding the total of an overpayment.

(4) If the ALJ does not agree that the initial order contains one or more clerical errors, the ALJ enters a written order denying the request for a corrected order.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0540, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0540, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0545** How a party requests a corrected initial order. {#sec-182-526-0545 omnilex-key=us-wa-regs-official--title-182--182-526-0545}

(1) A party may request that the administrative law judge (ALJ) issue a corrected initial order by calling or writing to the office of administrative hearings field office that held the hearing.

(2) When asking for a corrected initial order, the party must identify the clerical error that is claimed.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0545, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0545, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0550** Deadline for a party to request a corrected initial order. {#sec-182-526-0550 omnilex-key=us-wa-regs-official--title-182--182-526-0550}

(1) A party requesting a corrected initial order from the administrative law judge (ALJ) must make the request on or before the tenth calendar day after the order was served.

(2) The time period provided in subsection (1) of this section and the time it takes the ALJ to deny the request or make a decision regarding the request for a corrected initial order, do not count against any deadline for a review judge to enter a final order.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0550, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0550, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0555** Process after a party requests a corrected initial order. {#sec-182-526-0555 omnilex-key=us-wa-regs-official--title-182--182-526-0555}

(1) When a party requests a corrected initial order, the administrative law judge (ALJ) must either:

(a) Serve all parties a corrected order within ten calendar days; or

(b) Deny the request in writing within three business days of receiving it.

(2) If the ALJ corrects an initial order and a party does not request review, the corrected initial order becomes a final order at 5:00 p.m., twenty-one calendar days after the corrected initial order was served.

(3) If the ALJ denies a request for a corrected initial order and a party does not request review, the initial order becomes a final order at 5:00 p.m., twenty-one calendar days after the initial order was served.

(4) If the ALJ denies the request for a corrected initial order and the party still wants the initial order corrected, the party must request review by a review judge.

(5) Requesting an ALJ to correct the initial order only extends the deadline to request review of the initial order by a review judge if a corrected initial order is subsequently issued.

(6) When a party needs more time to request review of an initial order, the party must ask for more time to request review as permitted by WAC 182-526-0580(2).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0555, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0555, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0560** Review of an initial order by a review judge. {#sec-182-526-0560 omnilex-key=us-wa-regs-official--title-182--182-526-0560}

(1) A party who disagrees with the initial order entered by an administrative law judge (ALJ) may request review by a review judge at the board of appeals (BOA).

(2) When a review judge reviews an initial order, the review judge does not hold another hearing. See WAC 182-526-0595.

(3) Review judges may not review an initial order after the order becomes a final order, except as permitted by WAC 182-526-0580.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0560, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0560, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0565** Evidence a review judge considers in reviewing an initial order. {#sec-182-526-0565 omnilex-key=us-wa-regs-official--title-182--182-526-0565}

(1) The review judge, in most cases, only considers evidence admitted in the record by the administrative law judge.

(2) The review judge considers the request, the initial order, and the record before deciding if the initial order should be changed.

(3) The review judge may allow the parties to make oral argument when reviewing initial orders.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0565, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0570** Request for review of an initial order. {#sec-182-526-0570 omnilex-key=us-wa-regs-official--title-182--182-526-0570}

(1) Any party may request a review judge to review the initial order.

(2) If more than one party requests review, each request must meet the deadlines in WAC 182-526-0580.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0570, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0575** How to request review of an initial order. {#sec-182-526-0575 omnilex-key=us-wa-regs-official--title-182--182-526-0575}

(1) A party must make the request for review of an initial order in writing and file the request with the board of appeals (BOA) at the address given in WAC 182-526-0030 and within the deadlines set forth in WAC 182-526-0580.

(2) The request for review should identify the parts of the initial order with which the party disagrees and should identify the evidence in the hearing record supporting the party's position.

(3) The party seeking review should also send a copy of the review request to the other parties.

(4) After receiving a request for review of an initial order, BOA serves a copy on the other parties and their representatives. The other parties and their representatives may respond as described in WAC 182-526-0590.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-06-049, s 182-526-0575, filed 2/25/26, effective 3/28/26*
- *WSR 17-05-066, § 182-526-0575, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0575, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0580** Deadline for requesting review of an initial order by a review judge. {#sec-182-526-0580 omnilex-key=us-wa-regs-official--title-182--182-526-0580}

(1) The board of appeals (BOA) must receive the written review request of an initial order on or before 5:00 p.m. on the 21st calendar day after the initial order was served, unless an extension of the deadline is granted by the review judge.

(2) A party may file the written review request by physical mail, by facsimile transmission (fax), electronically by email, or in-person delivery. For the BOA contact information, see WAC 182-526-0030.

(3) A review judge may extend the deadline to request review if a party:

(a) Asks for more time before the deadline expires; and

(b) Gives a good reason for more time.

(4) A review judge may accept a review request after the 21 calendar day deadline only if:

(a) BOA receives the review request on or before the 30th calendar day after the deadline; and

(b) A party shows good cause for missing the deadline.

(5) The time periods provided by this section for requesting review of an initial order, including any extensions, does not count against a deadline, if any, for a review judge to enter the final order.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-20-046, § 182-526-0580, filed 9/28/22, effective 10/29/22*
- *WSR 17-05-066, § 182-526-0580, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0580, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0590** Response to a request for review. {#sec-182-526-0590 omnilex-key=us-wa-regs-official--title-182--182-526-0590}

(1) A party does not have to respond to the request for review. A response is optional.

(2) If a party decides to respond, that party must file the response so that the board of appeals (BOA) receives it on or before the seventh business day after the date the other party's review request was served to the party by the BOA.

(3) The party should send a copy of the response to all other parties or their representatives.

(4) A review judge may extend the deadline in subsection (2) of this section if a party asks for more time before the deadline to respond expires and gives a good reason.

(5) If a party asks for more time to respond, the time period provided by this section for responding to the review request, including any extensions, does not count against any deadline for a review judge to enter the final order.

(6) A review judge may accept and consider a party's response even if it is filed after the deadline.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0590, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0595** Process after review response deadline. {#sec-182-526-0595 omnilex-key=us-wa-regs-official--title-182--182-526-0595}

(1) After the response deadline, the record on review is closed unless the review judge finds there is a good reason to keep it open.

(2) A review judge is assigned to review the initial order after the record on review is closed. To find out which judge is assigned, call the board of appeals.

(3) After the record is closed, the assigned review judge:

(a) Reviews the record, including the initial order; and

(b) Enters a final order that affirms, modifies, dismisses or reverses the initial order; or

(c) Returns the case to the office of administrative hearings for further action.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0595, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0595, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0600** Authority of the review judge. {#sec-182-526-0600 omnilex-key=us-wa-regs-official--title-182--182-526-0600}

(1) In some cases, review judges review initial orders and enter final orders. The review judge has the same decision-making authority as the administrative law judge (ALJ). The review judge considers the entire record and decides the case de novo (anew). In reviewing findings of fact, the review judge must give due regard to the ALJ's opportunity to observe witnesses.

(2) Review judges may remand (return) cases to the office of administrative hearings for further action.

(3) In cases where there is a consolidated hearing under WAC 182-526-0387, any party may request review of the initial order in accordance with the requirements contained in this chapter.

(4) Review judges may not review an ALJ order after the order becomes final, except as provided in WAC 182-526-0580.

(5) A review judge conducts the hearing and enters the final order in cases where a contractor for the delivery of nursing facility services requests an administrative hearing under WAC 388-96-904(5).

**History**
- *Statutory Authority: RCW 41.05.021 and, 41.05.160. WSR 17-05-066, § 182-526-0600, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0600, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0605** Reconsideration of a final order entered by a review judge. {#sec-182-526-0605 omnilex-key=us-wa-regs-official--title-182--182-526-0605}

(1) If a party does not agree with the final order and wants it reconsidered, the party may request the review judge to reconsider the decision.

(2) The party must make the request in writing and clearly state why the party wants the final order reconsidered. The party must file the written reconsideration request with BOA and it must be received by the deadline under WAC 182-526-0620.

(3) The party should send a copy of the request to all other parties or their representatives.

(4) After receiving a reconsideration request, BOA serves a copy to the other parties and representatives and gives them time to respond.

(5) The final order or the reconsideration decision is the final HCA decision. If a party disagrees with that decision, the party must petition for judicial review to change it.

(6) If a party asks for reconsideration of the final order, the reconsideration process must be completed before a party requests judicial review. However, the party does not need to request reconsideration of a final order before requesting judicial review.

(7) The party may ask the court to stay or stop the HCA action after filing the petition for judicial review.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0605, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0605, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0620** Deadline for requesting reconsideration. {#sec-182-526-0620 omnilex-key=us-wa-regs-official--title-182--182-526-0620}

(1) To request reconsideration of a final order entered by a review judge, the BOA must receive a written reconsideration request on or before the tenth calendar day after the final order was served.

(2) The review judge may extend its deadline for filing a request for reconsideration if a party:

(a) Asks for more time before the deadline expires; and

(b) Gives a good reason for the extension.

(3) If a reconsideration request is filed after the deadline, the final order will not be reconsidered and the deadline to ask for judicial review of the final HCA decision continues to run.

(4) If a party does not request reconsideration or fails to ask for an extension within the deadline, the final order may not be reconsidered and it becomes the final HCA decision.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0620, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0630** Responding to a reconsideration request. {#sec-182-526-0630 omnilex-key=us-wa-regs-official--title-182--182-526-0630}

(1) A party does not have to respond to a request for reconsideration of a final order. A response is optional.

(2) If a party responds, that party must file a response with the board of appeals (BOA) by or before the seventh business day after the date the review judge mailed the request to the party.

(3) A party should send a copy of the response to any other party or representative.

(4) If a party needs more time to respond, the review judge may extend its deadline if the party gives a good reason within the deadline in subsection (2) of this section.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0630, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0635** Process after a party requests reconsideration. {#sec-182-526-0635 omnilex-key=us-wa-regs-official--title-182--182-526-0635}

(1) After the review judge receives a reconsideration request, the review judge has twenty calendar days to enter and serve a reconsideration decision unless the review judge serves notice allowing more time.

(2) After the BOA receives a reconsideration request, the review judge must either:

(a) Write a reconsideration decision; or

(b) Serve all parties an order denying the request.

(3) If the review judge does not serve an order or notice granting more time within twenty days of receipt of the reconsideration request, the request is denied.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0635, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0640** Judicial review of a final order. {#sec-182-526-0640 omnilex-key=us-wa-regs-official--title-182--182-526-0640}

(1) Judicial review is the process of appealing a final order to a court.

(2) The party that requested the hearing may appeal a final order by filing a written petition for judicial review that meets the requirements of RCW 34.05.546. HCA may not request judicial review.

(3) The party seeking judicial review must consult RCW 34.05.510 to 34.05.598 for further details of the judicial review process.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-05-066, § 182-526-0640, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0640, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0645** Deadline for petition for judicial review and filing requirements. {#sec-182-526-0645 omnilex-key=us-wa-regs-official--title-182--182-526-0645}

A party must file a petition for judicial review with the superior court within thirty calendar days after the final order is served to the parties.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0645, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0647** Exhaustion of administrative remedies required. {#sec-182-526-0647 omnilex-key=us-wa-regs-official--title-182--182-526-0647}

Generally, a party may file a petition for judicial review only after it has completed the administrative hearing process. See RCW 34.05.534.

**History**
- *Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0647, filed 12/19/12, effective 2/1/13.*

##### **Wash. Admin. Code § 182-526-0650** Service of petition for judicial review. {#sec-182-526-0650 omnilex-key=us-wa-regs-official--title-182--182-526-0650}

(1) The party requesting judicial review must:

(a) File a petition for judicial review with the court;

(b) File and serve the petition for judicial review of a final order within 30 days after the date it was mailed to the parties; and

(c) Serve copies of the petition on the health care authority (HCA), the office of the attorney general, and all other parties.

(2) To serve HCA, the petitioning party must deliver a copy of the petition for judicial review to the HCA board of appeals (BOA). The party may hand deliver the petition, send it by mail that gives proof of receipt, or serve it electronically. See WAC 182-526-0030 for the BOA physical, mailing, and electronic service addresses.

(3) To serve the office of the attorney general and other parties, the petitioning party may send a copy of the petition for judicial review by regular mail. The party may send a petition to the address for the attorney of record to serve a party. The party may serve the office of the attorney general by hand delivery to:

Office of the Attorney General

7141 Cleanwater Drive S.W.

Tumwater, WA 98501

The mailing address of the attorney general is:

Office of the Attorney General

P.O. Box 40124

Olympia, WA 98504-0124

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-04-009, s 182-526-0650, filed 1/23/25, effective 2/23/25*
- *WSR 17-05-066, § 182-526-0650, filed 2/13/17, effective 3/16/17. Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0650, filed 12/19/12, effective 2/1/13.*

## **Chapter 182-527** Estate recovery and pre death liens. {#struct-chapter-182-527}

##### **Wash. Admin. Code § 182-527-2730** Definitions. {#sec-182-527-2730 omnilex-key=us-wa-regs-official--title-182--182-527-2730}

The following definitions apply to this chapter:

"Contract health service delivery area (CHSDA)" means the geographic area within which contract health services will be made available by the Indian health service to members of an identified Indian community who reside in the area as identified in 42 C.F.R. Secs. 136.21(d) and 136.22.

"Estate" means all property and any other assets that pass upon the client's death under the client's will or by intestate succession under chapter 11.04 or 11.62 RCW. The value of the estate will be reduced by any valid liability against the client's property when the client died. An estate also includes:

(1) For a client who died after June 30, 1995, and before July 27, 1997, nonprobate assets as defined by RCW 11.02.005, except property passing through a community property agreement; or

(2) For a client who died after July 26, 1997, and before September 14, 2006, nonprobate assets as defined by RCW 11.02.005.

(3) For a client who died on or after September 14, 2006, nonprobate assets as defined by RCW 11.02.005 and any life estate interest held by the client immediately before death.

"Heir" means a person entitled to inherit a deceased client's property under a valid will accepted by the court, or a person entitled to inherit under the Washington state intestacy statute, RCW 11.04.015.

"Life estate" means an ownership interest in a property only during the lifetime of the person owning the life estate.

"Lis pendens" means a notice filed in public records warning that title to certain real property is in litigation and the outcome of the litigation may affect the title.

"Long-term care services (LTC)" means, for the purposes of this chapter only, the services administered directly or through contract by the department of social and health services (DSHS) for clients of the home and community services division of DSHS and the developmental disabilities community services division of DSHS including, but not limited to, nursing facility care and home and community services.

"Property" means everything a person owns, whether in whole or in part.

(1) "Personal property" means any movable or intangible thing a person owns, whether in whole or in part;

(2) "Real property" means land and anything growing on, attached to, or built on it, excluding anything that may be removed without injury to the land;

(3) "Trust property" means any type of property held in trust for the benefit of another.

"Qualified long-term care insurance partnership" means an agreement between the Centers for Medicare and Medicaid services (CMS) and the Washington state insurance commission which allows for the disregard of any assets or resources in an amount equal to the insurance benefit payments that are made to or on behalf of a person who is a beneficiary under a long-term care insurance policy that has been determined by the Washington state insurance commission to meet the requirements of section 1917 (b)(1)(C)(iii) of the act.

"Recover" or "recovery" means the agency or the agency's designee's receipt of funds to satisfy the client's debt.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-527-2730, filed 11/4/25, effective 12/5/25*
- *WSR 16-05-054, § 182-527-2730, filed 2/12/16, effective 3/14/16. Statutory Authority: RCW 41.05.021. WSR 13-19-038, § 182-527-2730, filed 9/11/13, effective 10/12/13. WSR 12-19-070, recodified as § 182-527-2730, filed 9/17/12, effective 10/1/12. Statutory Authority: RCW 74.08.090 and 2008 Medicare Improvements for Patient and Providers Act (which amended Section 1917 (b)(1)(B)(ii) of the Social Security Act)*
- *Deficit Reduction Act of 2005 (incorporating language regarding LTC partnership agreements). WSR 10-08-110, § 388-527-2730, filed 4/7/10, effective 5/8/10. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and chapter 26.60 RCW. WSR 09-07-038, § 388-527-2730, filed 3/10/09, effective 4/10/09. Statutory Authority: 2005 c 292, RCW 43.20B.080, 74.39A.170, 42 U.S.C. Section 1396p. WSR 06-17-075, § 388-527-2730, filed 8/14/06, effective 9/14/06. Statutory Authority: RCW 43.17.240, 43.20B.80 [ 43.20B.080], 74.08.090, 74.34.090, Section 1917(b) of the Social Security Act and 2001 2nd sp.s. c 7, Part II. WSR 04-10-060, § 388-527-2730, filed 4/30/04, effective 6/1/04. Statutory Authority: RCW 43.20B.080, 74.08.090 and 74.34.010. WSR 99-11-076, § 388-527-2730, filed 5/18/99, effective 6/18/99. Statutory Authority: 1995 1st sp.s. c 18 and RCW 74.08.090. WSR 95-19-001 and 95-24-037 (Orders 3893 and 3893A), § 388-527-2730, filed 9/6/95 and 11/29/95, effective 10/7/95 and 12/30/95.*

##### **Wash. Admin. Code § 182-527-2734** Liens during a client's lifetime. {#sec-182-527-2734 omnilex-key=us-wa-regs-official--title-182--182-527-2734}

For the purposes of this section, the term "agency" includes the agency's designee.

(1) When the agency may file.

(a) The agency may file a lien against the property of a Washington apple health client during the client's lifetime if:

(i) The client resides in a skilled nursing facility, intermediate care facility for individuals with an intellectual disability, or other medical institution under WAC 182-500-0050;

(ii) The agency determines that a client cannot reasonably be expected to return home because:

(A) The agency receives a physician's verification that the client will not be able to return home; or

(B) The client has resided for six months or longer in an institution as defined in WAC 182-500-0050; and

(iii) None of the following people lawfully reside in the client's home:

(A) The client's spouse or state-registered domestic partner;

(B) The client's child who is age twenty or younger, or is blind or permanently disabled as defined in WAC 182-512-0050; or

(C) A client's sibling who has an equity interest in the home and who has been residing in the home for at least one year immediately before the client's admission to the medical institution.

(b) If the client returns home from the medical institution, the agency releases the lien.

(2) Amount of the lien.

(a) The agency may file a lien to recoup the cost of all non-MAGI-based and deemed eligible services under WAC 182-503-0510 it correctly purchased on the client's behalf, regardless of the client's age on the date of service.

(b) Services provided under the medicaid transformation project, defined in WAC 182-500-0070, are excluded when determining the amount of the lien.

(3) Notice requirement.

(a) Before the agency may file a lien under this section, it sends notice via first class mail to:

(i) The client's last known address;

(ii) The client's authorized representative, if any;

(iii) The address of the property subject to the lien; and

(iv) Any other person known to hold title to the property.

(b) The notice states:

(i) The client's name;

(ii) The agency's intent to file a lien against the client's property;

(iii) The county in which the property is located; and

(iv) How to request an administrative hearing.

(4) Interest assessed on past-due debt.

(a) Interest on a past-due debt accrues at a rate of one percent per month under RCW 43.17.240.

(b) A lien under this section becomes a past-due debt when the agency has recorded the lien in the county where the property is located and:

(i) Thirty days have passed since the property was transferred; or

(ii) Nine months have passed since the lien was filed.

(c) The agency may waive interest if reasonable efforts to sell the property have failed.

(5) Administrative hearing. An administrative hearing under this section is governed by WAC 182-527-2753.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160, 2016 1st sp.s. c 36 § 213 (1)(e), section 1115 of the Social Security Act, and 42 C.F.R. §§ 431.400 through 431.428. WSR 17-12-019, § 182-527-2734, filed 5/30/17, effective 7/1/17. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-05-054, § 182-527-2734, filed 2/12/16, effective 3/14/16.*

##### **Wash. Admin. Code § 182-527-2738** Estate recovery—General right to recover. {#sec-182-527-2738 omnilex-key=us-wa-regs-official--title-182--182-527-2738}

For the purposes of this section, the term "agency" includes the agency's designee.

(1) When the agency may file. After a Washington apple health client has died, the medicaid agency may file liens to recover the cost of services subject to recovery that were correctly paid on the client's behalf.

(2) Notice requirement.

(a) Before the agency may file a lien under this section, it sends notice via first class mail as follows:

(i) If the estate has a personal representative, the agency sends notification to:

(A) The personal representative; and

(B) Any known title holder.

(ii) If the estate has known heirs but no personal representative, the agency sends notification to:

(A) Any known heir; and

(B) Any known title holder.

(iii) If the estate has no personal representative and no known heirs, the agency sends notification to:

(A) The address listed on the title; and

(B) Any known title holder.

(b) The notice states:

(i) The agency's intent to file a lien against the deceased client's property;

(ii) The amount the agency seeks to recover;

(iii) The deceased client's name, identification number, date of birth, and date of death;

(iv) The county in which the property is located; and

(v) How to request an administrative hearing.

(3) The agency may not recover from the client's estate so long as there remains:

(a) A surviving spouse; or

(b) A surviving child who:

(i) Is age twenty or younger; or

(ii) Is blind or disabled as defined in WAC 182-512-0050.

(4) Interest assessed on past-due debt.

(a) Interest on a past-due debt accrues at a rate of one percent per month under RCW 43.17.240.

(b) A lien under this section becomes a past-due debt when the agency has recorded the lien in the county where the property is located and nine months have passed since the lien was recorded or a creditor's claim was filed, whichever is sooner.

(c) The agency may waive interest if reasonable efforts to sell the property have failed.

(5) Administrative hearing. An administrative hearing under this section is governed by WAC 182-527-2753.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-05-054, § 182-527-2738, filed 2/12/16, effective 3/14/16.*

##### **Wash. Admin. Code § 182-527-2740** Estate recovery—Age-related limitations. {#sec-182-527-2740 omnilex-key=us-wa-regs-official--title-182--182-527-2740}

For the purposes of this section, the term "agency" includes the agency's designee.

(1) Liability for medicaid services.

(a) Beginning July 26, 1987, a client's estate is liable for medicaid services subject to recovery that were provided on or after the client's 65th birthday.

(b) Beginning July 1, 1994, a client's estate is liable for medicaid services subject to recovery that were provided on or after the client's 55th birthday.

(2) Liability for state-only-funded long-term care services.

(a) A client's estate is liable for all state-only-funded long-term care services provided by the home and community services division of the department of social and health services (DSHS) on or after July 1, 1995.

(b) A client's estate is liable for all state-only-funded long-term care services provided by the developmental disabilities community services division of DSHS on or after June 1, 2004.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-527-2740, filed 11/4/25, effective 12/5/25*
- *WSR 16-05-054, § 182-527-2740, filed 2/12/16, effective 3/14/16. Statutory Authority: RCW 41.05.021. WSR 13-19-038, § 182-527-2740, filed 9/11/13, effective 10/12/13. WSR 12-19-070, recodified as § 182-527-2740, filed 9/17/12, effective 10/1/12. Statutory Authority: RCW 43.17.240, 43.20B.80 [ 43.20B.080], 74.08.090, 74.34.090, Section 1917(b) of the Social Security Act and 2001 2nd sp.s. c 7, Part II. WSR 04-10-060, § 388-527-2740, filed 4/30/04, effective 6/1/04. Statutory Authority: RCW 43.20B.080, 74.08.090 and 74.34.010. WSR 99-11-076, § 388-527-2740, filed 5/18/99, effective 6/18/99. Statutory Authority: 1995 1st sp.s. c 18 and RCW 74.08.090. WSR 95-19-001 and 95-24-037 (Orders 3893 and 3893A), § 388-527-2740, filed 9/6/95 and 11/29/95, effective 10/7/95 and 12/30/95.*

##### **Wash. Admin. Code § 182-527-2742** Estate recovery—Service-related limitations. {#sec-182-527-2742 omnilex-key=us-wa-regs-official--title-182--182-527-2742}

For the purposes of this section, the term "agency" includes the agency's designee.

The agency's payment for the following services is subject to recovery:

(1) State-only funded services, except:

(a) Adult protective services;

(b) Offender reentry community safety program services;

(c) Supplemental security payments (SSP) authorized by developmental disabilities community services (DDCS);

(d) Volunteer chore services; and

(e) Guardianship and conservatorship assistance program services.

(2) For dates of service on and after January 1, 2014:

(a) Basic plus waiver services;

(b) Community first choice (CFC) services;

(c) Community option program entry system (COPES) services;

(d) Community protection waiver services;

(e) Core waiver services;

(f) Hospice services;

(g) Intermediate care facility for individuals with intellectual disabilities services provided in either a private community setting or in a rural health clinic;

(h) Individual and family services;

(i) Medicaid personal care services;

(j) New Freedom consumer directed services;

(k) Nursing facility services;

(l) Personal care services funded under Title XIX or XXI;

(m) Private duty nursing administered by the home and community living administration (HCLA);

(n) Residential habilitation center services;

(o) Residential support waiver services;

(p) Roads to community living demonstration project services;

(q) The portion of the managed care premium used to pay for HCLA-authorized long-term care services under the program of all-inclusive care for the elderly (PACE); and

(r) The hospital and prescription drug services provided to a client while the client was receiving services listed in this subsection.

(3) For dates of service beginning January 1, 2010, through December 31, 2013:

(a) Medicaid services;

(b) Premium payments to managed care organizations (MCOs); and

(c) The client's proportional share of the state's monthly contribution to the Centers for Medicare and Medicaid Services to defray the costs for outpatient prescription drug coverage provided to a person who is eligible for medicare Part D and medicaid.

(4) For dates of service beginning June 1, 2004, through December 31, 2009:

(a) Medicaid services;

(b) Medicare premiums for people also receiving medicaid;

(c) Medicare savings programs (MSPs) services for people also receiving medicaid; and

(d) Premium payments to MCOs.

(5) For dates of service beginning July 1, 1995, through May 31, 2004:

(a) Adult day health services;

(b) Home and community-based services;

(c) Medicaid personal care services;

(d) Nursing facility services;

(e) Private duty nursing services; and

(f) The hospital and prescription drug services provided to a client while the client was receiving services listed in this subsection.

(6) For dates of service beginning July 1, 1994, through June 30, 1995:

(a) Home and community-based services;

(b) Nursing facility services; and

(c) The hospital and prescription drug services provided to a client while the client was receiving services listed in this subsection.

(7) For dates of service beginning July 26, 1987, through June 30, 1994: Medicaid services.

(8) For dates of service through December 31, 2009. If a client was eligible for the MSP, but not otherwise medicaid eligible, the client's estate is liable only for any sum paid to cover medicare premiums and cost-sharing benefits.

(9) For dates of service beginning January 1, 2010. If a client was eligible for medicaid and the MSP, the client's estate is not liable for any sum paid to cover medical assistance cost-sharing benefits.

(10) For dates of service beginning July 1, 2017, long-term services and supports authorized under the medicaid transformation project are exempt from estate recovery. Exempted services include those provided under:

(a) Medicaid alternative care under WAC 182-513-1600;

(b) Tailored supports for older adults under WAC 182-513-1610;

(c) Supportive housing under WAC 388-106-1700 through 388-106-1765; or

(d) Supported employment under WAC 388-106-1800 through 388-106-1865.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-527-2742, filed 11/4/25, effective 12/5/25*
- *WSR 24-12-011, § 182-527-2742, filed 5/23/24, effective 6/23/24. Statutory Authority: RCW 41.05.021 and 41.05.160, 2016 1st sp.s. c 36 § 213 (1)(e), section 1115 of the Social Security Act, and 42 C.F.R. §§ 431.400 through 431.428. WSR 17-12-019, § 182-527-2742, filed 5/30/17, effective 7/1/17. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-05-054, § 182-527-2742, filed 2/12/16, effective 3/14/16. Statutory Authority: RCW 41.05.021, 41.05.160 and Public Law 111-148, Patient Protection and Affordable Care Act. WSR 14-20-091, § 182-527-2742, filed 9/29/14, effective 10/30/14. Statutory Authority: RCW 41.05.021. WSR 13-19-038, § 182-527-2742, filed 9/11/13, effective 10/12/13. WSR 12-19-070, recodified as § 182-527-2742, filed 9/17/12, effective 10/1/12. Statutory Authority: RCW 74.08.090 and 2008 Medicare Improvements for Patient and Providers Act (which amended Section 1917 (b)(1)(B)(ii) of the Social Security Act)*
- *Deficit Reduction Act of 2005 (incorporating language regarding LTC partnership agreements). WSR 10-08-110, § 388-527-2742, filed 4/7/10, effective 5/8/10. Statutory Authority: 2005 c 292, RCW 43.20B.080, 74.39A.170, 42 U.S.C. Section 1396p. WSR 06-17-075, § 388-527-2742, filed 8/14/06, effective 9/14/06. Statutory Authority: RCW 43.17.240, 43.20B.80 [ 43.20B.080], 74.08.090, 74.34.090, Section 1917(b) of the Social Security Act and 2001 2nd sp.s. c 7, Part II. WSR 04-10-060, § 388-527-2742, filed 4/30/04, effective 6/1/04. Statutory Authority: RCW 43.20B.080, 74.08.090 and 74.34.010. WSR 99-11-076, § 388-527-2742, filed 5/18/99, effective 6/18/99. Statutory Authority: RCW 74.08.090 and 1995 1st sp.s. c 18. WSR 95-19-001 (Order 3893), § 388-527-2742, filed 9/6/95, effective 10/7/95.*

##### **Wash. Admin. Code § 182-527-2746** Estate recovery—Asset-related limitations. {#sec-182-527-2746 omnilex-key=us-wa-regs-official--title-182--182-527-2746}

For the purposes of this section, the term "agency" includes the agency's designee.

(1) Before July 25, 1993. For services received before July 25, 1993, that are subject to recovery, the agency may exempt:

(a) The first fifty thousand dollars of the estate's value at the time of the client's death; and

(b) Sixty-five percent of the remaining value of the estate.

(2) July 24, 1993, through June 30, 1994. For services that are subject to recovery that were received on or after July 25, 1993, through June 30, 1994, the agency exempts two thousand dollars' worth of personal property.

(3) Life estate.

(a) The agency may file a lien against a client's life estate interest in real property.

(b) The agency's lien against the property may not exceed the value of the client's life estate. Under this subsection, value means the fair market value of the property multiplied by the life estate factor that corresponds to the client's age on the client's last birthday. For a list of life estate factors, see the life estate and remainder interest tables maintained by the Social Security Administration.

(c) The agency may not enforce a lien under this subsection against any property right that vested before July 1, 2005.

(4) Joint tenancy.

(a) The agency may file a lien against property in which a client was a joint tenant when the client died.

(b) The agency's lien against the property may not exceed the value of the client's interest in the property. Under this subsection, value means the fair market value of the property divided by the number of joint tenants on the day the client died.

(c) The agency may not enforce a lien under this subsection against any property right that vested before July 1, 2005.

(5) Qualified long-term care partnership.

(a) Assets designated as protected by a qualified long-term care partnership (QLTCP) policy issued after November 30, 2011, may be disregarded for estate recovery purposes if:

(i) The insured person's estate is the recipient of the estate recovery exemption; or

(ii) The insured person holds title to property which is potentially subject to a predeath lien and that person asserts the property is protected under the QLTCP policy.

(b) A person must provide clear and convincing evidence to the office of financial recovery that the asset in question was designated as protected, including:

(i) Proof of a valid QLTCP policy;

(ii) Verification from the LTC insurance company of the dollar amount paid out by the policy; and

(iii) A current department of social and health services QLTCP asset designation form when the QLTCP policy paid out more than was previously designated.

(c) The insured person's estate must provide clear and convincing evidence proving an asset is protected before the final recovery settlement.

(6) Rules specific to American Indians and Alaska natives.

(a) Certain properties belonging to American Indians/Alaska natives (AI/AN) are exempt from estate recovery if at the time of death:

(i) The deceased client was enrolled in a federally recognized tribe; and

(ii) The estate or heir documents the deceased client's ownership interest in trust or nontrust real property and improvements located on a reservation, near a reservation as designated and approved by the Bureau of Indian Affairs of the U.S. Department of the Interior, or located:

(A) Within the most recent boundaries of a prior federal reservation; or

(B) Within the contract health service delivery area boundary for social services provided by the deceased client's tribe to its enrolled members.

(b) Protection of trust and nontrust property under subsection (4) of this section is limited to circumstances when the real property and improvements pass from an Indian (as defined in 25 U.S.C. Chapter 17, Sec. 1452(b)) to one or more relatives (by blood, adoption, or marriage), including Indians not enrolled as members of a tribe and non-Indians, such as spouses and stepchildren, that their tribe would nonetheless recognize as family members, to a tribe or tribal organization and/or to one or more Indians.

(c) Certain AI/AN income and resources (such as interests in and income derived from tribal land and other resources currently held in trust status and judgment funds from the Indian Claims Commission and the U.S. Claims Court) are exempt from estate recovery by other laws and regulations.

(d) Ownership interests in or usage rights to items that have unique religious, spiritual, traditional, and/or cultural significance or rights that support subsistence or a traditional life style according to applicable tribal law or custom.

(e) Government reparation payments specifically excluded by federal law in determining eligibility are exempt from estate recovery as long as such funds have been kept segregated and not commingled with other countable resources and remain identifiable.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-05-054, § 182-527-2746, filed 2/12/16, effective 3/14/16.*

##### **Wash. Admin. Code § 182-527-2750** Estate recovery—Delay of recovery for undue hardship. {#sec-182-527-2750 omnilex-key=us-wa-regs-official--title-182--182-527-2750}

For the purposes of this section, the term "agency" includes the agency's designee.

(1) If an undue hardship exists at the time of the client's death, an heir may ask the agency to delay recovery.

(a) Undue hardship exists only when:

(i) The property subject to recovery is the sole income-producing asset of an heir;

(ii) Recovery would deprive an heir of shelter and the heir cannot afford alternative shelter; or

(iii) The client is survived by a state-registered domestic partner.

(b) Undue hardship does not exist if the client or the heir created circumstances to avoid estate recovery.

(2) If the agency determines recovery would cause an undue hardship for an heir, the agency may delay recovery until the hardship no longer exists.

(3) If the agency denies an heir's request to delay recovery, the agency notifies the heir in writing. The notice includes instructions on how to request a hearing.

(4) If the agency grants a delay of recovery under this section, the heir must:

(a) Timely comply with any agency request for information or records;

(b) Not sell, transfer, or encumber the property;

(c) Reside on the property;

(d) Timely pay property taxes and utilities;

(e) Insure the property for its fair market value;

(f) Name the state of Washington as the primary payee on the property insurance policy;

(g) Provide the agency with a copy of the property insurance policy upon request;

(h) Continue to satisfy the requirements in subsection (1) of this section.

(5) If the heir dies, or violates any provision of subsection (4) of this section, the agency may begin recovery.

(6) If the agency denies the request, the heir may request an administrative hearing under WAC 182-527-2753.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-05-054, § 182-527-2750, filed 2/12/16, effective 3/14/16. Statutory Authority: RCW 41.05.021. WSR 13-19-038, § 182-527-2750, filed 9/11/13, effective 10/12/13. WSR 12-19-070, recodified as § 182-527-2750, filed 9/17/12, effective 10/1/12. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and chapter 26.60 RCW. WSR 09-07-038, § 388-527-2750, filed 3/10/09, effective 4/10/09. Statutory Authority: 2005 c 292, RCW 43.20B.080, 74.39A.170, 42 U.S.C. Section 1396p. WSR 06-17-075, § 388-527-2750, filed 8/14/06, effective 9/14/06. Statutory Authority: RCW 43.17.240, 43.20B.80 [43.20B.080], 74.08.090, 74.34.090, Section 1917(b) of the Social Security Act and 2001 2nd sp.s. c 7, Part II. WSR 04-10-060, § 388-527-2750, filed 4/30/04, effective 6/1/04. Statutory Authority: RCW 74.08.090. WSR 01-02-076, § 388-527-2750, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 43.20B.080, 74.08.090 and 74.34.010. WSR 99-11-076, § 388-527-2750, filed 5/18/99, effective 6/18/99. Statutory Authority: 1995 1st sp.s. c 18 and RCW 74.08.090. WSR 95-19-001 and 95-24-037 (Orders 3893 and 3893A), § 388-527-2750, filed 9/6/95 and 11/29/95, effective 10/7/95 and 12/30/95.*

##### **Wash. Admin. Code § 182-527-2753** Hearings. {#sec-182-527-2753 omnilex-key=us-wa-regs-official--title-182--182-527-2753}

For the purposes of this section, the term "agency" includes the agency's designee.

(1) An administrative hearing to contest action under this chapter determines only:

(a) In the case of a lien filed during the client's lifetime under WAC 182-527-2734:

(i) Whether the client can reasonably be expected to return home from the medical institution;

(ii) Whether the client, or the client's estate, holds legal title to the identified property; and

(iii) Whether the client received services subject to recovery.

(b) In the case of a lien filed after the client's death:

(i) The cost the agency correctly paid for services subject to recovery;

(ii) Whether the client, or the client's estate, holds legal title to the identified property; and

(iii) Whether the agency's denial of an heir's request for a delay of recovery for undue hardship under WAC 182-527-2750 was correct.

(2) A request for an administrative hearing must:

(a) Be in writing;

(b) State the basis for contesting the agency's proposed action;

(c) Be signed by the requestor and include the client's name, the requestor's address and telephone number; and

(d) Within twenty-eight days of the date on the agency's notice, be filed with the office of financial recovery either:

(i) In person at the Office of Financial Recovery, 712 Pear St. S.E., Olympia, WA 98504-0001; or

(ii) By certified mail, return receipt requested, to Office of Financial Recovery, P.O. Box 9501, Olympia, WA 98507-9501.

(3) Upon receiving a request for an administrative hearing, the office of administrative hearings notifies any known titleholder of the time and place of the administrative hearing.

(4) An administrative hearing under this subsection is governed by chapters 34.05 RCW and 182-526 WAC and this section. If a provision in this section conflicts with a provision in chapter 182-526 WAC, the provision in this section governs.

(5) Disputed assets must not be distributed while in litigation.

(6) Absent an administrative or court order to the contrary, the agency may file a lien twenty-eight calendar days after the date the agency mailed notice of its intent to file a lien.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-05-054, § 182-527-2753, filed 2/12/16, effective 3/14/16.*

## **Chapter 182-530** Prescription drugs (outpatient). {#struct-chapter-182-530}

##### **Wash. Admin. Code § 182-530-1000** Outpatient drug program—General. {#sec-182-530-1000 omnilex-key=us-wa-regs-official--title-182--182-530-1000}

(1) The purpose of the outpatient drug program is to reimburse providers for outpatient drugs, vitamins, minerals, devices, and drug-related supplies according to medicaid agency rules and subject to the limitations and requirements in this chapter.

(2) The agency reimburses for outpatient drugs, vitamins, minerals, devices, and pharmaceutical supplies that are:

(a) Covered. Refer to WAC 182-530-2000 for covered drugs, vitamins, minerals, devices, and drug-related supplies and to WAC 182-530-2100 for noncovered drugs and drug-related supplies;

(b) Prescribed by a provider with prescriptive authority (see exceptions for family planning and emergency contraception for women 18 years of age and older in WAC 182-530-2000 (1)(b), and over-the-counter (OTC) drugs to promote smoking cessation in WAC 182-530-2000 (1)(g));

(c) Prescribed by:

(i) A provider with an approved core provider agreement;

(ii) A provider who is enrolled as a servicing provider on an approved core provider agreement; or

(iii) A provider who is enrolled as a nonbilling provider.

(d) Within the scope of an eligible client's medical assistance program;

(e) Medically necessary as defined in WAC 182-500-0070 and determined according to the process found in WAC 182-501-0165;

(f) Authorized, as required within this chapter;

(g) Billed according to WAC 182-502-0150 and 182-502-0160; and

(h) Billed according to the requirements of this chapter.

(3) Coverage determinations for the agency are made by the agency's pharmacists or medical consultants in accordance with applicable federal law. The agency's determination may include consultation with the drug use review (DUR) board.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-21-061, § 182-530-1000, filed 10/12/23, effective 11/12/23. Statutory Authority: 42 C.F.R. 455.410, RCW 41.05.021. WSR 13-19-037, § 182-530-1000, filed 9/11/13, effective 10/12/13. Statutory Authority: RCW 41.05.021 and 42 C.F.R. 455.410. WSR 13-04-095, § 182-530-1000, filed 2/6/13, effective 3/9/13. WSR 11-14-075, recodified as § 182-530-1000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 09-05-007, § 388-530-1000, filed 2/5/09, effective 3/8/09. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.700, 2008 c 245. WSR 08-21-107, § 388-530-1000, filed 10/16/08, effective 11/16/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-1000, filed 9/26/07, effective 11/1/07*
- *WSR 06-24-036, § 388-530-1000, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. WSR 02-17-023, § 388-530-1000, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. WSR 01-01-028, § 388-530-1000, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. WSR 96-21-031, § 388-530-1000, filed 10/9/96, effective 11/9/96.*

##### **Wash. Admin. Code § 182-530-1050** Definitions. {#sec-182-530-1050 omnilex-key=us-wa-regs-official--title-182--182-530-1050}

In addition to the definitions and abbreviations found in chapter 182-500 WAC, Medical definitions, the following definitions apply to this chapter.

"340B program" - The federal program that requires drug manufacturers participating in the medicaid drug rebate program (MDRP) to provide covered outpatient drugs to enrolled "covered entities" at or below the ceiling price, as described in 42 U.S.C. § 256b. This requirement is described in section 340B of the Public Health Service Act and codified in 42 U.S.C. § 256b.

"340B provider" or "PHS-qualified covered entity" - Any provider including, but not limited to, a clinic, facility, hospital, pharmacy, or program listed in 42 U.S.C. § 256b as eligible to purchase, dispense, or administer outpatient drugs through the 340B program, has submitted its valid medicaid provider number(s) or national provider identification (NPI) number to the public health service (PHS), health resources and services administration (HRSA), office of pharmacy affairs (OPA), and has registered with and been approved by OPA.

"340B maximum allowable cost (340B MAC)" - The maximum amount the medicaid agency reimburses a participating 340B public health services (PHS)-qualified covered entity to purchase, dispense, or administer a covered outpatient drug, device, or drug-related supply.

"Active ingredient" - The chemical component of a drug responsible for a drug's prescribed/intended therapeutic effect. The medicaid agency or the agency's designee limits coverage of active ingredients to those with an 11-digit national drug code (NDC) and those specifically authorized by the agency or the agency's designee.

"Actual acquisition cost (AAC)" - The true cost paid for a specific drug or product in the package size purchased, including discounts, rebates, charge backs that affect the provider's invoice price, and other adjustments to the price of the drug, device, or drug-related supply, excluding dispensing fees.

"Administer" - Includes the direct application of a prescription drug or device by injection, insertion, inhalation, ingestion, or any other means, to the body of a patient by a practitioner, or at the direction of the practitioner.

"Appointing authority" - The following people acting jointly: The director of the Washington state health care authority and the director of the Washington state department of labor and industries.

"Authorized generic drug" - Any drug sold, licensed, or marketed under a new drug application (NDA) approved by the Food and Drug Administration (FDA) under section 505(c) of the Federal Food, Drug and Cosmetic Act (FFDCA) that is marketed, sold or distributed under a different labeler code, product code, trade name, trademark, or packaging (other than repackaging the listed drug for use in institutions) than the brand name drug.

"Automated authorization" - Adjudication of claims using submitted NCPDP data elements or claims history to verify that the medicaid agency's or its designee's authorization requirements have been satisfied without the need for the medicaid agency or its designee to request additional clinical information.

"Average manufacturer price (AMP)" - The average price paid to a manufacturer by wholesalers for drugs distributed to retail pharmacies.

"Average sales price (ASP)" - The weighted average of all nonfederal sales to wholesaler's net of charge backs, discounts, rebates, and other benefits tied to the purchase of the drug product, whether it is paid to the wholesaler or the retailer.

"Average wholesale price (AWP)" - A reference price of a drug product that is published at a point in time and reported to the medicaid agency or its designee by the agency's drug file contractor.

"Brand name drug" - A single-source or innovator multiple-source drug.

"Compendia of drug information" - Includes the following:

(1) The American Hospital Formulary Service Drug Information;

(2) The United States Pharmacopeia Drug Information; and

(3) DRUGDEX Information System.

"Compounding" - The act of combining two or more active ingredients or adjusting therapeutic strengths in the preparation of a prescription.

"Deliver or delivery" - The transfer of a drug or device from one person to another.

"Dispense as written (DAW)" - An instruction to the pharmacist forbidding substitution of a generic drug or a therapeutically equivalent product for the specific drug product prescribed.

"Dispensing fee" - Means professional dispensing fee. See professional dispensing fee.

"Drug file" - A list of drug products, pricing and other information provided to the medicaid agency or its designee and maintained by a drug file contractor.

"Drug file contractor" - An entity which has been contracted to provide regularly updated information on drugs, devices, and drug-related supplies at specified intervals, for the purpose of pharmaceutical claim adjudication. Information is provided specific to individual national drug codes, including product pricing.

"Drug-related supplies" - Nondrug items necessary for the administration, delivery, or monitoring of a drug or drug regimen.

"Drug use review (DUR)" - A review of covered outpatient drug use that assures prescriptions are appropriate, medically necessary, and not likely to result in adverse medical outcomes.

"Effectiveness" - The extent to which a given intervention is likely to produce beneficial results for which it is intended in ordinary circumstances.

"Efficacy" - The extent to which a given intervention is likely to produce beneficial effects in the context of the research study.

"Emergency kit" - A set of limited pharmaceuticals furnished to a nursing facility by the pharmacy that provides prescription dispensing services to that facility. Each kit is specifically set up to meet the emergency needs of each nursing facility's client population and is for use during those hours when pharmacy services are unavailable.

"Endorsing practitioner" - A practitioner who has reviewed the Washington preferred drug list (Washington PDL) and has enrolled with the health care authority (HCA), agreeing to allow therapeutic interchange (substitution) of a preferred drug for any nonpreferred drug in a given therapeutic class on the Washington PDL.

"Estimated acquisition cost (EAC)" - The medicaid agency's estimate of the price providers generally and currently pay for a drug marketed or sold by a particular manufacturer or labeler.

"Evidence-based drug reviews" - The application of a set of principles and methods for comprehensive independent and objective evaluation of clinical evidence provided in well-designed and well-conducted studies and objective clinical data to determine the level of evidence that proves to the greatest extent possible, that a health care service is safe, effective, and beneficial when making population-based coverage policies or individual medical necessity decisions. Classifying evidence by its epistemologic strength and requiring that only the strongest types (coming from meta-analyses, systematic reviews, and randomized controlled trials) can yield strong recommendations; weaker types (such as from case-control studies) can yield weak recommendations.

"Evidence-based practice center" or "EPC" - A research organization that has been designated by the Agency for Healthcare Research and Quality (AHRQ) to develop evidence reports and technology assessments on topics relevant to clinical and other health care organization and delivery issues, specifically those that are common, expensive, or significant for the medicare and medicaid populations.

"Federal drug rebates" - Dollars returned to medicaid from pharmaceutical manufacturers under the terms of the manufacturers' national rebate agreement with the federal Department of Health and Human Services (DHHS).

"Federal upper limit (FUL)" - The maximum allowable reimbursement set by the Centers for Medicare and Medicaid Services (CMS) for a multiple-source drug.

"Generic drug" - A drug that is approved by the Food and Drug Administration (FDA) under an abbreviated new drug application.

"Inactive ingredient" - A drug component that remains chemically unchanged during compounding but serves as the:

(1) Necessary vehicle for the delivery of the therapeutic effect; or

(2) Agent for the intended method or rate of absorption for the drug's active therapeutic agent.

"Ingredient cost" - The portion of a prescription's cost attributable to the covered drug ingredients or chemical components.

"Innovator multiple-source drug" - A multiple-source drug that was originally marketed under a new drug application (NDA) approved by the Food and Drug Administration (FDA), including an authorized generic drug. This includes:

(1) A drug product marketed by any cross-licensed producers, labelers, or distributors operating under the NDA; or

(2) A covered outpatient drug approved under a biologics license application (BLA), product license application (PLA), establishment license application (ELA), or antibiotic drug application (ADA).

"Less than effective drug" or "DESI" - A drug for which:

(1) Effective approval of the drug application has been withdrawn by the Food and Drug Administration (FDA) for safety or efficacy reasons as a result of the drug efficacy study implementation (DESI) review; or

(2) The secretary of the federal Department of Health and Human Services (DHHS) has issued a notice of an opportunity for a hearing under section 505(e) of the federal Food, Drug, and Cosmetic Act on a proposed order of the secretary to withdraw approval of an application for such drug under such section because the secretary has determined the drug is less than effective for some or all conditions of use prescribed, recommended, or suggested in its labeling.

"Maximum allowable cost (MAC)" - The maximum amount the medicaid agency or its designee reimburses for a drug, device, or drug-related supply.

"Medicaid preferred drug list (medicaid PDL)" - The list of all drugs in drug classes approved for inclusion by the Washington medicaid drug use review (DUR) board and each drug's preferred or nonpreferred status as approved by the agency director or designee. The list includes at minimum all drugs and drug classes on the Washington PDL and may include additional drugs and drug classes recommended by the DUR board and approved by the agency director or designee.

"Medically accepted indication" - Any use for a covered outpatient drug:

(1) Which is approved under the federal Food, Drug, and Cosmetic Act; or

(2) The use of which is supported by one or more citations included or approved for inclusion in any of the compendia of drug information, as defined in this chapter.

"Modified unit dose delivery system" (also known as blister packs or "bingo/punch cards") - A method in which each patient's medication is delivered to a nursing facility:

(1) In individually sealed, single dose packages or "blisters"; and

(2) In quantities for one month's supply, unless the prescriber specifies a shorter period of therapy.

"Multiple-source drug" - A drug for which there is at least one other drug product sold in the United States that is pharmaceutically equivalent and bioequivalent, as determined by the Food and Drug Administration (FDA).

"National drug code (NDC)" - The 11-digit numerical code that includes the labeler code, product code, and package code.

"National rebate agreement" - The agreement developed by the Centers for Medicare and Medicaid Services (CMS) to implement section 1927 of the Social Security Act, and entered into by a manufacturer and the federal Department of Health and Human Services (DHHS).

"Noninnovator multiple-source drug" - A drug that is:

(1) A multiple-source drug that is not an innovator multiple-source drug or a single-source drug;

(2) A multiple-source drug marketed under an abbreviated new drug application (ANDA) or an abbreviated antibiotic drug application;

(3) A covered outpatient drug that entered the market before 1962 and was originally marketed under a new drug application (NDA); or

(4) Any drug that has not gone through a Food and Drug Administration (FDA) approval process but otherwise meets the definition of a covered outpatient drug.

If any of the drug products listed in this definition of a noninnovator multiple-source drug subsequently receive an NDA or ANDA approval from the FDA, the product's drug category changes to correlate with the new product application type.

"Nonpreferred drug" - A drug within a therapeutic class of drugs on the medicaid preferred drug list (medicaid PDL) that has not been selected as a preferred drug.

"Obsolete NDC" - A national drug code replaced or discontinued by the manufacturer or labeler.

"Over-the-counter (OTC) drugs" - Drugs that do not require a prescription before they can be sold or dispensed.

"Peer reviewed medical literature" - A research study, report, or findings regarding the specific use of a drug that has been submitted to one or more professional journals, reviewed by experts with appropriate credentials, and subsequently published by a reputable professional journal. A clinical drug study used as the basis for the publication must be a double blind, randomized, placebo or active control study.

"Pharmacist" - A person licensed in the practice of pharmacy by the state in which the prescription is filled.

"Pharmacy" - Every location licensed by the state board of pharmacy in the state where the practice of pharmacy is conducted.

"Pharmacy and therapeutic (P&T) committee" - The independent Washington state committee created by RCW 41.05.021 (1)(a)(iii) and 70.14.050. At the election of the medicaid agency or its designee, the committee may serve as the drug use review board provided for in WAC 182-530-4000.

"Point-of-sale (POS)" - A pharmacy claims processing system capable of receiving and adjudicating claims online.

"Practice of pharmacy" - The practice of and responsibility for:

(1) Accurately interpreting prescription orders;

(2) Compounding drugs;

(3) Dispensing, labeling, administering, and distributing of drugs and devices;

(4) Providing drug information to the client that includes, but is not limited to, the advising of therapeutic values, hazards, and the uses of drugs and devices;

(5) Monitoring of drug therapy and use;

(6) Proper and safe storage of drugs and devices;

(7) Documenting and maintaining records;

(8) Initiating or modifying drug therapy in accordance with written guidelines or protocols previously established and approved for a pharmacist's practice by a practitioner authorized to prescribe drugs; and

(9) Participating in drug use reviews and drug product selection.

"Practitioner" - An individual who has met the professional and legal requirements necessary to provide a health care service, such as a physician, nurse, dentist, physical therapist, pharmacist, or other person authorized by state law as a practitioner.

"Preferred drug" - A drug within a therapeutic class of drugs on the medicaid preferred drug list (medicaid PDL) that has been selected as a preferred drug.

"Prescriber" - A physician, osteopathic physician/surgeon, dentist, nurse, physician assistant, optometrist, pharmacist, or other person authorized by law or rule to prescribe drugs. See WAC 246-945-350 for pharmacists' prescriptive authority.

"Prescription" - An order for drugs or devices issued by a practitioner authorized by state law or rule to prescribe drugs or devices, in the course of the practitioner's professional practice, for a legitimate medical purpose.

"Prescription drugs" - Drugs required by any applicable federal or state law or regulation to be dispensed by prescription only or that are restricted to use by practitioners only.

"Professional dispensing fee":

(1) The fee the medicaid agency or its designee pays pharmacists and dispensing providers for covered prescriptions. The fee pays for costs in excess of the ingredient cost of a covered outpatient drug when a covered outpatient drug is dispensed; and

(2) Includes only costs associated with ensuring that possession of the appropriate covered outpatient drug is transferred to a medicaid beneficiary. Pharmacy and dispensing provider costs include, but are not limited to, reasonable costs associated with a prescriber's time in checking the computer for information about an individual's coverage, performing drug utilization review and preferred drug list review activities, measurement or mixing of the covered outpatient drug, filling the container, beneficiary counseling, physically providing the completed prescription to the medicaid beneficiary, delivery, special packaging, and overhead associated with maintaining the facility and equipment necessary to operate the dispensing entity.

"Prospective drug use review (Pro-DUR)" - A process in which a request for a drug product for a particular client is screened, before the product is dispensed, for potential drug therapy problems.

"Reconstitution" - The process of returning a single active ingredient, previously altered for preservation and storage, to its approximate original state. Reconstitution is not compounding.

"Retrospective drug use review (Retro-DUR)" - The process in which drug utilization is reviewed on an ongoing periodic basis to identify patterns of fraud, abuse, gross overuse, or inappropriate or not medically necessary care.

"Single-source drug" - A drug produced or distributed under an original new drug application (NDA) approved by the Food and Drug Administration (FDA) with an approved new drug application (NDA) number issued by the FDA. This includes:

(1) A drug product marketed by any cross-licensed producers, labelers, or distributors operating under the NDA; or

(2) A drug approved under a biologics license application (BLA), product license application (PLA), establishment license application (ELA), or antibiotic drug application (ADA).

For the purposes of this definition, an ANDA is not an NDA.

"Systematic review" - A specific and reproducible method to identify, select, and appraise all the studies that meet minimum quality standards and are relevant to a particular question. The results of the studies are then analyzed and summarized into evidence tables to be used to guide evidence-based decisions.

"Terminated NDC" - An 11-digit national drug code (NDC) that is discontinued by the manufacturer for any reason. The NDC may be terminated immediately due to health or safety issues or it may be phased out based on the product's shelf life.

"Therapeutic alternative" - A drug product that contains a different chemical structure than the drug prescribed, but is in the same pharmacologic or therapeutic class and can be expected to have a similar therapeutic effect and adverse reaction profile when administered to patients in a therapeutically equivalent dosage.

"Therapeutic class" - A group of drugs used for the treatment, remediation, or cure of a specific disorder or disease.

"Therapeutic interchange" - To dispense a therapeutic alternative to the prescribed drug when an endorsing practitioner who has indicated that substitution is permitted, prescribes the drug. See therapeutic interchange program (TIP).

"Therapeutic interchange program (TIP)" - The process developed by participating state agencies under RCW 69.41.190 and 70.14.050, to allow prescribers to endorse a Washington preferred drug list, and in most cases, requires pharmacists to automatically substitute a preferred, equivalent drug from the list.

"Therapeutically equivalent" - Drug products that contain different chemical structures but have the same efficacy and safety when administered to an individual, as determined by:

(1) Information from the Food and Drug Administration (FDA);

(2) Published and peer-reviewed scientific data;

(3) Randomized controlled clinical trials; or

(4) Other scientific evidence.

"Tiered dispensing fee system" - A system of paying pharmacies different dispensing fee rates, based on the individual pharmacy's total annual prescription volume and/or the drug delivery system used.

"True unit dose delivery" - A method in which each patient's medication is delivered to the nursing facility in quantities sufficient only for the day's required dosage.

"Unit dose drug delivery" - True unit dose or modified unit dose delivery systems.

"Usual and customary charge" - The fee that the provider typically charges the general public for the product or service.

"Washington preferred drug list (Washington PDL)" - The list of drugs selected by the appointing authority to be used by applicable state agencies as the basis for purchase of drugs in state-operated health care programs.

"Wholesale acquisition cost" - Refers to either the actual wholesale cost paid by a wholesaler for drugs purchased from a manufacturer or a list price published as wholesale acquisition cost.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-09-050, s 182-530-1050, filed 4/10/25, effective 5/11/25*
- *WSR 24-08-061, § 182-530-1050, filed 3/29/24, effective 5/1/24*
- *WSR 17-07-001, § 182-530-1050, filed 3/1/17, effective 4/1/17. Statutory Authority: RCW 41.05.021. WSR 13-18-035, § 182-530-1050, filed 8/28/13, effective 9/28/13. Statutory Authority: RCW 41.05.021 and section 1927 of the Social Security Act. WSR 12-18-062, § 182-530-1050, filed 8/31/12, effective 10/1/12. WSR 11-14-075, recodified as § 182-530-1050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.700, 2008 c 245. WSR 08-21-107, § 388-530-1050, filed 10/16/08, effective 11/16/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-1050, filed 9/26/07, effective 11/1/07. Statutory Authority: RCW 74.08.090, 70.14.050, 69.41.150, 69.41.190, chapter 41.05 RCW. WSR 05-02-044, § 388-530-1050, filed 12/30/04, effective 1/30/05. Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. WSR 02-17-023, § 388-530-1050, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. WSR 01-24-066, § 388-530-1050, filed 11/30/01, effective 1/2/02*
- *WSR 01-01-028, § 388-530-1050, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. WSR 96-21-031, § 388-530-1050, filed 10/9/96, effective 11/9/96.*

##### **Wash. Admin. Code § 182-530-1075** Requirements—Use of tamper-resistant prescription pads. {#sec-182-530-1075 omnilex-key=us-wa-regs-official--title-182--182-530-1075}

(1) The medicaid agency requires providers to use tamper-resistant prescription pads or paper for written outpatient prescriptions, including over-the-counter drugs, for Washington apple health clients.

(2) This requirement applies to all outpatient prescription drugs, including:

(a) Prescriptions when medicaid is primary or secondary payer (including medicare Part D prescriptions).

(b) Signed hardcopy prescriptions given to a client, whether handwritten or computer-generated.

(3) This requirement does not apply to:

(a) Prescriptions paid for by Washington's healthy options (HO) program or other agency-contracted managed care organizations.

(b) Prescription drugs that are part of the per diem or bundled rate and not reimbursed separately in designated institutional or clinical settings, such as a nursing facility, ICF/MR, dental office, hospice, or radiology. For example, a morphine prescription used to control a hospice client's cancer pain is covered under the hospice per diem rate and therefore the tamper-resistant prescription requirement is not required.

(c) Telephone, fax, or electronic prescriptions.

(d) Refill prescriptions, if the original written prescriptions were presented at a pharmacy before April 1, 2008.

(e) Prescriber or clinic drug samples given directly to the client.

(f) An institutional setting, as defined in WAC 182-500-0050, where the prescriber writes the order into the medical records and the orders go directly to the pharmacy.

(4) Effective April 1, 2008, the tamper-resistant prescription pads and paper must meet at least one of the following industry recognized characteristics:

(a) One or more features designed to prevent unauthorized copying of a completed or blank prescription form;

(b) One or more features designed to prevent the erasure or modification of information written on the prescription by the prescriber; or

(c) One or more features designed to prevent the use of counterfeit prescription forms.

(5) Effective October 1, 2008, the tamper-resistant prescription pads and paper must contain all of the three characteristics in subsection (4) of this section.

(6) If the written prescription is not on tamper-resistant paper, the pharmacy may provide the prescription on an emergency basis. The pharmacy must verify the prescription with the prescriber by telephone, fax, or electronic communication, or by physical receipt of a tamper-resistant written prescription within seventy-two hours of filling the prescription.

(7) Federal controlled substance laws on controlled substances apply when prescribing or dispensing schedule II drugs.

(8) Record retention requirements under WAC 182-502-0020 remain in effect. Additional documentation is required as follows:

(a) Documentation by the pharmacy of verbal confirmation of a noncompliant written prescription.

(b) Documentation by the pharmacy of verbal confirmation about the authenticity of the tamper-resistant prescription.

(9) To submit a claim for a medicaid client retroactively certified for medicaid, the following applies:

(a) The prescription must meet the tamper-resistant compliance requirement.

(b) Refills that occur after the date on which the client is determined to be eligible require a new, tamper-resistant prescription in compliance with this WAC.

(c) If the original order is not compliant with subsection (4) of this section, the pharmacy must obtain a verbal, faxed, or email confirmation of the prescription from the prescriber.

(d) The pharmacy must reimburse the client under WAC 182-502-0160.

(10) The pharmacy accepting a prescription transfer from another pharmacy must confirm the authenticity of the prescription by telephone or facsimile from the transferring pharmacy.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-01-046, § 182-530-1075, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-1075, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 74.09.500 and Section 1903(i) of the Social Security Act (42 U.S.C. Section 1936b (i)(23))*
- *Section 7002(b), U.S. Troop Readiness, Veterans' Care, Katrina Recovery, and Iraq Accountability Appropriations Act, 2007 (Pub.L. 110-28). WSR 08-07-048, § 388-530-1075, filed 3/14/08, effective 4/14/08.*

##### **Wash. Admin. Code § 182-530-1080** Requirements for prescribing and dispensing controlled substances—Prescription monitoring program (PMP). {#sec-182-530-1080 omnilex-key=us-wa-regs-official--title-182--182-530-1080}

This section identifies the steps prescribers must take before prescribing a controlled substance and the steps pharmacists must take when dispensing a controlled substance from an outpatient pharmacy to check an apple health client's prescription drug history in the prescription monitoring program (PMP) described in chapter 246-470 WAC.

(1) PMP review required. Except as identified in subsection (4) of this section, a prescriber, before prescribing, and a pharmacist, when dispensing, must check all of a client's current prescriptions in the PMP, including any prescriptions not paid for by apple health.

(2) Retrieval by delegates allowed. A prescriber or pharmacist may delegate the retrieval of the client's PMP information to anyone in their practice setting with authorization to access the PMP, so long as the prescriber or pharmacist reviews all of the client's current prescriptions in the PMP before prescribing or when dispensing a controlled substance.

(3) Documentation. The prescriber and pharmacist must document in the client's record the date and time of the:

(a) Retrieval of information from the PMP; and

(b) Review of information from the PMP.

(4) Good faith effort exception.

(a) If a prescriber, pharmacist, or their delegate is unable to access the client's record in the PMP after a good faith effort, that attempt must be documented in the client's record.

(b) A prescriber or pharmacist must document the reason or reasons they were unable to conduct the check.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and Public Law 115-271. WSR 21-13-099, § 182-530-1080, filed 6/18/21, effective 10/1/21.*

##### **Wash. Admin. Code § 182-530-2000** Covered—Outpatient drugs, devices, and drug-related supplies. {#sec-182-530-2000 omnilex-key=us-wa-regs-official--title-182--182-530-2000}

(1) The medicaid agency covers:

(a) Outpatient drugs, including over-the-counter (OTC) drugs, as defined in WAC 182-530-1050, subject to the limitations and requirements in this chapter, when:

(i) The drug is approved by the Food and Drug Administration (FDA);

(ii) The drug is for a medically accepted indication as defined in WAC 182-530-1050;

(iii) The drug is not excluded from coverage under WAC 182-530-2100;

(iv) The manufacturer has a signed drug rebate agreement with the federal Department of Health and Human Services (DHHS). Exceptions to the drug rebate requirement are described in WAC 182-530-7500; and

(v) The drug is prescribed by a provider with prescriptive authority. Exceptions to the prescription requirement exist for family planning and emergency contraception in (b) of this subsection.

(b) Family planning drugs, devices, and drug-related supplies per chapter 182-532 WAC and as follows:

(i) OTC family planning drugs, devices, and drug-related supplies without a prescription when the agency determines it necessary for client access and safety;

(ii) Family planning drugs that do not meet the federal drug rebate requirement in WAC 182-530-7500 on a case-by-case basis; and

(iii) Contraceptive patches, contraceptive rings, and oral contraceptives, excluding emergency contraception, when dispensed in a one-year supply only, unless:

(A) A smaller supply is directed by the prescriber;

(B) A smaller supply is requested by the client;

(C) The pharmacy does not have adequate stock.

(c) Vitamins, minerals, and enzymes when prescribed for:

(i) Prenatal vitamins, when prescribed and dispensed to pregnant women;

(ii) A medical condition caused by a clinically documented deficiency;

(iii) A United States Preventive Services Task Force recommendation with an A or B rating;

(iv) Fluoride for clients under age twenty-one; or

(v) A clinically documented medical condition that causes vitamin, mineral, or enzyme deficiencies, and the deficiency cannot be treated through other dietary interventions.

(d) OTC drugs, vitamins, and minerals when determined by the agency to be the least costly therapeutic alternative for a medically accepted indication. All covered OTC products determined to be the least costly therapeutic alternatives for medically accepted indications will be included on the agency's published apple health preferred drug list. This subsection does not apply to products prescribed for the treatment of cough or cold symptoms. See this subsection (1) (h) of this section and WAC 182-530-2100 (1)(b)(v) for coverage of products prescribed for the treatment of cough and cold symptoms.

(e) Drug-related devices and drug-related supplies as an outpatient pharmacy benefit when:

(i) Prescribed by a provider with prescribing authority;

(ii) Essential for the administration of a covered drug;

(iii) Not excluded from coverage under WAC 182-530-2100; and

(iv) Determined by the agency that a product covered under chapter 182-543 WAC related to medical equipment and supplies should be available at retail pharmacies.

(f) Preservatives, flavoring, or coloring agents, only when used as a suspending agent in a compound.

(g) OTC and prescription drugs to promote tobacco/nicotine cessation.

(h) For the treatment of cough and cold, only those products included with a preferred status on the apple health preferred drug list (PDL), as described in WAC 182-530-4100, on the date a client's prescription is dispensed.

(2) The agency does not reimburse for any drug, device, or drug-related supply not meeting the coverage requirements under this section.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-02-004, § 182-530-2000, filed 12/23/20, effective 1/23/21. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1927, (42 U.S.C. 1396r-8) (d)(2)(D) and (G), (d)(7)(A), (k)(4). WSR 19-22-016, § 182-530-2000, filed 10/25/19, effective 11/25/19. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-17-071, § 182-530-2000, filed 8/16/16, effective 9/16/16. WSR 11-14-075, recodified as § 182-530-2000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, SSA § 1927 (42 U.S.C. 1396r-8(d)(2)(D)), and 2009 c 564 § 1109. WSR 09-22-005, § 388-530-2000, filed 10/22/09, effective 11/22/09. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 09-05-007, § 388-530-2000, filed 2/5/09, effective 3/8/09. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.700, 2008 c 245. WSR 08-21-107, § 388-530-2000, filed 10/16/08, effective 11/16/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-2000, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-2100** Noncovered—Outpatient drugs and pharmaceutical supplies. {#sec-182-530-2100 omnilex-key=us-wa-regs-official--title-182--182-530-2100}

(1) The medicaid agency does not cover:

(a) A drug that is:

(i) Not approved by the Food and Drug Administration (FDA); or

(ii) Prescribed for a nonmedically accepted indication, including diagnosis, dose, or dosage schedule that is not evidenced-based.

(b) A drug prescribed:

(i) For weight loss or gain;

(ii) For infertility, frigidity, impotency;

(iii) For sexual or erectile dysfunction;

(iv) For cosmetic purposes or hair growth; or

(v) For treatment of cough or cold symptoms, except as listed in WAC 182-530-2000 (1)(h).

(c) Drugs used to treat sexual or erectile dysfunction, in accordance with section 1927 (d)(2)(K) of the Social Security Act, unless such drugs are used to treat a condition other than sexual or erectile dysfunction, and these uses have been approved by the Food and Drug Administration.

(d) Drugs listed in the federal register as "less-than-effective" ("DESI" drugs) or which are identical, similar, or related to such drugs.

(e) Outpatient drugs for which the manufacturer requires as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or manufacturer's designee.

(f) A product:

(i) With an obsolete National Drug Code (NDC) for more than two years;

(ii) With a terminated NDC;

(iii) Whose shelf life has expired; or

(iv) Which does not have an eleven-digit NDC.

(g) Over-the-counter (OTC) drugs, vitamins, and minerals, except as allowed under WAC 182-530-2000 (1)(h).

(h) Any drug regularly supplied by other public agencies as an integral part of program activity (e.g., immunization vaccines for children).

(i) Free pharmaceutical samples.

(2) A noncovered drug can be requested through the exception to rule process as described in WAC 182-501-0160.

(3) For clients age 20 and younger, providers must follow the rules for the early periodic screening, diagnosis, and treatment program; see chapter 182-534 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-21-142, s 182-530-2100, filed 10/21/25, effective 11/21/25*
- *WSR 21-02-004, § 182-530-2100, filed 12/23/20, effective 1/23/21. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1927, (42 U.S.C. 1396r-8) (d)(2)(D) and (G), (d)(7)(A), (k)(4). WSR 19-22-016, § 182-530-2100, filed 10/25/19, effective 11/25/19. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-17-071, § 182-530-2100, filed 8/16/16, effective 9/16/16. Statutory Authority: RCW 41.05.021. WSR 13-18-035, § 182-530-2100, filed 8/28/13, effective 9/28/13. Statutory Authority: RCW 41.05.021 and section 1927 of the Social Security Act. WSR 12-18-062, § 182-530-2100, filed 8/31/12, effective 10/1/12. WSR 11-14-075, recodified as § 182-530-2100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, SSA § 1927 (42 U.S.C. 1396r-8(d)(2)(D)), and 2009 c 564 § 1109. WSR 09-22-005, § 388-530-2100, filed 10/22/09, effective 11/22/09. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 09-05-007, § 388-530-2100, filed 2/5/09, effective 3/8/09. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.700, 2008 c 245. WSR 08-21-107, § 388-530-2100, filed 10/16/08, effective 11/16/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-2100, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-3000** When the medicaid agency requires authorization. {#sec-182-530-3000 omnilex-key=us-wa-regs-official--title-182--182-530-3000}

Covered drugs, devices, or drug-related supplies require authorization for reimbursement when:

(1) The medicaid agency's pharmacists or medical consultants:

(a) Have determined that authorization for the drug, device, or drug-related supply is required, as described in WAC 182-530-3100; or

(b) Have not yet reviewed the drug, device, or drug-related supply as described in WAC 182-530-3100.

(2) The drug, device, or drug-related supply is in a therapeutic drug class on the Washington preferred drug list and the product is one of the following:

(a) Nonpreferred as described in WAC 182-530-4100; and

(i) The prescriber is a nonendorsing practitioner; or

(ii) The drug is designated as exempt from the therapeutic interchange program per WAC 182-530-4100(6) or 182-530-4150 (2)(a);

(b) Preferred for a special population or specific indication and has been prescribed by a nonendorsing practitioner under conditions for which the drug, device, or drug-related supply is not preferred; or

(c) Determined to require authorization for safety.

(3) The agency is promoting safety, efficacy, and effectiveness of drug therapy, or the agency identifies clients or groups of clients who would benefit from further clinical review.

(4) The agency designates the prescriber(s) as requiring authorization because the prescriber(s) is under agency review or is sanctioned for substandard quality of care.

(5) Utilization data indicate there are health and safety concerns or the potential for misuse and abuse. Examples of utilization concerns include:

(a) Multiple prescriptions filled for the same drug in the same calendar month;

(b) Prescriptions filled earlier than necessary for optimal therapeutic response;

(c) Therapeutic duplication;

(d) Therapeutic contraindication;

(e) Excessive dosing, excessive duration of therapy, or subtherapeutic dosing as determined by FDA labeling or the compendia of drug information; and

(f) Number of prescriptions filled per month in total or by therapeutic drug class.

(6) The pharmacy requests reimbursement in excess of the maximum allowable cost and the drug has been prescribed with instructions to dispense as written.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-07-001, § 182-530-3000, filed 3/1/17, effective 4/1/17*
- *WSR 16-01-046, § 182-530-3000, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-3000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.700, 2008 c 245. WSR 08-21-107, § 388-530-3000, filed 10/16/08, effective 11/16/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-3000, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-3100** How the medicaid agency determines when a drug requires authorization. {#sec-182-530-3100 omnilex-key=us-wa-regs-official--title-182--182-530-3100}

(1) The medicaid agency's pharmacists or medical consultants periodically evaluate covered drugs, covered indications, or new dosages approved by the Food and Drug Administration (FDA) to determine the drug authorization requirement.

(a) The clinical team evaluates and grades available information for each drug or drug class based on quality evidence contained in compendia of drug information and peer-reviewed medical literature. The information evaluated includes, but is not limited to:

(i) Evidence for efficacy and safety;

(ii) Cost comparisons of drugs with similar existing drugs;

(iii) Potential for clinical misuse;

(iv) Potential for client misuse or abuse;

(v) Drugs with a narrow therapeutic index;

(vi) Other safety concerns; or

(vii) Product cost and outcome data demonstrating the cost effectiveness of the drug, device, or drug-related supply.

(b) In performing this evaluation the clinical team may consult with other agency clinical staff, financial experts, and program managers. The agency clinical team may also consult with an evidence-based practice center (EPC), evidence-based drug reviews, other purchasers, the drug use review (DUR) board, and medical experts in this evaluation.

(c) Based on the clinical team's evaluation, the agency may determine that the drug, device, or drug-related supply:

(i) Requires authorization;

(ii) Requires authorization to exceed agency-established limitations; or

(iii) Does not require authorization.

(2) The agency periodically reviews existing drugs, devices, or drug-related supplies and reassigns authorization requirements as necessary according to the same provisions as outlined above for new drugs, devices, or pharmaceutical supplies.

(3) For any drug, device, or drug-related supply with limitations or requiring authorization, the agency may elect to apply automated authorization criteria according to WAC 182-530-3200.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-07-001, § 182-530-3100, filed 3/1/17, effective 4/1/17*
- *WSR 16-01-046, § 182-530-3100, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-3100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-3100, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-3200** The medicaid agency's authorization process. {#sec-182-530-3200 omnilex-key=us-wa-regs-official--title-182--182-530-3200}

(1) The agency may establish automated ways for pharmacies to meet authorization requirements for specified drugs, devices, and drug-related supplies, or circumstances as listed in WAC 182-530-3000 including, but not limited to:

(a) Use of expedited authorization codes as published in the agency's prescription drug program billing instructions;

(b) Use of specified values in national council of prescription drug programs (NCPDP) claim fields;

(c) Use of diagnosis codes; and

(d) Evidence of previous therapy within the agency's claim history.

(2) When the automated requirements in subsection (1) of this section do not apply or cannot be satisfied, the pharmacy provider must request authorization from the agency before dispensing. The pharmacy provider must:

(a) Ensure the request states the medical diagnosis and includes medical justification for the drug, device, drug-related supply, or circumstance as listed in WAC 182-530-3000; and

(b) Keep documentation on file of the prescriber's medical justification that is communicated to the pharmacy by the prescriber at the time the prescription is filled. The records must be retained for the period specified in WAC 182-502-0020(5).

(3) When the agency receives the request for authorization:

(a) The agency acknowledges receipt:

(i) Within twenty-four hours if the request is received during normal state business hours; or

(ii) Within twenty-four hours of opening for business on the next business day if received outside of normal state business hours.

(b) The agency reviews all evidence submitted and takes one of the following actions within fifteen business days:

(i) Approves the request;

(ii) Denies the request if the requested service is not medically necessary; or

(iii) Requests the prescriber submit additional justifying information.

(A) The prescriber must submit the additional information within ten days of the agency's request.

(B) The agency approves or denies the request within five business days of the receipt of the additional information.

(C) If the prescriber fails to provide the additional information within ten days, the agency will deny the requested service. The agency sends a copy of the request to the client at the time of denial.

(4) The agency's authorization determination may be based on, but not limited to:

(a) Requirements under this chapter and WAC 182-501-0165;

(b) Client safety;

(c) Appropriateness of drug therapy;

(d) Quantity and duration of therapy;

(e) Client age, gender, pregnancy status, or other demographics; and

(f) The least costly therapeutically equivalent alternative.

(5) The agency evaluates request for authorization of covered drugs, devices, and drug-related supplies that exceed limitations in this chapter on a case-by-case basis in conjunction with subsection (4) of this section and WAC 182-501-0169.

(6) If a provider needs authorization to dispense a covered drug outside of normal state business hours, the provider may dispense the drug without authorization only in an emergency. The agency must receive justification from the provider within seven days of the fill date to be reimbursed for the emergency fill.

(7) The agency may remove authorization requirements under WAC 182-530-3000 for, but not limited to, the following:

(a) Prescriptions written by specific practitioners based on consistent high quality of care; or

(b) Prescriptions filled at specific pharmacies and billed to the agency at the pharmacies' lower acquisition cost.

(8) Authorization requirements in WAC 182-530-3000 are not a denial of service.

(9) Rejection of a claim due to the authorization requirements listed in WAC 182-530-3000 is not a denial of service.

(10) When a claim requires authorization, the pharmacy provider must request authorization from the agency. If the pharmacist fails to request authorization as required, the agency does not consider this a denial of service.

(11) Denials that result as part of the authorization process will be issued by the agency in writing.

(12) The agency's authorization:

(a) Is a decision of medical appropriateness; and

(b) Does not guarantee payment.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-07-001, § 182-530-3200, filed 3/1/17, effective 4/1/17*
- *WSR 16-17-071, § 182-530-3200, filed 8/16/16, effective 9/16/16. WSR 11-14-075, recodified as § 182-530-3200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-014, § 388-530-3200, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.700, 2008 c 245. WSR 08-21-107, § 388-530-3200, filed 10/16/08, effective 11/16/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-3200, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-4000** Drug use review (DUR) board. {#sec-182-530-4000 omnilex-key=us-wa-regs-official--title-182--182-530-4000}

In accordance with 42 C.F.R. 456.716, the medicaid agency establishes a drug use review (DUR) board.

(1) The DUR board:

(a) Includes health professionals who are actively practicing and licensed in the state of Washington and who have recognized knowledge and expertise in one or more of the following:

(i) The clinically appropriate prescribing of outpatient drugs;

(ii) The clinically appropriate dispensing and monitoring of outpatient drugs;

(iii) Drug use review, evaluation, and intervention; and

(iv) Medical quality assurance.

(b) Is made up of at least one-third but not more than fifty-one percent physicians, and at least one-third pharmacists.

(2) The agency may appoint members of the pharmacy and therapeutics committee established by the agency under chapter 182-50 WAC or other qualified individuals to serve as members of the DUR board.

(3) The DUR board meets periodically to:

(a) Advise the agency on drug use review activities;

(b) Review provider and patient profiles;

(c) Review scientific literature to establish evidence-based guidelines for the appropriate use of drugs, including the appropriate indications and dosing;

(d) Recommend adoption of standards and treatment guidelines for drug therapy;

(e) Recommend interventions targeted toward correcting drug therapy problems; and

(f) Produce an annual report.

(4) The agency has the authority to accept or reject the recommendations of the DUR board in accordance with 42 C.F.R. 456.716(c).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-01-046, § 182-530-4000, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-4000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-4000, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-4050** Drug use and claims review. {#sec-182-530-4050 omnilex-key=us-wa-regs-official--title-182--182-530-4050}

(1) The agency's drug use review (DUR) consists of:

(a) A prospective drug use review (Pro-DUR) that requires all pharmacy providers to:

(i) Obtain patient histories of allergies, idiosyncrasies, or chronic condition or conditions which may relate to drug utilization;

(ii) Screen for potential drug therapy problems;

(iii) Counsel the patient in accordance with existing state pharmacy laws and federal regulations; and

(iv) Obtain authorization as described in WAC 182-530-3200 prior to dispensing when required by the agency or an agency designee.

(b) A retrospective drug use review (Retro-DUR), in which the agency provides for the ongoing periodic examination of claims data and other records in order to identify patterns of fraud, abuse, gross overuse, excessive utilization, inappropriate or medically unnecessary care, or prescribing billing practices that indicate abuse or excessive utilization among physicians, pharmacists, and individuals receiving benefits.

(2) The agency reviews a periodic sampling of claims to determine if drugs are appropriately ordered, prescribed, administered, dispensed, and billed. If a review of the sample finds that a provider is inappropriately ordering, prescribing, administering, dispensing, or billing for drugs, the agency may implement corrective action that includes, but is not limited to:

(a) Educating the provider regarding the problem practice or practices;

(b) Requiring the provider to maintain specific documentation in addition to the normal documentation requirements regarding the provider's ordering, prescribing, administering, dispensing, or billing practices;

(c) Applying additional provider-specific requirements for obtaining authorization prior to ordering, prescribing, administering, dispensing, or billing for drugs;

(d) Recouping the payment for the drug or drugs; or

(e) Terminating the provider's core provider agreement (CPA).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, H.R. 6, § 1004, 42 U.S.C. 1396a(a) and 1396r-8(g). WSR 20-06-077, § 182-530-4050, filed 3/4/20, effective 4/4/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-01-046, § 182-530-4050, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-4050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-4050, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-4100** Medicaid preferred drug list (medicaid PDL). {#sec-182-530-4100 omnilex-key=us-wa-regs-official--title-182--182-530-4100}

(1) The medicaid agency contracts with a vendor to perform systematic evidence-based drug reviews.

(2) The pharmacy and therapeutics (P&T) committee or the drug use review (DUR) board reviews and evaluates the safety, efficacy, and outcomes of prescribed drugs, using evidence-based drug reviews.

(3) The P&T committee makes recommendations to state agencies as to which drugs to include on the Washington PDL under chapter 182-50 WAC. The DUR board makes recommendations to the medicaid agency about which additional drug classes to include in the medicaid PDL.

(4) The agency director or designee makes the final selection of drugs or drug classes included on the medicaid PDL.

(5) Drugs in a drug class on the medicaid PDL which are not on the Washington PDL are not subject to therapeutic interchange program (TIP) and dispense as written (DAW) rules under WAC 182-530-4150.

(6) Drugs in a drug class on the medicaid PDL that have not been reviewed by the P&T committee or the DUR board may be treated as nonpreferred drugs and are not subject to DAW or TIP.

(7) A nonpreferred drug is considered for authorization after the client has:

(a) Tried and failed or is intolerant to at least one preferred drug; and

(b) Met agency-established criteria for the nonpreferred drug.

(8) Drugs in a drug class on the medicaid PDL may be designated as preferred drugs for special populations or specific indications.

(9) Drugs in a drug class on the medicaid PDL may require authorization regardless of preferred or nonpreferred status.

(10) When a preferred innovator drug or biological product on the medicaid PDL loses its patent, the agency may:

(a) Designate an available, equally effective, generic equivalent, or biosimilar biological product as a preferred drug; and

(b) Make the innovator drug or biological product nonpreferred.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-07-001, § 182-530-4100, filed 3/1/17, effective 4/1/17*
- *WSR 15-12-093, § 182-530-4100, filed 6/2/15, effective 7/3/15. WSR 11-14-075, recodified as § 182-530-4100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.09.700, 74.08.090, 2009 c 575. WSR 10-06-011, § 388-530-4100, filed 2/19/10, effective 3/22/10. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.700, 2008 c 245. WSR 08-21-107, § 388-530-4100, filed 10/16/08, effective 11/16/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-4100, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-4125** Generics first for a client's first course of treatment. {#sec-182-530-4125 omnilex-key=us-wa-regs-official--title-182--182-530-4125}

(1) The medicaid agency may require preferred generic drugs on the Washington preferred drug list (Washington PDL) be used before any brand name or nonpreferred generic drugs for a client's first course of treatment within that therapeutic class of drugs, according to RCW 69.41.190.

(2) For drug classes selected by the agency that meet the criteria of subsection (1) of this section, only preferred generic drugs are covered for a client's first course of treatment, except as identified in subsection (3) of this section.

(3) Endorsing practitioners' prescriptions written "dispense as written (DAW)" for preferred and nonpreferred brand name drugs and nonpreferred generics in the specific drug classes on the Washington PDL reviewed by the drug use review (DUR) board will be subject to authorization to establish medical necessity as defined in WAC 182-500-0070.

(4) The agency uses point-of-sale (POS) claim messaging to tell pharmacies to use a preferred generic drug for the client's first course of treatment in specific drug classes.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-07-001, § 182-530-4125, filed 3/1/17, effective 4/1/17*
- *WSR 15-12-093, § 182-530-4125, filed 6/2/15, effective 7/3/15. WSR 11-14-075, recodified as § 182-530-4125, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.09.700, 74.08.090, 2009 c 575. WSR 10-06-011, § 388-530-4125, filed 2/19/10, effective 3/22/10.*

##### **Wash. Admin. Code § 182-530-4150** Therapeutic interchange program (TIP). {#sec-182-530-4150 omnilex-key=us-wa-regs-official--title-182--182-530-4150}

This section contains the medicaid agency's rules for the endorsing practitioner therapeutic interchange program (TIP). TIP is established under RCW 69.41.190 and 70.14.050.

(1) TIP applies only to drugs:

(a) Within therapeutic classes on the Washington preferred drug list (Washington PDL);

(b) Included in a motion passed by the pharmacy and therapeutics (P&T) committee; and

(c) Prescribed by an endorsing practitioner.

(2) TIP does not apply to a drug when:

(a) The P&T committee determines that TIP does not apply to the drug or its therapeutic class on the Washington PDL;

(b) Prescribed by a nonendorsing practitioner;

(c) The endorsing practitioner signs the prescription "dispense as written (DAW)"; or

(d) Otherwise prohibited under RCW 69.41.190.

(3) The agency may impose nonendorsing status on an endorsing practitioner only under the circumstances outlined in RCW 69.41.190.

(4) Except as otherwise provided in subsection (5) of this section, the agency may restrict a client's first course of treatment within a therapeutic class, according to the provisions in RCW 69.41.190.

(5) In accordance with WAC 182-530-4125(3) and 182-501-0165, the agency will request and review the endorsing practitioner's medical justification for preferred and nonpreferred brand name drugs and nonpreferred generic drugs for the client's first course of treatment.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-07-001, § 182-530-4150, filed 3/1/17, effective 4/1/17*
- *WSR 16-01-046, § 182-530-4150, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-4150, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.09.700, 74.08.090, 2009 c 575. WSR 10-06-011, § 388-530-4150, filed 2/19/10, effective 3/22/10. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.700, 2008 c 245. WSR 08-21-107, § 388-530-4150, filed 10/16/08, effective 11/16/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-4150, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-5000** Billing requirements—Pharmacy claim payment. {#sec-182-530-5000 omnilex-key=us-wa-regs-official--title-182--182-530-5000}

(1) When billing the medicaid agency for pharmacy services, providers must:

(a) Use the appropriate agency claim form or electronic billing specifications;

(b) Include the actual 11-digit national drug code (NDC) number of the product dispensed from a rebate eligible manufacturer;

(c) Bill the agency using metric decimal quantities which is the National Council for Prescription Drug Programs (NCPDP) billing unit standard;

(d) Meet the general provider documentation and record retention requirements in WAC 182-502-0020; and

(e) Maintain proof of delivery receipts.

(i) When a provider delivers an item directly to the client or the client's designee, the provider must be able to furnish proof of delivery, including the signature of either the client, the client's designee, or the provider, the client's name, and a detailed description of the item or items delivered.

(ii) When a provider mails an item to the client, the provider must be able to furnish proof of delivery including a mail log.

(iii) When a provider uses a delivery or shipping service to deliver items, the provider must be able to furnish proof of delivery and it must:

(A) Include the delivery service tracking slip with the client's name or a reference to the client's package or packages; the delivery service package identification number; and the delivery address.

(B) Include the supplier's shipping invoice, with the client's name; the shipping service package identification number; and a detailed description.

(iv) Make proof of delivery receipts available to the agency upon request.

(2) When billing drugs under the expedited authorization process, providers must insert the authorization number, which includes the corresponding criteria code or codes in the appropriate data field on the drug claim.

(3) Pharmacy services for clients on restriction under WAC 182-501-0135 must be prescribed by the client's primary care provider and are paid only to the client's primary pharmacy, except in cases of:

(a) Emergency;

(b) Family planning services; or

(c) Services properly referred from the client's assigned pharmacy or physician/ARNP.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-13-004, § 182-530-5000, filed 6/8/23, effective 7/9/23*
- *WSR 21-05-043, § 182-530-5000, filed 2/11/21, effective 3/14/21*
- *WSR 16-01-046, § 182-530-5000, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-5000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-5000, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-5050** Billing requirements—Point-of-sale (POS) system/prospective drug use review (Pro-DUR). {#sec-182-530-5050 omnilex-key=us-wa-regs-official--title-182--182-530-5050}

(1) Pharmacy claims for drugs and other products listed in the medicaid agency's drug file and billed to the agency by national drug code (NDC) are adjudicated by the agency's point-of-sale (POS) system. Claims must be submitted for payment using the billing unit standard identified in WAC 182-530-5000.

(2) All pharmacy drug claims processed through the POS system undergo a system-facilitated prospective drug use review (Pro-DUR) screening as a complement to the Pro-DUR screening required of pharmacists.

(3) If the POS system identifies a potential drug therapy problem during Pro-DUR screening, a message will alert the pharmacy provider indicating the type of potential problem. The alerts regarding possible drug therapy problems include, but are not limited to:

(a) Therapeutic duplication;

(b) Duration of therapy exceeds the recommended maximum period;

(c) Drug-to-drug interaction;

(d) Drug disease precaution;

(e) High dose;

(f) Ingredient duplication;

(g) Drug-to-client age conflict;

(h) Drug-to-client gender conflict; or

(i) Refill too soon.

(4) The agency provides pharmacy providers with a list of codes from which to choose in overriding POS system alert messages. These codes come from the National Council for Prescription Drug Programs (NCPDP).

(5) The dispensing pharmacist evaluates the potential drug therapy conflict and enters applicable NCPDP codes representing their professional interaction.

(a) If the resolution to the conflict satisfies agency requirements, the claim will be processed accordingly.

(b) If the resolution to the conflict does not satisfy agency requirements, the agency requires prior authorization. This includes all claims for which an alert message is triggered in the POS system and an NCPDP override code is not appropriate.

(6) The agency requires providers to retain documentation of the justification for the use of payment system override codes as described in subsections (4) and (5) of this section. The agency requires the documentation be retained for the same period as that described in WAC 182-502-0020.

(7) POS/Pro-DUR screening is not applicable to pharmacy claims included in the managed care capitated rate.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-01-046, § 182-530-5050, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-5050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-5050, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-5100** Billing requirements—Unit dose. {#sec-182-530-5100 omnilex-key=us-wa-regs-official--title-182--182-530-5100}

(1) To be eligible for a unit dose dispensing fee from the medicaid agency, a pharmacy must:

(a) Notify the agency in writing of its intent to provide unit dose service;

(b) Identify the nursing facility or facilities to be served;

(c) Indicate the approximate date unit dose service to the facility or facilities will commence; and

(d) Follow agency requirements for unit dose payment.

(2) Under a unit dose delivery system, a pharmacy must bill only for the number of drug units actually used by the client in the nursing facility, except as provided in subsections (3), (4), and (5) of this section. It is the unit dose pharmacy provider's responsibility to coordinate with nursing facilities to ensure that the unused drugs the pharmacy dispensed to clients are returned to the pharmacy for credit.

(3) The pharmacy must submit an adjustment form or claims reversal of the charge to the agency for the cost of all unused drugs returned to the pharmacy from the nursing facility on or before the sixtieth day following the date the drug was dispensed, except as provided in subsection (5) of this section. Such adjustment must conform to the nursing facility's monthly log as described in subsection (7) of this section.

(4) The agency pays a unit dose provider a dispensing fee when a provider-packaged unit dose prescription is returned, in its entirety, to the pharmacy. A dispensing fee is not paid if the returned prescription is for a drug with a manufacturer-designated unit dose national drug code (NDC). In addition to the dispensing fee paid under this subsection, the provider may bill the agency one unit of the tablet or capsule but must credit the agency for the remainder of the ingredient costs for the returned prescription.

(5) Unit dose providers do not have to credit the agency for federally designated schedule two drugs which are returned to the pharmacy. These returned drugs must be disposed of according to federal regulations.

(6) Pharmacies must not charge clients or the agency a fee for repackaging a client's bulk medications in unit dose form. The costs of repackaging are the responsibility of the nursing facility when the repackaging is done:

(a) To conform with a nursing facility's drug delivery system; or

(b) For the nursing facility's convenience.

(7) The pharmacy must maintain detailed records of medications dispensed under unit dose delivery systems. The pharmacy must keep a monthly log for each nursing facility served including, but not limited to, the following information:

(a) Facility name and address;

(b) Client's name and patient identification code (PIC);

(c) Drug name/strength;

(d) National drug code (NDC);

(e) Quantity and date dispensed;

(f) Quantity and date returned;

(g) Value of returned drugs or amount credited;

(h) Explanation for no credit given or nonreusable returns; and

(i) Prescription number.

(8) Upon the agency's request, the pharmacy must submit copies of the logs referred to in subsection (7) of this section.

(9) When the pharmacy submits the completed annual prescription volume survey to the agency, it must include an updated list of all nursing facilities currently served under unit dose systems.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-01-046, § 182-530-5100, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-5100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-5100, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-6000** Mail-order and specialty pharmacy services. {#sec-182-530-6000 omnilex-key=us-wa-regs-official--title-182--182-530-6000}

Clients may elect to receive pharmacy services through any mail-order or specialty pharmacy enrolled with the agency.

(1) Mail-order pharmacies or specialty pharmacies licensed to do business in Washington state under RCW 18.64.360 may enroll with the agency in the same manner as other pharmacies according to chapter 182-502 WAC, including out-of-state mail-order or specialty pharmacies.

(2) The agency considers mail-order and specialty classes of trade the same as retail class of trade for the purpose of enrollment with the agency. When enrolling with the agency, a mail-order or specialty pharmacy must enroll as a retail pharmacy unless participating with the agency under a mail-order or specialty pharmacy contract. Mail-order and specialty pharmacies cannot enroll under a mail-order designation by taxonomy or other indicator except when providing services under a mail-order contract with the agency separate from and in addition to the pharmacy's core provider agreement.

(3) Out-of-state pharmacies must comply with all applicable Revised Code of Washington and Washington Administrative Code when serving agency clients.

(4) The provisions of this chapter apply equally to all pharmacies and services provided by pharmacies regardless of the pharmacy's class of trade, except when those services are provided under a contract with the agency separate from and in addition to the pharmacy's core provider agreement.

(5) The agency may contract with one or more mail-order or specialty pharmacies separate from and in addition to the pharmacy's core provider agreement.

(a) Provisions of the contract may differ from requirements detailed in this chapter including, but not limited to, reimbursement rates, dispensing limitations, and authorization requirements.

(b) Mail-order or specialty pharmacy contract provisions supersede individual sections or subsections of this chapter when specifically cited in contract, leaving in effect all other provisions of this chapter.

(c) Mail-order contract provisions for a dispensing pharmacy must not allow for a higher reimbursement than is allowed under this chapter for a retail pharmacy.

(d) When opening enrollment under a mail-order or specialty contract, the agency will make publicly available the contract provisions and minimum requirements to participate under the contract including, but not limited to, the reimbursement rate and methodology the provider must accept. Any pharmacy enrolled with Washington medicaid as a billing provider may choose to accept and participate with the agency under the terms of the mail-order or specialty pharmacy contract.

(e) The agency may use the same contract for both mail-order and specialty pharmacies, or may have separate standard contracts for each class of trade.

(f) The agency may base contract provisions on information supplied through a request for information to interested parties before making the finalized contract publicly available.

(6) The agency may implement programs or contract provisions that provide favorable conditions to contracted mail-order pharmacies, specialty pharmacies, or clients to encourage participation by pharmacies or the use of mail-order and specialty services by clients.

(7) The agency may designate specific products or classes of products to be made available to clients through mail-order or specialty pharmacies only.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-07-001, § 182-530-6000, filed 3/1/17, effective 4/1/17*
- *WSR 16-01-046, § 182-530-6000, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-6000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-6000, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-7000** Reimbursement. {#sec-182-530-7000 omnilex-key=us-wa-regs-official--title-182--182-530-7000}

(1) The medicaid agency's reimbursement for a prescription drug dispensed through point-of-sale (POS) must not exceed the lesser of actual acquisition cost (AAC) plus a professional dispensing fee or the provider's usual and customary charge.

(2) The agency selects the sources for pricing information used to set AAC.

(3) The AAC is calculated as the lowest of:

(a) National average drug acquisition cost (NADAC);

(b) Maximum allowable cost (MAC);

(c) Federal upper limit (FUL);

(d) 340B MAC for covered outpatient drugs purchased, dispensed, or administered under section 340B of the Public Health Service (PHS) Act (see WAC 182-530-7900 for exceptions); or

(e) Submitted ingredient cost.

(4) Where NADAC does not exist, other available reference prices from national sources such as wholesale acquisition cost, or average manufacturer price may be used as the basis of the reimbursement.

(5) Where NADAC does not accurately reflect the actual acquisition costs in Washington state, a percentage adjustment to NADAC will be made to the reimbursement.

(6) The agency may set AAC for specified drugs, drug categories, or providers at a maximum allowable cost other than that determined in subsection (2) of this section based on specific product acquisition costs. The agency considers product acquisition costs in setting a rate for a drug or a class of drugs.

(7) The agency bases AAC drug reimbursement on the actual package size dispensed.

(8) The agency reimburses a pharmacy for the least costly dosage form of a drug within the same route of administration, unless the prescriber has designated a medically necessary specific dosage form or the agency has selected the more expensive dosage form as a preferred drug.

(9) If the pharmacy provider offers a discount, rebate, promotion, or other incentive which directly relates to the reduction of the price of a prescription to the individual nonmedicaid customer, the provider must similarly reduce its charge to the agency for the prescription.

(10) If the pharmacy provider gives an otherwise covered product for free to the general public, the pharmacy must not submit a claim to the agency.

(11) The agency does not reimburse for:

(a) Prescriptions written on presigned prescription blanks filled out by nursing facility operators or pharmacists;

(b) Prescriptions without the date of the original order;

(c) Drugs used to replace those taken from a nursing facility emergency kit;

(d) Drugs used to replace a physician's stock supply;

(e) Outpatient drugs, biological products, insulin, supplies, appliances, and equipment included in other reimbursement methods including, but not limited to:

(i) Diagnosis-related group (DRG);

(ii) Ratio of costs-to-charges (RCC);

(iii) Nursing facility daily rates;

(iv) Managed care capitation rates;

(v) Block grants; or

(vi) Drugs prescribed for clients who are on the agency's hospice program when the drugs are related to the client's terminal illness and related condition.

(f) Hemophilia and von Willebrand related products shipped to clients for administration in the home unless the products are provided through a qualified hemophilia treatment center of excellence (COE) as defined in WAC 182-531-1625.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-08-061, § 182-530-7000, filed 3/29/24, effective 5/1/24*
- *WSR 17-07-001, § 182-530-7000, filed 3/1/17, effective 4/1/17. Statutory Authority: RCW 41.05.021. WSR 12-16-061, § 182-530-7000, filed 7/30/12, effective 11/1/12. WSR 11-14-075, recodified as § 182-530-7000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-7000, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-7050** Reimbursement—Dispensing fee determination. {#sec-182-530-7050 omnilex-key=us-wa-regs-official--title-182--182-530-7050}

(1) Subject to the provisions of WAC 182-530-7000 and the exceptions permitted in WAC 182-530-2000, the medicaid agency pays a dispensing fee for each covered, prescribed drug.

(2) The agency does not pay a dispensing fee for:

(a) Nondrug items, devices, or drug-related supplies; or

(b) Drugs administered by a health care professional.

(3) The agency periodically examines the sufficiency of pharmacy dispensing fees and may adjust the dispensing fee by considering factors including, but not limited to:

(a) Legislative appropriations for vendor rates;

(b) Input from provider and advocacy groups;

(c) Input from state-employed or contracted actuaries; and

(d) Dispensing fees paid by other third-party payers including, but not limited to, health care plans and other states' medicaid agencies.

(4) The agency uses a tiered dispensing fee system which pays higher volume pharmacies at a lower fee and lower volume pharmacies at a higher fee.

(5) The agency uses total annual prescription volume (both medicaid and nonmedicaid) reported to the agency to determine each pharmacy's dispensing fee tier. The following tier levels are effective for dates of service on and after July 1, 2023:

(a) A pharmacy which fills 70,000 or more prescriptions annually is a high-volume pharmacy. The agency considers hospital-based pharmacies that serve both inpatient and outpatient clients as high-volume pharmacies.

(b) A pharmacy which fills between 30,000 and 69,999 prescriptions annually is a mid-volume pharmacy.

(c) A pharmacy which fills less than 30,000 prescriptions annually is a low-volume pharmacy.

(6) The agency determines a pharmacy's annual total prescription volume as follows:

(a) The agency sends out a prescription volume survey form to pharmacy providers during the first quarter of the calendar year;

(b) Pharmacies return completed prescription volume surveys to the agency each year. Pharmacy providers not responding to the survey by the specified date are assigned to the high volume category;

(c) Pharmacies must include all prescriptions dispensed from the same physical location in the pharmacy's total prescription count;

(d) The agency considers prescriptions dispensed to nursing facility clients as outpatient prescriptions; and

(e) Assignment to a new dispensing fee tier is effective on the first of the month, following the date specified by the agency.

(7) A pharmacy may request a change in dispensing fee tier during the interval between the annual prescription volume surveys. The pharmacy must substantiate such a request with documentation showing that the pharmacy's most recent six-month dispensing data, annualized, would qualify the pharmacy for the new tier. If the agency receives the documentation by the twentieth of the month, assignment to a new dispensing fee tier is effective on the first of the following month.

(8) The agency grants general dispensing fee rate increases only when authorized by the legislature. Amounts authorized for dispensing fee increases may be distributed nonuniformly (e.g., tiered dispensing fee based upon volume).

(9) The agency may pay true unit dose pharmacies at a different rate for unit dose dispensing.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-03-170, § 182-530-7050, filed 1/24/24, effective 2/24/24*
- *WSR 17-07-001, § 182-530-7050, filed 3/1/17, effective 4/1/17*
- *WSR 16-01-046, § 182-530-7050, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-7050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-7050, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-7100** Reimbursement—Pharmaceutical supplies. {#sec-182-530-7100 omnilex-key=us-wa-regs-official--title-182--182-530-7100}

(1) The medicaid agency reimburses for selected pharmaceutical supplies through the pharmacy point-of-sale (POS) system when it is necessary for client access and safety.

(2) The agency bases reimbursement of pharmaceutical items or supplies that are not payable through the POS on agency-published fee schedules.

(3) The agency uses any or all of the following methodologies to set the maximum allowable reimbursement rate for drugs, devices, and drug-related supplies:

(a) A pharmacy provider's acquisition cost. Upon review of the claim, the agency may require an invoice which must show the name of the item, the manufacturer, the product description, the quantity, and the current cost including any free goods associated with the invoice;

(b) Medicare's reimbursement rate for the item; or

(c) A specified discount off the item's list price or manufacturer's suggested retail price (MSRP).

(4) The agency does not pay a dispensing fee for nondrug items, devices, or drug-related supplies. See WAC 182-530-7050.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-01-046, § 182-530-7100, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-7100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-7100, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-7150** Reimbursement—Compounded prescriptions. {#sec-182-530-7150 omnilex-key=us-wa-regs-official--title-182--182-530-7150}

(1) The medicaid agency does not consider reconstitution to be compounding.

(2) The agency covers a drug ingredient used for a compounded prescription only when the manufacturer has a signed rebate agreement with the federal Department of Health and Human Services (DHHS).

(3) The agency considers bulk chemical supplies used in compounded prescriptions as nondrug items, which do not require a drug rebate agreement. The agency covers such bulk chemical supplies only as specifically approved by the agency.

(4) The agency reimburses pharmacists for compounding drugs only if the client's drug therapy needs are unable to be met by commercially available dosage strengths or forms of the medically necessary drug.

(a) The pharmacist must ensure the need for the adjustment of the drug's therapeutic strength or form is well-documented in the client's file.

(b) The pharmacist must ensure that the ingredients used in a compounded prescription are for an approved use as defined in "medically accepted indication" in WAC 182-530-1050.

(5) The agency requires that each drug ingredient used for a compounded prescription be billed to the agency using its eleven-digit national drug code (NDC) number.

(6) Compounded prescriptions are reimbursed as follows:

(a) The agency allows only the lowest cost for each covered ingredient, whether that cost is determined by actual acquisition cost (AAC), federal upper limit (FUL), maximum allowable cost (MAC), or amount billed.

(b) The agency applies current prior authorization requirements to drugs used as ingredients in compounded prescriptions, except as provided under (c) of this subsection. The agency denies payment for a drug requiring authorization when authorization is not obtained.

(c) The agency may designate selected drugs as not requiring authorization when used for compounded prescriptions. For the list of selected drugs, refer to the agency's prescription drug program billing instructions.

(d) The agency pays a professional dispensing fee as described under WAC 182-530-7050 for each drug ingredient used in compounding when the conditions of this section are met and each ingredient is billed separately by the eleven-digit NDC.

(e) The agency does not pay a separate fee for compounding time.

(7) The agency requires pharmacists to document the need for each inactive ingredient added to the compounded prescription. The agency limits reimbursement to the inactive ingredients that meet the following criteria. To be reimbursed by the agency, each inactive ingredient must be:

(a) A necessary component of a compounded drug; and

(b) Billed by an eleven-digit national drug code (NDC).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-22-005, s 182-530-7150, filed 10/23/24, effective 11/23/24*
- *WSR 17-07-001, § 182-530-7150, filed 3/1/17, effective 4/1/17*
- *WSR 16-01-046, § 182-530-7150, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-7150, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-7150, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-7200** Reimbursement—Out-of-state prescriptions. {#sec-182-530-7200 omnilex-key=us-wa-regs-official--title-182--182-530-7200}

(1) The medicaid agency reimburses out-of-state pharmacies for prescription drugs provided to an eligible client within the scope of the client's medical care program if the pharmacy:

(a) Contracts with the agency to be an enrolled provider; and

(b) Meets the same criteria the agency requires for in-state pharmacy providers.

(2) The agency considers pharmacies located in bordering areas listed in WAC 182-501-0175 the same as in-state pharmacies.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-01-046, § 182-530-7200, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-7200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-7200, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-7250** Reimbursement—Miscellaneous. {#sec-182-530-7250 omnilex-key=us-wa-regs-official--title-182--182-530-7250}

(1) The medicaid agency reimburses for covered drugs, devices, and drug-related supplies provided or administered by nonpharmacy providers under specified conditions, as follows:

(a) The agency reimburses for drugs administered or prepared and delivered for individual use by an authorized prescriber during an office visit according to specific program rules found in:

(i) Chapter 182-531 WAC, Physician-related services;

(ii) Chapter 182-532 WAC, Reproductive health/family planning programs; and

(iii) Chapter 182-540 WAC, Kidney disease program and kidney center services.

(b) Providers who are participating PHS-qualified covered entities under section 340B of the Public Health Services (PHS) Act must comply with PHS 340B program requirements and Washington medicaid requirements for 340B providers participating with medicaid. (See WAC 182-530-7900.)

(2) The agency may require providers to submit a current invoice for the actual cost of the drug, device, or drug-related supply billed. If an invoice is required, the invoice must show the:

(a) Name of the drug, device, or drug-related supply;

(b) Drug or product manufacturer;

(c) NDC of the product or products;

(d) Drug strength;

(e) Product description;

(f) Quantity; and

(g) Cost, including any discounts or free goods associated with the invoice.

(3) The agency does not reimburse providers for the cost of vaccines obtained through the state department of health (DOH). The agency does pay physicians, advanced registered nurse practitioners (ARNP), and pharmacists a fee for administering the vaccine.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-08-061, § 182-530-7250, filed 3/29/24, effective 5/1/24*
- *WSR 23-11-007, § 182-530-7250, filed 5/4/23, effective 6/4/23*
- *WSR 17-07-001, § 182-530-7250, filed 3/1/17, effective 4/1/17*
- *WSR 16-01-046, § 182-530-7250, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-7250, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-7250, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-7300** Reimbursement—Requesting a change. {#sec-182-530-7300 omnilex-key=us-wa-regs-official--title-182--182-530-7300}

Upon request from a provider, the medicaid agency may reimburse at the provider's actual acquisition cost (AAC) for a drug that would otherwise be reimbursed at maximum allowable cost (MAC) when:

(1) The availability of lower cost equivalents in the marketplace is severely curtailed and the price disparity between AAC for the drug and the MAC reimbursement affects clients' access; and

(2) An invoice documenting AAC relevant to the date the drug was dispensed is provided to the agency.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-08-061, § 182-530-7300, filed 3/29/24, effective 5/1/24*
- *WSR 17-07-001, § 182-530-7300, filed 3/1/17, effective 4/1/17*
- *WSR 16-01-046, § 182-530-7300, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-7300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-7300, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-7350** Reimbursement—Unit dose drug delivery systems. {#sec-182-530-7350 omnilex-key=us-wa-regs-official--title-182--182-530-7350}

(1) The medicaid agency pays for unit dose drug delivery systems only for clients residing in nursing facilities, except as provided in subsections (7) and (8) of this section.

(2) Unit dose delivery systems may be either true or modified unit dose.

(3) The agency pays pharmacies that provide unit dose delivery services the agency's highest allowable dispensing fee for each unit dose prescription dispensed to clients in nursing facilities. The agency reimburses ingredient costs for drugs under unit dose systems as described in WAC 182-530-7000.

(4) The agency pays a pharmacy that dispenses drugs in bulk containers or multidose forms to clients in nursing facilities the regular dispensing fee applicable to the pharmacy's total annual prescription volume tier. Drugs the agency considers not deliverable in unit dose form include, but are not limited to, liquids, creams, ointments, ophthalmic and otic solutions. The agency reimburses ingredient costs as described in WAC 182-530-7000.

(5) The agency pays a pharmacy that dispenses drugs prepackaged by the manufacturer in unit dose form to clients in nursing facilities the regular dispensing fee applicable under WAC 182-530-7050. The agency reimburses ingredient costs for drugs prepackaged by the manufacturer in unit dose form as described in WAC 182-530-7000.

(6) The agency limits its coverage and payment for manufacturer-designated unit dose packaging to the following conditions:

(a) The drug is a single source drug and a multidose package for the drug is not available;

(b) The drug is a multiple source drug but there is no other multidose package available among the drug's generic equivalents; or

(c) The manufacturer-designated unit dose package is the most cost-effective package available or it is the least costly alternative form of the drug.

(7) The agency reimburses a pharmacy provider for manufacturer-designated unit dose drugs dispensed to clients not residing in nursing facilities only when such drugs:

(a) Are available in the marketplace only in manufacturer-designated unit dose packaging; and

(b) Would otherwise be covered as an outpatient drug. The unit dose dispensing fee does not apply in such cases. The agency pays the pharmacy the dispensing fee applicable to the pharmacy's total annual prescription volume tier.

(8) The agency may pay for unit dose delivery systems for clients of developmental disabilities community services residing in approved community living arrangements.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-530-7350, filed 11/4/25, effective 12/5/25*
- *WSR 16-01-046, § 182-530-7350, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-7350, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-7350, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-7400** Reimbursement—Compliance packaging services. {#sec-182-530-7400 omnilex-key=us-wa-regs-official--title-182--182-530-7400}

(1) The medicaid agency reimburses pharmacies for compliance packaging services provided to clients considered at risk for adverse drug therapy outcomes. Clients who are eligible for compliance packaging services must not reside in a nursing home or other inpatient facility, and must meet (a) and either (b) or (c) of this subsection. The client must:

(a) Have one or more of the following representative disease conditions:

(i) Alzheimer's disease;

(ii) Blood clotting disorders;

(iii) Cardiac arrhythmia;

(iv) Congestive heart failure;

(v) Depression;

(vi) Diabetes;

(vii) Epilepsy;

(viii) HIV/AIDS;

(ix) Hypertension;

(x) Schizophrenia; or

(xi) Tuberculosis.

(b) Concurrently consume two or more prescribed medications for chronic medical conditions, that are dosed at three or more intervals per day; or

(c) Have demonstrated a pattern of noncompliance that is potentially harmful to the client's health. The client's pattern of noncompliance with the prescribed drug regimen must be fully documented in the provider's file.

(2) Compliance packaging services include:

(a) Reusable hard plastic containers of any type (e.g., medisets); and

(b) Nonreusable compliance packaging devices (e.g., blister packs).

(3) The agency pays a filling fee and reimburses pharmacies for the compliance packaging device and container. The frequency of fills and number of payable compliance packaging devices per client is subject to limits specified by the agency. The agency does not pay filling or preparation fees for blister packs.

(4) Pharmacies must use the CMS-1500 claim form to bill the agency for compliance packaging services.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-01-046, § 182-530-7400, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-7400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-7400, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-7500** Drug rebate requirement. {#sec-182-530-7500 omnilex-key=us-wa-regs-official--title-182--182-530-7500}

(1) The medicaid agency reimburses for outpatient prescription drugs only when they are supplied by manufacturers who have a signed drug rebate agreement with the federal Department of Health and Human Services (DHHS), according to 42 U.S.C. 1396r-8. The manufacturer must be listed on the list of participating manufacturers as published by the Center for Medicare and Medicaid Services (CMS).

(2) The fill date must be within the manufacturer's beginning and ending eligibility dates to be reimbursed by the agency.

(3) The agency may extend this rebate requirement to any outpatient drug reimbursements as allowed or required by federal law.

(4) The agency may exempt drugs from the rebate requirement, on a case-by-case basis, when:

(a) It determines that the availability of a single source drug or innovator multiple source drug is essential to the health of beneficiaries; and

(b) All other rebate exemption requirements of SSA Sec. 1927 (42 U.S.C. 1396r-8)(3) are also satisfied.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-01-046, § 182-530-7500, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-7500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-7500, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-7600** Reimbursement—Clients enrolled in managed care. {#sec-182-530-7600 omnilex-key=us-wa-regs-official--title-182--182-530-7600}

Except as specified under the medicaid agency's managed care contracts, the agency does not reimburse providers for any drugs or pharmaceutical supplies provided to clients who have pharmacy benefits under agency-contracted managed care plans. The managed care plan is responsible for payment.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-01-046, § 182-530-7600, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-7600, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-7600, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-7700** Reimbursement—Dual eligible clients/medicare. {#sec-182-530-7700 omnilex-key=us-wa-regs-official--title-182--182-530-7700}

For clients who are dually eligible for medical assistance and medicare benefits, the following applies:

(1) The agency pays medicare coinsurance, copayments, and deductibles for Part A, Part B, and medicare advantage Part C, subject to the limitations in WAC 182-502-0110.

(2) Medicare Part D:

(a) Medicare is the payer for drugs included in the medicare Part D benefit.

(b) The agency does not pay for Part D drugs or Part D copayments.

(c) For drugs excluded from the medicare Part D benefit:

(i) The agency offers the same drug benefit as a nondual eligible client has within those same classes;

(ii) If the client has another third party insurer, that insurer is the primary payer; and

(iii) The agency is the payer of last resort.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-07-001, § 182-530-7700, filed 3/1/17, effective 4/1/17. Statutory Authority: RCW 41.05.021, 2011 c 5, 2010 2nd sp.s. c 1 § 208 (25), and Section 1902 (n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997. WSR 13-14-052, § 182-530-7700, filed 6/27/13, effective 7/28/13. WSR 11-14-075, recodified as § 182-530-7700, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-7700, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-7800** Reimbursement—Clients with third-party liability. {#sec-182-530-7800 omnilex-key=us-wa-regs-official--title-182--182-530-7800}

(1) The medicaid agency requires providers to meet the third-party requirements of WAC 182-501-0200.

(2) The following definitions apply to this section:

(a) "Closed pharmacy network" means an arrangement made by an insurer which restricts prescription coverage to an exclusive list of pharmacies. This arrangement prohibits the coverage and/or payment of prescriptions provided by a pharmacy that is not included on the exclusive list.

(b) "Private point-of-sale (POS) authorization system" means an insurer's system, other than the agency's POS system, which requires that coverage be verified by or submitted to the insurer for authorization at the time of service and at the time the prescription is filled.

(3) This subsection applies to clients who have a third-party resource that is a managed care entity other than an agency-contracted plan, or have other insurance that requires the use of "closed pharmacy networks" or "private point-of-sale authorization system." The agency will not pay pharmacies for prescription drug claims until the pharmacy provider submits an explanation of benefits from the private insurance demonstrating that the pharmacy provider has complied with the terms of the third party's coverage.

(a) If the private insurer pays a fee based on the incident of care, the pharmacy provider must file a claim with the agency consistent with the agency's billing requirements.

(b) If the private insurer pays the pharmacy provider a monthly capitation fee for all prescription costs related to the client, the pharmacy provider must submit a claim to the agency for the amount of the client copayment, coinsurance, and/or deductible. The agency pays the provider the lesser of:

(i) The billed amount; or

(ii) The agency's maximum allowable fee for the prescription.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-01-046, § 182-530-7800, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-7800, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-7800, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-7900** Drugs purchased under the Public Health Service (PHS) Act. {#sec-182-530-7900 omnilex-key=us-wa-regs-official--title-182--182-530-7900}

(1) Providers registered and approved as PHS-qualified covered entities participate in the 340B program under their medicaid provider number or NPI listed on the quarterly medicaid exclusion file (MEF).

(2) PHS-qualified covered entities participating in the 340B program must follow federal and state 340B program requirements and applicable medicaid agency rules including, but not limited to, this chapter, chapters 182-501 and 182-502 WAC, and agency billing instructions.

(3) All claims submitted to Washington apple health through fee-for-service (FFS) or managed care for outpatient drugs purchased, dispensed, or administered by PHS-qualified covered entities participating in the 340B program:

(a) May be billed only by the PHS-qualified covered entity participating in the 340B program under their participating medicaid provider number or NPI listed in the quarterly medicaid exclusion file; and

(b) Are excluded from medicaid drug rebate invoicing. See WAC 182-530-7500 for information on the drug rebate program.

(4) With the exception of claim types identified in subsection (5) of this section, all drugs purchased, dispensed, or administered by a PHS-qualified covered entity participating in the 340B program must be billed at the actual acquisition cost (AAC) when submitted through FFS to the agency.

(5) Exceptions to the AAC billing requirement are only made for:

(a) Outpatient hospital claims paid under the enhanced ambulatory payment group (EAPG) methodology (see WAC 182-550-7000); and

(b) Ambulatory surgery claims paid under payment groups methodology.

(6) As part of participation in the 340B program, providers must submit a completed annual attestation form (HCA 13-0047) to the agency acknowledging that all claims for Washington apple health clients in both FFS and managed care are subject to all applicable 340B rules. Providers who fail to submit a completed attestation form to the agency may receive a compliance audit and be at risk of duplicate discounts.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-08-061, § 182-530-7900, filed 3/29/24, effective 5/1/24*
- *WSR 21-08-021, § 182-530-7900, filed 3/29/21, effective 5/1/21*
- *WSR 17-07-001, § 182-530-7900, filed 3/1/17, effective 4/1/17*
- *WSR 16-01-046, § 182-530-7900, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-7900, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-7900, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-8000** Reimbursement method—Actual acquisition cost (AAC). {#sec-182-530-8000 omnilex-key=us-wa-regs-official--title-182--182-530-8000}

The medicaid agency uses the following sources to determine actual acquisition cost (AAC) including, but not limited to:

(1) National average drug acquisition cost (NADAC) published by the Centers for Medicare and Medicaid Services (CMS);

(2) Acquisition cost data made available to the agency by:

(a) Audit results from federal or state agencies;

(b) Other state health care purchasing organizations;

(c) Pharmacy benefit managers;

(d) Individual pharmacy providers participating in the agency's programs;

(e) Other third-party payers;

(f) Drug file databases; and

(g) Actuaries or other consultants.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-08-061, § 182-530-8000, filed 3/29/24, effective 5/1/24*
- *WSR 17-07-001, § 182-530-8000, filed 3/1/17, effective 4/1/17*
- *WSR 16-01-046, § 182-530-8000, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-8000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050 and 74.08.090. WSR 10-24-021, § 388-530-8000, filed 11/19/10, effective 12/20/10. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-8000, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-8050** Reimbursement—Federal upper limit (FUL). {#sec-182-530-8050 omnilex-key=us-wa-regs-official--title-182--182-530-8050}

(1) The medicaid agency adopts the federal upper limit (FUL) set by the Centers for Medicare and Medicaid Services (CMS).

(2) The agency's maximum payment for multiple-source drugs for which CMS has set FULs will not exceed, in the aggregate, the prescribed upper limits plus the dispensing fees set by the agency.

(3) Except as provided in WAC 182-530-7300, the agency uses the FUL as the agency's reimbursement rate for the drug when the FUL price is the lowest of the rates calculated under the methods listed in WAC 182-530-7000.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-01-046, § 182-530-8050, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-8050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-8050, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-530-8100** Reimbursement—Maximum allowable cost (MAC). {#sec-182-530-8100 omnilex-key=us-wa-regs-official--title-182--182-530-8100}

(1) The medicaid agency establishes a maximum allowable cost (MAC) for covered outpatient drugs.

(2) The agency determines the MAC for covered outpatient drugs:

(a) When specific regional and local drug acquisition cost data is available, the agency:

(i) Identifies what products are available from wholesalers for each drug being considered for MAC pricing;

(ii) Determines pharmacy providers' approximate acquisition costs for these products; and

(iii) Establishes the MAC at a level which gives pharmacists access to at least one product from a manufacturer with a qualified rebate agreement (see WAC 182-530-7500(4)).

(b) When specific regional and local drug acquisition cost data is not available, the agency may estimate acquisition cost based on national pricing sources.

(3) The MAC established for covered outpatient drugs does not apply if the written prescription identifies that a specific brand is medically necessary for a particular client. In such cases, the actual acquisition cost (AAC) for the particular brand applies, provided authorization is obtained from the agency as specified under WAC 182-530-3000.

(4) Except as provided in subsection (3) of this section, the agency reimburses providers for covered outpatient drugs at the lowest of the rates calculated under the methods listed in WAC 182-530-7000.

(5) The MAC established for covered outpatient drugs may vary by package size, including those identified as unit dose national drug codes (NDCs) by the manufacturer or manufacturers of the drug.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-08-061, § 182-530-8100, filed 3/29/24, effective 5/1/24*
- *WSR 17-07-001, § 182-530-8100, filed 3/1/17, effective 4/1/17*
- *WSR 16-01-046, § 182-530-8100, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-8100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-8100, filed 9/26/07, effective 11/1/07.*

## **Chapter 182-531** Physician-related services. {#struct-chapter-182-531}

##### **Wash. Admin. Code § 182-531-0050** Physician-related services definitions. {#sec-182-531-0050 omnilex-key=us-wa-regs-official--title-182--182-531-0050}

The following definitions and abbreviations and those found in chapter 182-500 WAC, apply to this chapter.

"Actual acquisition cost" - See WAC 182-530-1050.

"Acute care" - Care provided for clients who are not medically stable. These clients require frequent monitoring by a health care professional in order to maintain their health status. See also WAC 246-335-015.

"Acute physical medicine and rehabilitation (PM&R)" - A comprehensive inpatient and rehabilitative program coordinated by a multidisciplinary team at a medicaid agency-approved rehabilitation facility. The program provides 24-hour specialized nursing services and an intense level of specialized therapy (speech, physical, and occupational) for a diagnostic category for which the client shows significant potential for functional improvement (see WAC 182-550-2501).

"Add-on procedure(s)" - Secondary procedure(s) that are performed in addition to another procedure.

"Admitting diagnosis" - The medical condition responsible for a hospital admission, as defined by the ICD diagnostic code.

"Advanced registered nurse practitioner (ARNP)" - A registered nurse prepared in a formal educational program to assume an expanded health services provider role in accordance with WAC 246-840-300 and 246-840-305.

"Allowed charges" - The maximum amount reimbursed for any procedure that is allowed by the medicaid agency.

"Anesthesia technical advisory group (ATAG)" - An advisory group representing anesthesiologists who are affected by the implementation of the anesthesiology fee schedule.

"Bariatric surgery" - Any surgical procedure, whether open or by laparoscope, which reduces the size of the stomach with or without bypassing a portion of the small intestine and whose primary purpose is the reduction of body weight in an obese individual.

"Base anesthesia units (BAU)" - A number of anesthesia units assigned to a surgical procedure that includes the usual preoperative, intraoperative, and postoperative visits. This includes the administration of fluids and/or blood incident to the anesthesia care, and interpretation of noninvasive monitoring by the anesthesiologist.

"Bundled services" - Services integral to the major procedure that are included in the fee for the major procedure. Bundled services are not reimbursed separately.

"Bundled supplies" - Supplies that are considered to be included in the practice expense RVU of the medical or surgical service of which they are an integral part.

"By report (BR)" - See WAC 182-500-0015.

"Call" - A face-to-face encounter between the client and the provider resulting in the provision of services to the client.

"Cast material maximum allowable fee" - A reimbursement amount based on the average cost among suppliers for one roll of cast material.

"Center of excellence (COE)" - 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)" - See WAC 182-500-0020.

"Certified registered nurse anesthetist (CRNA)" - An advanced registered nurse practitioner (ARNP) with formal training in anesthesia who meets all state and national criteria for certification. The American Association of Nurse Anesthetists specifies the national certification and scope of practice.

"Children's health insurance plan (CHIP)" - See chapter 182-505 WAC.

"Clinical Laboratory Improvement Amendment (CLIA)" - Regulations from the U.S. Department of Health and Human Services that require all laboratory testing sites to have either a CLIA registration or a CLIA certificate of waiver in order to legally perform testing anywhere in the U.S.

"Conversion factors" - Dollar amounts the medicaid agency uses to calculate the maximum allowable fee for physician-related services.

"Covered service" - A service that is within the scope of the eligible client's medical care program, subject to the limitations in this chapter and other published WAC.

"CPT" - See "current procedural terminology."

"Critical care services" - Physician services for the care of critically ill or injured clients. Critical care is given in a critical care area, such as the coronary care unit, intensive care unit, respiratory care unit, or the emergency care facility.

"Critical illness or injury" - An impairment to one or more vital organ systems with an increased risk of rapid or imminent life-threatening health deterioration.

"Current procedural terminology (CPT)" - A systematic listing of descriptive terms and identifying codes for reporting medical services, procedures, and interventions performed by physicians and other practitioners who provide physician-related services. CPT is copyrighted and published annually by the American Medical Association (AMA).

"Emergency medical condition(s)" - See WAC 182-500-0030.

"Emergency services" - Medical services required by and provided to a patient experiencing an emergency medical condition.

"Evaluation and management (E&M) codes" - Procedure codes that categorize physician services by type of service, place of service, and patient status.

"Expedited prior authorization" - The process of obtaining authorization that must be used for selected services, in which providers use a set of numeric codes to indicate to the medicaid agency which acceptable indications, conditions, diagnoses, and/or criteria are applicable to a particular request for services.

"Experimental" - A term to describe a health care service that lacks sufficient scientific evidence of safety and effectiveness. A service is not "experimental" if the service:

(a) Is generally accepted by the medical profession as effective and appropriate; and

(b) Has been approved by the federal Food and Drug Administration or other requisite government body, if such approval is required.

"Federally approved hemophilia treatment center" - A hemophilia treatment center (HTC) that:

(a) Receives funding from the U.S. Department of Health and Human Services, Maternal and Child Health Bureau National Hemophilia Program;

(b) Is qualified to participate in 340B discount purchasing as an HTC. See WAC 182-530-7900;

(c) Has a U.S. Center for Disease Control (CDC) and prevention surveillance site identification number and is listed in the HTC directory on the CDC website;

(d) Is recognized by the Federal Regional Hemophilia Network that includes Washington state; and

(e) Is a direct care provider offering comprehensive hemophilia care consistent with treatment recommendations set by the Medical and Scientific Advisory Council (MASAC) of the National Hemophilia Foundation in their standards and criteria for the care of persons with congenital bleeding disorders.

"Fee-for-service" - See WAC 182-500-0035.

"Flat fee" - The maximum allowable fee established by the agency for a service or item that does not have a relative value unit (RVU) or has an RVU that is not appropriate.

"Geographic practice cost index (GPCI)" - As defined by medicare, means a medicare adjustment factor that includes local geographic area estimates of how hard the provider has to work (work effort), what the practice expenses are, and what malpractice costs are. The GPCI reflects one-fourth the difference between the area average and the national average.

"Global surgery reimbursement" - See WAC 182-531-1700.

"HCPCS Level II" - Health care common procedure coding system, a coding system established by Centers for Medicare and Medicaid Services (CMS) to define services and procedures not included in CPT.

"Health care financing administration common procedure coding system (HCPCS)" - The name used for the Centers for Medicare and Medicaid Services (formerly known as the Health Care Financing Administration) codes made up of CPT and HCPCS level II codes.

"Health care team" - A group of health care providers involved in the care of a client.

"Hospice" - A medically directed, interdisciplinary program of palliative services which is provided under arrangement with a Title XVIII Washington licensed and certified Washington state hospice for terminally ill clients and the clients' families.

"ICD" - See "International Classification of Diseases."

"Informed consent" - That an individual consents to a procedure after the provider who obtained a properly completed consent form has done all the following:

(a) Disclosed and discussed the client's diagnosis;

(b) Offered the client an opportunity to ask questions about the procedure and to request information in writing;

(c) Given the client a copy of the consent form;

(d) Communicated effectively using any language interpretation or special communication device necessary per 42 C.F.R. Chapter IV 441.257; and

(e) Given the client oral information about all the following:

(i) The client's right to not obtain the procedure, including potential risks, benefits, and the consequences of not obtaining the procedure;

(ii) Alternatives to the procedure including potential risks, benefits, and consequences; and

(iii) The procedure itself, including potential risks, benefits, and consequences.

"Inpatient hospital admission" - An admission to a hospital that is limited to medically necessary care based on an evaluation of the client using objective clinical indicators, assessment, monitoring, and therapeutic service required to best manage the client's illness or injury, and that is documented in the client's medical record.

"International Classification of Diseases (ICD)" - The systematic listing that transforms verbal descriptions of diseases, injuries, conditions, and procedures into numerical or alphanumerical designations (coding).

"Investigational" - A term to describe a health care service that lacks sufficient scientific evidence of safety and effectiveness for a particular condition. A service is not "investigational" if the service:

(a) Is generally accepted by the medical professional as effective and appropriate for the condition in question; or

(b) Is supported by an overall balance of objective scientific evidence, that examines the potential risks and potential benefits and demonstrates the proposed service to be of greater overall benefit to the client in the particular circumstance than another generally available service.

"Life support" - Mechanical systems, such as ventilators or heart-lung respirators, which are used to supplement or take the place of the normal autonomic functions of a living person.

"Limitation extension" - See WAC 182-501-0169.

"Long-acting reversible contraceptive (LARC)" - Subdermal implants and intrauterine devices (IUDs).

"Maximum allowable fee" - The maximum dollar amount that the medicaid agency will reimburse a provider for specific services, supplies, and equipment.

"Medically necessary" - See WAC 182-500-0070.

"Medicare clinical diagnostic laboratory fee schedule" - The fee schedule used by medicare to reimburse for clinical diagnostic laboratory procedures in the state of Washington.

"Medicare physician fee schedule database (MPFSDB)" - The official CMS publication of the medicare policies and RVUs for the RBRVS reimbursement program.

"Medicare program fee schedule for physician services (MPFSPS)" - The official CMS publication of the medicare fees for physician services.

"Medication for opioid use disorder (MOUD)" - The use of Food and Drug Administration-approved medications that have published evidence of effectiveness, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders.

"Mentally incompetent" - A client who has been declared mentally incompetent by a federal, state, or local court.

"Modifier" - A two-digit alphabetic or numeric, or both, identifier that is added to the procedure code to indicate the type of service performed. The modifier provides the means by which the reporting physician can describe or indicate that a performed service or procedure has been altered by some specific circumstance but not changed in its definition or code. The modifier can affect payment or be used for information only. Modifiers are listed in fee schedules.

"Outpatient" - See WAC 182-500-0080.

"Peer-reviewed medical literature" - A research study, report, or findings regarding a medical treatment that is published in one or more reputable professional journals after being critically reviewed by appropriately credentialed experts for scientific validity, safety, and effectiveness.

"Physician care plan" - A written plan of medically necessary treatment that is established by and periodically reviewed and signed by a physician. The plan describes the medically necessary services to be provided by a home health agency, a hospice agency, or a nursing facility.

"Physician standby" - Physician attendance without direct face-to-face client contact and which does not involve provision of care or services.

"Physician's current procedural terminology" - See "current procedural terminology (CPT)."

"PM&R" - See acute physical medicine and rehabilitation.

"Podiatric service" - The diagnosis and medical, surgical, mechanical, manipulative, and electrical treatments of ailments of the foot and ankle.

"Pound indicator (#)" - A symbol (#) indicating a CPT procedure code listed in the medicaid agency's fee schedules that is not routinely covered.

"Preventive" - Medical practices that include counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of appropriate laboratory and diagnostic procedures intended to help a client avoid or reduce the risk or incidence of illness or injury.

"Prior authorization" - See WAC 182-500-0085.

"Professional component" - The part of a procedure or service that relies on the provider's professional skill or training, or the part of that reimbursement that recognizes the provider's cognitive skill.

"Prognosis" - The probable outcome of a client's illness, including the likelihood of improvement or deterioration in the severity of the illness, the likelihood for recurrence, and the client's probable life span as a result of the illness.

"Prolonged services" - Face-to-face client services furnished by a provider, either in the inpatient or outpatient setting, which involve time beyond what is usual for such services. The time counted toward payment for prolonged E&M services includes only face-to-face contact between the provider and the client, even if the service was not continuous.

"Provider" - See WAC 182-500-0085.

"Qualified health care professional (QHCP)" - An individual who is authorized to provide health care services based on their scope of practice and who may independently report those services.

"Radioallergosorbent test" or "RAST" - A blood test for specific allergies.

"RBRVS" - See resource based relative value scale.

"RBRVS RVU" - A measure of the resources required to perform an individual service or intervention. It is set by medicare based on three components - Physician work, practice cost, and malpractice expense. Practice cost varies depending on the place of service.

"Reimbursement" - Payment to a provider or other agency-approved entity who bills according to the provisions in WAC 182-502-0100.

"Reimbursement steering committee (RSC)" - An interagency work group that establishes and maintains RBRVS physician fee schedules and other payment and purchasing systems utilized by the medicaid agency and the department of labor and industries.

"Relative value guide (RVG)" - A system used by the American Society of Anesthesiologists for determining base anesthesia units (BAUs).

"Relative value unit (RVU)" - A unit that is based on the resources required to perform an individual service or intervention.

"Resource based relative value scale (RBRVS)" - A scale that measures the relative value of a medical service or intervention, based on the amount of physician resources involved.

"RSC RVU" - A unit established by the RSC for a procedure that does not have an established RBRVS RVU or has an RBRVS RVU deemed by the RSC as not appropriate for the service.

"RVU" - See relative value unit.

"Stat laboratory charges" - Charges by a laboratory for performing tests immediately. "Stat" is an abbreviation for the Latin word "statim," meaning immediately.

"Sterile tray" - A tray containing instruments and supplies needed for certain surgical procedures normally done in an office setting. For reimbursement purposes, tray components are considered by CMS to be nonroutine and reimbursed separately.

"Technical advisory group (TAG)" - An advisory group with representatives from professional organizations whose members are affected by implementation of RBRVS physician fee schedules and other payment and purchasing systems utilized by the agency and the department of labor and industries.

"Technical component" - The part of a procedure or service that relates to the equipment set-up and technician's time, or the part of the procedure and service reimbursement that recognizes the equipment cost and technician time.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-18-049, s 182-531-0050, filed 8/27/25, effective 9/27/25*
- *WSR 25-07-078, s 182-531-0050, filed 3/17/25, effective 4/17/25*
- *WSR 24-08-061, § 182-531-0050, filed 3/29/24, effective 5/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and 2018 c 299. WSR 19-09-052, § 182-531-0050, filed 4/12/19, effective 5/13/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-21-040, § 182-531-0050, filed 10/12/17, effective 11/12/17*
- *WSR 17-09-002, § 182-531-0050, filed 4/5/17, effective 5/6/17*
- *WSR 16-01-039, § 182-531-0050, filed 12/9/15, effective 1/9/16. Statutory Authority: RCW 41.05.021. WSR 12-16-061, § 182-531-0050, filed 7/30/12, effective 11/1/12. WSR 11-14-075, recodified as § 182-531-0050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0050, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 04-20-059, § 388-531-0050, filed 10/1/04, effective 11/1/04. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and Public Law 104-191. WSR 03-19-081, § 388-531-0050, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090. WSR 03-06-049, § 388-531-0050, filed 2/28/03, effective 3/31/03. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0050, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-0100** Scope of coverage for physician-related and health care professional services—General and administrative. {#sec-182-531-0100 omnilex-key=us-wa-regs-official--title-182--182-531-0100}

WAC 182-531-0100

(1) The medicaid agency covers health care services, equipment, and supplies listed in this chapter, according to agency rules and subject to the limitations and requirements in this chapter, when they are:

(a) Within the scope of an eligible client's Washington apple health program. Refer to WAC 182-501-0060 and 182-501-0065; and

(b) Medically necessary as defined in WAC 182-500-0070.

(2) The agency evaluates a request for a service that is in a covered category under the provisions of WAC 182-501-0165.

(3) The agency evaluates requests for covered services that are subject to limitations or other restrictions and approves such services beyond those limitations or restrictions as described in WAC 182-501-0169.

(4) For children age 20 and younger, providers must follow the rules for the early periodic screening, diagnosis, and treatment (EPSDT) program, see chapter 182-534 WAC.

(5) The agency covers the following physician-related services and health care professional services, subject to the conditions in subsections (1), (2), (3), and (4) of this section:

(a) Alcohol and substance misuse counseling (refer to WAC 182-531-1710);

(b) Allergen immunotherapy services;

(c) Anesthesia services;

(d) Dialysis and end stage renal disease services (refer to chapter 182-540 WAC);

(e) Emergency physician services;

(f) ENT (ear, nose, and throat) related services;

(g) Habilitative services (refer to WAC 182-545-400);

(h) Reproductive health services (refer to chapter 182-532 WAC);

(i) Hospital inpatient services (refer to chapter 182-550 WAC);

(j) Maternity care, delivery, and newborn care services (refer to chapter 182-533 WAC);

(k) Office visits;

(l) Vision-related services (refer to chapter 182-544 WAC for vision hardware for clients 20 years of age and younger);

(m) Osteopathic treatment services;

(n) Pathology and laboratory services;

(o) Physiatry and other rehabilitation services (refer to chapter 182-550 WAC);

(p) Foot care and podiatry services (refer to WAC 182-531-1300);

(q) Primary care services;

(r) Psychiatric services;

(s) Psychotherapy services (refer to WAC 182-531-1400);

(t) Pulmonary and respiratory services;

(u) Radiology services;

(v) Surgical services;

(w) Cosmetic, reconstructive, or plastic surgery, and related services and supplies to correct physiological defects (e.g., congenital or as a result of illness or physical trauma), or for mastectomy reconstruction for post cancer treatment;

(x) Telemedicine (refer to WAC 182-501-0300);

(y) Tobacco/nicotine cessation counseling (refer to WAC 182-531-1720);

(z) Vaccines for adults, adolescents, and children in the United States administered according to the advisory committee on immunization practices (ACIP) recommended immunizations published by the Centers for Disease Control and Prevention (CDC) or those recommended by the Washington state department of health. The agency pays for vaccines approved by the U.S. Food and Drug Administration (FDA) outside the regular schedule when medically necessary;

(aa) Other outpatient physician services.

(6) The agency covers physical examinations for Washington apple health clients only when the physical examination is for one or more of the following:

(a) A well-child checkup covered by the EPSDT program (see WAC 182-534-0100);

(b) An annual exam for clients of the division of developmental disabilities; or

(c) A screening pap smear, mammogram, or prostate exam.

(7) By providing covered services to a client eligible for Washington apple health, a provider who meets the requirements in WAC 182-502-0005(3) accepts the agency's rules and fees which includes federal and state law and regulations, billing instructions, and provider notices.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-13-039, s 182-531-0100, filed 6/10/26, effective 7/11/26*
- *WSR 25-21-142, s 182-531-0100, filed 10/21/25, effective 11/21/25. Statutory Authority: RCW 41.05.021, 41.05.160, and 2021 c 157. WSR 23-04-048, § 182-531-0100, filed 1/26/23, effective 2/26/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-22-017, § 182-531-0100, filed 10/25/19, effective 11/25/19*
- *WSR 18-21-058, § 182-531-0100, filed 10/9/18, effective 11/9/18*
- *WSR 15-03-041, § 182-531-0100, filed 1/12/15, effective 2/12/15. Statutory Authority: RCW 41.05.021. WSR 13-18-035, § 182-531-0100, filed 8/28/13, effective 9/28/13. Statutory Authority: RCW 41.05.021 and 42 C.F.R. 455.410. WSR 13-04-095, § 182-531-0100, filed 2/6/13, effective 3/9/13. Statutory Authority: RCW 41.05.021 and section 1927 of the Social Security Act. WSR 12-18-062, § 182-531-0100, filed 8/31/12, effective 10/1/12. WSR 11-14-075, recodified as § 182-531-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-14-055, § 388-531-0100, filed 6/29/11, effective 7/30/11. Statutory Authority: RCW 74.09.521. WSR 08-12-030, § 388-531-0100, filed 5/29/08, effective 7/1/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-531-0100, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0100, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-0150** Noncovered physician-related and health care professional services—General and administrative. {#sec-182-531-0150 omnilex-key=us-wa-regs-official--title-182--182-531-0150}

(1) The medicaid agency evaluates a request for noncovered services in this chapter under WAC 182-501-0160. In addition to noncovered services found in WAC 182-501-0070, except as provided in subsection (2) of this section, the agency does not cover:

(a) Acupuncture, massage, or massage therapy;

(b) Any service specifically excluded by statute;

(c) Care, testing, or treatment of infertility or sexual dysfunction. This includes procedures for donor ovum, donor sperm, gestational carrier, and reversal of vasectomy or tubal ligation;

(d) Hysterectomy performed solely for the purpose of sterilization;

(e) Cosmetic treatment or surgery, except as provided in WAC 182-531-0100 (5)(w);

(f) Experimental or investigational services, procedures, treatments, devices, drugs, or application of associated services, except when the individual factors of an individual client's condition justify a determination of medical necessity under WAC 182-501-0165;

(g) Hair transplantation;

(h) Marital counseling or sex therapy;

(i) More costly services when the medicaid agency determines that less costly, equally effective services are available;

(j) Vision-related services as follows:

(i) Services for cosmetic purposes only;

(ii) Group vision screening for eyeglasses; and

(iii) Refractive surgery of any type that changes the eye's refractive error. The intent of the refractive surgery procedure is to reduce or eliminate the need for eyeglass or contact lens correction. This refractive surgery does not include intraocular lens implantation following cataract surgery;

(k) Payment for body parts, including organs, tissues, bones and blood, except as allowed in WAC 182-531-1750;

(l) Physician-supplied medication, except those drugs which the client cannot self-administer and therefore are administered by the physician in the physician's office;

(m) Physical examinations or routine checkups, except as provided in WAC 182-531-0100;

(n) Foot care, unless the client meets criteria and conditions outlined in WAC 182-531-1300, as follows:

(i) Routine foot care including, but not limited to:

(A) Treatment of tinea pedis;

(B) Cutting or removing warts, corns and calluses; and

(C) Trimming, cutting, clipping, or debriding of nails.

(ii) Nonroutine foot care including, but not limited to, treatment of:

(A) Flat feet;

(B) High arches (cavus foot);

(C) Onychomycosis;

(D) Bunions and tailor's bunion (hallux valgus);

(E) Hallux malleus;

(F) Equinus deformity of foot, acquired;

(G) Cavovarus deformity, acquired;

(H) Adult acquired flatfoot (metatarsus adductus or pes planus);

(I) Hallux limitus.

(iii) Any other service performed in the absence of localized illness, injury, or symptoms involving the foot;

(o) Except as provided in WAC 182-531-1600, weight reduction and control services, procedures, treatments, devices, drugs, products, gym memberships, equipment for the purpose of weight reduction, or the application of associated services;

(p) Nonmedical equipment;

(q) Nonemergent admissions and associated services to out-of-state hospitals or noncontracted hospitals in contract areas;

(r) Early elective deliveries as defined in WAC 182-500-0030; and

(s) Physician standby services.

(2) The medicaid agency covers excluded services listed in (1) of this subsection if those services are mandated under and provided to a client who is eligible for one of the following:

(a) The EPSDT program, see chapter 182-534 WAC;

(b) A Washington apple health program for qualified medicare beneficiaries (QMBs); or

(c) A waiver program.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-07-034, s 182-531-0150, filed 3/11/26, effective 4/11/26*
- *WSR 25-21-142, s 182-531-0150, filed 10/21/25, effective 11/21/25. Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 117-169. WSR 23-23-058, § 182-531-0150, filed 11/8/23, effective 12/9/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-07-105, § 182-531-0150, filed 3/23/22, effective 4/23/22*
- *WSR 15-24-021, § 182-531-0150, filed 11/19/15, effective 1/1/16*
- *WSR 15-03-041, § 182-531-0150, filed 1/12/15, effective 2/12/15. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-531-0150, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-531-0150, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-14-055, § 388-531-0150, filed 6/29/11, effective 7/30/11*
- *WSR 10-19-057, § 388-531-0150, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-12-022, § 388-531-0150, filed 5/20/05, effective 6/20/05*
- *WSR 01-01-012, § 388-531-0150, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-0200** Physician-related and health care professional services requiring prior authorization. {#sec-182-531-0200 omnilex-key=us-wa-regs-official--title-182--182-531-0200}

(1) The medicaid agency requires prior authorization for certain services. Prior authorization includes expedited prior authorization (EPA) and limitation extension (LE). See WAC 182-501-0165.

(2) EPA is designed to eliminate the need for written authorization. The agency establishes authorization criteria and identifies the criteria with specific codes, enabling providers to use that EPA number if a client meets the EPA criteria.

(a) The provider must create an authorization number using the process explained in the medicaid agency's physician-related billing instructions.

(b) Upon request, the provider must provide supporting clinical documentation to the medicaid agency showing how the authorization number was created.

(c) Selected nonemergency admissions to contract hospitals require EPA. These are identified in the medicaid agency billing instructions.

(d) Procedures allowing expedited prior authorization include, but are not limited to, the following:

(i) Reduction mammoplasties/mastectomy for gynecomastia;

(ii) Strabismus surgery for clients 18 years of age and older;

(iii) Meningococcal vaccine;

(iv) Placement of drug eluting stent and device;

(v) Cochlear implant devices;

(vi) Hyperbaric oxygen therapy;

(vii) Visual exam/refraction for clients 21 years of age and older;

(viii) Blepharoplasties; and

(ix) Neuropsychological testing for clients 16 years of age and older.

(3) The medicaid agency evaluates new technologies under the procedures in WAC 182-531-0550. These require prior authorization.

(4) Prior authorization is required for the following:

(a) Abdominoplasty;

(b) All inpatient hospital stays for acute physical medicine and rehabilitation (PM&R);

(c) Cochlear implant devices (refer to WAC 182-531-0375);

(d) Diagnosis and treatment of eating disorders for clients 21 years of age and older;

(e) Osteopathic manipulative therapy in excess of the medicaid agency's published limits;

(f) Panniculectomy;

(g) Bariatric surgery (see WAC 182-531-1600);

(h) Vagus nerve stimulator insertion, which also:

(i) For coverage, must be performed in an inpatient or outpatient hospital facility; and

(ii) For reimbursement, must have the invoice attached to the claim.

(i) Osseointegrated/bone anchored hearing aids (BAHA) for clients 20 years of age and younger;

(j) Removal or repair of previously implanted BAHA or cochlear implant devices for clients 21 years of age and older when medically necessary; and

(k) Gender reassignment surgery (see WAC 182-531-1675).

(5) All hysterectomies performed for medical reasons may require prior authorization, as explained in subsection (2) of this section.

(a) Hysterectomies may be performed without prior authorization in either of the following circumstances:

(i) The client has been diagnosed with cancer(s) of the female reproductive organs; and/or

(ii) A hysterectomy is needed due to trauma.

(b) The agency reimburses all attending providers for a hysterectomy procedure only when the provider submits an accurately completed agency-approved consent form with the claim for reimbursement.

(6) The medicaid agency may require a second opinion and/or consultation before authorizing any elective surgical procedure.

(7) Children six years of age and younger do not require authorization for hospitalization.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-03-049, § 182-531-0200, filed 1/10/24, effective 2/10/24*
- *WSR 15-16-084, § 182-531-0200, filed 7/31/15, effective 8/31/15. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-531-0200, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-531-0200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-14-055, § 388-531-0200, filed 6/29/11, effective 7/30/11*
- *WSR 10-19-057, § 388-531-0200, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-12-022, § 388-531-0200, filed 5/20/05, effective 6/20/05*
- *WSR 01-01-012, § 388-531-0200, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-0250** Who can provide and bill for physician-related and health care professional services. {#sec-182-531-0250 omnilex-key=us-wa-regs-official--title-182--182-531-0250}

(1) The health care professionals and health care entities listed in WAC 182-502-0002 and enrolled with the medicaid agency can bill for physician-related and health care professional services that are within their scope of practice.

(2) The agency pays for services provided by, or in conjunction with, a resident physician when:

(a) The services are billed under the teaching hospital's national provider identifier (NPI) or the supervising physician's NPI;

(b) The servicing provider is identified on the claim under the teaching or resident physician's NPI; and

(c) The services are provided and billed according to this chapter and chapters 182-501 and 182-502 WAC.

(3) The agency does not pay for services performed by any of the health care professionals listed in WAC 182-502-0003.

(4) The agency pays eligible providers for physician-related services and health care professional services if those services are mandated by, and provided to clients who are eligible for, one of the following:

(a) The early periodic screening, diagnosis, and treatment (EPSDT) program, see chapter 182-534 WAC;

(b) A Washington apple health program for qualified medicare beneficiaries (QMB); or

(c) A waiver program.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-21-142, s 182-531-0250, filed 10/21/25, effective 11/21/25*
- *WSR 23-21-061, § 182-531-0250, filed 10/12/23, effective 11/12/23*
- *WSR 15-17-066, § 182-531-0250, filed 8/14/15, effective 9/14/15*
- *WSR 15-03-041, § 182-531-0250, filed 1/12/15, effective 2/12/15. WSR 11-14-075, recodified as § 182-531-0250, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-14-055, § 388-531-0250, filed 6/29/11, effective 7/30/11. Statutory Authority: RCW 74.09.521. WSR 08-12-030, § 388-531-0250, filed 5/29/08, effective 7/1/08. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-12-022, § 388-531-0250, filed 5/20/05, effective 6/20/05*
- *WSR 01-01-012, § 388-531-0250, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-0300** Anesthesia providers and covered physician-related services. {#sec-182-531-0300 omnilex-key=us-wa-regs-official--title-182--182-531-0300}

The medicaid agency bases coverage of anesthesia services on medicare policies and the following rules:

(1) The agency reimburses providers for covered anesthesia services performed by a qualified anesthesiologist provider, which includes:

(a) Anesthesiologists as defined in RCW 18.71D.010;

(b) A doctor of medicine or osteopathy (other than an anesthesiologist);

(c) A dentist or oral surgeon who is qualified to administer anesthesia;

(d) Certified registered nurse anesthetists (CRNAs);

(e) Certified anesthesiologist assistants (CAAs); and

(f) Other providers who have a special agreement with the agency to provide anesthesia services.

(2) The agency covers and reimburses anesthesia services for children and noncooperative clients in those situations where the medically necessary procedure cannot be performed if the client is not anesthetized. A statement of the client-specific reasons why the procedure could not be performed without specific anesthesia services must be kept in the client's medical record. Examples of such procedures include:

(a) Computerized tomography (CT);

(b) Dental procedures;

(c) Electroconvulsive therapy; and

(d) Magnetic resonance imaging (MRI).

(3) The agency covers anesthesia services provided for any of the following:

(a) Dental restorations and/or extractions:

(b) Maternity per subsection (9) of this section. See WAC 182-531-1550 for information about sterilization/hysterectomy anesthesia;

(c) Pain management per subsection (5) of this section;

(d) Radiological services as listed in WAC 182-531-1450; and

(e) Surgical procedures.

(4) For each anesthesia case under the medical direction of an anesthesiologist, the anesthesiologist provider must do all of the following:

(a) Perform a preanesthetic examination and evaluation;

(b) Prescribe the anesthesia plan;

(c) Personally participate in the most demanding aspects of the anesthesia plan, including, if applicable, induction and emergence;

(d) Ensure that any procedures in the anesthesia plan that the anesthesiologist does not perform are performed by a qualified anesthesia provider as described in subsection (1) of this section;

(e) At frequent intervals, monitor the course of anesthesia during administration;

(f) Remain physically present and available for immediate diagnosis and treatment of emergencies; and

(g) Provide indicated post anesthesia care.

(5) The agency does not allow the anesthesiologist to:

(a) Direct more than four anesthesia services concurrently; and

(b) Perform any other services while directing the single or concurrent services, other than attending to medical emergencies and other limited services as allowed by medicare instructions.

(6) The agency requires the anesthesiologist to document in the client's medical record that the medical direction requirements in subsection (4) of this section were met.

(7) For anesthesia reimbursement, see WAC 182-531-0350.

(8) Pain management:

(a) The agency pays CRNAs or anesthesiologists for pain management services.

(b) The agency allows two postoperative or pain management epidurals per client, per hospital stay plus the two associated E&M fees for pain management.

(9) Maternity anesthesia:

(a) To determine total time for obstetric epidural anesthesia during normal labor and delivery and c-sections, time begins with insertion and ends with removal for a maximum of six hours. "Delivery" includes labor for single or multiple births, and/or cesarean section delivery.

(b) The agency does not apply the six-hour limit for anesthesia to procedures performed as a result of post-delivery complications.

(c) See WAC 182-531-1550 for information on anesthesia services during a delivery with sterilization.

(d) See chapter 182-533 WAC for more information about maternity-related services.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-12-058, s 182-531-0300, filed 5/29/25, effective 7/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, and 42 C.F.R. § 482.52. WSR 22-16-037, § 182-531-0300, filed 7/27/22, effective 8/27/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-04-039, § 182-531-0300, filed 1/25/17, effective 2/25/17. WSR 11-14-075, recodified as § 182-531-0300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0300, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0300, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-0350** Anesthesia services—Reimbursement for physician-related services. {#sec-182-531-0350 omnilex-key=us-wa-regs-official--title-182--182-531-0350}

(1) The medicaid agency reimburses anesthesia services on the basis of base anesthesia units (BAU) plus time.

(2) The agency calculates payment for anesthesia by adding the BAU to the time units and multiplying that sum by the conversion factor. The formula used in the calculation is: (BAU × 15) + time) × (conversion factor divided by 15) = reimbursement.

(3) The agency obtains new BAU values from the most current Centers for Medicare and Medicaid Services (CMS) anesthesia base unit file and reviews them annually for updates.

(4) The agency determines a budget neutral anesthesia conversion factor by:

(a) Determining the BAUs, time units, and expenditures for a base period for the provided procedure. Then,

(b) Adding the latest BAU to the time units for the base period to obtain an estimate of the new time unit for the procedure. Then,

(c) Multiplying the time units obtained in (b) of this subsection for the new period by a conversion factor to obtain estimated expenditures. Then,

(d) Comparing the expenditures obtained in (c) of this subsection with base period expenditure levels obtained in (a) of this subsection. Then,

(e) Adjusting the dollar amount for the anesthesia conversion factor and the projected time units at the new BAUs equals the allocated amount determined in (a) of this subsection.

(5) The agency calculates anesthesia time units as follows:

(a) One minute equals one unit.

(b) The total time is calculated to the next whole minute.

(c) Anesthesia time begins when the qualified anesthesia provider begins physically preparing the client for the induction of anesthesia; this must take place in the operating room or its equivalent. When there is a break in continuous anesthesia care, blocks of time may be added together as long as there is continuous monitoring. Examples of this include, but are not limited to, the following:

(i) The time a client spends in an anesthesia induction room; or

(ii) The time a client spends under the care of an operating room nurse during a surgical procedure.

(d) Anesthesia time ends when the qualified anesthesia provider is no longer in constant attendance (i.e., when the client can be safely placed under post-operative supervision).

(6) When more than one surgical procedure is performed at the same operative session, the agency uses the BAU of the major procedure to determine anesthesia allowed charges.

(7) The agency reimburses for add-on procedures as defined by CPT only for the time spent on the add-on procedure that is in addition to the time spent on the major procedure.

(8) The agency does not reimburse the attending surgeon for anesthesia services.

(9) When more than one anesthesia provider is present on a case, the agency reimburses as follows:

(a) The medical directing anesthesiologist receives 50 percent of the allowed amount;

(b) The CRNA or CAA under medical direction receives 50 percent of the allowed amount; and

(c) For anesthesia provided by a team, the agency limits reimbursement to 100 percent of the total allowed reimbursement for the service.

(10) The agency considers an anesthesiologist who supervises a resident anesthesiologist to be a teaching anesthesiologist and reimburses as follows:

(a) When supervising one resident only, the teaching anesthesiologist receives 100 percent of the allowed amount.

(b) When supervising two or more residents concurrently, the teaching anesthesiologist receives 50 percent of the allowed amount for each case supervised.

(11) The agency changes anesthesia conversion factors if the legislature grants a vendor rate increase, or other increase, and if the effective date of that increase is not the same as the agency's annual update.

(12) If the legislatively authorized vendor rate increase or other increase becomes effective at the same time as the agency's annual update, the agency applies the increase after calculating the budget-neutral conversion factor.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-12-058, s 182-531-0350, filed 5/29/25, effective 7/1/25. WSR 11-14-075, recodified as § 182-531-0350, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0350, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0350, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-0375** Audiology services. {#sec-182-531-0375 omnilex-key=us-wa-regs-official--title-182--182-531-0375}

(1) The agency covers medically necessary cochlear implant devices with prior authorization for eligible clients.

(2) The agency covers BAHAs for clients 20 years of age and younger with prior authorization.

(3) The agency covers replacement parts and batteries for BAHAs and cochlear implant devices. See WAC 182-547-0800 and 182-547-0850.

(4) The agency considers requests for removal or repair of previously implanted BAHAs and cochlear implant devices when medically necessary. Prior authorization from the agency is required.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-03-049, § 182-531-0375, filed 1/10/24, effective 2/10/24*
- *WSR 15-03-042, § 182-531-0375, filed 1/12/15, effective 2/12/15. WSR 11-14-075, recodified as § 182-531-0375, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-14-055, § 388-531-0375, filed 6/29/11, effective 7/30/11.*

##### **Wash. Admin. Code § 182-531-0400** Client responsibility for reimbursement for physician-related services. {#sec-182-531-0400 omnilex-key=us-wa-regs-official--title-182--182-531-0400}

Clients may be responsible to reimburse the provider, as described under WAC 182-501-0100, for noncovered services as defined in WAC 182-501-0050 or for services excluded from the client's benefits package as defined under WAC 182-501-0060. Clients whose care is provided under CHIP may be responsible for copayments as outlined in chapter 182-542 WAC. Also, see WAC 182-502-0160 Billing the client.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-04-039, § 182-531-0400, filed 1/25/17, effective 2/25/17. WSR 11-14-075, recodified as § 182-531-0400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-14-055, § 388-531-0400, filed 6/29/11, effective 7/30/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0400, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-0425** Collaborative care. {#sec-182-531-0425 omnilex-key=us-wa-regs-official--title-182--182-531-0425}

(1) Under the authority of RCW 74.09.497, and subject to available funds, the medicaid agency covers collaborative care provided in clinical care settings.

(2) For the purposes of this section:

(a) Collaborative care means a specific type of integrated care where medical providers and behavioral health providers work together to address behavioral health conditions, including mental health conditions and substance use disorders.

(b) Collaborative care model is a model of behavior health integration that enhances usual clinical care by adding two key services:

(i) Care management support for clients receiving behavioral health treatment; and

(ii) Regular psychiatric or board certified addiction medicine consultation with the clinical care team, particularly for clients whose conditions are not improving.

(c) Collaborative care team means a team of licensed or certified behavioral health professionals operating within their scope of practice who participate on the clinical care team along with the collaborative care billing provider to provide collaborative care to eligible clients. The team must include a collaborative care billing provider, a behavioral health care manager, and a psychiatric consultant. Professionals making up this team include, but are not limited to:

(i) Advanced registered nurse practitioner;

(ii) Behavioral health support specialist under the supervision of a licensed practitioner whose scope of practice includes assessment, diagnosis, and treatment of identifiable mental and behavioral health conditions;

(iii) Marriage and family therapist;

(iv) Marriage and family therapist associate under the supervision of a licensed marriage and family therapist or equally qualified mental health practitioner;

(v) Mental health counselor;

(vi) Mental health counselor associate under the supervision of a licensed mental health counselor, psychiatrist, or physician;

(vii) Psychiatric advanced registered nurse practitioner;

(viii) Psychiatrist;

(ix) Psychological associate under the supervision of a licensed supervisor under chapter 246-924 WAC;

(x) Psychologist;

(xi) Physician;

(xii) Physician assistant;

(xiii) Registered nurse;

(xiv) Social worker;

(xv) Social worker associate-advanced, under the supervision of a licensed independent clinical social worker, advanced social worker, or equally qualified mental health practitioner;

(xvi) Social worker associate-independent clinical, under the supervision of a licensed independent clinical social worker or equally qualified mental health practitioner;

(xvii) Substance use disorder professional (SUDP); and

(xviii) Substance use disorder professional trainee (SUDPT) under the supervision of a certified SUDP.

(3) The behavioral health care manager is a designated licensed professional with formal education or specialized training in behavioral health (including social work, nursing, or psychology), working under the oversight and direction of the treating medical provider.

(4) The collaborative care billing provider must meet all of the following:

(a) Be enrolled with the agency as one of the following:

(i) A physician licensed under Titles 18 RCW and 246 WAC;

(ii) An advanced registered nurse practitioner licensed under Titles 18 RCW and 246 WAC;

(iii) A federally qualified health center (FQHC);

(iv) A rural health clinic (RHC); or

(v) A clinic that is not an FQHC or RHC that meets the requirements of Titles 70 RCW and 247 WAC.

(b) Complete, sign, and return the Attestation for Collaborative Care Model, form HCA 13-0017, to the agency; and

(c) Agree to follow the agency's guidelines for practicing a collaborative care model.

(5) Providers of collaborative care must:

(a) Use a registry to track the client's clinical outcomes;

(b) Use at least one validated clinical rating scale;

(c) Ensure the registry is used in conjunction with the practice's electronic health records (EHR);

(d) Include a plan of care; and

(e) Identify outcome goals of the treatments.

(6) If a provider no longer meets the agreed upon requirements in the agency's Attestation for Collaborative Care Model, form HCA 13-0017, the provider must immediately notify the agency. The agency does not pay for collaborative care if a provider does not meet the agreed upon requirements.

(7) Providers are subject to post pay review by the agency. The agency may recoup payment if the provider is found to have not met the requirements for providing collaborative care as agreed to in the agency's Attestation for Collaborative Care Model, form HCA 13-0017.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2024 c 371, and chapter 246-929 WAC. WSR 25-22-061, s 182-531-0425, filed 10/30/25, effective 1/1/26. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-043, s 182-531-0425, filed 6/11/25, effective 7/12/25*
- *WSR 24-21-163, s 182-531-0425, filed 10/23/24, effective 11/23/24*
- *WSR 21-20-132, § 182-531-0425, filed 10/6/21, effective 11/6/21. Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 c 226. WSR 19-13-022, § 182-531-0425, filed 6/10/19, effective 7/11/19.*

##### **Wash. Admin. Code § 182-531-0450** Critical care—Physician-related services. {#sec-182-531-0450 omnilex-key=us-wa-regs-official--title-182--182-531-0450}

(1) The medicaid agency pays physicians or qualified health care professionals (QHCPs) for critical care physician-related services to critically ill or injured clients as follows:

(a) More than one physician or QHCP if the services provided involve different specialties; or

(b) Only one physician or QHCP for services provided in the emergency room.

(2) The agency pays preoperative and postoperative critical care in addition to the global surgical package when all the following apply:

(a) The client is critically ill or injured and the physician or QHCP is engaged in work directly related to the client's care;

(b) The critical care is unrelated to the specific anatomic injury or general surgical procedure performed and goes beyond the normal procedure; and

(c) The provider uses an appropriate modifier when billing the agency if appropriate.

(3) The agency does not pay separately for the following services performed by the provider when delivering critical care during a critical care period:

(a) Collection and interpretation of physiologic data; (e.g., electrocardiogram, blood pressure, hematologic data, etc.);

(b) Blood draw for a specimen;

(c) Blood gases;

(d) Cardiac output measurement;

(e) Chest X-rays;

(f) Gastric intubation;

(g) Pulse oximetry;

(h) Temporary transcutaneous pacing;

(i) Vascular access procedures; and

(j) Ventilator management.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-18-049, s 182-531-0450, filed 8/27/25, effective 9/27/25. WSR 11-14-075, recodified as § 182-531-0450, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0450, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0450, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-0500** Emergency physician-related services. {#sec-182-531-0500 omnilex-key=us-wa-regs-official--title-182--182-531-0500}

(1) The department reimburses for E&M services provided in the hospital emergency department to clients who arrive for immediate medical attention.

(2) The department reimburses emergency physician services only when provided by physicians assigned to the hospital emergency department or the physicians on call to cover the hospital emergency department.

(3) The department pays a provider who is called back to the emergency room at a different time on the same day to attend a return visit [to] the same client. When this results in multiple claims on the same day, the time of each encounter must be clearly indicated on the claim.

(4) The department does not pay emergency room physicians for hospital admission charges or additional service charges.

**History**
- *to] the same client. When this results in multiple claims on the same day, the time of each encounter must be clearly indicated on the claim.(4) The department does not pay emergency room physicians for hospital admission charges or additional service charges.[WSR 11-14-075, recodified as § 182-531-0500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0500, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0500, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-0550** Experimental and investigational services. {#sec-182-531-0550 omnilex-key=us-wa-regs-official--title-182--182-531-0550}

(1) When the medicaid agency determines a proposed service is experimental or investigational, the agency follows the procedures in this section.

(2) The determination of whether to authorize an experimental or investigational service is subject to a medical necessity review under the provisions of WAC 182-501-0165.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-09-002, § 182-531-0550, filed 4/5/17, effective 5/6/17. WSR 11-14-075, recodified as § 182-531-0550, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0550, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0550, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-0600** HIV/AIDS counseling and testing as physician-related services. {#sec-182-531-0600 omnilex-key=us-wa-regs-official--title-182--182-531-0600}

The department covers one pre- and one post-HIV/AIDS counseling/testing session per client each time the client is tested for HIV/AIDS.

**History**
- *WSR 11-14-075, recodified as § 182-531-0600, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0600, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0600, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-0650** Hospital physician-related services not requiring authorization when provided in agency-approved centers of excellence or hospitals authorized to provide the specific services. {#sec-182-531-0650 omnilex-key=us-wa-regs-official--title-182--182-531-0650}

The medicaid agency covers the following services without prior authorization when provided in agency-approved centers of excellence. The agency issues periodic publications listing centers of excellence. These services include sleep studies including, but not limited to, polysomnograms for clients one year of age and older. The agency allows sleep studies only in outpatient hospital settings as described under WAC 182-550-6350. See also WAC 182-531-1500.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-01-096, s 182-531-0650, filed 12/13/24, effective 1/13/25*
- *WSR 17-04-039, § 182-531-0650, filed 1/25/17, effective 2/25/17. WSR 11-14-075, recodified as § 182-531-0650, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0650, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-12-022, § 388-531-0650, filed 5/20/05, effective 6/20/05*
- *WSR 01-01-012, § 388-531-0650, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-0700** Inpatient chronic pain management physician-related services. {#sec-182-531-0700 omnilex-key=us-wa-regs-official--title-182--182-531-0700}

(l) The department covers inpatient chronic pain management services only when the services are obtained through a department-approved chronic pain facility.

(2) A client qualifies for inpatient chronic pain management services when all of the following apply:

(a) The client has had chronic pain for at least three months, that has not improved with conservative treatment, including tests and therapies;

(b) At least six months have passed since a previous surgical procedure was done in relation to the pain problem; and

(c) Clients with active substance abuse must have completed a detoxification program, if appropriate, and must be free from drugs or alcohol for six months.

(3) For chronic pain management, the department limits coverage to only one inpatient hospital stay per client's lifetime, up to a maximum of twenty-one days.

(4) The department reimburses for only the chronic pain management services and procedures that are listed in the fee schedule.

**History**
- *WSR 11-14-075, recodified as § 182-531-0700, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0700, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0700, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-0750** Inpatient hospital physician-related services. {#sec-182-531-0750 omnilex-key=us-wa-regs-official--title-182--182-531-0750}

(1) The department separately reimburses the attending provider for inpatient hospital professional services rendered by the attending provider during the surgical follow-up period only if the services are performed for an emergency condition or a diagnosis that is unrelated to the inpatient stay.

(2) The department reimburses for only one inpatient hospital call per client, per day for the same or related diagnoses. If a call is included in the global surgery reimbursement, the department does not reimburse separately.

(3) The department reimburses a hospital admission related to a planned surgery through the global fee for surgery.

**History**
- *WSR 11-14-075, recodified as § 182-531-0750, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0750, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0750, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-0800** Laboratory and pathology physician-related services. {#sec-182-531-0800 omnilex-key=us-wa-regs-official--title-182--182-531-0800}

(1) The medicaid agency pays providers for laboratory services only when:

(a) The provider is certified according to Title XVII of the Social Security Act (medicare), if required; and

(b) The provider has a clinical laboratory improvement amendment (CLIA) certificate and identification number.

(2) The agency includes a handling, packaging, and mailing fee in the reimbursement for lab tests and does not reimburse these separately.

(3) The agency pays for one blood drawing fee per client, per day. The agency allows additional reimbursement for an independent laboratory when it goes to a nursing facility or a private home to obtain a specimen.

(4) The agency pays for only one catheterization for collection of a urine specimen per client, per day.

(5) The agency pays for automated multichannel tests done alone or as a group, as follows:

(a) The provider must bill a panel if all individual tests are performed. If not all tests are performed, the provider must bill individual tests.

(b) If the provider bills one automated multichannel test, the agency reimburses the test at the individual procedure code rate, or the internal code maximum allowable fee, whichever is lower.

(c) Tests may be performed in a facility that owns or leases automated multichannel testing equipment. The facility may be any of the following:

(i) A clinic;

(ii) A hospital laboratory;

(iii) An independent laboratory; or

(iv) A physician's office.

(6) The agency allows a STAT fee in addition to the maximum allowable fee when a laboratory procedure is performed STAT.

(a) The agency pays for STAT charges for only those procedures identified by the clinical laboratory advisory council as appropriate to be performed STAT.

(b) Tests generated in the emergency room do not automatically justify a STAT order, the physician must specifically order the tests as STAT.

(c) Refer to the fee schedule for a list of STAT procedures.

(7) The agency pays for drug screen charges only when medically necessary and when ordered by a physician as part of a total medical evaluation.

(8) The agency does not pay for drug screens for clients in the division of behavioral health and recovery (DBHR) within the department of social and health services (DSHS)-contracted methadone treatment programs. These are reimbursed through a contract issued by DBHR DSHS.

(9) The agency does not pay for drug screens to monitor for program compliance in either a residential or outpatient drug or alcohol treatment program.

(10) The agency may require a drug or alcohol screen in order to determine a client's suitability for a specific test.

(11) An independent laboratory must bill the agency directly. The agency does not pay a medical practitioner for services referred to or performed by an independent laboratory.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-03-041, § 182-531-0800, filed 1/12/15, effective 2/12/15. WSR 11-14-075, recodified as § 182-531-0800, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0800, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0800, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-0850** Laboratory and pathology physician-related services reimbursement. {#sec-182-531-0850 omnilex-key=us-wa-regs-official--title-182--182-531-0850}

(1) The agency pays for clinical diagnostic laboratory procedures based on the medicare clinical laboratory fee schedule (CLFS). The agency obtains information used to update fee schedule regulations from the CMS CLFS website.

(2) The agency updates budget-neutral fees each year by:

(a) Determining the units of service and expenditures for a base period. Then,

(b) Determining in total the ratio of current agency fees to existing medicare fees. Then,

(c) Determining new agency fees by adjusting the new medicare fee by the ratio. Then,

(d) Multiplying the units of service by the new agency fee to obtain total estimated expenditures. Then,

(e) Comparing the expenditures in (d) of this subsection to the base period expenditures. Then,

(f) Adjusting the new ratio until estimated expenditures equals the base period amount.

(3) The agency calculates maximum allowable fees (MAF) by:

(a) Calculating fees using methodology described in subsection (2) of this section for procedure codes that have an applicable CLFS.

(b) Establishing RSC fees for procedure codes that have no applicable CLFS.

(c) Establishing maximum allowable fees, or "flat fees" for procedure codes that have no applicable CLFS or RSC fees.

(d) If appropriate, the agency may adjust fees using market research. The agency reimbursement for clinical laboratory procedures does not exceed the regional CLFS.

(i) "Market research" means the systematic collection and analysis of relevant and verifiable data related to the health care marketplace, including commercial benchmarks, medicaid rates from other states, and relevant economic indicators.

(ii) Market research will be appropriate when a material change in market conditions is demonstrated or is directed by the legislature.

(4) The agency may change fees based on legislative direction. If the legislatively authorized change becomes effective at the same time as the agency's annual update, the agency applies the change after calculating budget-neutral fees, if applicable.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-10-082, s 182-531-0850, filed 5/6/25, effective 6/6/25. WSR 11-14-075, recodified as § 182-531-0850, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0850, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0850, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-0900** Neonatal intensive care unit (NICU) and pediatric intensive care unit (PICU) physician-related services. {#sec-182-531-0900 omnilex-key=us-wa-regs-official--title-182--182-531-0900}

(1) The medicaid agency reimburses a provider for one neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU) service per client, per day.

(2) The agency pays for NICU and PICU physician-related services when the billing physician or other qualified health care professional (QHCP) follows standard current procedural terminology (CPT) coding guidelines.

(3) The agency pays for NICU services in addition to prolonged services and newborn resuscitation when the physician or QHCP is present at the delivery.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-18-049, s 182-531-0900, filed 8/27/25, effective 9/27/25. WSR 11-14-075, recodified as § 182-531-0900, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0900, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0900, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-0950** Office and other outpatient physician-related services. {#sec-182-531-0950 omnilex-key=us-wa-regs-official--title-182--182-531-0950}

(l) The medicaid agency pays eligible providers for the following:

(a) Two calls per month for routine medical conditions for a client residing in a nursing facility; and

(b) One call per noninstitutionalized client, per day, for an individual physician, except for valid call-backs to the emergency room per WAC 182-531-0500.

(2) The provider must provide justification based on medical necessity at the time of billing for visits in excess of subsection (l) of this section and follow the requirements in WAC 182-501-0169.

(3) See the agency's physician-related services/health care professional services billing instructions for procedures that are included in the office call and that cannot be billed separately.

(4) Using selected diagnosis codes, the agency reimburses the provider at the appropriate level of physician office call for history and physical procedures in conjunction with dental surgery services performed in an outpatient setting.

(5) The agency may reimburse providers for injection procedures and/or injectable drug products only when:

(a) The injectable drug is administered during an office visit; and

(b) The injectable drug used is from office stock and which was purchased by the provider from a pharmacy, drug manufacturer, or drug wholesaler.

(6) The agency does not reimburse a prescribing provider for a drug when a pharmacist dispenses the drug.

(7) The agency does not reimburse the prescribing provider for an immunization when the immunization material is received from the department of health; the agency does reimburse an administrative fee.

(8) The agency reimburses immunizations as follows:

(a) For immunizations that are not part of the vaccines for children program through the department of health, the agency reimburses for the immunization:

(i) At the medicare Part B drug file price; or

(ii) When a medicare Part B price is not available, the agency uses the actual acquisition cost (AAC) rate effective July 1st of each year; or

(iii) Invoice cost.

(b) The agency reimburses a separate administration fee for these immunizations.

(c) Covered immunizations are listed in the professional administered drugs fee schedule.

(9) The agency reimburses therapeutic and diagnostic injections subject to certain limitations as follows:

(a) The agency does not pay separately for the administration of intra-arterial and intravenous therapeutic or diagnostic injections provided in conjunction with intravenous infusion therapy services. The agency does pay separately for the administration of these injections when they are provided on the same day as an E&M service. The agency does not pay separately an administrative fee for injectables when both E&M and infusion therapy services are provided on the same day. The agency reimburses separately for the drug(s).

(b) The agency does not pay separately for subcutaneous or intramuscular administration of antibiotic injections provided on the same day as an E&M service. If the injection is the only service provided, the agency pays an administrative fee. The agency reimburses separately for the drug.

(c) The agency reimburses injectable drugs at actual acquisition cost. The provider must document the name, strength, and dosage of the drug and retain that information in the client's file. The provider must provide an invoice when requested by the agency. This subsection does not apply to drugs used for chemotherapy; see subsection (11) in this section for chemotherapy drugs.

(d) The provider must submit a manufacturer's invoice to document the name, strength, and dosage on the claim form when billing the agency for the following drugs:

(i) Classified drugs where the billed charge to the agency is over $1,100; and

(ii) Unclassified drugs where the billed charge to the agency is over $100. This does not apply to unclassified antineoplastic drugs.

(10) The agency reimburses allergen immunotherapy only as follows:

(a) Antigen/antigen preparation codes are reimbursed per dose.

(b) When a single client is expected to use all the doses in a multiple dose vial, the provider may bill the total number of doses in the vial at the time the first dose from the vial is used. When remaining doses of a multiple dose vial are injected at subsequent times, the agency reimburses the injection service (administration fee) only.

(c) When a multiple dose vial is used for more than one client, the provider must bill the total number of doses provided to each client out of the multiple dose vial.

(d) The agency covers the antigen, the antigen preparation, and an administration fee.

(e) The agency reimburses a provider separately for an E&M service if there is a diagnosis for conditions unrelated to allergen immunotherapy.

(f) The agency reimburses for RAST testing when the physician has written documentation in the client's record indicating that previous skin testing failed and was negative.

(11) The agency reimburses for chemotherapy drugs:

(a) Administered in the physician's office only when:

(i) The physician personally supervises the E&M services furnished by office medical staff; and

(ii) The medical record reflects the physician's active participation in or management of course of treatment.

(b) At established maximum allowable fees that are based on medicare Part B pricing, or AAC, maximum allowable cost (MAC), or invoice cost;

(c) For unclassified antineoplastic drugs, the provider must submit the following information on the claim form:

(i) The name of the drug used;

(ii) The dosage and strength used; and

(iii) The National Drug Code (NDC).

(12) Notwithstanding the provisions of this section, the agency reserves the option of determining drug pricing for any particular drug based on the best evidence available to the agency, or other good and sufficient reasons (e.g., fairness/equity, budget), regarding the actual acquisition cost, after discounts and promotions, paid by typical providers nationally or in Washington state.

(13) The agency may request an invoice as necessary.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 117-169. WSR 23-23-058, § 182-531-0950, filed 11/8/23, effective 12/9/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-21-040, § 182-531-0950, filed 10/12/17, effective 11/12/17*
- *WSR 15-20-057, § 182-531-0950, filed 10/1/15, effective 11/1/15*
- *WSR 15-03-041, § 182-531-0950, filed 1/12/15, effective 2/12/15. WSR 11-14-075, recodified as § 182-531-0950, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0950, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0950, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-1000** Ophthalmic services. {#sec-182-531-1000 omnilex-key=us-wa-regs-official--title-182--182-531-1000}

Refer to chapter 182-544 WAC for vision-related hardware coverage.

(1) The medicaid agency covers eye examinations, refraction and fitting services. The agency pays for these services without prior authorization as follows:

(a) Once every twenty-four months for asymptomatic clients age twenty-one and older;

(b) Once every twelve months for asymptomatic clients age twenty and younger; or

(c) Once every twelve months, regardless of age, for asymptomatic clients of the division of developmental disabilities.

(2) The agency covers additional eye examinations and refraction services when:

(a) The provider is diagnosing or treating the client for a medical condition that has symptoms of vision problems or disease;

(b) The client is on medication that affects vision; or

(c) An eye examination or refraction is necessary due to lost or broken eyeglasses or contacts. In this case:

(i) No type of authorization is required for clients age twenty or younger or for clients of the division of developmental disabilities, regardless of age.

(ii) Providers must follow the agency's expedited prior authorization process to receive payment for clients age twenty-one or older. Providers must also document the following in the client's file:

(A) The eyeglasses or contacts are lost or broken; and

(B) The last examination was at least eighteen months ago.

(3) The agency covers visual field exams for the diagnosis and treatment of abnormal signs, symptoms, or injuries. Providers must document all of the following in the client's record:

(a) The extent of the testing;

(b) Why the testing was reasonable and necessary for the client; and

(c) The medical basis for the frequency of testing.

(4) The agency covers orthoptics and vision training therapy. Providers must obtain prior authorization from the agency.

(5) The agency covers ocular prosthetics for clients when provided by any of the following:

(a) An ophthalmologist;

(b) An ocularist; or

(c) An optometrist who specializes in prosthetics.

(6) The agency covers cataract surgery, without prior authorization when the following clinical criteria are met:

(a) Correctable visual acuity in the affected eye at 20/50 or worse, as measured on the Snellen test chart; or

(b) One or more of the following conditions:

(i) Dislocated or subluxated lens;

(ii) Intraocular foreign body;

(iii) Ocular trauma;

(iv) Phacogenic glaucoma;

(v) Phacogenic uveitis;

(vi) Phacoanaphylactic endopthalmitis; or

(vii) Increased ocular pressure in a person who is blind and is experiencing ocular pain.

(7) The agency covers strabismus surgery as follows:

(a) For clients age seventeen and younger. The provider must clearly document the need in the client's record. The agency does not require authorization for clients age seventeen and younger; and

(b) For clients age eighteen and older, when the clinical criteria are met. To receive payment, providers must follow the expedited prior authorization process. The clinical criteria are:

(i) The client has double vision; and

(ii) The surgery is not being performed for cosmetic reasons.

(8) The agency covers blepharoplasty or blepharoptosis surgery for clients when all of the clinical criteria are met. To receive payment, providers must follow the agency's expedited prior authorization process. The clinical criteria are:

(a) The client's excess upper eyelid skin is blocking the superior visual field; and

(b) The blocked vision is within ten degrees of central fixation using a central visual field test.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-531-1000, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-531-1000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-14-055, § 388-531-1000, filed 6/29/11, effective 7/30/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1000, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-1050** Manipulative therapy. {#sec-182-531-1050 omnilex-key=us-wa-regs-official--title-182--182-531-1050}

(1) The medicaid agency pays for manipulative therapy only when:

(a) Provided by an osteopathic physician licensed under chapter 18.57 RCW or naturopathic physicians licensed under chapter 18.36A RCW; and

(b) Billed using the appropriate CPT codes that involve the number of body regions involved.

(2) The agency allows an osteopathic physician or naturopathic physician to bill the agency for an evaluation and management (E&M) service in addition to the manipulative therapy when one of the following apply:

(a) The physician diagnoses the condition requiring manipulative therapy and provides it during the same visit;

(b) The existing related diagnosis or condition fails to respond to manipulative therapy or the condition significantly changes or intensifies, requiring E&M services beyond those included in the manipulation codes; or

(c) The physician treats the client during the same encounter for an unrelated condition that does not require manipulative therapy.

(3) The agency pays for ten manipulations per client, per calendar year. The agency evaluates a request for manipulations that is in excess of the limitations or restrictions according to WAC 182-501-0169. Payment for each manipulation includes a brief evaluation as well as the manipulation.

(4) The agency does not pay for physical therapy services performed by osteopathic physicians or naturopathic physicians.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-03-041, § 182-531-1050, filed 1/12/15, effective 2/12/15. WSR 11-14-075, recodified as § 182-531-1050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1050, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1050, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-1100** Out-of-state physician services. {#sec-182-531-1100 omnilex-key=us-wa-regs-official--title-182--182-531-1100}

(1) The medicaid agency covers medical services provided to eligible clients who are temporarily located outside the state, subject to the provisions of this chapter and WAC 182-501-0180.

(2) Out-of-state border areas as described under WAC 182-501-0175 are not subject to out-of-state limitations. The agency considers physicians in border areas as providers in the state of Washington.

(3) In order to be eligible for reimbursement, out-of-state physicians must meet all criteria for, and must comply with all procedures required of in-state physicians, in addition to other requirements of this chapter.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-04-039, § 182-531-1100, filed 1/25/17, effective 2/25/17. WSR 11-14-075, recodified as § 182-531-1100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1100, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1100, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-1150** Care plan oversight services. {#sec-182-531-1150 omnilex-key=us-wa-regs-official--title-182--182-531-1150}

(1) The medicaid agency covers care plan oversight services only when:

(a) The billing physician or other qualified health care professional (QHCP) follows standard current procedural terminology (CPT) coding guidelines;

(b) The client is served by a home health agency, a nursing facility, or a hospice;

(c) The facility/agency has established a plan of care; and

(d) The physician or QHCP spends 30 or more minutes per calendar month providing oversight for the client's care.

(2) The medicaid agency pays for only one care plan oversight service per client, per month.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-18-049, s 182-531-1150, filed 8/27/25, effective 9/27/25. WSR 11-14-075, recodified as § 182-531-1150, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1150, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1150, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-1200** Physician office medical supplies. {#sec-182-531-1200 omnilex-key=us-wa-regs-official--title-182--182-531-1200}

(1) Refer to the medicaid agency's published physician-related services/health care professional services billing guide for a list of:

(a) Supplies that are a routine part of office or other outpatient procedures and that cannot be billed separately; and

(b) Supplies that can be billed separately and that the medicaid agency considers nonroutine to office or outpatient procedures.

(2) The agency reimburses at actual acquisition cost certain supplies under $50 that do not have a maximum allowable fee listed in the fee schedule. The provider must retain invoices for these items and make them available to the agency upon request.

(3) Providers must submit invoices for items costing $50 or more.

(4) The agency reimburses for sterile tray for certain surgical services only. Refer to the fee schedule for a list of covered items.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-08-061, § 182-531-1200, filed 3/29/24, effective 5/1/24. WSR 11-14-075, recodified as § 182-531-1200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1200, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1200, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-1300** Foot care services for clients 21 years of age and older. {#sec-182-531-1300 omnilex-key=us-wa-regs-official--title-182--182-531-1300}

(1) This section addresses care of the lower extremities (foot and ankle) referred to as foot care and applies to clients 21 years of age and older.

(2) The department covers the foot care services listed in this section when those services are provided by any of the following health care providers and billed to the department using procedure codes and diagnosis codes that are within their scope of practice:

(a) Physicians or physician assistants;

(b) Osteopathic physicians, surgeons, or physician assistants;

(c) Podiatric physicians and surgeons; or

(d) Advanced registered nurse practitioners (ARNP).

(3) The department covers evaluation and management visits to assess and diagnose conditions of the lower extremities. Once diagnosis is made, the department covers treatment if the criteria in subsection (4) of this section are met.

(4) The department pays for:

(a) Treatment of the following conditions of the lower extremities only when there is an acute condition, an exacerbation of a chronic condition, or presence of a systemic condition such as metabolic, neurologic, or peripheral vascular disease and evidence that the treatment will prevent, cure or alleviate a condition in the client that causes pain resulting in the inability to perform activities of daily living, acute disability, or threatens to cause the loss of life or limb, unless otherwise specified:

(i) Acute inflammatory processes such as, but not limited to tendonitis;

(ii) Circulatory compromise such as, but are not limited to:

(A) Lymphedema;

(B) Raynaud's disease;

(C) Thromboangiitis obliterans; and

(D) Phlebitis.

(iii) Injuries, fractures, sprains, and dislocations;

(iv) Gout;

(v) Lacerations, ulcerations, wounds, blisters;

(vi) Neuropathies (e.g., reflex sympathetic dystrophy, secondary to diabetes, charcot arthropathy);

(vii) Osteomyelitis;

(viii) Post-op complications;

(ix) Warts, corns, or calluses in the presence of an acute condition such as infection and pain effecting the client's ability to ambulate as a result of the warts, corns, or calluses and meets the criteria in subsection (4) of this section;

(x) Soft tissue conditions, such as, but are not limited to:

(A) Rashes;

(B) Infections (fungal, bacterial);

(C) Gangrene;

(D) Cellulitis of lower extremities;

(E) Soft tissue tumors; and

(F) Neuroma.

(xi) Nail bed infections (paronychia); and

(xii) Tarsal tunnel syndrome.

(b) Trimming and/or debridement of nails to treat, as applicable, conditions from the list in subsection (4)(a) of this section. The department pays for one treatment in a 60-day period. The department covers additional treatments in this period if documented in the client's medical record as being medically necessary;

(c) A surgical procedure to treat one of the conditions in subsection (4) of this section performed on the lower extremities, and performed by a qualified provider;

(d) Impression casting to treat one of the conditions in subsection (4) of this section. The department includes 90-day follow-up care in the reimbursement;

(e) Custom fitted and/or custom molded orthotic devices to treat one of the conditions in subsection (4) of this section.

(i) The department's fee for the orthotic device includes reimbursement for a biomechanical evaluation (an evaluation of the foot that includes various measurements and manipulations necessary for the fitting of an orthotic device); and

(ii) The department includes an evaluation and management (E&M) fee reimbursement in addition to an orthotic fee reimbursement if the E&M services are justified and well documented in the client's medical record.

(5) The department does not pay for:

(a) The following radiology services:

(i) Bilateral X-rays for a unilateral condition; or

(ii) X-rays in excess of three views; or

(iii) X-rays that are ordered before the client is examined.

(b) Podiatric physicians or surgeons for X-rays for any part of the body other than the foot or ankle.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-21-163, s 182-531-1300, filed 10/23/24, effective 11/23/24. WSR 11-14-075, recodified as § 182-531-1300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-14-055, § 388-531-1300, filed 6/29/11, effective 7/30/11*
- *WSR 10-19-057, § 388-531-1300, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1300, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-1350** Prolonged physician-related services. {#sec-182-531-1350 omnilex-key=us-wa-regs-official--title-182--182-531-1350}

(1) The medicaid agency pays for prolonged services based on established medicare guidelines. The services provided may or may not be continuous. The services provided must meet both of the following:

(a) Consist of face-to-face contact between the physician or qualified health care professional (QHCP) and the client; and

(b) Be provided with other services.

(2) The medicaid agency pays for a prolonged service procedure in addition to an evaluation and management (E&M) procedure or consultation subject to applicable coding limitations and appropriate modifiers.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-18-049, s 182-531-1350, filed 8/27/25, effective 9/27/25. WSR 11-14-075, recodified as § 182-531-1350, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1350, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1350, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-1400** Psychiatric physician-related services and other professional mental health services. {#sec-182-531-1400 omnilex-key=us-wa-regs-official--title-182--182-531-1400}

(1) The mental health services covered in this section are different from the mental health services covered under community mental health and involuntary treatment programs in chapter 182-538D WAC.

(2) Inpatient and outpatient mental health services not covered under chapter 182-538D WAC may be covered by the medicaid agency under this section.

Inpatient mental health services

(3) For hospital inpatient psychiatric admissions, providers must comply with chapter 182-538D WAC.

(4) The agency covers professional inpatient mental health services as follows:

(a) When provided by a psychiatrist, psychiatric advanced registered nurse practitioner (ARNP), psychiatric mental health nurse practitioner-board certified (PMHNP-BC), or psychologist in conjunction with the prescribing provider;

(b) The agency pays only for the total time spent on direct psychiatric client care during each visit, including services provided when making rounds. The agency considers services provided during rounds to be direct client care services and may include, but are not limited to:

(i) Individual psychotherapy up to one hour;

(ii) Family/group therapy; or

(iii) Electroconvulsive therapy.

(c) One electroconvulsive therapy or narcosynthesis per client, per day, and only when performed by a psychiatrist.

Outpatient mental health services

(5) The agency covers outpatient mental health services when provided by the following licensed or certified health care practitioners who are eligible providers under chapter 182-502 WAC:

(a) Advanced social worker;

(b) Advanced social worker associate;

(c) Certified behavioral health support specialist;

(d) Independent clinical social worker;

(e) Independent clinical social worker associate;

(f) Marriage and family therapist;

(g) Marriage and family therapist associate;

(h) Mental health counselor;

(i) Mental health counselor associate;

(j) Psychiatric advanced registered nurse practitioner (ARNP);

(k) Psychiatric mental health nurse practitioner-board certified (PMHNP-BC);

(l) Psychiatrist;

(m) Psychological associate; or

(n) Psychologist.

(6) With the exception of child psychiatrists, as defined in RCW 71.34.020, qualified practitioners listed in subsection (5) of this section who diagnose and treat clients age 18 and younger must meet one of the following:

(a) The education and experience requirements for a child mental health specialist found in WAC 182-538D-0200; or

(b) Be working under the supervision of a practitioner who meets these requirements.

(7) The agency does not limit the total number of outpatient mental health visits a licensed health care professional can provide.

(8) The agency evaluates a request for covered outpatient mental health services in excess of the limitations in this section under WAC 182-501-0169.

(9) The agency covers outpatient mental health services with the following limitations:

(a) Diagnostic evaluations. One psychiatric diagnostic evaluation, per provider, per client, per calendar year, unless significant change in the client's circumstances renders an additional evaluation medically necessary and is authorized by the agency.

(i) For clients 20 years of age and younger, additional evaluations are paid for when medically necessary and authorized by the agency, per WAC 182-534-0100 and 182-501-0165.

(ii) For clients five years of age and younger, the agency pays for the following without requiring prior authorization:

(A) Up to five sessions to complete a psychiatric diagnostic evaluation; and

(B) Evaluations in the home or community setting, including reimbursement for provider travel.

(iii) For clients age five through age 20, the services in (a)(ii)(A) and (B) of this subsection are paid for when medically necessary and authorized by the agency.

(b) Psychotherapy. One or more individual or family/group psychotherapy visits, with or without the client, per day, per client, when medically necessary.

(c) Medication management. One psychiatric medication management service, per client, per day, in an outpatient setting when performed by one of the following:

(i) Psychiatrist;

(ii) Psychiatric ARNP; or

(iii) PMHNP-BC.

(10) To receive payment for providing mental health services, providers must bill the agency using the agency's published billing instructions.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2024 c 371, and chapter 246-929 WAC. WSR 25-22-061, s 182-531-1400, filed 10/30/25, effective 1/1/26. Statutory Authority: RCW 18.227.100, 41.05.021, and 41.05.160. WSR 25-04-011, s 182-531-1400, filed 1/23/25, effective 2/23/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-12-036, § 182-531-1400, filed 5/30/24, effective 7/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and 71.34.020. WSR 23-11-097, § 182-531-1400, filed 5/18/23, effective 6/18/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 2021 c 126 § (2)(11). WSR 22-11-028, § 182-531-1400, filed 5/11/22, effective 6/11/22. Statutory Authority: RCW 41.05.021, 41.05.16 [ 41.05.160], and 2017 c 226. WSR 19-15-107, § 182-531-1400, filed 7/22/19, effective 8/22/19. Statutory Authority: RCW 41.05.021, 41.05.160, 2014 c 225. WSR 16-06-053, § 182-531-1400, filed 2/24/16, effective 4/1/16. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 15-03-041, § 182-531-1400, filed 1/12/15, effective 2/12/15. WSR 11-14-075, recodified as § 182-531-1400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.09.521. WSR 08-12-030, § 388-531-1400, filed 5/29/08, effective 7/1/08. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1400, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-1450** Radiology physician-related services. {#sec-182-531-1450 omnilex-key=us-wa-regs-official--title-182--182-531-1450}

(1) The medicaid agency reimburses radiology services subject to the limitations in this section and under WAC 182-531-0300.

(2) The agency does not make separate payments for contrast material. The exception is low osmolar contrast media (LOCM) used in intrathecal, intravenous, and intra-arterial injections. Clients receiving these injections must have one or more of the following conditions:

(a) A history of previous adverse reaction to contrast material. An adverse reaction does not include a sensation of heat, flushing, or a single episode of nausea or vomiting;

(b) A history of asthma or allergy;

(c) Significant cardiac dysfunction including recent or imminent cardiac decompensation, severe arrhythmias, unstable angina pectoris, recent myocardial infarction, and pulmonary hypertension;

(d) Generalized severe debilitation;

(e) Sickle cell disease;

(f) Preexisting renal insufficiency; and/or

(g) Other clinical situations where use of any media except LOCM would constitute a danger to the health of the client.

(3) The agency reimburses separately for radiopharmaceutical diagnostic imaging agents for nuclear medicine procedures. Providers must submit invoices for these procedures when requested by the agency, and reimbursement is at actual acquisition cost.

(4) The agency reimburses general anesthesia for radiology procedures. See WAC 182-531-0300.

(5) The agency reimburses radiology procedures in combination with other procedures according to the rules for multiple surgeries. See WAC 182-531-1700. The procedures must meet all of the following conditions:

(a) Performed on the same day;

(b) Performed on the same client; and

(c) Performed by the same physician or more than one member of the same group practice.

(6) The agency reimburses consultation on X-ray examinations. The consulting physician must bill the specific radiological X-ray code with the appropriate professional component modifier.

(7) The agency reimburses for portable X-ray services furnished in the client's home or in nursing facilities, limited to the following:

(a) Chest or abdominal films that do not involve the use of contrast media;

(b) Diagnostic mammograms; and

(c) Skeletal films involving extremities, pelvis, vertebral column, or skull.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-08-061, § 182-531-1450, filed 3/29/24, effective 5/1/24*
- *WSR 17-04-039, § 182-531-1450, filed 1/25/17, effective 2/25/17. WSR 11-14-075, recodified as § 182-531-1450, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1450, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1450, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-1500** Sleep studies. {#sec-182-531-1500 omnilex-key=us-wa-regs-official--title-182--182-531-1500}

(1) Purpose. For the purposes of this section, sleep studies include polysomnography (PSG), unattended home sleep test (HST), and multiple sleep latency testing (MSLT). The medicaid agency covers attended, full-channel, PSG, MSLT, and unattended HSTs when:

(a) Ordered by the client's physician;

(b) Performed by an agency-designated center of excellence (COE) that is an independent diagnostic testing facility, sleep laboratory, or outpatient hospital; and

(c) Results are used to:

(i) Establish a diagnosis of narcolepsy or sleep apnea; or

(ii) Evaluate a client's response to therapy, such as continuous positive airway pressure (CPAP).

(2) Definitions. The following definitions, those found in chapter 182-500 WAC, and definitions found in other sections of this chapter, apply to this section:

(a) "American Academy of Sleep Medicine" or "AASM" - The only professional society dedicated exclusively to the medical subspecialty of sleep medicine. AASM sets standards and promotes excellence in health care, education, and research. Members specialize in studying, diagnosing, and treating disorders of sleep and daytime alertness such as insomnia, narcolepsy, and obstructive sleep apnea.

(b) "Continuous positive airway pressure" or "CPAP" - See WAC 182-552-0005.

(c) "Core provider agreement" or "CPA" - The basic contract the agency holds with providers serving medical assistance clients.

(d) "Multiple sleep latency test" or "MSLT" - A sleep disorder diagnostic tool used to measure the time elapsed from the start of a daytime nap period to the first signs of sleep, called sleep latency. The MSLT is used extensively to test for narcolepsy, to distinguish between physical tiredness and true excessive daytime sleepiness, or to assess whether treatments for breathing disorders are working.

(e) "Obstructive sleep apnea" or "OSA" - See WAC 182-552-0005.

(f) "Polysomnogram" - The test results from a polysomnography.

(g) "Polysomnography" - A multiparametric test that electronically transmits and records specific physical activities while a person sleeps. The recordings become data that are analyzed by a qualified sleep specialist to determine whether or not a person has a sleep disorder.

(h) "PSG" - The abbreviation for both "polysomnography" and "polysomnogram."

(i) "Registered polysomnographic technologist" or "RPSGT" - A sleep technologist credentialed by the board of registered polysomnographic technologists to assist sleep specialists in the clinical assessment, physiological monitoring and testing, diagnosis, management, and prevention of sleep-related disorders with the use of various diagnostic and therapeutic tools. These tools include, but are not limited to, polysomnograph, positive airway pressure devices, oximeter, capnograph, actigraph, nocturnal oxygen, screening devices, and questionnaires. To become certified as a registered polysomnographic technologist, a sleep technologist must have the necessary clinical experience, hold CPR certification or its equivalent, adhere to the board of registered polysomnographic technologists standards of conduct, and pass the registered polysomnographic technologist examination for polysomnographic technologists.

(3) Client eligibility. Clients in the following agency programs are eligible to receive sleep studies as described in this section:

(a) Categorically needy (CN);

(b) Apple health for kids and other children's medical assistance programs as defined in WAC 182-505-0210;

(c) Medical care services as described in WAC 182-508-0005 (within Washington state or border areas only); and

(d) Medically needy (MN) only when the client is either:

(i) Twenty years of age or younger and referred by a screening provider under the early and periodic screening, diagnosis, and treatment program as described in chapter 182-534 WAC; or

(ii) Receiving home health care services as described in chapter 182-551 WAC, subchapter II.

(4) Provider requirements. To be paid for providing sleep studies as described in this section to eligible clients, the facility must:

(a) Be a sleep study COE. Refer to subsection (5) of this section for information on becoming an agency-approved sleep study COE;

(b) Be currently accredited by AASM and continuously meet the accreditation standards of AASM;

(c) Have at least one physician on staff who is board certified in sleep medicine; and

(d) Have at least one registered polysomnographic technologist (RPSGT) in the sleep lab when studies are being performed.

(5) Documentation.

(a) To become an agency-approved COE, a sleep center must send the following documentation to the Health Care Authority, c/o Provider Enrollment, P.O. Box 45510, Olympia, WA 98504-5510:

(i) A completed CPA; and

(ii) A copy of the sleep center's current accreditation certificate by AASM.

(b) Facilities accredited by the AASM must be in compliance with all accreditation standards at the time of application and throughout the accreditation period.

(c) Sleep centers must request reaccreditation from AASM in time to avoid expiration of COE status with the agency.

(d) At least one physician on staff at the sleep center must be board certified in sleep medicine. If the only physician on staff who is board certified in sleep medicine resigns, the sleep center must ensure another physician on staff at the sleep center obtains board certification or another board-certified physician is hired. The sleep center must then send provider enrollment a copy of the physician's board certification.

(e) If a certified medical director leaves a COE, the COE status does not transfer with the medical director to another sleep center.

(f) The COE must maintain a record of the physician's order for the sleep study.

(6) Coverage.

(a) The agency pays for only medically necessary sleep studies. The need for the sleep study must be confirmed by medical evidence (e.g., physician examination and laboratory tests).

(b) For clients age twenty-one and older, the agency covers:

(i) An unattended home sleep test (HST) as follows:

(A) Using one of the following HST devices:

(I) Type II home sleep monitoring device;

(II) Type III home sleep monitoring device; or

(III) Type IV home sleep monitoring device that measures at least three channels.

(B) To confirm obstructive sleep apnea (OSA) in an individual with signs or symptoms consistent with OSA (e.g., loud snoring, awakening with gasping or choking, excessive daytime sleepiness, observed cessation of breathing during sleep, etc.).

(ii) Full-night, in-laboratory PSG for either of the following:

(A) Confirmation of obstructive sleep apnea (OSA) in an individual with signs or symptoms consistent with OSA (e.g., loud snoring, awakening with gasping or choking, excessive daytime sleepiness, observed cessation of breathing during sleep, etc.); or

(B) Titration of positive airway pressure therapy when initial PSG confirms the diagnosis of OSA, and positive airway pressure is ordered; or

(iii) Split-night, in-laboratory PSG in which the initial diagnostic portion of the PSG is followed by positive airway pressure titration when the PSG meets either of the following criteria:

(A) The apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) is greater than or equal to fifteen events per hour; or

(B) The AHI or RDI is greater than or equal to five and less than or equal to fourteen events per hour with documentation of either of the following:

(I) Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or

(II) Hypertension, ischemic heart disease, or history of stroke.

(c) The agency considers any of the following indications medically necessary for clients age twenty and younger:

(i) OSA suspected based on clinical assessment;

(ii) Obesity, Trisomy 21, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidosis (MPS), prior to adenotonsillectomy in a child;

(iii) Residual symptoms of OSA following mild preoperative OSA;

(iv) Residual symptoms of OSA in a child with preoperative evidence of moderate to severe OSA, obesity, craniofacial anomalies that obstruct the upper airway, or neurologic disorder following adenotonsillectomy;

(v) Titration of positive airway pressure in a child with OSA;

(vi) Suspected congenital central alveolar hypoventilation syndrome or sleep related hypoventilation due to neuromuscular disorder or chest wall deformities;

(vii) Primary apnea of infancy;

(viii) Evidence of a sleep-related breathing disorder in an infant who has experienced an apparent life threatening event;

(ix) Child being considered for adenotonsillectomy to treat OSA; or

(x) Clinical suspicion of an accompanying sleep-related breathing disorder in a child with chronic asthma, cystic fibrosis, pulmonary hypertension, bronchopulmonary dysplasia, or chest wall abnormality.

(7) Noncoverage. The agency does not cover sleep studies:

(a) When documentation for a repeat study does not indicate medical necessity (e.g., no new clinical documentation indicating the need for a repeat study); or

(b) For the following indications, except when an underlying physiology exists (e.g., loud snoring, awakening with gasping or choking, excessive daytime sleepiness, observed cessation of breathing during sleep, etc.):

(i) Chronic insomnia; and

(ii) Snoring.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-11-106, § 182-531-1500, filed 5/21/18, effective 7/1/18*
- *WSR 16-13-158, § 182-531-1500, filed 6/22/16, effective 7/23/16*
- *WSR 15-20-057, § 182-531-1500, filed 10/1/15, effective 11/1/15. Statutory Authority: RCW 41.05.021. WSR 13-07-029, § 182-531-1500, filed 3/13/13, effective 4/13/13. WSR 11-14-075, recodified as § 182-531-1500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1500, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1500, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-1550** Sterilization physician-related services. {#sec-182-531-1550 omnilex-key=us-wa-regs-official--title-182--182-531-1550}

(1) For purposes of this section, sterilization is any medical procedure, treatment, or operation for the purpose of rendering a client permanently incapable of reproducing.

Hysterectomy results in sterilization and is not covered by the medicaid agency solely for that purpose. (See WAC 182-531-0150 and 182-531-0200 for more information about hysterectomies.)

STERILIZATION

(2) The agency covers sterilization when all of the following apply:

(a) The client is at least eighteen years of age at the time an agency-approved consent form is signed;

(b) The client is a mentally competent individual;

(c) The client participates in a medical assistance program (see WAC 182-501-0060);

(d) The client has voluntarily given informed consent; and

(e) The date the client signed a sterilization consent is at least thirty days and not more than one hundred eighty days before the date of the sterilization procedure.

(3) Any medicaid provider who is licensed to do sterilizations within their scope of practice may provide vasectomies and tubal sterilizations to any medicaid client.

(4) The agency requires at least a seventy-two hour waiting period rather than the usual thirty-day waiting period for sterilization in either of the following circumstances:

(a) At the time of a premature delivery when the client gave consent at least thirty days before the expected date of delivery. (The expected date of delivery must be documented on the consent form.)

(b) For emergency abdominal surgery. (The nature of the emergency must be described on the consent form.)

(5) The agency does not accept informed consent obtained when the client is:

(a) In labor or childbirth;

(b) In the process of seeking to obtain or obtaining an abortion; or

(c) Under the influence of alcohol or other substances, including pain medications for labor and delivery, that affects the client's state of awareness.

(6) The agency has certain consent requirements that the provider must meet before the agency reimburses sterilization of an institutionalized client or a client with mental incompetence. The agency requires both of the following:

(a) A court order, which includes both a statement that the client is to be sterilized, and the name of the client's legal guardian who will be giving consent for the sterilization; and

(b) A sterilization consent form signed by the legal guardian, sent to the agency at least thirty days before the procedure.

(7) The agency reimburses epidural anesthesia in excess of the six-hour limit for deliveries if sterilization procedures are performed in conjunction with or immediately following a delivery.

(a) For reimbursement, anesthesia time for sterilization is added to the time for the delivery when the two procedures are performed during the same operative session.

(b) If the sterilization and delivery are performed during different operative sessions, the anesthesia time is calculated separately.

(8) The agency reimburses all attending providers for the sterilization procedure only when the provider submits an agency-approved and complete consent form with the claim for reimbursement.

(a) The physician must complete and sign the physician statement on the consent form within thirty days of the sterilization procedure.

(b) The agency reimburses attending providers after the procedure is completed.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-20-010, § 182-531-1550, filed 9/24/20, effective 1/1/21*
- *WSR 20-06-034, § 182-531-1550, filed 2/27/20, effective 3/29/20. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-531-1550, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-531-1550, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-24-071, § 388-531-1550, filed 11/30/10, effective 1/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1550, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-1600** Bariatric surgery. {#sec-182-531-1600 omnilex-key=us-wa-regs-official--title-182--182-531-1600}

(1) The agency covers medically necessary bariatric surgery for eligible clients.

(2) Bariatric surgery must be performed in a hospital with a bariatric surgery program, and the hospital must be:

(a) Located in the state of Washington or approved border cities (see WAC 182-501-0175); and

(b) Meet the requirements of WAC 182-550-2301.

(3) For clients age 20 and younger, providers must follow the rules for the early periodic screening, diagnosis, and treatment (EPSDT) program, see chapter 182-534 WAC.

(4) The agency authorizes payment for bariatric surgery and bariatric surgery-related services in three stages:

(a) Stage one - Initial assessment of client;

(b) Stage two - Evaluations for bariatric surgery and successful completion of a weight loss regimen; and

(c) Stage three - Bariatric surgery.

Stage one - Initial assessment

(5) Any agency-enrolled provider who is licensed to practice medicine in the state of Washington may examine a client requesting bariatric surgery to ascertain if the client meets the criteria listed in subsection (6) of this section.

(6) The client meets the preliminary conditions of stage one when:

(a) The client is:

(i) Twenty-one through 59 years of age; or

(ii) Eighteen through 20 years old for laparoscopic adjustable gastric banding (LAGB) only;

(b) The client has a body mass index (BMI) of 35 or greater;

(c) The client is not pregnant. (Pregnancy within the first two years following bariatric surgery is not recommended. When applicable, a family planning consultation is highly recommended prior to bariatric surgery);

(d) The client is diagnosed with one of the following:

(i) Diabetes mellitus;

(ii) Degenerative joint disease of a major weight bearing joint(s) (the client must be a candidate for joint replacement surgery if weight loss is achieved); or

(iii) Other rare comorbid conditions (such as pseudo tumor cerebri) in which there is medical evidence that bariatric surgery is medically necessary and that the benefits of bariatric surgery outweigh the risk of surgical mortality; and

(e) The client has an absence of other medical conditions such as multiple sclerosis (MS) that would increase the client's risk of surgical mortality or morbidity from bariatric surgery.

(7) If a client meets the criteria in subsection (6) of this section, the provider must request prior authorization from the agency before referring the client to stage two of the bariatric surgery authorization process. The provider must attach a medical report to the request for prior authorization with supporting documentation that the client meets the stage one criteria in subsections (5) and (6) of this section.

(8) The agency evaluates requests for covered services that are subject to limitations or other restrictions and approves such services beyond those limitations or restrictions when medically necessary, under the provisions of WAC 182-501-0165 and 182-501-0169.

Stage two - Evaluations for bariatric surgery and successful completion of a weight loss regimen

(9) After receiving prior authorization from the agency to begin stage two of the bariatric surgery authorization process, the client must:

(a) Undergo a comprehensive psychosocial evaluation performed by a psychiatrist, licensed psychiatric ARNP, or licensed independent social worker with a minimum of two years postmasters' experience in a mental health setting. Upon completion, the results of the evaluation must be forwarded to the agency. The comprehensive psychosocial evaluation must include:

(i) An assessment of the client's mental status or illness to:

(A) Evaluate the client for the presence of substance abuse problems or psychiatric illness which would preclude the client from participating in presurgical dietary requirements or postsurgical lifestyle changes; and

(B) If applicable, document that the client has been successfully treated for psychiatric illness and has been stabilized for at least six months and/or has been rehabilitated and is free from any drug and/or alcohol abuse and has been drug and/or alcohol free for a period of at least one year.

(ii) An assessment and certification of the client's ability to comply with the postoperative requirements such as lifelong required dietary changes and regular follow-up.

(b) Undergo an internal medicine evaluation performed by an internist to assess the client's preoperative condition and mortality risk. Upon completion, the internist must forward the results of the evaluation to the agency.

(c) Undergo a surgical evaluation by the surgeon who will perform the bariatric surgery (see subsection (13) of this section for surgeon requirements). Upon completion, the surgeon must forward the results of the surgical evaluation to the agency and to the licensed medical provider who is supervising the client's weight loss regimen (refer to WAC 182-531-1600 (9)(d)(ii)).

(d) Under the supervision of a licensed medical provider, the client must participate in a weight loss regimen prior to surgery. The client must, within 180 days from the date of the agency's stage one authorization, lose at least five percent of his or her initial body weight. If the client does not meet this weight loss requirement within 180 days from the date of the agency's initial authorization, the agency will cancel the authorization. The client or the client's provider must reapply for prior authorization from the agency to restart stage two. For the purpose of this section, "initial body weight" means the client's weight at the first evaluation appointment.

(i) The purpose of the weight loss regimen is to help the client achieve the required five percent loss of initial body weight prior to surgery and to demonstrate the client's ability to adhere to the radical and lifelong behavior changes and strict diet that are required after bariatric surgery.

(ii) The weight loss regimen must:

(A) Be supervised by a licensed medical provider who has a core provider agreement with the agency;

(B) Include monthly visits to the medical provider;

(C) Include counseling twice a month by a registered dietician referred to by the treating provider or surgeon; and

(D) Be at least six months in duration.

(iii) Documentation of the following requirements must be retained in the client's medical file. Copies of the documentation must be forwarded to the agency upon completion of stage two. The agency will evaluate the documentation and authorize the client for bariatric surgery if the stage two requirements were successfully completed.

(A) The provider must document the client's compliance in keeping scheduled appointments and the client's progress toward weight loss by serial weight recordings. The client must lose at least five percent of his or her initial body weight and must maintain the five percent weight loss until surgery;

(B) For diabetic clients, the provider must document the efforts in diabetic control or stabilization;

(C) The registered dietician must document the client's compliance (or noncompliance) in keeping scheduled appointments, and the client's weight loss progress;

(D) The client must keep a journal of active participation in the medically structured weight loss regimen including the activities under (d)(iii)(A), (d)(iii)(B) if appropriate, and (d)(iii)(C) of this subsection.

(10) If the client fails to complete all of the requirements of subsection (9) of this section, the agency will not authorize stage three - Bariatric surgery.

(11) If the client is unable to meet all of the stage two criteria, the client or the client's provider must reapply for prior authorization from the agency to reenter stage two.

Stage three - Bariatric surgery

(12) The agency may withdraw authorization of payment for bariatric surgery at any time up to the actual surgery if the agency determines that the client is not complying with the requirements of this section.

(13) A surgeon who performs bariatric surgery for medical assistance clients must:

(a) Have a signed core provider agreement with the agency;

(b) Have a valid medical license in the state of Washington; and

(c) Be affiliated with a bariatric surgery program that meets the requirements of WAC 182-550-2301.

(14) For hospital requirements for stage three - Bariatric surgery, see WAC 182-550-2301.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-21-142, s 182-531-1600, filed 10/21/25, effective 11/21/25. Statutory Authority: RCW 41.05.021. WSR 13-14-016, § 182-531-1600, filed 6/21/13, effective 7/22/13. WSR 11-14-075, recodified as § 182-531-1600, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-531-1600, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-12-022, § 388-531-1600, filed 5/20/05, effective 6/20/05*
- *WSR 01-01-012, § 388-531-1600, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-1625** Outpatient hemophilia treatment requirements—Center of excellence. {#sec-182-531-1625 omnilex-key=us-wa-regs-official--title-182--182-531-1625}

A hemophilia treatment center of excellence (COE) uses a comprehensive care model to provide care for persons with bleeding disorders. The comprehensive care model includes specialized prevention, diagnostic, and treatment programs designed to provide family-centered education, state-of-the-art treatment, research, and support services for individuals and families living with bleeding disorders.

(1) The agency pays for hemophilia and von Willebrand related products for administration in the home only when provided through a qualified hemophilia treatment COE.

(2) To become a qualified hemophilia treatment COE, a hemophilia center must meet all of the following:

(a) Have a current core provider agreement in accordance with WAC 182-502-0005;

(b) Be a federally approved hemophilia treatment center (HTC) as defined in WAC 182-531-0050 and meet or exceed all Medical and Scientific Advisory Council (MASAC) standards of care and delivery of services;

(c) Participate in the public health service 340B provider drug discount program and be listed in the medicaid exclusion files maintained by the federal Health Resources and Services Administration (HRSA) Office of Pharmacy Affairs (OPA);

(d) Submit a written request to the agency to be a qualified hemophilia treatment center of excellence and include proof of the following:

(i) U.S. Center for Disease Control (CDC) and prevention surveillance site identification number; and

(ii) Listing in the hemophilia treatment center (HTC) directory.

(e) Receive written approval including conditions of payment and billing procedures from the agency.

(3) To continue as a qualified hemophilia treatment COE, the HTC must annually submit to the agency:

(a) Copies of grant documents and reports submitted to the maternal and child health bureau/human resources and services administration/department of health and human services or to their designated subcontractors; and

(b) Proof of continued federal funding by the National Hemophilia Program and listing with the regional hemophilia network and the CDC.

(4) Services rendered by a hemophilia treatment COE may be subject to the agency's limitations and authorization requirements.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 12-16-061, § 182-531-1625, filed 7/30/12, effective 11/1/12.*

##### **Wash. Admin. Code § 182-531-1650** Substance abuse detoxification physician-related services. {#sec-182-531-1650 omnilex-key=us-wa-regs-official--title-182--182-531-1650}

(1) The department covers physician services for three-day alcohol detoxification or five-day drug detoxification services for a client eligible for medical care program services in a department-enrolled hospital-based detoxification center.

(2) The department covers treatment in programs certified under chapter 388-805 WAC or its successor.

(3) The department covers detoxification and medical stabilization services to chemically using pregnant (CUP) women for up to twenty-seven days in an inpatient hospital setting.

**History**
- *WSR 11-14-075, recodified as § 182-531-1650, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1650, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and Public Law 104-191. WSR 03-19-081, § 388-531-1650, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1650, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-1675** Washington apple health—Gender affirming interventions for gender dysphoria. {#sec-182-531-1675 omnilex-key=us-wa-regs-official--title-182--182-531-1675}

(1) Overview of treatment program.

(a) Medicaid agency coverage. The medicaid agency covers the services listed in (b) of this subsection to treat gender dysphoria (also referred to as gender incongruence) under WAC 182-501-0050 and 182-531-0100. These services include life-changing procedures that may not be reversible.

(b) Medical services covered. Medical services covered by the agency include, but are not limited to:

(i) Presurgical and postsurgical hormone therapy;

(ii) Puberty suppression therapy;

(iii) Behavioral health services;

(iv) Gender affirming hair removal services; and

(v) Surgical and ancillary services including, but not limited to:

(A) Anesthesia;

(B) Labs;

(C) Pathology;

(D) Radiology;

(E) Hospitalization;

(F) Physician services; and

(G) Hospitalizations and physician services required to treat postoperative complications of procedures performed under this section.

(c) Diagnosis of gender dysphoria/gender incongruence. A diagnosis of gender dysphoria/gender incongruence is required to obtain services under this program and must be made by a provider who meets the qualifications outlined in chapter 182-502 WAC.

(d) Medical necessity. The agency authorizes and pays for only medically necessary services. Medical necessity is defined in WAC 182-500-0070 and is determined under WAC 182-501-0165 and limitation extensions in accordance with WAC 182-501-0169.

(e) Provider requirements. Providers should be knowledgeable of gender-nonconforming identities and expressions, and the assessment and treatment of gender dysphoria/gender incongruence, including experience utilizing standards of care that include the World Professional Association for Transgender Health (WPATH) Standards of Care.

(f) Clients age 20 and younger. For clients age 20 and younger, providers must follow the rules for the early periodic screening, diagnosis, and treatment program, see chapter 182-534 WAC.

(g) Transportation services. The agency covers transportation services under the provisions of chapter 182-546 WAC.

(h) Out-of-state care. Any out-of-state care, including a presurgical consultation, must be prior authorized as an out-of-state service under WAC 182-501-0182.

(i) Corrective surgeries for intersex traits. The agency covers corrective or reparative surgeries for people with intersex traits who received surgeries that were performed without the person's consent.

(2) Prior authorization.

(a) Prior authorization requirements for surgical services. As a condition of payment, the agency requires prior authorization for all surgical services to treat gender dysphoria/gender incongruence, except as provided in subsection (3) of this section. This includes modifications or revisions to, or correcting complications from, a previous surgery related to infections or impairment of a function.

(b) Required documentation. The provider must include the following documentation with the prior authorization request:

(i) Behavioral health assessment. Documentation of a behavioral health assessment performed within 18 months preceding surgery by a qualified behavioral health professional as defined in WAC 182-531-1400. This provider must be a licensed health care professional who is eligible under chapter 182-502 WAC, as follows:

(A) Psychiatrist;

(B) Psychologist;

(C) Psychiatric advanced practice registered nurse (APRN);

(D) Psychiatric mental health nurse practitioner-board certified (PMHNP-BC);

(E) Mental health counselor (LMHC);

(F) Independent clinical social worker (LICSW);

(G) Advanced social worker (LASW); or

(H) Marriage and family therapist (LMFT).

(ii) Evaluation requirements. The comprehensive behavioral health assessment must:

(A) Confirm the diagnosis of gender dysphoria, or gender incongruence, or both, as defined by the Diagnostic Statistical Manual of Mental Disorders;

(B) Document that:

(I) The client's experience of gender incongruence is marked and sustained;

(II) The client has the desire to make their body as congruent as possible with a desired gender through surgery, hormone treatment, or other medical therapies;

(III) Gender incongruence causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and

(IV) The client has no contraindicating behavioral health conditions that would impair the ability to give informed consent, as described in (c) of this subsection. If a client has a behavioral health condition that interferes with their ability to give informed consent and the client understands the risks, benefits, and alternatives to gender affirming treatment, the provider must facilitate treatment of the underlying behavioral health condition to support the client's ability to provide informed consent.

(iii) Hormone therapy. Documentation from the primary care provider or the provider prescribing hormone therapy that the client has:

(A) As appropriate to the client's gender goal for the following procedures:

(I) Had six continuous months of hormone therapy immediately preceding a request for genital surgery; or

(II) Twelve continuous months of continuous hormone therapy immediately preceding a request for breast augmentation surgery, unless:

• Hormones are not clinically indicated for the client or hormones are not aligned with the client's gender health care plan, or both; or

• The client has requested a mastectomy or reduction mammoplasty; or

• The client has a medical contraindication to hormone therapy; and

• The client has a medical necessity for surgery and the client is adherent with current gender dysphoria treatment.

(B) Gender dysphoria/gender incongruence that is not a symptom of another medical condition; and

(C) Had no medical conditions that would impair the client's ability to give informed consent.

(iv) Surgical. Documentation from the surgeon of the client's:

(A) Medical history and physical examination(s) performed within the 12 months preceding surgery;

(B) Medical necessity for surgery and surgical plan; and

(C) For hysterectomies, a completed agency hysterectomy consent form must be submitted.

(c) Informed consent. The surgeon must provide documentation showing that they informed the client of:

(i) The nature of the proposed care, treatment, services, medications, and procedures;

(ii) Potential benefits, risks, or side effects, including potential problems that might occur during recuperation;

(iii) The likelihood of achieving the client's treatment goals;

(iv) Reasonable alternatives;

(v) Relevant risks, benefits, and side effects related to alternatives, including the possible results of not receiving care, treatment, and services;

(vi) Any limitations on the confidentiality of information learned from or about the patient;

(vii) The effect of gender-affirming treatment on reproduction; and

(viii) Reproductive options before having gender-affirming surgeries that have the potential to create iatrogenic infertility.

(d) Requirements for hair removal. For facial or body hair removal, a client must submit:

(i) A letter written within the past 18 months from the provider managing the client's gender-affirming hormone therapy describing the client's attempted hair removal techniques that failed, for each affected part of the body.

(ii) A letter of medical necessity from the client's dermatologist or primary care provider written within the past 18 months that includes:

(A) The size and location of the area to be treated; and

(B) For each area of the body, the number of expected units needed to complete treatment.

(iii) Photographs of the areas to be treated, if requested by the agency.

(e) Other requirements. If the client fails to complete all of the requirements in (b) of this subsection, the agency will not authorize gender affirming surgery unless:

(i) The clinical decision-making process is provided in the referral letter and attachments described in (b) of this subsection; and

(ii) The agency has determined that the request is medically necessary in accordance with WAC 182-501-0165 based on review of all submitted information.

(f) Behavioral health provider requirements. The behavioral health provider who performs the behavioral health assessment described in (b)(i) of this subsection must:

(i) Meet the provisions of WAC 182-531-1400;

(ii) Be competent in using the Diagnostic Statistical Manual of Mental Disorders, and the International Classification of Diseases for diagnostic purposes;

(iii) Be able to recognize and diagnose coexisting behavioral health conditions and to distinguish these from gender dysphoria/gender incongruence;

(iv) Be knowledgeable of gender-nonconforming identities and expressions, and the assessment and treatment of gender dysphoria; and

(v) Have completed continuing education in the assessment and treatment of gender dysphoria. This may include attending relevant professional meetings, workshops, or seminars; obtaining supervision from a behavioral health professional with relevant experience; or participating in research related to gender nonconformity and gender dysphoria.

(g) Clients age 17 and younger. Clients age 17 and younger must meet the requirements for prior authorization identified in (a) through (d) of this subsection, except that the comprehensive behavioral health assessment required in (b)(i) of this subsection must be a biopsychosocial behavioral health assessment performed by a behavioral health provider who specializes in adolescent transgender care and meets the qualifications outlined in WAC 182-531-1400.

(3) Expedited prior authorization (EPA).

(a) Approved EPA procedures. The agency allows a provider to use the EPA process for clients age 17 and older for the following medically necessary procedures:

(i) Bilateral mastectomy or reduction mammoplasty with or without chest reconstruction; and

(ii) Genital or donor skin graft site hair removal when medically necessary to prepare for genital reassignment.

(b) Clinical criteria and documentation. To use the EPA process for procedures identified in (a) of this subsection, the following clinical criteria and documentation must be kept in the client's record and made available to the agency upon request:

(i) One comprehensive biopsychosocial behavioral health assessment performed by a licensed behavioral health provider within the 18 months preceding surgery that meets the requirements identified in subsection (2) of this section;

(ii) Documentation from the primary care provider or the provider prescribing hormone therapy of the medical necessity for surgery and confirmation that the client is adherent with current gender dysphoria treatment; and

(iii) Documentation from the surgeon of the client's:

(A) Medical history and physical examinations performed within the 12 months preceding surgery; and

(B) Medical necessity for surgery and surgical plan.

(c) Documentation exception. When the requested procedure is for genital or donor skin graft site hair removal to prepare for bottom surgery, there is an exception to the requirements in (b) of this subsection. The only documentation required is either a:

(i) Letter of medical necessity from the treating surgeon that includes the size and location of the area to be treated, and expected date of planned genital surgery; or

(ii) Letter of medical necessity from the provider who will perform the hair removal that includes the surgical consult for bottom surgery and addresses the need for hair removal prior to gender affirming surgery.

(d) Prior authorization required for other surgeries. All other surgeries to treat gender dysphoria, including modifications to, or complications from a previous surgery require prior authorization to determine medical necessity.

(e) Recoupment. The agency may recoup any payment made to a provider for procedures listed in this subsection if the provider does not follow the EPA process outlined in WAC 182-501-0163 or if the provider does not maintain the documentation required by this subsection.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-21-142, s 182-531-1675, filed 10/21/25, effective 11/21/25*
- *WSR 24-21-072, s 182-531-1675, filed 10/14/24, effective 11/14/24*
- *WSR 23-03-071, § 182-531-1675, filed 1/13/23, effective 2/13/23*
- *WSR 21-08-058, § 182-531-1675, filed 4/5/21, effective 5/6/21*
- *WSR 15-16-084, § 182-531-1675, filed 7/31/15, effective 8/31/15.*

##### **Wash. Admin. Code § 182-531-1700** Surgical physician-related services. {#sec-182-531-1700 omnilex-key=us-wa-regs-official--title-182--182-531-1700}

(1) The agency's global surgical reimbursement for all covered surgeries includes all of the following:

(a) The operation itself;

(b) Postoperative dressing changes, including:

(i) Local incision care and removal of operative packs;

(ii) Removal of cutaneous sutures, staples, lines, wire, tubes, drains, and splints;

(iii) Insertion, irrigation, and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; or

(iv) Change and removal of tracheostomy tubes.

(c) All additional medical or surgical services required because of complications that do not require additional operating room procedures.

(2) The agency's global surgical reimbursement for major surgeries, includes all of the following:

(a) Preoperative visits, in or out of the hospital, beginning on the day before surgery; and

(b) Services by the primary surgeon, in or out of the hospital, during a standard ninety-day postoperative period.

(3) The agency's global surgical reimbursement for minor surgeries includes all of the following:

(a) Preoperative visits beginning on the day of surgery; and

(b) Follow-up care for zero or ten days, depending on the procedure.

(4) When a second physician provides follow-up services for minor procedures performed in hospital emergency departments, the agency does not include these services in the global surgical reimbursement. The physician may bill these services separately.

(5) The agency's global surgical reimbursement for multiple surgical procedures is as follows:

(a) Payment for multiple surgeries performed on the same client on the same day equals one hundred percent of the agency's allowed fee for the highest value procedure. Then,

(b) For additional surgical procedures, payment equals fifty percent of the agency's allowed fee for each procedure.

(6) The agency allows separate reimbursement for any of the following:

(a) The initial evaluation or consultation;

(b) Preoperative visits more than one day before the surgery;

(c) Postoperative visits for problems unrelated to the surgery; and

(d) Postoperative visits for services that are not included in the normal course of treatment for the surgery.

(7) The agency's reimbursement for endoscopy is as follows:

(a) The global surgical reimbursement fee includes follow-up care for zero or ten days, depending on the procedure.

(b) Multiple surgery rules apply when a provider bills multiple endoscopies from different endoscopy groups. See subsection (4) of this section.

(c) When a physician performs more than one endoscopy procedure from the same group on the same day, the agency pays the full amount of the procedure with the highest maximum allowable fee.

(d) The agency pays the procedure with the second highest maximum allowable fee at the maximum allowable fee minus the base diagnostic endoscopy procedure's maximum allowed amount.

(e) The agency does not pay when payment for other codes within an endoscopy group is less than the base code.

(8) The agency restricts reimbursement for surgery assists to selected procedures as follows:

(a) The agency applies multiple surgery reimbursement rules for surgery assists. See subsection (4) of this section.

(b) Surgery assists are reimbursed at twenty percent of the maximum allowable fee for the surgical procedure.

(c) A surgical assist fee for a registered nurse first assistant (RNFA) is reimbursed if the nurse has been assigned a provider number.

(d) A provider must use a modifier on the claim with the procedure code to identify surgery assist.

(9) The agency bases payment splits between preoperative, intraoperative, and postoperative services on medicare determinations for given surgical procedures or range of procedures. The agency pays any procedure that does not have an established medicare payment split according to a split of ten percent - eighty percent - ten percent respectively.

(10) For preoperative and postoperative critical care services provided during a global period refer to WAC 182-531-0450.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-04-039, § 182-531-1700, filed 1/25/17, effective 2/25/17. WSR 11-14-075, recodified as § 182-531-1700, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1700, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1700, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-1710** Screening, brief intervention, and referral to treatment (SBIRT). {#sec-182-531-1710 omnilex-key=us-wa-regs-official--title-182--182-531-1710}

(1) The medicaid agency covers alcohol and substance misuse counseling through screening, brief intervention, and referral to treatment (SBIRT) services when delivered by, or under the supervision of, a qualified licensed physician or other qualified licensed health care professional within the scope of their practice.

(2) SBIRT is a comprehensive, evidence-based public health practice designed to identify, reduce and prevent problematic use, abuse, and dependence on alcohol and illicit drugs. SBIRT can be used to identify people who are at risk for or have some level of substance use disorder which can lead to illness, injury, or other long-term morbidity or mortality. SBIRT services are provided in a wide variety of medical and community health care settings such as primary care centers, hospital emergency rooms, trauma centers, and dental offices.

(3) The following health care professionals are eligible to become qualified SBIRT providers to deliver SBIRT services or supervise qualified staff to deliver SBIRT services:

(a) Advanced registered nurse practitioners, in accordance with chapters 18.79 RCW and 246-840 WAC;

(b) Certified behavioral health support specialist, in accordance with chapters 18.227 RCW and 246-821 WAC;

(c) Dental hygienist, in accordance with chapters 18.29 RCW and 246-815 WAC;

(d) Dentist, in accordance with chapters 18.260 RCW and 246-817 WAC;

(e) Independent and advanced social worker, in accordance with chapters 18.225 RCW and 246-809 WAC;

(f) Licensed practical nurse, in accordance with chapters 18.79 RCW and 246-840 WAC;

(g) Marriage and family therapist, in accordance with chapters 18.225 RCW and 246-809 WAC;

(h) Marriage and family therapist associate, in accordance with chapters 18.225 RCW and 246-809 WAC;

(i) Mental health counselor, in accordance with chapters 18.225 RCW and 246-809 WAC;

(j) Mental health counselor associate, in accordance with chapters 18.225 RCW and 246-809 WAC;

(k) Psychological associate, in accordance with chapters 18.83 RCW and 246-924 WAC;

(l) Psychologist, in accordance with chapters 18.83 RCW and 246-924 WAC;

(m) Physician, in accordance with chapters 18.71 RCW and 246-919 WAC;

(n) Physician assistant, in accordance with chapters 18.71A RCW and 246-918 WAC;

(o) Registered nurse, in accordance with chapters 18.79 RCW and 246-840 WAC; and

(p) Substance use disorder professional (SUDP), in accordance with chapters 18.205 RCW and 246-811 WAC.

(4) To become a qualified SBIRT provider, eligible licensed or certified health care professionals must:

(a) Complete agency-approved SBIRT training and mail or fax the SBIRT training certificate or other proof of this training completion to the agency; or

(b) Have an addiction specialist certification and mail or fax proof of this certification to the agency.

(5) The agency pays for SBIRT as follows:

(a) Screenings, which are included in the reimbursement for the evaluation and management code billed;

(b) Brief interventions, limited to four sessions per client, per provider, per calendar year; and

(c) When billed by one of the following qualified SBIRT health care professionals:

(i) Advanced registered nurse practitioner;

(ii) Dental hygienist;

(iii) Dentist;

(iv) Independent and advanced social worker;

(v) Marriage and family therapist;

(vi) Mental health counselor;

(vii) Physician; and

(viii) Psychologist.

(6) The agency evaluates a request for additional sessions in excess of the limitations or restrictions according to WAC 182-501-0169.

(7) To be paid for providing alcohol and substance misuse counseling through SBIRT, providers must bill the agency using the agency's published billing instructions.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2024 c 371, and chapter 246-929 WAC. WSR 25-22-061, s 182-531-1710, filed 10/30/25, effective 1/1/26. Statutory Authority: RCW 18.227.100, 41.05.021, and 41.05.160. WSR 25-04-011, s 182-531-1710, filed 1/23/25, effective 2/23/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-20-132, § 182-531-1710, filed 10/6/21, effective 11/6/21*
- *WSR 18-12-045, § 182-531-1710, filed 5/30/18, effective 7/1/18*
- *WSR 15-03-041, § 182-531-1710, filed 1/12/15, effective 2/12/15.*

##### **Wash. Admin. Code § 182-531-1720** Tobacco/nicotine cessation counseling. {#sec-182-531-1720 omnilex-key=us-wa-regs-official--title-182--182-531-1720}

(1) The medicaid agency covers tobacco/nicotine cessation counseling when:

(a) Delivered by qualified providers through an agency-approved tobacco/nicotine cessation telephone counseling service;

(b) The client is pregnant or in the postpartum period as defined in 42 C.F.R. 435.170. The agency pays for face-to-face office visits for tobacco/nicotine cessation counseling for these clients with the following limits:

(i) Counseling must be provided by qualified physicians, advanced registered nurse practitioners (ARNPs), physician assistants, naturopathic physicians, pharmacists, certified nurse-midwives (CNM), licensed midwives (LM), psychologists, or dentists;

(ii) Two tobacco/nicotine cessation counseling attempts are allowed every 12 months. An attempt is defined as up to four tobacco/nicotine cessation counseling sessions; and

(iii) The agency does not cover more than one face-to-face tobacco/nicotine cessation counseling session per client, per day. The provider must keep written documentation in the client's record for each session.

(c) Provided through screening, brief intervention, and referral to treatment (SBIRT). To receive payment for tobacco/nicotine cessation counseling through SBIRT, providers must bill the agency using the agency's published billing instructions.

(2) A provider may prescribe pharmacotherapy for tobacco/nicotine cessation when the provider considers the treatment appropriate for the client. The agency covers certain pharmacotherapy for tobacco/nicotine cessation, including prescription drugs and over-the-counter (OTC) nicotine replacement therapy (NRT), as described in chapter 182-530 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-21-163, s 182-531-1720, filed 10/23/24, effective 11/23/24*
- *WSR 19-22-017, § 182-531-1720, filed 10/25/19, effective 11/25/19*
- *WSR 15-03-041, § 182-531-1720, filed 1/12/15, effective 2/12/15.*

##### **Wash. Admin. Code § 182-531-1740** Treat and refer services. {#sec-182-531-1740 omnilex-key=us-wa-regs-official--title-182--182-531-1740}

(1) The purpose of treat and refer services is to reduce the number of avoidable emergency room transports, i.e., transports that are nonemergency or nonurgent.

(2) Treat and refer services are covered health care services for a client who has accessed 911 or a similar public dispatch number, and whose condition does not require ambulance transport to an emergency department based on the clinical information available at the time of service.

(3) Treat and refer services can be provided by any city and town fire department, fire protection district organized under Title 52 RCW, regional fire protection service authority organized under chapter 52.26 RCW, provider of emergency medical services that levy a tax under RCW 84.52.069, and federally recognized Indian tribe.

(4) To receive payment for covered health care services provided to clients under this section, an entity that meets the criteria in subsection (3) of this section must be an enrolled medicaid provider with an active core provider agreement for the service period specified in the claim, and have an established community assistance referral and education services program under RCW 35.21.930.

(a) Prior to billing and receiving payment, participating providers must submit a participation agreement and attestation form to the agency certifying their compliance with RCW 35.21.930.

(b) Providers must immediately notify the agency if they no longer meet the requirements of RCW 35.21.930. Providers who no longer meet the requirements of the program and continue to bill and receive payment under the program must return any overpayment under RCW 41.05A.170.

(5) Treat and refer services must be documented in a standard medical incident report that includes a clinical or mental health assessment.

(6) The health care professionals providing treat and refer services must:

(a) Be state-certified emergency medical technicians, state-certified advanced emergency medical technicians, or state-certified paramedics under chapters 18.71 and 18.73 RCW;

(b) Be under the supervision and direction of an approved medical director according to RCW 35.21.930(1); and

(c) Not perform medical procedures they are not trained and certified to perform, according to RCW 35.21.930(1).

(7) Entities that meet the criteria in subsections (3) and (4) of this section must retain the standard medical incident report in subsection (5) of this section according to WAC 182-502-0020.

(8) Payments under this section are subject to review and audit under chapter 182-502A WAC.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2017 c 273. WSR 19-19-090, § 182-531-1740, filed 9/18/19, effective 10/19/19.*

##### **Wash. Admin. Code § 182-531-1750** Transplant coverage for physician-related services. {#sec-182-531-1750 omnilex-key=us-wa-regs-official--title-182--182-531-1750}

The medicaid agency covers transplants when performed in a facility, as defined in WAC 247-04-020, that has a transplant certificate of need (CON) issued by the department of health. See WAC 182-550-1900 for information regarding transplant coverage.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-01-096, s 182-531-1750, filed 12/13/24, effective 1/13/25*
- *WSR 17-04-039, § 182-531-1750, filed 1/25/17, effective 2/25/17. WSR 11-14-075, recodified as § 182-531-1750, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1750, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1750, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-1800** Transplant coverage—Medical criteria to receive transplants. {#sec-182-531-1800 omnilex-key=us-wa-regs-official--title-182--182-531-1800}

See WAC 182-550-2000 for information about medical criteria to receive transplants.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-04-039, § 182-531-1800, filed 1/25/17, effective 2/25/17. WSR 11-14-075, recodified as § 182-531-1800, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1800, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-1850** Payment methodology for physician-related services—General and billing modifiers. {#sec-182-531-1850 omnilex-key=us-wa-regs-official--title-182--182-531-1850}

GENERAL PAYMENT METHODOLOGY

(l) The medicaid agency bases the payment methodology for most physician-related services on medicare's resource-based relative value scale (RBRVS). The agency obtains information used to update the agency's RBRVS from the centers for medicare and medicaid services (CMS) relative value unit (RVU) file.

(2) The agency updates and revises the RBRVS calculations during the agency's annual update.

(3) The agency determines a budget-neutral conversion factor (CF) for each RBRVS update, by doing the following:

(a) First, determining the units of service and expenditures for a base period;

(b) Second, applying the latest medicare RVU obtained from the medicare physician fee schedule database (MPFSDB), as published in the CMS RVU file, and blended Washington (WA) geographic practice cost indices (GCPI) to obtain projected units of service for the new period;

(c) Third, multiplying the projected units of service by conversion factors to obtain estimated expenditures;

(d) Fourth, comparing expenditures obtained in (c) of this subsection with base period expenditure levels; and

(e) Fifth, adjusting the dollar amount for the conversion factor until the product of the conversion factor and the projected units of service at the new RVUs equals the base period amount.

(4) The agency calculates maximum allowable fees (MAFs) in the following ways:

(a) For procedure codes that have applicable medicare RVUs, the agency determines RBRVS RVUs by:

(i) First, multiplying the medicare RVU by the blended statewide geographic practice cost index (GPCI); and

(ii) Second, multiplying the sum of these products by the applicable conversion factor.

(b) For procedure codes with no RBRVS RVUs, the agency establishes maximum allowable fees, also known as "flat" fees.

(i) The agency does not use the conversion factor for these codes.

(ii) The agency updates flat fee reimbursement based on market research or when the legislature authorizes a vendor rate increase, except for the following categories which are revised annually during the update:

(A) The agency reimburses for professional administered drug codes at the medicare Part B drug file price or using point-of-sale (POS) pricing methodology, described in WAC 182-530-7000, when there is no Part B rate. When the provider receives immunization materials from the department of health, the agency pays only a flat administrative fee for storage.

(B) The agency uses established medicare contractor rates.

(iii) For information regarding the agency's reimbursement of other supplies, see WAC 182-543-9000.

(c) For procedure codes with no RVU or maximum allowable fee, the agency reimburses "by report." The agency reimburses for by report codes at a percentage of the amount billed for the service.

(d) The agency adjusts composite rates annually when the codes that make up the composite rates are updated.

(5) The agency reviews RBRVS changes.

(6) The agency also makes fee schedule changes when:

(a) The legislature grants a vendor rate increase outside of the agency's annual update;

(b) There are coverage changes due to policy updates; or

(c) CMS adds or deletes procedure codes.

(7) If the legislatively authorized vendor rate increase, or other increase, becomes effective at the same time as the annual update, the agency applies the increase after calculating budget-neutral fees. The agency pays providers a higher reimbursement rate for primary health care evaluation and management (E&M) services that are provided to children age 20 and younger.

(8) The agency may adjust rates to maintain or increase access to health care services as directed by the legislature.

(9) The agency does not allow separate reimbursement for CMS bundled services, except when allowed for a particular service by a governing statute, another rule, or by an agreement with CMS.

(10) Variations of payment methodology which are specific to particular services, and which differ from the general payment methodology described in this section, are included in the sections dealing with those particular services.

CURRENT PROCEDURAL TERMINOLOGY (CPT)/HEALTHCARE FINANCING ADMINISTRATION (HCFA) MODIFIERS

(11) Certain services and procedures require modifiers for the agency to reimburse the provider. This information is included in the sections dealing with those particular services and procedures, as well as the fee schedule.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-14-051, s 182-531-1850, filed 6/26/25, effective 7/27/25*
- *WSR 23-16-059, § 182-531-1850, filed 7/26/23, effective 8/26/23*
- *WSR 21-23-050, § 182-531-1850, filed 11/10/21, effective 12/11/21*
- *WSR 17-21-040, § 182-531-1850, filed 10/12/17, effective 11/12/17*
- *WSR 17-04-039, § 182-531-1850, filed 1/25/17, effective 2/25/17. WSR 11-14-075, recodified as § 182-531-1850, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1850, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1850, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-1900** Payment—General requirements for physician-related services. {#sec-182-531-1900 omnilex-key=us-wa-regs-official--title-182--182-531-1900}

(1) The medicaid agency pays physicians and related providers for covered services provided to eligible clients on a fee-for-service basis, subject to the exceptions, restrictions, and other limitations listed in this chapter and other published issuances.

(2) To receive payment, physicians must bill the agency according to the conditions of payment under WAC 182-502-0100.

(3) The agency does not separately reimburse certain administrative costs or services. The agency considers these costs to be included in the payment. These costs and services include the following:

(a) Delinquent payment fees;

(b) Educational supplies;

(c) Mileage;

(d) Missed or canceled appointments;

(e) Reports, client charts, insurance forms, and copying expenses;

(f) Service charges;

(g) Take home drugs; and

(h) Telephoning (e.g., for prescription refills).

(4) The agency does not routinely pay for procedure codes which have a "#" or "NC" indicator in the fee schedule. The agency reviews these codes for conformance to medicaid program policy only as an exception to policy or as a limitation extension. See WAC 182-501-0160 and 182-501-0165.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-17-066, § 182-531-1900, filed 8/14/15, effective 9/14/15. WSR 11-14-075, recodified as § 182-531-1900, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-1900, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-1900, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-531-2000** Increased payments for physician-related services for qualified trauma cases. {#sec-182-531-2000 omnilex-key=us-wa-regs-official--title-182--182-531-2000}

(1) The health care authority's physician trauma care fund (TCF) is an amount that is legislatively appropriated to the medicaid agency each biennium for the purpose of increasing the agency's payment to physicians and other clinicians (those who are performing services within their licensed and credentialed scope of practice) providing qualified trauma care services to medical assistance clients covered under the agency's medical assistance programs.

(2) Trauma care services provided to clients in:

(a) Medicaid, disability lifeline (DL), incapacity-based medical care services (MCS), children's health insurance program (CHIP), and apple health for kids, qualify for enhanced rate payments from the TCF. Trauma care services provided to a DL or MCS client qualify for enhanced rates only during the client's certification period. See WAC 182-504-0010;

(b) The alien emergency medical (AEM), refugee assistance, and alien medical programs do not qualify for enhanced rate payments from the TCF; and

(c) The agency's managed care programs qualify for enhanced rate payments from the TCF, effective with dates of service on and after July 1, 2012.

(3) To receive payments from the TCF, a physician or other clinician must:

(a) Be on the designated trauma services response team of any department of health (DOH)-designated or DOH-recognized trauma service center;

(b) Meet the provider requirements in this section and other applicable rules;

(c) Meet the billing requirements in this section and other applicable rules; and

(d) Submit all information the agency requires to monitor the trauma program.

(4) Except as described in subsection (5) of this section and subject to the limitations listed, the agency makes payments from the TCF to physicians and other clinicians:

(a) For only those trauma services that are designated by the agency as "qualified." Qualified trauma care services include:

(i) Follow-up surgical services provided within six months of the date of the injury. These surgical procedures must have been planned during the initial acute episode of injury; and

(ii) Physiatrist services provided during an inpatient stay immediately following, and within six months of, the qualifying traumatic injury.

(b) For hospital-based professional services-only, and for follow-up surgeries performed in a medicare-certified ambulatory surgery center (ASC). The follow-up surgery must have been performed within six months of the initial traumatic injury.

(c) Only for trauma cases that meet the injury severity score (ISS) (a summary rating system for traumatic anatomic injuries) criteria specified by the agency. The current qualifying ISS are:

(i) Thirteen or greater for an adult trauma patient (a client age fifteen or older); and

(ii) Nine or greater for a pediatric trauma patient (a client younger than age fifteen).

(d) On a per-client basis in any DOH-designated or DOH-recognized trauma service center.

(e) At a rate of two and one-half times the agency's current fee-for-service rate for qualified trauma services, or other payment enhancement percentage the agency deems appropriate.

(i) The agency monitors the payments from the TCF during each state fiscal year (SFY) and makes necessary adjustments to the rate to ensure that total payments from the TCF for the SFY will not exceed the legislative appropriation for that SFY.

(ii) Laboratory and pathology charges are not eligible for payments from the TCF. (See subsection (6)(b) of this section.)

(5) When a trauma case is transferred from one hospital to another, the agency makes payments from the TCF to physicians and clinicians, according to the ISS score as follows:

(a) If the transferred case meets or exceeds the appropriate ISS threshold described in subsection (4)(c) of this section, providers who furnish qualified trauma services, whether in the transferring or receiving facility, are eligible for payments from the TCF.

(b) If the transferred case is below the ISS threshold described in subsection (4)(c) of this section, only providers who furnish qualified trauma services in the receiving hospital are eligible for payments from the TCF.

(6) The agency makes a TCF payment to a physician or clinician:

(a) Only when the provider submits an eligible trauma claim with the appropriate trauma indicator within the time frames specified by the agency; and

(b) On a per-claim basis. Each qualifying trauma service and/or procedure on the provider's claim is paid at the agency's current fee-for-service rate, multiplied by the appropriate payment enhancement percentage described in subsection (4)(e) of this section. Laboratory and pathology services and/or procedures are not eligible for payments from the TCF and are paid at the agency's current fee-for-service rate.

(7) For purposes of the payments from the TCF to physicians and other clinicians, all of the following apply:

(a) The agency considers a request for a claim adjustment submitted by a provider only if the agency receives the adjustment request within three hundred sixty-five days from the date of the initial trauma service. At its discretion, and with sufficient public notice, the agency may adjust the deadline for submission and/or adjustment of trauma claims in response to budgetary or other program needs;

(b) Except as provided in subsection (7)(a) of this section, the deadline for making adjustments to a trauma claim is the same as the deadline for submitting the initial claim to the agency as specified in WAC 182-502-0150(3). See WAC 182-502-0150 (11) and (12) for other time limits applicable to trauma claims;

(c) All claims and claim adjustments are subject to federal and state audit and review requirements; and

(d) The total payments from the TCF disbursed to providers by the agency in an SFY cannot exceed the amount appropriated by the legislature for that SFY. The agency has the authority to take whatever actions are needed to ensure the agency stays within its TCF appropriation (see subsection (4)(e)(i) of this section).

**History**
- *Statutory Authority: RCW 41.05.021. WSR 12-14-041, § 182-531-2000, filed 6/27/12, effective 7/28/12. WSR 11-14-075, recodified as § 182-531-2000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 70.168.040, 74.08.090, and 74.09.500. WSR 10-12-013, § 388-531-2000, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.500, and chapter 43.20A RCW. WSR 08-18-029, § 388-531-2000, filed 8/27/08, effective 9/27/08. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 05-20-050, § 388-531-2000, filed 9/30/05, effective 10/31/05*
- *WSR 04-19-113, § 388-531-2000, filed 9/21/04, effective 10/22/04.*

##### **Wash. Admin. Code § 182-531-2010** Enhanced reimbursement—Independent advanced registered nurse practitioners (ARNPs). {#sec-182-531-2010 omnilex-key=us-wa-regs-official--title-182--182-531-2010}

(1) Effective for dates of service July 1, 2013, through December 31, 2014, the agency is authorized by the legislature to increase reimbursement rates to medicare levels for independent ARNPs who provide qualified primary care services to eligible medicaid clients.

(2) For the purpose of this section, the following definitions apply:

(a) Independent ARNP – Means a health care practitioner who is not supervised by an eligible primary care physician and not already receiving increased rates for evaluation and management services and vaccine administration services as provided under the Affordable Care Act, section 1202.

(b) Qualified primary care services – Means evaluation and management services and vaccine administration services provided to eligible medicaid clients.

(3) The agency calculates the enhanced rate for independent ARNPs using medicare's payment methodology.

(a) ARNP services are paid at eighty percent of the lesser of the actual charge or eighty-five percent of what a physician is paid under the medicare physician fee schedule.

(b) For the purpose of this enhanced rate calculation, the amount payable to a physician is determined by the Centers for Medicare and Medicaid Services (CMS) as authorized by C.F.R. 447.405 for qualified services in calendar years 2013 and 2014.

(4) If the enhanced rate is less than the agency's published fee schedule rate, the agency's payment will equal the published rate.

(5) This rate increase does not apply to either of the following:

(a) Federally qualified health center services and rural health clinic services reimbursed as part of the encounter rate.

(b) Services provided under state-only funded programs.

(c) Services paid at an enhanced or supplemental rate through a separate provision or regulation.

**History**
- *Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213(26). WSR 14-06-049, § 182-531-2010, filed 2/26/14, effective 3/29/14.*

##### **Wash. Admin. Code § 182-531-2020** Enhanced reimbursement—Long-acting reversible contraception (LARC). {#sec-182-531-2020 omnilex-key=us-wa-regs-official--title-182--182-531-2020}

(1) Effective for dates of service on or after September 1, 2015, the medicaid agency pays enhanced rates for physician procedure codes directly related to insertion or implant of long-acting reversible contraceptives (LARC).

(2) The agency pays the enhanced rate as a set amount above the standard resource based relative value scale (RBRVS) rate calculation described in WAC 182-531-1850.

(3) The agency will pay the enhanced rate to all providers eligible to bill for these services.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-01-039, § 182-531-2020, filed 12/9/15, effective 1/9/16.*

##### **Wash. Admin. Code § 182-531-2030** Enhanced rates for pediatric care services and administration of vaccines. {#sec-182-531-2030 omnilex-key=us-wa-regs-official--title-182--182-531-2030}

(1) Subject to available funds, the medicaid agency pays an enhanced rate for covered pediatric care services and the administration of vaccines provided to clients age 20 and younger.

(2) For the purposes of this section, pediatric care services are defined as covered evaluation and management services.

(3) The agency uses the resource-based relative value scale (RBRVS) payment methodology described in WAC 182-531-1850 to calculate the enhanced rate.

(4) If the enhanced rate is less than the agency's published fee schedule rate, the agency pays the published rate.

(5) This enhanced rate applies only to pediatric care services and administration of vaccines for clients age 20 and younger that are not already paid at an enhanced rate.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-12-083, § 182-531-2030, filed 6/5/24, effective 7/6/24. Statutory Authority: RCW 41.05.021, 41.05.160, and 2018 c 299 § 213 (1)(ddd). WSR 18-17-047, § 182-531-2030, filed 8/8/18, effective 10/1/18.*

##### **Wash. Admin. Code § 182-531-2040** Enhanced reimbursement—Medication for opioid use disorder. {#sec-182-531-2040 omnilex-key=us-wa-regs-official--title-182--182-531-2040}

(1) The medicaid agency pays an enhanced reimbursement using the medicare rate when medication for opioid use disorder (MOUD) is part of the visit for selected evaluation and management (E/M) codes and the provider meets the criteria in this section.

(2) The purpose of this enhanced reimbursement is to increase client access to evidence-based treatment using medications for opioid use disorder.

(3) To receive the enhanced reimbursement for MOUD, a provider must:

(a) Bill using the agency's expedited prior authorization process;

(b) Bill for treating a client with a qualifying primary or secondary diagnosis for opioid use disorder;

(c) Ensure the client was offered, administered, or received a prescription for a federal Food and Drug Administration-approved medication for the treatment of opioid use disorder at the time the service was provided; and

(d) Provide opioid-related counseling during the visit.

(4) The agency payment for MOUD under this section is limited to one enhanced reimbursement, per client, per day.

(5) The agency does not pay an enhanced reimbursement for services a client receives for opioid use disorder through an opioid treatment program facility licensed by the department of health.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-07-078, s 182-531-2040, filed 3/17/25, effective 4/17/25*
- *WSR 23-16-058, § 182-531-2040, filed 7/26/23, effective 8/26/23. Statutory Authority: RCW 41.05.021, 41.05.160, and 2018 c 299. WSR 19-09-052, § 182-531-2040, filed 4/12/19, effective 5/13/19.*

## **Chapter 182-531A** Applied behavior analysis. {#struct-chapter-182-531a}

##### **Wash. Admin. Code § 182-531A-0100** Applied behavior analysis (ABA)—Purpose. {#sec-182-531a-0100 omnilex-key=us-wa-regs-official--title-182--182-531A-0100}

Applied behavior analysis (ABA) assists clients and their families to improve the core symptoms associated with autism spectrum disorders and intellectual or developmental disabilities for which there is evidence ABA is effective, per WAC 182-501-0165. ABA services support learning, skill development, and assistance in any of the following areas or domains: Social, behavior, adaptive, motor, vocational, or cognitive.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and Thurston County Superior Court in J.C. and H.S. v. Washington State Health Care Authority, no. 20-2-01813-34. WSR 22-08-035, § 182-531A-0100, filed 3/29/22, effective 4/29/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 14-24-083, § 182-531A-0100, filed 12/1/14, effective 1/1/15.*

##### **Wash. Admin. Code § 182-531A-0200** Applied behavior analysis (ABA)—Definitions. {#sec-182-531a-0200 omnilex-key=us-wa-regs-official--title-182--182-531A-0200}

The following definitions and those found in chapter 182-500 WAC, medical definitions, and chapter 182-531 WAC, physician-related services, apply throughout this chapter.

Applied behavior analysis or ABA - Applied behavior analysis (ABA) is an empirically validated approach to improve behavior and skills related to core impairments associated with autism and a number of other developmental disabilities. ABA involves the systematic application of scientifically validated principles of human behavior to change inappropriate behaviors. ABA uses scientific methods to reliably demonstrate that behavioral improvements are caused by the prescribed interventions. ABA's focus on social significance promotes a family-centered and whole-life approach to intervention. Common methods used include: Assessment of behavior, caregiver interviews, direct observation, and collection of data on targeted behaviors. A single-case design is used to demonstrate the relationship between the environment and behavior as a means to implement client-specific ABA therapy treatment plans with specific goals and promote lasting change. ABA also includes the implementation of a functional behavior assessment to identify environmental variables that maintain challenging behavior and allow for more effective interventions to be developed that reduce challenging behaviors and teach appropriate replacement behaviors.

Autism spectrum disorder (ASD) - A condition, as defined by Diagnostic and Statistical Manual of Mental Disorders (DSM) or Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC 0-5) criteria.

Autism spectrum disorder (ASD) diagnostic tool - A validated tool used to establish the presence (or absence) of autism and to make a definitive diagnosis which will be the basis for treatment decisions and assist in the development of a multidisciplinary clinical treatment plan. Examples of autism diagnostic tools include:

(a) Autism Diagnosis Interview (ADI); and

(b) Autism Diagnostic Observation Schedule (ADOS).

Autism spectrum disorder (ASD) screening tool - A tool used to detect ASD indicators or risk factors which then require confirmation. Examples of screening tools include, but are not limited to:

(a) Ages and Stages Questionnaire (ASQ);

(b) Communication and Symbolic Behavior Scales (CSBS);

(c) Parent's Evaluation and Developmental Status (PEDS);

(d) Modified Checklist for Autism in Toddlers (MCHAT); and

(e) Screening Tools for Autism in Toddlers and young children (STAT).

Centers of excellence (COE) - An individual provider who has been trained, as listed in WAC 182-531A-0800, to establish or confirm the diagnosis of autism spectrum disorder and that has been designated by the agency as a center of excellence provider. For the purposes of this chapter, center of excellence (COE) refers to an individual provider, not a facility.

Client - For the purposes of this chapter, client means a person enrolled in Washington apple health (WAH).

Family member - A client's parent, guardian, caregiver, or other support person.

Qualifying diagnosis - A diagnosis of an ASD, as defined by the DSM or DC 0-5, or other intellectual or developmental disability for which there is evidence ABA is effective.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-20-128, § 182-531A-0200, filed 10/4/23, effective 11/4/23. Statutory Authority: RCW 41.05.021, 41.05.160, and Thurston County Superior Court in J.C. and H.S. v. Washington State Health Care Authority, no. 20-2-01813-34. WSR 22-08-035, § 182-531A-0200, filed 3/29/22, effective 4/29/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 14-24-083, § 182-531A-0200, filed 12/1/14, effective 1/1/15.*

##### **Wash. Admin. Code § 182-531A-0300** Applied behavior analysis (ABA)—Threshold requirements. {#sec-182-531a-0300 omnilex-key=us-wa-regs-official--title-182--182-531A-0300}

The medicaid agency pays for ABA services when the services are:

(1) Covered;

(2) Medically necessary;

(3) Within the scope of the eligible client's medical care program;

(4) Provided to clients who meet the criteria in WAC 182-531A-0400;

(5) Within currently accepted standards of evidence-based clinical practice;

(6) Not duplicative of ABA services paid for by other state agencies using medicaid funds;

(7) Completed in the stages described in this chapter;

(8) Provided by qualified health care professionals, as described in this chapter;

(9) Authorized, as required within this chapter, chapters 182-501 and 182-502 WAC, and the agency's Applied Behavior Analysis Provider Guide; and

(10) Billed according to this chapter, chapters 182-501 and 182-502 WAC, and the agency's Applied Behavior Analysis Provider Guide.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and Thurston County Superior Court in J.C. and H.S. v. Washington State Health Care Authority, no. 20-2-01813-34. WSR 22-08-035, § 182-531A-0300, filed 3/29/22, effective 4/29/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 14-24-083, § 182-531A-0300, filed 12/1/14, effective 1/1/15.*

##### **Wash. Admin. Code § 182-531A-0400** Applied behavior analysis (ABA)—Client eligibility. {#sec-182-531a-0400 omnilex-key=us-wa-regs-official--title-182--182-531A-0400}

To be eligible for applied behavior analysis (ABA) services, a client must:

(1) Be covered under Washington apple health (WAH);

(2) Provide documentation created by a COE provider that:

(a) Establishes the presence of functional impairment; delay in communication, behavior, or social interaction; or repetitive or stereotyped behavior;

(b) Establishes that the client's impairment, delay, or behaviors adversely affect development or communication, or both, such that:

(i) The client cannot adequately participate in home, school, or community activities because the behavior or skill deficit interferes with these activities; or

(ii) The client's behavior endangers the client or another person, or impedes access to home and community activities; and

(c) An agency-recognized center of excellence (COE) provider has confirmed that:

(i) The client meets all requirements in (a) and (b) of this subsection;

(ii) The client has a qualifying diagnosis;

(A) Autism spectrum disorder; or

(B) Developmental/intellectual disability;

(iii) There is a reasonable expectation the requested services will result in measurable improvement in either the client's behavior, skills, or both; and

(iv) Either:

(A) Less intrusive or less intensive behavioral interventions have been tried and have not been successful; or

(B) No equally effective and substantially less costly alternative is available for reducing interfering behaviors, increasing prosocial skills and behaviors, or maintaining desired behaviors.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-20-128, § 182-531A-0400, filed 10/4/23, effective 11/4/23. Statutory Authority: RCW 41.05.021, 41.05.160, and Thurston County Superior Court in J.C. and H.S. v. Washington State Health Care Authority, no. 20-2-01813-34. WSR 22-08-035, § 182-531A-0400, filed 3/29/22, effective 4/29/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 14-24-083, § 182-531A-0400, filed 12/1/14, effective 1/1/15.*

##### **Wash. Admin. Code § 182-531A-0500** Applied behavior analysis (ABA)—Stage one: COE evaluation and prescription. {#sec-182-531a-0500 omnilex-key=us-wa-regs-official--title-182--182-531A-0500}

(1) Any person may refer a client suspected of meeting the criteria in WAC 182-531A-0400 to a center of excellence (COE) provider for an evaluation.

(2) The individual COE provider must complete a comprehensive diagnostic evaluation and provide:

(a) Documentation showing how the autism spectrum disorder or other intellectual/developmental disability (for which there is evidence ABA is effective) diagnosis was made or confirmed by an approved individual COE provider that includes:

(i) Results of formal diagnostic procedures performed by a provider, including name of measure, dates, and results, as available; or

(ii) Clinical findings and observations used to confirm the diagnosis;

(b) Documentation showing that the client's behaviors or skills deficits adversely affect development or communication, or demonstrating injurious behavior, such that:

(i) The client cannot adequately participate in home, school, or community activities because behavior or skill deficit interferes with these activities; or

(ii) The client presents a safety risk to self or others;

(c) Documentation showing:

(i) Less intrusive or less intensive behavioral interventions have been tried and were not successful; or

(ii) There is no equally effective alternative available for reducing interfering behaviors, increasing prosocial behaviors, or maintaining desired behaviors;

(d) Recommendations that address all of the client's health care needs;

(e) A statement that the evaluating and prescribing provider believes that there is a reasonable expectation that the requested ABA services will result in measurable improvement in the client's behavior or skills; and

(f) A prescription for ABA services. If prescribed, a copy of the COE provider's comprehensive diagnostic evaluation and multidisciplinary clinical treatment plan must be forwarded to the ABA provider selected by the client or the client's guardian under this chapter or provided to the client or the client's guardian to forward to the selected ABA provider.

(3) The COE provider must also include the following items if they possess a copy:

(a) Results of routine developmental screening;

(b) Audiology and vision assessment results, or documentation that vision and hearing were determined to be within normal limits during assessment and not a barrier to completing a valid evaluation;

(c) The name of the completed autism spectrum disorder (ASD) screening tool, including date completed and significant results;

(d) Documentation of a formal cognitive or developmental assessment performed by the COE provider or another qualified provider, including name of measure, dates, results, and standardized scores providing verbal, nonverbal, and full-scale scores; and

(e) Documentation of a formal adaptive behavior assessment performed by the COE provider for developmental/intellectual disability or another qualified provider, including name of measure, dates, results, and standardized scores providing scores of each domain.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-20-128, § 182-531A-0500, filed 10/4/23, effective 11/4/23. Statutory Authority: RCW 41.05.021, 41.05.160, and Thurston County Superior Court in J.C. and H.S. v. Washington State Health Care Authority, no. 20-2-01813-34. WSR 22-08-035, § 182-531A-0500, filed 3/29/22, effective 4/29/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 14-24-083, § 182-531A-0500, filed 12/1/14, effective 1/1/15.*

##### **Wash. Admin. Code § 182-531A-0600** Applied behavior analysis (ABA)—Stage two: Functional assessment and treatment plan development. {#sec-182-531a-0600 omnilex-key=us-wa-regs-official--title-182--182-531A-0600}

(1) If the center of excellence (COE) provider has prescribed applied behavior analysis (ABA) services, the client may begin stage two - ABA assessment, functional analysis, and ABA therapy treatment plan development.

(2) Prior authorization must be obtained from the agency prior to implementing the ABA therapy treatment plan. The prior authorization request must be received no more than 60 days from the date of the assessment and ABA therapy treatment plan. See WAC 182-501-0165 for agency authorization requirements.

(3) The client or the client's legal guardian selects the ABA provider and the setting in which services will be rendered. ABA services may be rendered in one of the following settings:

(a) Day services program, which mean an agency-approved, outpatient facility or clinic-based program that:

(i) Employs or contracts with a lead behavior analysis therapist (LBAT), therapy assistant, speech therapist, and if clinically indicated, an occupational therapist, physical therapist, psychologist, medical provider, and dietitian;

(ii) Provides multidisciplinary services in a short-term day treatment program setting;

(iii) Delivers comprehensive intensive services;

(iv) Embeds early, intensive behavioral interventions in a developmentally appropriate context;

(v) Provides an individualized developmentally appropriate ABA therapy treatment plan for each client; and

(vi) Includes family support and training.

(b) Community-based program, which means a program that provides services in a natural setting, such as a school, home, workplace, office, or clinic. A community-based program:

(i) May be used after discharge from a day services program (see subsection (3)(a) of this section);

(ii) Provides a developmentally appropriate ABA therapy treatment plan for each client;

(iii) Provides ABA services in the home (wherever the client resides), office, clinic, or community setting, as required to accomplish the goals in the ABA therapy treatment plan. Examples of community settings are: A park, restaurant, child care, early childhood education, school, or place of employment and must be included in the ABA therapy treatment plan with services being provided by the enrolled LBAT or therapy assistant approved to provide services via authorization;

(iv) Requires recertification of medical necessity through continued authorization; and

(v) Includes family or caregiver education, support, and training.

(4) An assessment, as described in this chapter, must be conducted and an ABA therapy treatment plan developed by an LBAT in the setting chosen by the client or the client's legal guardian. The ABA therapy treatment plan must follow the agency's ABA therapy treatment plan report template and:

(a) Be signed by the LBAT responsible for the plan development and oversight;

(b) Be applicable to the services to be rendered over the next six months, based on the LBAT's judgment, and correlate with the COE provider's current diagnostic evaluation (see WAC 182-531A-0500(2));

(c) Address each behavior, skill deficit, and symptom that prevents the client from adequately participating in home, school, employment, community activities, or that presents a safety risk to the client or others;

(d) Be individualized;

(e) Be client-centered, family-focused, community-based, culturally competent, and minimally intrusive;

(f) Take into account all school or other community resources available to the client, confirm that the requested services are not redundant or in conflict with, but are in coordination with, other services already being provided or otherwise available, and coordinate services (e.g., from school and special education, from early intervention programs and early intervention providers or from developmental disabilities community services) with other interventions and treatments (e.g., speech therapy, occupational therapy, physical therapy, family counseling, and medication management);

(g) Focus on family engagement and training;

(h) Identify and describe in detail the targeted behaviors and symptoms;

(i) Include objective, baseline measurement levels for each target behavior/symptom in terms of frequency, intensity, and duration, including use of curriculum-based measures, single-case studies, or other generally accepted assessment tools;

(j) Include a comprehensive description of treatment interventions, or type of treatment interventions, and techniques specific to each of the targeted behaviors/symptoms, (e.g., discrete trial training, reinforcement, picture exchange, communication systems) including documentation of the number of service hours, in terms of frequency and duration, for each intervention;

(k) Establish treatment goals and objective measures of progress for each intervention specified to be accomplished in the authorized treatment period;

(l) Incorporate strategies for promoting the learning of skills that improve targeted behaviors within settings as listed in this chapter;

(m) Integrate family education, goals, training, support services, and modeling and coaching family/client interaction;

(n) Incorporate strategies for coordinating treatment with school-based education and vocational programs, behavioral health treatment, habilitative supports, and community-based early intervention programs, and plan for transition through a continuum of treatments, services, and settings; and

(o) Include measurable discharge criteria and a discharge plan.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-531A-0600, filed 11/4/25, effective 12/5/25*
- *WSR 23-20-128, § 182-531A-0600, filed 10/4/23, effective 11/4/23. Statutory Authority: RCW 41.05.021, 41.05.160, and Thurston County Superior Court in J.C. and H.S. v. Washington State Health Care Authority, no. 20-2-01813-34. WSR 22-08-035, § 182-531A-0600, filed 3/29/22, effective 4/29/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 14-24-083, § 182-531A-0600, filed 12/1/14, effective 1/1/15.*

##### **Wash. Admin. Code § 182-531A-0700** Applied behavior analysis (ABA)—Stage three: Delivery of ABA services. {#sec-182-531a-0700 omnilex-key=us-wa-regs-official--title-182--182-531A-0700}

(1) A provider must obtain prior authorization before delivery of applied behavior analysis (ABA) services. To request prior authorization, a provider must submit the following documents to the medicaid agency or follow the managed care organization (MCO) process:

(a) The comprehensive diagnostic evaluation and multidisciplinary clinical treatment plan completed by the center of excellence (COE) described in this chapter;

(b) The ABA assessment and ABA therapy treatment plan described in this chapter; and

(c) Any documents required by the agency's ABA provider guide.

(2) After the services are prior authorized, the lead behavior analysis therapist (LBAT) or a certified behavior technician implements the ABA therapy treatment plan in conjunction with other care team members. The LBAT is responsible for ongoing communication and collaboration with other care team members to ensure consistent approaches to achieving treatment goals.

(3) If services are rendered by a certified behavior technician, they must:

(a) Assess the client's response to techniques and report that response to the LBAT;

(b) Provide direct on-site services in the client's natural setting (e.g., in the home, office, place of employment, education setting, clinic, or community), or in the day services program;

(c) Be supervised directly by an LBAT for at least five percent of total direct care per week;

(d) Consult the LBAT if:

(i) Considering modifying a technique;

(ii) A barrier or challenge prevents implementation of the treatment plan; and

(iii) Clinically indicated.

(e) Ensure family involvement through modeling, coaching, and training to support generalization and maintenance of achieved behaviors;

(f) Document each visit with the client or family and include:

(i) Targeted behavior, interventions, response, modifications in techniques;

(ii) A plan for the next visit; and

(iii) Behavior tracking sheets that record and graph data collected for each visit.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and Thurston County Superior Court in J.C. and H.S. v. Washington State Health Care Authority, no. 20-2-01813-34. WSR 22-08-035, § 182-531A-0700, filed 3/29/22, effective 4/29/22. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 15-19-121, § 182-531A-0700, filed 9/21/15, effective 10/22/15*
- *WSR 14-24-083, § 182-531A-0700, filed 12/1/14, effective 1/1/15.*

##### **Wash. Admin. Code § 182-531A-0800** Applied behavior analysis (ABA)—Provider requirements. {#sec-182-531a-0800 omnilex-key=us-wa-regs-official--title-182--182-531A-0800}

Center of excellence.

(1) For the purposes of this chapter, center of excellence (COE) refers to an individual provider, not a facility.

(2) A center of excellence (COE) must be an evaluating and prescribing provider.

(3) The COE provider must be:

(a) A person licensed under Title 18 RCW who is experienced in the diagnosis and treatment of autism spectrum disorders and is:

(i) A developmental pediatrician;

(ii) A neurologist;

(iii) A pediatric neurologist;

(iv) A pediatric psychiatrist;

(v) A psychiatrist; or

(vi) A psychologist; or

(b) A qualified medical provider who meets qualifications in subsection (4) of this section and who has been designated by the agency as a COE provider.

(4) With the exception of providers listed in subsection (3)(a) of this section, advanced registered nurse practitioners (ARNPs) including psychiatric mental health nurse practitioners, physicians, physician assistants, and naturopaths must complete the required COE training, for all ages, authorized by the agency. The COE provider must be prequalified by the agency and meet the following criteria:

(a) ARNPs including psychiatric mental health nurse practitioners, physicians, physician assistants, and naturopaths must have demonstrated expertise in diagnosing an autism spectrum disorder by:

(i) Using a validated diagnostic tool;

(ii) Confirming the diagnosis by observing the client's behavior and interviewing family members; or

(iii) Reviewing the documentation available from the client's primary care provider, individualized education plan, or individualized family service plan;

(b) ARNPs including psychiatric mental health nurse practitioners, physicians, physician assistants, and naturopaths must understand the medically necessary use of applied behavior analysis (ABA); and

(c) ARNPs including psychiatric mental health nurse practitioners, physicians, physician assistants, and naturopaths must be sufficiently qualified to conduct and document a comprehensive diagnostic evaluation and develop a multidisciplinary clinical treatment plan under WAC 182-531A-0500(2).

(5) To be recognized as a COE by the agency, the provider, as listed in subsection (4)(a) of this section, must submit a signed COE Attestation form, HCA 13-0009, to the agency.

(6) Providers listed in subsection (4)(a) of this section may require additional COE training for diagnosing and prescribing ABA for adults age 21 and over.

(7) To be reimbursed for fee-for-service or agency-contracted managed care organization (MCO) services:

(a) All COE providers must be enrolled with the agency.

(b) All COEs providing services to clients enrolled with an agency-contracted MCO must also be contracted with the MCO, per the MCO contract specifications in accordance with 42 C.F.R. § 438.14.

(8) All ABA providers must meet the specified minimum qualifications and comply with applicable state laws.

Lead behavior analysis therapist.

(9) The lead behavior analysis therapist (LBAT) must:

(a) Be licensed by the department of health (DOH) to practice independently as a behavior analyst or an assistant behavior analyst with supervision from a licensed behavior analyst or licensed psychologist (see chapter 18.380 RCW) and be an eligible provider according to chapter 182-502 WAC; or

(b) Be a DOH-licensed mental health counselor, DOH-licensed marriage and family therapist, DOH-licensed independent clinical social worker, DOH-licensed advanced social worker, or DOH-licensed psychologist (see chapter 18.380 RCW). Providers listed in this subsection must have a signed Applied Behavior Analysis (ABA) Attestation form, HCA 13-0008, regarding certification as a board-certified behavior analyst (BCBA) or a board-certified assistant behavior analyst (BCaBA) on file with the agency.

(10) The LBAT must enroll as a servicing provider under chapter 182-502 WAC, be authorized to supervise ancillary providers, and be:

(a) A DOH-licensed behavior analyst (LBA) (see chapter 18.380 RCW); or

(b) A DOH-licensed assistant behavior analyst (LABA) (see chapter 18.380 RCW).

(11) If the LBAT's role is filled by a LABA, the responsibilities below must be fulfilled by both the LABA and the supervising LBA or licensed psychologist, as required by DOH under chapter 246-805 WAC. The LBAT must:

(a) Develop and maintain an ABA therapy treatment plan that is comprehensive, incorporating treatment provided by other health care professionals, and that states how all treatment will be coordinated; and

(b) Supervise at least five percent of the total direct care provided by the certified behavior technician per week.

Certified behavior technician.

(12) The certified behavior technician (CBT) must

be certified by DOH as a CBT under chapter 18.380 RCW in good standing with no license restrictions.

(13) The CBT must enroll as a servicing provider under chapter 182-502 WAC.

(14) The CBT must:

(a) Deliver services according to the ABA therapy treatment plan;

(b) Be supervised by a DOH-licensed professional who meets the requirements under WAC 246-805-330; and

(c) Review the client's progress with the supervisor at least every two weeks to confirm that the ABA therapy treatment plan still meets the client's needs. If changes are clinically indicated, they must be made by the supervisor.

Facility-based day program.

(15) All facility-based day program providers must meet the requirements under WAC 182-531A-0600 (3)(a), and meet the following requirements:

(a) Outpatient hospital facilities must meet the applicable DOH licensure requirements under chapter 246-320 WAC;

(b) Any provider rendering direct ABA services in the facility-based day program must meet the qualifications and applicable licensure or certification requirements as described in this subsection, as applicable;

(c) Any provider serving as a member of the multidisciplinary care team must be licensed or certified under Title 18 RCW; and

(d) Have a signed ABA Day Program Capacity Attestation form, HCA 13-0007, on file with the agency.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-10-011, s 182-531A-0800, filed 4/25/25, effective 5/26/25*
- *WSR 23-20-128, § 182-531A-0800, filed 10/4/23, effective 11/4/23. Statutory Authority: RCW 41.05.021, 41.05.160, and Thurston County Superior Court in J.C. and H.S. v. Washington State Health Care Authority, no. 20-2-01813-34. WSR 22-08-035, § 182-531A-0800, filed 3/29/22, effective 4/29/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-16-071, § 182-531A-0800, filed 7/30/18, effective 8/30/18. Statutory Authority: RCW 41.05.021, 41.05.160, and 2015 c 118. WSR 18-09-036, § 182-531A-0800, filed 4/12/18, effective 5/13/18. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 15-19-121, § 182-531A-0800, filed 9/21/15, effective 10/22/15*
- *WSR 14-24-083, § 182-531A-0800, filed 12/1/14, effective 1/1/15.*

##### **Wash. Admin. Code § 182-531A-0900** Applied behavior analysis (ABA)—Covered services. {#sec-182-531a-0900 omnilex-key=us-wa-regs-official--title-182--182-531A-0900}

(1) The medicaid agency covers only the following applied behavior analysis (ABA) services, delivered in settings described in WAC 182-531A-0600, for eligible clients:

(a) The ABA assessments that determine the relationship between environmental events and the client's behaviors;

(b) The direct provision of ABA services by the therapy assistant (TA) or lead behavior analysis therapist (LBAT);

(c) Initial ABA assessment and development of a written, initial ABA therapy treatment plan, limited to one per year;

(d) Up to four additional ABA assessments and revisions of the initial ABA therapy treatment plan per year, if necessary to meet client's needs;

(e) One lifetime authorization of day treatment services. If a provider's request for covered services exceeds limitations in this section, the agency evaluates the request under WAC 182-501-0169.

(f) Supervision of the TA;

(g) Training and evaluation of family members or caregivers to carry out the approved ABA therapy treatment plans;

(h) Observation of the client's behavior to determine the effectiveness of the approved ABA therapy treatment plan; and

(i) On-site assistance in the event of a crisis.

(2) The agency covers the following services, which may be provided in conjunction with ABA services under other agency programs:

(a) Counseling;

(b) Dietician services;

(c) Interpreter services;

(d) Occupational therapy;

(e) Physical therapy;

(f) Speech and language therapy; and

(g) Transportation services.

(3) The agency does not pay for ABA services:

(a) That duplicate services provided in another setting; or

(b) That are provided by a family member.

(4) If a provider's request for covered services exceeds limitations in this section, the agency evaluates the request under WAC 182-501-0169.

(5) For clients age 20 and younger, see the early periodic screening, diagnosis, and treatment (EPSDT) program described in chapter 182-534 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-07-031, s 182-531A-0900, filed 3/11/26, effective 4/11/26*
- *WSR 24-11-043, § 182-531A-0900, filed 5/9/24, effective 6/9/24. Statutory Authority: RCW 41.05.021, 41.05.160, and Thurston County Superior Court in J.C. and H.S. v. Washington State Health Care Authority, no. 20-2-01813-34. WSR 22-08-035, § 182-531A-0900, filed 3/29/22, effective 4/29/22. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 15-19-121, § 182-531A-0900, filed 9/21/15, effective 10/22/15*
- *WSR 14-24-083, § 182-531A-0900, filed 12/1/14, effective 1/1/15.*

##### **Wash. Admin. Code § 182-531A-1000** Applied behavior analysis (ABA)—Noncovered services. {#sec-182-531a-1000 omnilex-key=us-wa-regs-official--title-182--182-531A-1000}

The medicaid agency does not cover certain services under the applied behavior analysis (ABA) program include, but are not limited to:

(1) Autism camps;

(2) Dolphin therapy;

(3) Equine therapy or hippo therapy;

(4) Primarily educational services;

(5) Recreational therapy;

(6) Respite care;

(7) Safety monitoring services;

(8) School-based health care services or early intervention program-based services under WAC 182-531A-0600 (3)(b)(iii), unless prior authorized;

(9) Vocational rehabilitation;

(10) Life coaching; and

(11) Treatment that is unproven or investigational (for example, holding therapy, Higashi (day life therapy), auditory integration therapy).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-19-121, § 182-531A-1000, filed 9/21/15, effective 10/22/15*
- *WSR 14-24-083, § 182-531A-1000, filed 12/1/14, effective 1/1/15.*

##### **Wash. Admin. Code § 182-531A-1100** Applied behavior analysis (ABA)—Prior authorization and recertification of ABA services. {#sec-182-531a-1100 omnilex-key=us-wa-regs-official--title-182--182-531A-1100}

(1) The medicaid agency requires prior authorization (PA) and recertification of the medical necessity of applied behavior analysis (ABA) services.

(2) Requirements for PA requests are described in WAC 182-531A-0700.

(3) The agency may reduce or deny services requested based on medical necessity (refer to subsection (5) of this section) when completing PA or recertification responsibilities.

(4) The following are requirements for recertification of ABA services:

(a) Continued ABA services require the agency's authorization. Authorization is granted in three-month increments, or longer at the agency's discretion;

(b) The lead behavior analysis therapist (LBAT) must request authorization for continuing services 15 calendar days prior to the expiration date of the current authorization. A reevaluation and revised ABA therapy treatment plan documenting the client's progress and showing measurable changes in the frequency, intensity, and duration of the targeted behavior/symptoms addressed in the previously authorized ABA therapy treatment plan must be submitted with this request. Documentation must include:

(i) Projection of eventual outcome;

(ii) Assessment instruments;

(iii) Developmental markers of readiness; and

(iv) Evidence of coordination with providers.

(c) When completing recertification responsibilities, the agency may request another evaluation from the COE to obtain that provider's review and recommendation. This COE provider must review the ABA therapy treatment plan, conduct a face-to-face visit with the client, facilitate a multidisciplinary record review of the client's progress, hold a family/caregiver conference, or request a second opinion before recommending continued ABA services. Services will continue pending recertification.

(d) When completing recertification responsibilities, the agency may retroactively authorize dates of service. Services will continue pending recertification.

(5) Basis for denial or reduction of services includes, but is not limited to, the following:

(a) Lack of medical necessity, for example:

(i) Failure to respond to ABA services, even after trying different ABA techniques and approaches, if applicable;

(ii) Absence of harmful behaviors (e.g., physical aggression to self or others or property destruction), if applicable; or

(iii) Absence of meaningful, measurable, functional improvement changes or progress has plateaued without documentation of significant interfering events (e.g., serious physical illness, major family/caregiver disruption, change of residence), if applicable. For changes to be meaningful they must be:

(A) Confirmed through data;

(B) Documented in charts and graphs;

(C) Durable over time beyond the end of the actual treatment session; and

(D) Generalizable outside of the treatment setting to the client's residence and the larger community within which the client resides; or

(b) A demonstrated lack of engagement as evidenced by the family/caregiver to:

(i) Keep appointments;

(ii) Attend treatment sessions;

(iii) Attend scheduled family training sessions;

(iv) Complete homework assignments; and

(v) Apply training as directed by the therapy assistant or LBAT. Absences that are reasonably justified (e.g., illness) are not considered a pattern.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and Thurston County Superior Court in J.C. and H.S. v. Washington State Health Care Authority, no. 20-2-01813-34. WSR 22-08-035, § 182-531A-1100, filed 3/29/22, effective 4/29/22. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 14-24-083, § 182-531A-1100, filed 12/1/14, effective 1/1/15.*

##### **Wash. Admin. Code § 182-531A-1200** Applied behavior analysis (ABA)—Services provided via telemedicine. {#sec-182-531a-1200 omnilex-key=us-wa-regs-official--title-182--182-531A-1200}

Applied behavior analysis (ABA) services delivered using telemedicine may be reimbursed by the agency when billed in accordance with the rules regarding telemedicine and store-and-forward technology in WAC 182-501-0300 and the agency's published billing instructions.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2021 c 157. WSR 23-04-052, § 182-531A-1200, filed 1/27/23, effective 2/27/23. Statutory Authority: RCW 41.05.021, 41.05.160, and Thurston County Superior Court in J.C. and H.S. v. Washington State Health Care Authority, no. 20-2-01813-34. WSR 22-08-035, § 182-531A-1200, filed 3/29/22, effective 4/29/22. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 15-19-121, § 182-531A-1200, filed 9/21/15, effective 10/22/15*
- *WSR 14-24-083, § 182-531A-1200, filed 12/1/14, effective 1/1/15.*

## **Chapter 182-532** Reproductive health/family planning only programs. {#struct-chapter-182-532}

##### **Wash. Admin. Code § 182-532-001** Reproductive health services—Definitions. {#sec-182-532-001 omnilex-key=us-wa-regs-official--title-182--182-532-001}

The following definitions and those found in chapter 182-500 WAC apply to this chapter.

340B dispensing fee - The medicaid agency's established fee paid to a registered and medicaid-participating 340B drug program provider under the public health service (PHS) act for expenses involved in acquiring, storing and dispensing prescription drugs or drug-containing devices (see WAC 182-530-7900). A dispensing fee is not paid for nondrug items, devices, or supplies (see WAC 182-530-7050).

"Complication" - A condition occurring subsequent to and directly arising from the family planning services received under the rules of this chapter.

"Comprehensive preventive family planning visit" - For the purposes of this program, a comprehensive, preventive, contraceptive visit that includes evaluation and management of an individual, such as: Age appropriate history, examination, counseling/anticipatory guidance, risk factor reduction interventions, and laboratory and diagnostic procedures that are covered under the client's respective agency program.

"Contraception"- Prevention of pregnancy through the use of contraceptive methods.

"Contraceptive" - Food and Drug Administration (FDA)-approved prescription and nonprescription methods, including devices, drugs, products, methods, or surgical interventions used to prevent pregnancy, as described in WAC 182-530-2000.

"Family planning only program" - The program that covers family planning only services for eligible clients for 12 months from the date the agency determines eligibility. This program was formerly referred to as TAKE CHARGE.

"Family planning-related services and supplies"- Services provided as part of, or as follow-up to, a family planning visit.

"Family planning services" - Medically safe and effective medical care, educational services, and contraceptives that enable individuals to plan and space the number of their children and avoid unintended pregnancies.

"Natural family planning" (also known as fertility awareness method)- Methods to identify the fertile days of the menstrual cycle and avoid unintended pregnancies, such as observing, recording, and interpreting the natural signs and symptoms associated with the menstrual cycle.

"Over-the-counter (OTC)" - Drugs, devices, and products that do not require a prescription to be sold or dispensed. (See WAC 182-530-1050)

"Reproductive health" - The prevention and treatment of illness, disease, and disability related to the function of reproductive systems during all stages of life and includes:

(a) Related, appropriate, and medically necessary care;

(b) Education of clients in medically safe and effective methods of family planning; and

(c) Pregnancy and reproductive health care.

"Reproductive health care services" - Any medical services or treatments, including pharmaceutical and preventive care service or treatments, directly involved in the reproductive system and its processes, functions, and organs involved in reproduction, in all stages of life. Reproductive health care services does not include infertility treatment.

"Reproductive system" - Includes, but is not limited to: Genitals, gonads, the uterus, ovaries, fallopian tubes, and breasts.

"Sexually transmitted infection (STI)" - A disease or infection acquired as a result of sexual contact.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-23-034, s 182-532-001, filed 11/13/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 74.09.830. WSR 25-06-057, s 182-532-001, filed 2/28/25, effective 3/31/25. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-001, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-001, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-001, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-001, filed 11/30/05, effective 12/31/05*
- *WSR 04-05-011, § 388-532-001, filed 2/6/04, effective 3/8/04.*

##### **Wash. Admin. Code § 182-532-050** Reproductive health services—General. {#sec-182-532-050 omnilex-key=us-wa-regs-official--title-182--182-532-050}

WAC 182-532-050 through 182-532-130 describe reproductive health services and related services covered by the medicaid agency. For maternity-related services, see chapter 182-533 WAC. For other related services, see chapter 182-531 WAC.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-050, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-050, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-050, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-050, filed 11/30/05, effective 12/31/05*
- *WSR 04-05-011, § 388-532-050, filed 2/6/04, effective 3/8/04. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800, and SSB 5968, 1999 c 392 § 2(12). WSR 02-21-021, § 388-532-050, filed 10/8/02, effective 11/8/02. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800. WSR 00-14-066, § 388-532-050, filed 7/5/00, effective 8/5/00.*

##### **Wash. Admin. Code § 182-532-100** Reproductive health services—Eligibility. {#sec-182-532-100 omnilex-key=us-wa-regs-official--title-182--182-532-100}

(1) The medicaid agency covers reproductive health services, as described under WAC 182-532-120, for clients covered by one of the Washington apple health programs as listed in the table in WAC 182-501-0060.

(2) A client enrolled in an agency-contracted managed care organization (MCO) may self-refer outside their MCO for reproductive health care services including, but not limited to, family planning, abortion, and sexually transmitted infection (STI) services from any agency-approved provider.

(3) A client who is age twenty-one or older may not self-refer outside their MCO for sterilizations.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-100, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-100, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-100, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-100, filed 11/30/05, effective 12/31/05*
- *WSR 04-05-011, § 388-532-100, filed 2/6/04, effective 3/8/04. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800, and SSB 5968, 1999 c 392 § 2(12). WSR 02-21-021, § 388-532-100, filed 10/8/02, effective 11/8/02. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800. WSR 00-14-066, § 388-532-100, filed 7/5/00, effective 8/5/00.*

##### **Wash. Admin. Code § 182-532-110** Reproductive health services—Provider requirements. {#sec-182-532-110 omnilex-key=us-wa-regs-official--title-182--182-532-110}

To receive payment for reproductive health services, a provider must:

(1) Meet the requirements under this chapter and chapters 182-501 and 182-502 WAC;

(2) Provide only those services that are within the scope of their licenses;

(3) Bill the agency according to the agency's published billing guides;

(4) Educate clients on Food and Drug Administration (FDA)-approved contraceptive methods and over-the-counter (OTC) contraceptive drugs, devices, and products, as well as related medical services;

(5) Provide medical services related to FDA-approved contraceptive methods and OTC contraceptive drugs, devices, and products upon request; and

(6) Supply or prescribe FDA-approved contraceptive methods and OTC contraceptive drugs, devices, and products upon request.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-110, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-110, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-110, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-110, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-110, filed 11/30/05, effective 12/31/05*
- *WSR 04-05-011, § 388-532-110, filed 2/6/04, effective 3/8/04.*

##### **Wash. Admin. Code § 182-532-120** Reproductive health services—Covered services. {#sec-182-532-120 omnilex-key=us-wa-regs-official--title-182--182-532-120}

In addition to the services listed in WAC 182-531-0100, the medicaid agency covers all of the following reproductive health services:

(1) For a client capable of reproducing, one comprehensive preventive family planning visit once every twelve months, based on nationally recognized clinical guidelines, including:

(a) Sexually transmitted infection (STI) and cancer screenings; and

(b) Comprehensive and client-centered counseling, education, risk reduction, and initiation or management of contraceptive methods.

(2) Contraception, including:

(a) Food and Drug Administration (FDA)-approved contraceptive methods, as described under WAC 182-530-2000;

(b) Education and supplies for FDA-approved contraceptives, natural family planning, and abstinence; and

(c) Sterilization procedures, as described under WAC 182-531-1550.

(3) Cervical, breast, and prostate cancer screenings, according to nationally recognized clinical guidelines;

(4) STI screening, testing, and treatment, according to nationally recognized clinical guidelines;

(5) Human papillomavirus (HPV) immunization, administered according to the recommended schedule published by the Centers for Disease Control and Prevention (CDC);

(6) Diagnostic services, follow-up visits, imaging, and laboratory services related to the services listed under WAC 182-532-120; and

(7) Pregnancy-related services including:

(a) Maternity-related services, as described under chapter 182-533 WAC; and

(b) Abortion.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-120, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-120, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-120, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-120, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-120, filed 11/30/05, effective 12/31/05*
- *WSR 04-05-011, § 388-532-120, filed 2/6/04, effective 3/8/04.*

##### **Wash. Admin. Code § 182-532-130** Reproductive health services—Noncovered services. {#sec-182-532-130 omnilex-key=us-wa-regs-official--title-182--182-532-130}

Noncovered reproductive health services are described in WAC 182-501-0070 and 182-531-0150.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-130, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-130, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-130, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-130, filed 11/30/05, effective 12/31/05*
- *WSR 04-05-011, § 388-532-130, filed 2/6/04, effective 3/8/04.*

##### **Wash. Admin. Code § 182-532-140** Reproductive health services—Reimbursement and payment limitations. {#sec-182-532-140 omnilex-key=us-wa-regs-official--title-182--182-532-140}

(1) The medicaid agency reimburses providers for covered reproductive health services using the medicaid agency's published fee schedules.

(2) Family planning pharmacy services, family planning lab services, and sterilization services are reimbursed by the medicaid agency under the rules and fee schedules applicable to these specific programs.

(3) The medicaid agency pays a dispensing fee only for contraceptive drugs that are purchased through the 340B program of the Public Health Service Act. (See chapter 182-530 WAC.)

(4) Family planning providers under contract with the agency's managed care plans must directly bill the plans for family planning or STI services received by clients enrolled in the plan.

(5) Family planning providers not under contract with the agency's managed care plans must bill using fee for service when providing services to managed care clients who self-refer outside their plans.

(6) Family planning providers or agency-contracted local health department STI clinics under contract with the agency's managed care plans must abide by their contract regarding lab services needed by clients from that plan.

(7) Family planning providers or agency-contracted local health department STI clinics not under contract with the agency's managed care plans must pay a lab directly for services provided to clients who self-refer outside of their managed care plan. Providers then must bill the medicaid agency for reimbursement for lab services.

(a) Labs must be certified through the Clinical Laboratory Improvements Act (CLIA).

(b) Documentation of current CLIA certification must be kept on file.

(8) Under WAC 182-501-0200, the medicaid agency requires a provider to seek timely reimbursement from a third party when a client has available third-party resources. The exceptions to this requirement are described under WAC 182-501-0200 (2) and (3).

**History**
- *Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-140, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-140, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-140, filed 11/30/05, effective 12/31/05*
- *WSR 04-05-011, § 388-532-140, filed 2/6/04, effective 3/8/04.*

##### **Wash. Admin. Code § 182-532-500** Family planning only programs—Purpose. {#sec-182-532-500 omnilex-key=us-wa-regs-official--title-182--182-532-500}

The purpose of family planning only programs is to provide family planning services to all clients capable of reproducing, regardless of gender, to:

(1) Improve access to family planning and family planning-related services; and

(2) Reduce unintended pregnancies.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-23-034, s 182-532-500, filed 11/13/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-500, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-500, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-500, filed 11/30/05, effective 12/31/05*
- *WSR 04-05-011, § 388-532-500, filed 2/6/04, effective 3/8/04.*

##### **Wash. Admin. Code § 182-532-510** Family planning only program—Eligibility. {#sec-182-532-510 omnilex-key=us-wa-regs-official--title-182--182-532-510}

For the purposes of this section, "full-scope coverage" means coverage under either the categorically needy (CN) program, the broadest, most comprehensive scope of health care services covered or the alternative benefits plan (ABP), the same scope of care as CN, applicable to the apple health for adults program.

(1) To be eligible for family planning only services, as defined in WAC 182-532-001, a client must:

(a) Provide a valid Social Security number (SSN) or proof of application to receive an SSN, be exempt from the requirement to provide an SSN as provided in WAC 182-503-0515, or meet good cause criteria listed in WAC 182-503-0515(2);

(b) Be a Washington state resident, as described under WAC 182-503-0520;

(c) Have an income at or below 260 percent of the federal poverty level, as described under WAC 182-505-0100;

(d) Need family planning services; and

(e) Have been denied apple health coverage within the last 30 days, unless the applicant:

(i) Has made an informed choice to not apply for full-scope coverage as described in WAC 182-500-0035 and 182-501-0060, including family planning;

(ii) Is age 26 or younger and seeking services in confidence;

(iii) Is a domestic violence victim who is seeking services in confidence; or

(iv) Has an income of 150 percent to 260 percent of the federal poverty level, as described in WAC 182-505-0100.

(2) A client is not eligible for family planning only medical if the client is:

(a) Pregnant;

(b) Sterilized;

(c) Covered under another apple health program that includes family planning services; or

(d) Covered by concurrent creditable coverage, as defined in RCW 48.66.020, unless they meet criteria in subsection (1)(e)(ii) or (iii) of this section.

(3) The agency does not limit the number of times a client may reapply for coverage.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-19-027, s 182-532-510, filed 9/5/25, effective 10/6/25. Statutory Authority: RCW 41.05.021, 41.05.160, and 74.09.830. WSR 25-06-057, s 182-532-510, filed 2/28/25, effective 3/31/25. Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 415 § 211(47). WSR 20-21-024, § 182-532-510, filed 10/9/20, effective 11/9/20. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-510, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-510, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-510, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-510, filed 11/30/05, effective 12/31/05*
- *WSR 04-05-011, § 388-532-510, filed 2/6/04, effective 3/8/04.*

##### **Wash. Admin. Code § 182-532-520** Family planning only programs—Provider requirements. {#sec-182-532-520 omnilex-key=us-wa-regs-official--title-182--182-532-520}

To be paid by the medicaid agency for services provided to clients eligible for family planning only programs, providers must:

(1) Comply with the requirements under this chapter and chapters 182-501 and 182-502 WAC;

(2) Provide only those services that are within the scope of their licenses;

(3) Bill the agency according to the agency's published billing guides;

(4) Educate clients on Food and Drug Administration (FDA)-approved contraceptive methods and over-the-counter (OTC) contraceptive drugs, devices, and products, as well as related medical services;

(5) Provide medical services related to FDA-approved contraceptive methods and OTC contraceptive drugs, devices, and products as medically necessary;

(6) Supply or prescribe FDA-approved contraceptive methods and OTC contraceptive drugs, devices, and products as medically appropriate and in compliance with WAC 182-530-2000 (1)(b); and

(7) Refer the client to available and affordable nonfamily planning primary care services, as needed.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-23-034, s 182-532-520, filed 11/13/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-520, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-520, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-520, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-520, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-520, filed 11/30/05, effective 12/31/05*
- *WSR 04-05-011, § 388-532-520, filed 2/6/04, effective 3/8/04.*

##### **Wash. Admin. Code § 182-532-530** Family planning only programs—Covered services. {#sec-182-532-530 omnilex-key=us-wa-regs-official--title-182--182-532-530}

The medicaid agency covers all of the following services:

(1) One comprehensive preventive family planning visit once every 12 months, based on nationally recognized clinical guidelines. This visit must have a primary focus and diagnosis of family planning and include counseling, education, risk reduction, and initiation or management of contraceptive methods;

(2) Assessment and management of family planning or contraceptive problems, when clinically appropriate. For purposes of this section, "clinically appropriate" means the type, frequency, extent, site, and duration of medical services must reasonably correlate to the client's needs;

(3) Family planning-related services and supplies;

(4) Contraception, including:

(a) Food and Drug Administration (FDA)-approved contraceptive methods, as described under WAC 182-530-2000 (1)(b);

(b) Education and supplies for Federal Drug Administration (FDA)-approved contraceptive, natural family planning, and abstinence; and

(c) Sterilization procedures, as described under WAC 182-531-1550;

(5) The following services, when clinically appropriate or according to nationally recognized guidelines:

(a) Pregnancy testing;

(b) Cervical cancer screening;

(c) Gonorrhea and chlamydia screening and treatment;

(d) Syphilis screening and treatment;

(e) Sexually transmitted infection (STI) screening, testing, and treatment, when medically indicated by symptoms or report of exposure, and medically necessary for the client's safe and effective use of their chosen contraceptive method;

(f) HIV testing, including rapid tests; and

(g) Viral hepatitis B and C testing;

(6) Hepatitis B and hepatitis A/B combination vaccines; and

(7) Human papillomavirus (HPV) vaccines.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-23-034, s 182-532-530, filed 11/13/25, effective 1/1/26*
- *WSR 22-02-025, § 182-532-530, filed 12/28/21, effective 2/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-530, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-530, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-530, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 08-11-031, § 388-532-530, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-530, filed 11/30/05, effective 12/31/05*
- *WSR 04-05-011, § 388-532-530, filed 2/6/04, effective 3/8/04.*

##### **Wash. Admin. Code § 182-532-550** Family planning only programs—Payment limitations. {#sec-182-532-550 omnilex-key=us-wa-regs-official--title-182--182-532-550}

(1) The medicaid agency limits payment under the family planning only programs to services that:

(a) Have a primary focus and diagnosis of family planning as determined by a qualified licensed medical practitioner;

(b) Are medically necessary for the client to safely and effectively use, or continue to use, the client's chosen contraceptive method; and

(c) Include family planning-related services and supplies listed in WAC 182-532-530.

(2) The agency pays:

(a) Providers for covered family planning services using the agency's published fee schedules;

(b) For family planning pharmacy services, family planning laboratory services, and sterilization services using the agency's published fee schedules; and

(c) A dispensing fee only for contraceptive drugs purchased through the 340B program of the Public Health Service Act. (See chapter 182-530 WAC)

(3) The agency does not pay for inpatient services under the family planning only programs, except for complications arising from covered family planning services.

(4) The agency requires providers to:

(a) Meet the timely billing requirements of WAC 182-502-0150; and

(b) Seek timely reimbursement from a third party when a client has available third-party resources, as described under WAC 182-501-0200. Exceptions to this requirement are described under WAC 182-501-0200 and 182-532-570.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-23-034, s 182-532-550, filed 11/13/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-550, filed 8/28/19, effective 10/1/19. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-532-550, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-532-550, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. WSR 05-24-032, § 388-532-550, filed 11/30/05, effective 12/31/05*
- *WSR 04-05-011, § 388-532-550, filed 2/6/04, effective 3/8/04.*

##### **Wash. Admin. Code § 182-532-560** Family planning only programs—Documentation requirements. {#sec-182-532-560 omnilex-key=us-wa-regs-official--title-182--182-532-560}

In addition to the requirements in WAC 182-502-0020, providers must document the following in the client's medical record:

(1) Primary focus and diagnosis of the visit is family planning or family planning-related;

(2) Contraceptive methods discussed;

(3) Plan for use of a contraceptive method, or the reason and plan for no contraceptive method;

(4) Education, counseling, and risk reduction with sufficient detail that allows for follow-up;

(5) Referrals to, or from, other providers; and

(6) If applicable, a copy of the completed consent form for sterilization. (See WAC 182-531-1550)

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-23-034, s 182-532-560, filed 11/13/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-560, filed 8/28/19, effective 10/1/19.*

##### **Wash. Admin. Code § 182-532-570** Family planning only programs—Good cause exemption from billing third-party insurance. {#sec-182-532-570 omnilex-key=us-wa-regs-official--title-182--182-532-570}

(1) For the purposes of this section, "good cause" means that the use of the third-party coverage would violate a client's confidentiality because the third party:

(a) Routinely sends written, verbal, or electronic communications, as defined in RCW 48.43.505, to the third-party subscriber and that subscriber is someone other than the client; or

(b) Requires the client to use a primary care provider who is likely to report the client's request for family planning services to the subscriber.

(2) Clients eligible for family planning only programs may request an exemption from the requirement to bill third-party insurance due to "good cause" if they are:

(a) Twenty-six years of age or younger and seeking services in confidence; or

(b) Domestic violence victims and seeking services in confidence.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-23-034, s 182-532-570, filed 11/13/25, effective 1/1/26. Statutory Authority: RCW 41.05.021, 41.05.160 and section 1115(a) of the Social Security Act. WSR 19-18-024, § 182-532-570, filed 8/28/19, effective 10/1/19.*

## **Chapter 182-533** Maternity-related services. {#struct-chapter-182-533}

##### **Wash. Admin. Code § 182-533-0300** Services under First Steps. {#sec-182-533-0300 omnilex-key=us-wa-regs-official--title-182--182-533-0300}

(1) Under the 1989 Maternity Care Access Act, and RCW 74.09.760 through 74.09.900, the agency established First Steps to provide access to services for eligible people and their infants.

(2) The rules for the:

(a) Maternity support services (MSS) component of First Steps are found in WAC 182-533-0310 through 182-533-0345.

(b) Infant case management (ICM) component of First Steps are found in WAC 182-533-0360 through 182-533-0386.

(c) Childbirth education (CBE) component of First Steps are found in WAC 182-533-0390.

(3) Other services under First Steps include:

(a) Medical services, including full medical coverage, prenatal care, delivery, post-pregnancy follow-up, and 12 months family planning services post-pregnancy;

(b) Ancillary services including, but not limited to, expedited medical eligibility determination; and

(c) Alcohol and drug assessment and treatment services for pregnant people available statewide and administered by the division of behavioral health and recovery.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 74.09.837, and 2024 c 213 s 2. WSR 26-04-069, s 182-533-0300, filed 1/28/26, effective 2/28/26. Statutory Authority: RCW 41.05.021 and 2011 c 5. WSR 12-01-097, § 182-533-0300, filed 12/20/11, effective 1/20/12. WSR 11-14-075, recodified as § 182-533-0300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 § 1109. WSR 10-12-011, § 388-533-0300, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. WSR 04-13-049, § 388-533-0300, filed 6/10/04, effective 7/11/04. Statutory Authority: RCW 74.08.090, 74.09.770, and 74.09.800. WSR 00-14-068, § 388-533-0300, filed 7/5/00, effective 8/5/00.*

##### **Wash. Admin. Code § 182-533-0310** Maternity support services—Purpose. {#sec-182-533-0310 omnilex-key=us-wa-regs-official--title-182--182-533-0310}

The purpose of maternity support services (MSS) is to:

(1) Improve and promote healthy birth outcomes. Services are delivered by an MSS interdisciplinary team to eligible pregnant and post-pregnant people and their infants.

(2) Help eligible clients to access:

(a) Prenatal care as early in the pregnancy as possible; and

(b) Health care for their infants.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 74.09.837, and 2024 c 213 s 2. WSR 26-04-069, s 182-533-0310, filed 1/28/26, effective 2/28/26. WSR 11-14-075, recodified as § 182-533-0310, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 § 1109. WSR 10-12-011, § 388-533-0310, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. WSR 04-13-049, § 388-533-0310, filed 6/10/04, effective 7/11/04.*

##### **Wash. Admin. Code § 182-533-0315** Maternity support services—Definitions. {#sec-182-533-0315 omnilex-key=us-wa-regs-official--title-182--182-533-0315}

The following definitions and those found in WAC 182-500-0005 apply to maternity support services (MSS) and infant case management (ICM) (see WAC 182-533-0360 through 182-533-0386 for ICM rules).

"Basic health messages" - For MSS, the preventive health education messages designed to promote healthy pregnancies, healthy newborns and healthy parenting during the first year of life.

"Care coordination" - Professional collaboration and communication between the client's MSS provider and other medical and/or health and social services providers to address the individual client's needs as identified in the care plan.

"Care plan" - A written statement developed for a person that continues throughout the eligibility period and outlines any medical, social, environmental or other interventions to achieve an improved quality of life, including health and social outcomes.

"Case conference" - A formal or informal consultation used by the MSS interdisciplinary team to consult with each other and, when needed, other pertinent providers and/or the client to optimize the client's care.

"Case management" - Services to help individuals access needed medical, social, educational, and other services.

"Childbirth education (CBE)" - A component of the First Steps program to provide educational sessions offered in a group setting that prepares a pregnant woman and her support person(s) for an upcoming childbirth and healthy parenting.

"Department of health (DOH)" - The state agency that works to protect and improve the health of people in Washington state.

"First Steps" - The program created under the 1989 Maternity Care Access Act.

"Infant case management (ICM)" - A component of the First Steps program to provide parent(s) with information and assistance in accessing needed medical, social, educational, and other services that improve the welfare of infants.

"Infant case management (ICM) screening" - A brief in-person evaluation provided by a qualified person, under WAC 182-533-0375, to determine whether an infant and the infant's parent(s) have a specific risk factor(s).

"Linking" - Assistance to clients for identifying and using community resources to address specific medical, social and educational needs.

"Maternity cycle" - An eligibility period for maternity support services that begins during pregnancy and continues to the end of the month in which the sixtieth-day post-pregnancy occurs.

"Maternity support services (MSS)" - A component of the First Steps program to provide screening, assessment, basic health messages, education, counseling, case management, care coordination, and other interventions delivered by an MSS interdisciplinary team during the maternity cycle.

"Maternity support services (MSS) interdisciplinary team" - A provider's group of qualified staff consisting of at least a community health nurse, a certified registered dietitian, a behavioral health specialist, and, at the discretion of the provider, a community health worker. Based upon individual client need, each team member provides maternity support services and consultation. (See WAC 182-533-0327(3).)

"Medicaid agency" - The health care authority.

"Parent(s)" - A person who resides with an infant, provides the infant's day-to-day care, and meets the legal description under WAC 182-533-0370 (1)(c).

"Risk factors" - The biopsychosocial factors that could lead to poor birth outcomes, infant morbidity, and/or infant mortality.

"Screening" - A method for systematically identifying and documenting risk factors and client need.

"Washington apple health (WAH)" - The public health insurance programs for eligible Washington residents. Washington apple health is the name used in Washington state for medicaid, the children's health insurance program (CHIP), and state-only funded health care programs. (See WAC 182-500-0120.)

**History**
- *Statutory Authority: RCW 41.05.021. WSR 14-09-061, § 182-533-0315, filed 4/16/14, effective 5/17/14. WSR 11-14-075, recodified as § 182-533-0315, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 § 1109. WSR 10-12-011, § 388-533-0315, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. WSR 04-13-049, § 388-533-0315, filed 6/10/04, effective 7/11/04.*

##### **Wash. Admin. Code § 182-533-0320** Maternity support services—Client eligibility. {#sec-182-533-0320 omnilex-key=us-wa-regs-official--title-182--182-533-0320}

(1) To receive maternity support services (MSS), a client must:

(a) Be covered under the alternative benefit plan, categorically needy, medically needy, or state-funded medical programs under Washington apple health; and

(b) Be within the eligibility period of a maternity cycle as defined in WAC 182-533-0315.

(2) Clients who do not agree with an eligibility decision for MSS have a right to a fair hearing under chapter 182-526 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-12-060, § 182-533-0320, filed 5/26/16, effective 6/26/16*
- *WSR 15-12-075, § 182-533-0320, filed 5/29/15, effective 7/1/15. Statutory Authority: RCW 41.05.021. WSR 14-09-061, § 182-533-0320, filed 4/16/14, effective 5/17/14. Statutory Authority: RCW 41.05.021 and 2011 c 5. WSR 12-01-097, § 182-533-0320, filed 12/20/11, effective 1/20/12. WSR 11-14-075, recodified as § 182-533-0320, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 § 1109. WSR 10-12-011, § 388-533-0320, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. WSR 04-13-049, § 388-533-0320, filed 6/10/04, effective 7/11/04.*

##### **Wash. Admin. Code § 182-533-0325** Maternity support services—Provider requirements. {#sec-182-533-0325 omnilex-key=us-wa-regs-official--title-182--182-533-0325}

Maternity support service providers may include community clinics, federally qualified health centers, local health departments, hospitals, nonprofit organizations, tribal health clinics, and private clinics.

(1) To be paid for providing maternity support services (MSS) and infant case management (ICM) services to eligible clients, a provider must:

(a) Be enrolled as an eligible provider with the medicaid agency (see WAC 182-502-0010).

(b) Be currently approved as an MSS/ICM provider by the medicaid agency.

(c) Meet the requirements in this chapter, chapter 182-502 WAC and the medicaid agency's current billing instructions.

(d) Ensure that professional staff providing services:

(i) Meet the minimum regulatory and educational qualifications for the scope of services provided under WAC 182-533-0327; and

(ii) Follow the requirements in this chapter and the medicaid agency's current billing instructions.

(e) Screen each client for risk factors using the agency's online MSS screening tool.

(f) Screen clients for ICM eligibility.

(g) Conduct case conferences under WAC 182-533-0327(2).

(h) Develop and implement an individualized care plan for each client.

(i) Initiate and participate in care coordination activities throughout the maternity cycle with at least MSS interdisciplinary team members, the client's prenatal care provider, the Women, Infants, and Children (WIC) Nutrition Program, and if applicable, the client's birth doula (see WAC 182-533-0610 through 182-533-0680).

(j) Comply with Section 1902 (a)(23) of the Social Security Act regarding the client's freedom to choose a provider.

(k) Comply with Section 1915 (g)(1) of the Social Security Act regarding the client's voluntary receipt of services.

(2) MSS providers may provide services in any of the following locations:

(a) A provider's office or clinic.

(b) The client's residence.

(c) An alternate site that is not the client's residence. (The reason for using an alternate site for visitation instead of the home must be documented in the client's record.)

(3) An individual or service organization that has a written contractual agreement with a qualified MSS provider also may provide MSS and ICM services to eligible clients. The provider must:

(a) Keep a copy of the written subcontractor agreement on file;

(b) Ensure that an individual or service organization staff member providing MSS/ICM services (the subcontractor) meets the minimum regulatory and educational qualifications required of an MSS/ICM provider;

(c) Ensure that the subcontractor provides MSS/ICM services under the requirements of this chapter;

(d) Maintain professional, financial, and administrative responsibility for the subcontractor;

(e) Bill for services using the provider's national provider identifier and MSS/ICM taxonomy; and

(f) Reimburse the subcontractor for MSS/ICM services provided under the written agreement.

(4) Providers must obtain agency approval of all MSS/ICM outreach-related materials, including websites and publications, prior to making those materials available to clients.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 74.09.837, and 2024 c 213 s 2. WSR 26-04-069, s 182-533-0325, filed 1/28/26, effective 2/28/26. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-12-060, § 182-533-0325, filed 5/26/16, effective 6/26/16*
- *WSR 15-12-075, § 182-533-0325, filed 5/29/15, effective 7/1/15. Statutory Authority: RCW 41.05.021. WSR 14-09-061, § 182-533-0325, filed 4/16/14, effective 5/17/14. Statutory Authority: RCW 41.05.021 and 2011 c 5. WSR 12-01-097, § 182-533-0325, filed 12/20/11, effective 1/20/12. WSR 11-14-075, recodified as § 182-533-0325, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 § 1109. WSR 10-12-011, § 388-533-0325, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. WSR 04-13-049, § 388-533-0325, filed 6/10/04, effective 7/11/04.*

##### **Wash. Admin. Code § 182-533-0327** Maternity support services—Professional staff qualifications and interdisciplinary team. {#sec-182-533-0327 omnilex-key=us-wa-regs-official--title-182--182-533-0327}

(1) MSS providers must use qualified professionals, as specified in this section.

(a) Behavioral health specialists who are currently credentialed, certified, or licensed in Washington by the department of health under chapters 246-809, 246-810, 246-811, and 246-924 WAC as one of the following:

(i) Licensed mental health counselor.

(ii) Licensed independent clinical social worker.

(iii) Licensed social worker.

(iv) Licensed marriage and family therapist.

(v) Licensed psychologist.

(vi) Associate mental health counselor.

(vii) Associate independent clinical social worker.

(viii) Associate social worker.

(ix) Associate marriage and family therapist.

(x) Certified counselor.

(xi) Certified substance use disorder professional.

(b) Certified dietitians who are currently registered with the commission on dietetic registration and certified by the Washington state department of health under chapter 246-822 WAC.

(c) Community health nurses who are currently licensed as registered nurses in the state of Washington by the department of health under chapter 246-840 WAC.

(d) Community health workers (CHWs) who have a high school diploma or the equivalent and:

(i) Have a minimum of one year of health care and/or social services experience.

(ii) Carry out all activities under the direction and supervision of a professional member or supervisor of the MSS interdisciplinary team.

(iii) Complete a training plan developed by their provider.

(2) The provider's qualified staff must participate in an MSS interdisciplinary team consisting of at least a community health nurse, a certified registered dietitian, a behavioral health specialist, and, at the discretion of the provider, a community health worker.

(a) The interdisciplinary team must work together to address risk factors identified in a client's care plan.

(b) Each qualified staff member acting within her/his area of expertise must address the variety of client needs identified during the maternity cycle.

(c) An MSS interdisciplinary team case conference is required at least once prenatally for clients who are entering MSS during pregnancy, and are eligible for the maximum level of service. Using clinical judgment and the client's risk factors, the provider may decide which interdisciplinary team members to include in case conferencing.

(3) All Indian health programs, tribes, and any MSS provider within a county with fewer than fifty-five medicaid births per year are required to have at least one MSS interdisciplinary team member, as described in subsection (1) of this section:

(a) A behavioral health specialist;

(b) A registered dietitian; or

(c) A community health nurse.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 18.205.020. WSR 21-06-042, § 182-533-0327, filed 2/24/21, effective 3/27/21. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-12-060, § 182-533-0327, filed 5/26/16, effective 6/26/16. Statutory Authority: RCW 41.05.021. WSR 14-09-061, § 182-533-0327, filed 4/16/14, effective 5/17/14.*

##### **Wash. Admin. Code § 182-533-0328** Maternity support services—Documentation requirements. {#sec-182-533-0328 omnilex-key=us-wa-regs-official--title-182--182-533-0328}

Providers must fulfill the documentation requirements under WAC 182-502-0020 and the medicaid agency's current billing instructions including:

(1) Required supervision records for community health workers;

(2) Continued education verification and renewal of credentials for professional staff;

(3) Subcontracting documents, as specified under WAC 182-533-0325(3); and

(4) Client records, which include consent forms and documentation for screening, assessments, care plans, case conferences, case management, and care coordination for each client.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 14-09-061, § 182-533-0328, filed 4/16/14, effective 5/17/14.*

##### **Wash. Admin. Code § 182-533-0330** Maternity support services—Covered services. {#sec-182-533-0330 omnilex-key=us-wa-regs-official--title-182--182-533-0330}

(1) The medicaid agency must cover these maternity support services (MSS) provided by an MSS interdisciplinary team:

(a) Screening(s) for risk factors related to pregnancy and birth outcomes;

(b) Brief assessment when indicated;

(c) Brief counseling;

(d) Education that relates to improving pregnancy and parenting outcomes;

(e) Interventions for risk factors identified on the care plan;

(f) Basic health messages;

(g) Case management services;

(h) Care coordination;

(i) Infant case management (ICM) screening.

(2) The medicaid agency must determine the maximum number of units of services allowed per client when directed by the legislature to achieve targeted expenditure levels for payment of maternity support services for any specific biennium. (The maximum number of MSS units allowed per client is published in the agency's current billing instructions.)

(3) The medicaid agency must pay for covered maternity support services according to WAC 182-533-0345.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 74.09.837, and 2024 c 213 s 2. WSR 26-04-069, s 182-533-0330, filed 1/28/26, effective 2/28/26. Statutory Authority: RCW 41.05.021. WSR 14-09-061, § 182-533-0330, filed 4/16/14, effective 5/17/14. WSR 11-14-075, recodified as § 182-533-0330, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 § 1109. WSR 10-12-011, § 388-533-0330, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. WSR 04-13-049, § 388-533-0330, filed 6/10/04, effective 7/11/04.*

##### **Wash. Admin. Code § 182-533-0340** Maternity support services—Noncovered services. {#sec-182-533-0340 omnilex-key=us-wa-regs-official--title-182--182-533-0340}

(1) The medicaid agency must cover only those services listed in WAC 182-533-0330.

(2) The medicaid agency must evaluate a request for any noncovered service under the provisions of WAC 182-501-0160.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 14-09-061, § 182-533-0340, filed 4/16/14, effective 5/17/14. WSR 11-14-075, recodified as § 182-533-0340, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 § 1109. WSR 10-12-011, § 388-533-0340, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-533-0340, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. WSR 04-13-049, § 388-533-0340, filed 6/10/04, effective 7/11/04.*

##### **Wash. Admin. Code § 182-533-0345** Maternity support services—Payment. {#sec-182-533-0345 omnilex-key=us-wa-regs-official--title-182--182-533-0345}

The medicaid agency pays for the covered maternity support services (MSS) described in WAC 182-533-0330, subject to the requirements in this section:

(1) MSS are:

(a) Provided to a client who meets the eligibility requirements in WAC 182-533-0320.

(b) Provided to a client during an encounter on an individual basis or in a group setting. If provided in a group setting, the group must consist of at least three but no more than 12 clients.

(c) Provided by a provider that meets the criteria in WAC 182-533-0325. When provided in a group setting, services may not be provided by a community health worker.

(d) Provided according to the agency's maternity support services (MSS)/infant case management (ICM) provider guide.

(e) Documented in the client's record or chart.

(f) Billed using:

(i) The eligible client's agency-assigned client identification number;

(ii) The appropriate procedure codes, modifiers, and allowed number of units identified in the agency's MSS/ICM provider guide; and

(iii) The provider's national provider identifier and MSS/ICM taxonomy.

(2) The agency:

(a) Reimburses providers for MSS-covered services using the agency's published fee schedule.

(b) Pays MSS-covered services in units of time with one unit being equal to 15 minutes of one-to-one service delivered in-person or through telemedicine according to WAC 182-501-0300.

(c) Pays MSS-covered services in units of time with one unit being more than or equal to 60 minutes for group services delivered face-to-face.

(d) Pays for one initial MSS screening, when provided by an MSS provider listed in WAC 182-533-0327 (1)(a) through (c), with the unit being more than or equal to 60 minutes and delivered in-person or through telemedicine.

(e) Pays for one postpartum MSS registered nurse visit, that takes place in the client's home or a homeless shelter within four weeks after the pregnancy ends, with the unit being more than or equal to 90 minutes and delivered in-person.

(3) The provider may request authorization for a limitation extension under WAC 182-501-0169 to exceed the number of allowed MSS units of service.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 74.09.837, and 2024 c 213 s 2. WSR 26-04-069, s 182-533-0345, filed 1/28/26, effective 2/28/26. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-12-075, § 182-533-0345, filed 5/29/15, effective 7/1/15. Statutory Authority: RCW 41.05.021. WSR 14-09-061, § 182-533-0345, filed 4/16/14, effective 5/17/14. WSR 11-14-075, recodified as § 182-533-0345, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 § 1109. WSR 10-12-011, § 388-533-0345, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. WSR 04-13-049, § 388-533-0345, filed 6/10/04, effective 7/11/04.*

##### **Wash. Admin. Code § 182-533-0360** Infant case management—Purpose. {#sec-182-533-0360 omnilex-key=us-wa-regs-official--title-182--182-533-0360}

The purpose of infant case management (ICM) is to improve the welfare of infants by providing their parent(s) with information and assistance to access needed medical, social, educational, and other services.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 14-09-061, § 182-533-0360, filed 4/16/14, effective 5/17/14. WSR 11-14-075, recodified as § 182-533-0360, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 § 1109. WSR 10-12-010, § 388-533-0360, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. WSR 04-13-049, § 388-533-0360, filed 6/10/04, effective 7/11/04.*

##### **Wash. Admin. Code § 182-533-0365** Infant case management—Definitions. {#sec-182-533-0365 omnilex-key=us-wa-regs-official--title-182--182-533-0365}

The definitions in WAC 182-533-0315 also apply to infant case management (ICM).

**History**
- *Statutory Authority: RCW 41.05.021. WSR 14-09-061, § 182-533-0365, filed 4/16/14, effective 5/17/14. WSR 11-14-075, recodified as § 182-533-0365, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 § 1109. WSR 10-12-010, § 388-533-0365, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. WSR 04-13-049, § 388-533-0365, filed 6/10/04, effective 7/11/04.*

##### **Wash. Admin. Code § 182-533-0370** Infant case management—Client eligibility. {#sec-182-533-0370 omnilex-key=us-wa-regs-official--title-182--182-533-0370}

(1) To be eligible to receive infant case management (ICM), an infant must meet all the following criteria:

(a) Be covered under categorically needy, medically needy, or state-funded medical programs under Washington apple health.

(b) Meet the age requirement for ICM, which is the day after the maternity cycle (defined in WAC 182-533-0315) ends, through the last day of the month of the infant's first birthday.

(c) Reside with at least one parent who provides the infant's day-to-day care and is:

(i) The infant's natural or adoptive parent(s);

(ii) A person other than a foster parent who has been granted legal custody of the infant; or

(iii) A person who is legally obligated to support the infant.

(d) Have a parent(s) who needs assistance in accessing medical, social, educational and/or other services to meet the infant's basic health and safety needs.

(e) Not be receiving any case management services funded through Title XIX medicaid that duplicate ICM services.

(2) Clients who meet the eligibility criteria and are enrolled in a medicaid agency-contracted managed care organization (MCO) are eligible for ICM services outside their plan.

(3) Clients who do not agree with an eligibility decision by the medicaid agency for ICM have a right to a fair hearing under chapter 182-526 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-06-026, § 182-533-0370, filed 2/28/19, effective 4/1/19. Statutory Authority: RCW 41.05.021. WSR 14-09-061, § 182-533-0370, filed 4/16/14, effective 5/17/14. Statutory Authority: RCW 41.05.021 and 2011 c 5. WSR 12-01-097, § 182-533-0370, filed 12/20/11, effective 1/20/12. WSR 11-14-075, recodified as § 182-533-0370, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 § 1109. WSR 10-12-010, § 388-533-0370, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. WSR 04-13-049, § 388-533-0370, filed 6/10/04, effective 7/11/04.*

##### **Wash. Admin. Code § 182-533-0375** Infant case management—Provider requirements. {#sec-182-533-0375 omnilex-key=us-wa-regs-official--title-182--182-533-0375}

(1) Infant case management (ICM) services may be provided only by a qualified infant case manager who is employed by a provider meeting the requirements in WAC 182-533-0325.

(2) The infant case manager must meet at least one of the following qualifications under (a), (b), or (c) of this subsection:

(a) Be a current member of the maternity support services (MSS) interdisciplinary team under WAC 182-533-0327 (1)(a), (b), or (c).

(b) Have a bachelor of arts, bachelor of science, or higher degree in a social service-related field, such as social work, behavioral sciences, psychology, child development, or mental health, plus at least one year of full-time experience working in one or more of the following areas:

(i) Community services;

(ii) Social services;

(iii) Public health services;

(iv) Crisis intervention;

(v) Outreach and referral programs; or

(vi) Other related fields.

(c) Have an associate of arts degree, or an associate's degree in a social service-related field, such as social work, behavioral sciences, psychology, child development, or mental health, plus at least two years of full-time experience working in one or more of the following areas:

(i) Community services;

(ii) Social services;

(iii) Public health services;

(iv) Crisis intervention;

(v) Outreach and referral programs;

(vi) Other related fields.

(3) The medicaid agency requires any staff person qualifying under subsection (2)(c) of this section to be under the supervision of a clinical staff person meeting the criteria in subsection (2)(a) or (b) of this section. Clinical supervision may include face-to-face meetings and/or chart reviews.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-12-060, § 182-533-0375, filed 5/26/16, effective 6/26/16. Statutory Authority: RCW 41.05.021. WSR 14-09-061, § 182-533-0375, filed 4/16/14, effective 5/17/14. WSR 11-14-075, recodified as § 182-533-0375, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 § 1109. WSR 10-12-010, § 388-533-0375, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. WSR 04-13-049, § 388-533-0375, filed 6/10/04, effective 7/11/04.*

##### **Wash. Admin. Code § 182-533-0378** Infant case management—Documentation requirements. {#sec-182-533-0378 omnilex-key=us-wa-regs-official--title-182--182-533-0378}

Providers must fulfill the documentation requirements under WAC 182-502-0020 and the medicaid agency's current billing instructions including:

(1) Required supervision records for infant case managers;

(2) Continued education verification and renewal of credentials for professional staff; and

(3) Client records that include consent forms and documentation for screening, assessments, care plans, case management, and care coordination for each client.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 14-09-061, § 182-533-0378, filed 4/16/14, effective 5/17/14.*

##### **Wash. Admin. Code § 182-533-0380** Infant case management—Covered services. {#sec-182-533-0380 omnilex-key=us-wa-regs-official--title-182--182-533-0380}

(1) The medicaid agency must cover infant case management (ICM) services subject to the restrictions and limitations in this section and other applicable WAC.

Covered services include:

(a) An initial in-person screening for ICM services, which includes an assessment of risk factors and the development of an individualized care plan;

(b) Case management services and care coordination;

(c) Referral and linking the infant and parent(s) to other services or resources;

(d) Advocacy for the infant and parent(s); and

(e) Follow-up contact(s) with the parent(s) to ensure the care plan continues to meet the needs of the infant and parent(s).

(2) The medicaid agency may determine the maximum number of units allowed per client when directed by the legislature to achieve targeted expenditure levels for payment in any specific biennium. (The maximum number of ICM units allowed per client is published in the agency's current billing instructions.)

(3) The medicaid agency must pay for covered ICM services according to WAC 182-533-0386.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 14-09-061, § 182-533-0380, filed 4/16/14, effective 5/17/14. Statutory Authority: RCW 41.05.021 and 2011 c 5. WSR 12-01-097, § 182-533-0380, filed 12/20/11, effective 1/20/12. WSR 11-14-075, recodified as § 182-533-0380, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 § 1109. WSR 10-12-010, § 388-533-0380, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. WSR 04-13-049, § 388-533-0380, filed 6/10/04, effective 7/11/04.*

##### **Wash. Admin. Code § 182-533-0385** Infant case management—Noncovered services. {#sec-182-533-0385 omnilex-key=us-wa-regs-official--title-182--182-533-0385}

(1) The medicaid agency must cover only those services that are listed in WAC 182-533-0380.

(2) The medicaid agency must evaluate a request for any noncovered service under the provisions of WAC 182-501-0160.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 14-09-061, § 182-533-0385, filed 4/16/14, effective 5/17/14. WSR 11-14-075, recodified as § 182-533-0385, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 § 1109. WSR 10-12-010, § 388-533-0385, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-533-0385, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. WSR 04-13-049, § 388-533-0385, filed 6/10/04, effective 7/11/04.*

##### **Wash. Admin. Code § 182-533-0386** Infant case management—Payment. {#sec-182-533-0386 omnilex-key=us-wa-regs-official--title-182--182-533-0386}

(1) The medicaid agency must pay for the covered infant case management (ICM) services described in WAC 182-533-0380 on a fee-for-service basis subject to the following requirements.

ICM services must be:

(a) Provided to a client who meets the eligibility requirements in WAC 182-533-0370.

(b) Provided by a person who meets the criteria established in WAC 182-533-0375.

(c) Provided according to the agency's current billing instructions.

(d) Documented in the infant's and/or the parent's record or chart.

(e) Billed using:

(i) The eligible infant's medicaid agency-assigned client identification number;

(ii) The appropriate procedure codes and modifiers identified in the agency's current billing instructions; and

(iii) The medicaid agency-assigned MSS/ICM provider number.

(2) The medicaid agency:

(a) Must pay ICM services in units of time, with one unit being equal to fifteen minutes of one-to-one service delivered face-to-face.

(b) When directed by the legislature to achieve targeted expenditure levels for payment of maternity support services for any specific biennium, may determine the maximum number of units allowed per client.

(c) Must publish the maximum number of units allowed per client in the agency's current billing instructions.

(3) The provider may request authorization for a limitation extension to exceed the number of allowed ICM units of service under WAC 182-501-0169.

(4) For a client enrolled in a managed care plan who is eligible to receive ICM, the medicaid agency must pay ICM services delivered outside the plan on a fee-for-service basis as described in this section.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 14-09-061, § 182-533-0386, filed 4/16/14, effective 5/17/14. WSR 11-14-075, recodified as § 182-533-0386, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 § 1109. WSR 10-12-010, § 388-533-0386, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. WSR 04-13-049, § 388-533-0386, filed 6/10/04, effective 7/11/04.*

##### **Wash. Admin. Code § 182-533-0390** Childbirth education (CBE) classes. {#sec-182-533-0390 omnilex-key=us-wa-regs-official--title-182--182-533-0390}

(1) Purpose. The purpose of childbirth education (CBE) classes is to help prepare the client and the client's support person(s):

(a) For the physiological, emotional, and psychological changes experienced during and after pregnancy;

(b) To develop self-advocacy skills;

(c) To increase knowledge about and access to local community resources;

(d) To improve parenting skills; and

(e) To improve the likelihood of positive birth outcomes.

(2) Definitions. The definitions in chapter 182-500 WAC, medical assistance definitions, and WAC 182-533-0315, maternity support services definitions, also apply to this section.

(3) Client eligibility. To be eligible for CBE classes, a client must be:

(a) Pregnant; and

(b) Covered under one of the medical assistance programs described in WAC 182-533-0320 (1)(a)(i) and (iv).

(4) Provider requirements. To be paid for providing CBE classes to eligible clients, an approved instructor must:

(a) Have a core provider agreement on file with the agency;

(b) Ensure that individuals providing CBE classes or following up during or after the completion of online classes have credentials and/or certification as outlined in the agency's current published billing instructions;

(c) Deliver CBE classes:

(i) In a series of group sessions; or

(ii) Through online classes approved by the agency; and

(d) Provide curriculum containing topics outlined in the agency's CBE curriculum checklist found in the agency's current published billing instructions. Topics include, but are not limited to:

(i) Pregnancy;

(ii) Labor and birth;

(iii) Newborns; and

(iv) Family adjustment.

(5) Documentation. Providers must:

(a) Follow the health care record requirements found in WAC 182-502-0020; and

(b) Maintain the following additional documentation:

(i) An original or electronically signed copy of each client's Freedom of Choice form and Consent for Services form;

(ii) A client sign-in sheet or log-in verification for each class; and

(iii) Names and ProviderOne Client ID numbers of eligible clients attending CBE classes and the date(s) they participated in each CBE class.

(6) Coverage.

(a) The agency covers one CBE class series per client, per pregnancy. In order for the provider to be reimbursed:

(i) The client must attend at least one CBE session or agency-approved online CBE class; and

(ii) The provider must follow up with clients participating in online classes through a telemedicine, including audio-only, visit or an in-person visit. If the client does not appear for the follow up visit, the provider must attempt to connect with the client one more time before billing the agency.

(b) CBE classes must include a minimum of six hours of instruction and are subject to the restrictions and limitations in this section and other applicable WAC.

(7) Payment. The agency pays for the CBE classes described in subsection (6) of this section on a fee-for-service basis subject to the following:

(a) CBE must:

(i) Include all classes, core materials, publications, and educational materials provided throughout the class series. Clients must receive the same materials as are offered to other attendees; and

(ii) Be billed according to the agency's current published billing instructions.

(b) The provider must accept the agency's fee as payment in full for classes provided to a client in accordance with 42 C.F.R. § 447.15.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-21-069, § 182-533-0390, filed 10/12/23, effective 11/12/23*
- *WSR 19-06-026, § 182-533-0390, filed 2/28/19, effective 4/1/19. Statutory Authority: RCW 41.05.021 and 2011 c 5. WSR 12-01-097, § 182-533-0390, filed 12/20/11, effective 1/20/12. WSR 11-14-075, recodified as § 182-533-0390, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. WSR 04-13-049, § 388-533-0390, filed 6/10/04, effective 7/11/04.*

##### **Wash. Admin. Code § 182-533-0400** Maternity care and newborn delivery. {#sec-182-533-0400 omnilex-key=us-wa-regs-official--title-182--182-533-0400}

(1) The following definitions and abbreviations and those found in chapter 182-500 WAC apply to this chapter.

(a) "Birthing center" means a specialized facility licensed as a childbirth center by the department of health (DOH) under chapter 246-329 WAC.

(b) "Bundled services" means services integral to the major procedure that are included in the fee for the major procedure. Under this chapter, certain services which are customarily bundled must be billed separately (unbundled) when the services are provided by different providers.

(c) "Facility fee" means the portion of the medicaid agency's payment for the hospital or birthing center charges. This does not include the agency's payment for the professional fee.

(d) "Global fee" means the fee the agency pays for total obstetrical care. Total obstetrical care includes all bundled antepartum care, delivery services and postpartum care.

(e) "High-risk" pregnancy means any pregnancy that poses a significant risk of a poor birth outcome.

(f) "Professional fee" means the portion of the agency's payment for services that rely on the provider's professional skill or training, or the part of the reimbursement that recognizes the provider's cognitive skill. (See WAC 182-531-1850 for reimbursement methodology.)

(2) The agency covers full scope medical maternity care and newborn delivery services for fee-for-service and managed care clients under WAC 182-501-0060.

(3) The agency does not provide maternity care and delivery services to clients who are eligible for:

(a) Family planning only programs (a pregnant client under these programs should be referred to the Washington healthplanfinder via www.wahealthplanfinder.org for eligibility review); or

(b) Any other program not listed in this section.

(4) The agency requires providers of maternity care and newborn delivery services to meet all the following requirements:

(a) Providers must be currently licensed:

(i) By the state of Washington's department of health (DOH), or department of licensing, or both; or

(ii) According to the laws and rules of any other state, if exempt under federal law.

(b) Providers must have a signed core provider agreement with the agency;

(c) Providers must be practicing within the scope of their licensure; and

(d) Providers must have valid certifications from the appropriate federal or state agency, if such is required to provide these services (e.g., federally qualified health centers (FQHCs), laboratories certified through the Clinical Laboratory Improvement Amendment (CLIA)).

(5) The agency covers total obstetrical care services (paid under a global fee). Total obstetrical care includes all the following:

(a) Routine antepartum care that begins in any trimester of a pregnancy;

(b) Delivery (intrapartum care and birth) services; and

(c) Postpartum care. This includes family planning counseling.

(6) When an eligible client receives all the services listed in subsection (5) of this section from one provider, the agency pays that provider a global obstetrical fee.

(7) When an eligible client receives services from more than one provider, the agency pays each provider for the services furnished. The separate services that the agency pays appear in subsection (5) of this section.

(8) The agency pays for antepartum care services in one of the following two ways:

(a) Under a global fee; or

(b) Under antepartum care fees.

(9) The agency's fees for antepartum care include all the following:

(a) Completing an initial and any subsequent patient history;

(b) Completing all physical examinations;

(c) Recording and tracking the client's weight and blood pressure;

(d) Recording fetal heart tones;

(e) Performing a routine chemical urinalysis (including all urine dipstick tests); and

(f) Providing maternity counseling.

(10) The agency covers certain antepartum services in addition to the bundled services listed in subsection (9) of this section as follows:

(a) The agency pays for either of the following, but not both:

(i) An enhanced prenatal management fee (a fee for medically necessary increased prenatal monitoring). The agency provides a list of diagnoses, or conditions, or both, that the agency identifies as justification for more frequent monitoring visits; or

(ii) A prenatal management fee for "high-risk" maternity clients. This fee is payable to either a physician or a certified nurse midwife.

(b) The agency pays for both of the following:

(i) Necessary prenatal laboratory tests except routine chemical urinalysis, including all urine dipstick tests, as described in subsection (9)(e) of this section; and

(ii) Treatment of medical problems that are not related to the pregnancy. The agency pays these fees to physicians or advanced registered nurse practitioners (ARNP).

(11) The agency covers high-risk pregnancies. The agency considers a pregnant client to have a high-risk pregnancy when the client:

(a) Has any high-risk medical condition (whether or not it is related to the pregnancy); or

(b) Has a diagnosis of multiple births.

(12) The agency covers delivery services for clients with high-risk pregnancies, described in subsection (11) of this section, when the delivery services are provided in a hospital.

(13) The agency pays a facility fee for delivery services in the following settings:

(a) Inpatient hospital; or

(b) Birthing centers.

(14) The agency pays a professional fee for delivery services in the following settings:

(a) Hospitals, to a provider who meets the criteria in subsection (4) of this section and who has privileges in the hospital;

(b) Planned home births and birthing centers.

(15) The agency covers hospital delivery services for an eligible client as defined in subsection (2) of this section. The agency's bundled payment for the professional fee for hospital delivery services include:

(a) The admissions history and physical examination; and

(b) The management of uncomplicated labor (intrapartum care); and

(c) The vaginal delivery of the newborn (with or without episiotomy or forceps); or

(d) Cesarean delivery of the newborn.

(16) The agency pays only a labor management fee to a provider who begins intrapartum care and unanticipated medical complications prevent that provider from following through with the birthing services.

(17) In addition to the agency's payment for professional services in subsection (15) of this section, the agency may pay separately for services provided by any of the following professional staff:

(a) A physician assistant or registered nurse "first assist" when delivery is by cesarean section;

(b) A physician, ARNP, or licensed midwife for newborn examination as the delivery setting allows; and

(c) An obstetrician, or gynecologist specialist, or both, for external cephalic version and consultation.

(18) In addition to the professional delivery services fee in subsection (15) or the global/total fees (i.e., those that include the hospital delivery services) in subsections (5) and (6) of this section, the agency allows additional fees for any of the following:

(a) High-risk vaginal delivery;

(b) Multiple vaginal births. The agency's typical payment covers delivery of the first child. For each subsequent child, the agency pays at 50 percent of the provider's usual and customary charge, up to the agency's maximum allowable fee; or

(c) High-risk cesarean section delivery.

(19) The agency does not pay separately for any of the following:

(a) More than one child delivered by cesarean section during a surgery. The agency's cesarean section surgery fee covers one or multiple surgical births;

(b) Postoperative care for cesarean section births. This is included in the surgical fee. Postoperative care is not the same as, or part of, postpartum care.

(20) The agency pays for an early delivery, including induction or cesarean section, before 39 weeks of gestation only if medically necessary. The agency considers an early delivery to be medically necessary:

(a) If the mother or fetus has a diagnosis listed in the Joint Commission's current table of Conditions Possibly Justifying Elective Delivery Prior to 39 Weeks Gestation; or

(b) If the provider documents a clinical situation that supports medical necessity.

(21) The agency will only pay for antepartum and postpartum professional services for an early elective delivery as defined in WAC 182-500-0030.

(22) The hospital will receive no payment for an early elective delivery as defined in WAC 182-500-0030.

(23) In addition to the services listed in subsection (10) of this section, the agency covers counseling for tobacco/nicotine cessation for eligible clients who are pregnant or in the postpartum period as defined in 42 C.F.R. 435.170. See WAC 182-531-1720.

(24) For clients age 20 and younger, see the rules for the early periodic screening, diagnosis, and treatment (EPSDT) program described in chapter 182-534 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-07-034, s 182-533-0400, filed 3/11/26, effective 4/11/26*
- *WSR 19-22-017, § 182-533-0400, filed 10/25/19, effective 11/25/19*
- *WSR 15-24-021, § 182-533-0400, filed 11/19/15, effective 1/1/16. WSR 11-14-075, recodified as § 182-533-0400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-014, § 388-533-0400, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.760, and 74.09.770. WSR 05-01-065, § 388-533-0400, filed 12/8/04, effective 1/8/05*
- *WSR 02-07-043, § 388-533-0400, filed 3/13/02, effective 4/13/02. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.800. WSR 00-23-052, § 388-533-0400, filed 11/13/00, effective 12/14/00.*

##### **Wash. Admin. Code § 182-533-0600** Planned home births and births in birthing centers. {#sec-182-533-0600 omnilex-key=us-wa-regs-official--title-182--182-533-0600}

WAC 182-533-0600

(1) Client eligibility. The medicaid agency covers planned home births and births in birthing centers for clients who choose to give birth at home or in an agency-approved birthing center and:

(a) Are eligible for the alternative benefit package under WAC 182-501-0060, categorically needy or medically needy scope of care under WAC 182-533-0400(2);

(b) Have an agency-approved medical provider who has accepted responsibility for the planned home birth or birth in birthing center under this section;

(c) Are expected to deliver the child vaginally and without complication (i.e., with a low risk of adverse birth outcome); and

(d) Pass the agency's risk screening criteria. The agency provides these risk-screening criteria to qualified medical services providers.

(2) Qualified providers. Only the following provider types may be reimbursed for planned home births and births in birthing centers:

(a) Physicians licensed under chapters 18.57 or 18.71 RCW;

(b) Nurse midwives licensed under chapter 18.79 RCW; and

(c) Midwives licensed under chapter 18.50 RCW.

(3) Birthing center requirements.

(a) Each participating birthing center must:

(i) Be licensed as a childbirth center by the department of health (DOH) under chapter 246-329 WAC;

(ii) Be specifically approved by the agency to provide birthing center services;

(iii) Have a valid core provider agreement with the agency; and

(iv) Maintain standards of care required by DOH for licensure.

(b) The agency suspends or terminates the core provider agreement of a birthing center if it fails to maintain DOH standards cited in (a) of this subsection.

(4) Home birth or birthing center providers. Home birth or birthing center providers must:

(a) Obtain from the client a signed consent form in advance of the birth;

(b) Follow the agency's risk screening criteria and consult with, or refer the client or newborn to, a physician or hospital when medically appropriate;

(c) Have current, written, and appropriate plans for consultation, emergency transfer and transport of a client or newborn to a hospital;

(d) Make appropriate referral of the newborn for pediatric care and medically necessary follow-up care;

(e) Inform parents of required prophylactic eye ointment and newborn screening tests for heritable or metabolic disorders, and congenital heart defects, and send the newborn's blood sample to the DOH for testing. Parents may refuse these services for religious reasons under RCW 70.83.020. The provider must obtain the signature from the parent(s) on:

(i) The reverse side of the screening card to document refusal of screenings for heritable or metabolic disorders; and

(ii) A waiver form to document refusal of prophylactic eye ointment or a screening for congenital heart defects;

(f) Inform parents of the benefits and risks of Vitamin K injections for newborns; and

(g) Have evidence of current cardiopulmonary resuscitation (CPR) training for:

(i) Adult CPR; and

(ii) Neonatal resuscitation.

(5) Planned home birth providers. Planned home birth providers must:

(a) Provide medically necessary equipment, supplies, and medications for each client;

(b) Have arrangements for 24 hour per day coverage;

(c) Have documentation of contact with local area emergency medical services to determine the level of response capability in the area; and

(d) Participate in a formal, state-sanctioned, quality assurance improvement program or professional liability review process.

(6) Newborn services. The agency pays for routine newborn services up to two weeks of age when the services are:

(a) Furnished by a qualified provider, as identified in subsection (2) of this section; and

(b) Within the provider's scope of practice.

(7) Limitations. The agency does not cover planned home births or births in birthing centers for pregnant people identified with any of the following conditions:

(a) Previous cesarean section;

(b) Current alcohol or drug addiction or abuse;

(c) Significant hematological disorders or coagulopathies;

(d) History of deep venous thrombosis or pulmonary embolism;

(e) Cardiovascular disease causing functional impairment;

(f) Chronic hypertension;

(g) Significant endocrine disorders including preexisting diabetes (type I or type II);

(h) Hepatic disorders including uncontrolled intrahepatic cholestasis of pregnancy or abnormal liver function tests;

(i) Isoimmunization, including evidence of Rh sensitization or platelet sensitization;

(j) Neurologic disorders or active seizure disorders;

(k) Pulmonary disease;

(l) Renal disease;

(m) Collagen-vascular diseases;

(n) Current severe psychiatric illness;

(o) Cancer affecting the female reproductive system;

(p) Multiple gestation;

(q) Breech presentation in labor with delivery not imminent; or

(r) Other significant deviations from normal as assessed by the provider.

(8) Clients age 20 and younger. For clients age 20 and younger, see the early periodic screening, diagnosis, and treatment (EPSDT) program described in chapter 182-534 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-15-039, s 182-533-0600, filed 7/8/26, effective 8/8/26*
- *WSR 26-07-031, s 182-533-0600, filed 3/11/26, effective 4/11/26*
- *WSR 20-02-068, § 182-533-0600, filed 12/26/19, effective 1/26/20. Statutory Authority: RCW 41.05.021, 41.05.160, 70.83.020, 2015 c 37, and WAC 246-100-202. WSR 15-19-122, § 182-533-0600, filed 9/21/15, effective 10/22/15. WSR 11-14-075, recodified as § 182-533-0600, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760, and 74.09.770. WSR 05-01-065, § 388-533-0600, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.800. WSR 00-23-052, § 388-533-0600, filed 11/13/00, effective 12/14/00.*

##### **Wash. Admin. Code § 182-533-0610** Birth doula services—Purpose. {#sec-182-533-0610 omnilex-key=us-wa-regs-official--title-182--182-533-0610}

WAC 182-533-0610 through 182-533-0680 establish the medicaid agency's provider and documentation requirements and coverage and payment rules for birth doula services when provided to eligible apple health clients. Birth doula services improve and promote healthy pregnancy, birth, postpartum, and infant outcomes. A birth doula delivers services to eligible pregnant and post-pregnant people, their infants, and their families.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2025 c 424 s 211(35). WSR 25-16-016, s 182-533-0610, filed 7/25/25, effective 8/25/25.*

##### **Wash. Admin. Code § 182-533-0620** Birth doula services—Definitions. {#sec-182-533-0620 omnilex-key=us-wa-regs-official--title-182--182-533-0620}

The following definitions and those found in chapter 182-500 WAC apply to birth doula services.

"Agency" - See WAC 182-500-0010.

"Birth doula" - A nonmedical support person certified under chapter 246-835 WAC and trained to provide physical, emotional, and informational support to birthing persons, their infants, and their families.

"Birth doula services" - Preventive services, as defined by 42 C.F.R. 440.130(c), provided by a birth doula to pregnant and post-pregnant people, their infants, and their families. Services include advocating for and supporting the birthing person and their family to self-advocate by helping them to know their rights and make informed decisions.

"Care coordination" - Collaboration and communication between the client's birth doula provider and other medical or health and social services providers, including Indian health care providers, or both, to partner with and address the individual client's and family's needs.

"Culturally congruent care" - See WAC 246-835-010.

"Department of health (DOH)" - The state agency that works with others to protect and improve the health of all people in Washington state and which certifies the birth doula profession under chapter 246-835 WAC.

"Health care record" - See WAC 182-502-0020 for health care record requirements.

"In person" - The client and the provider are face-to-face in the same location.

"Lived experience" - Having first-hand knowledge and insight gained from navigating challenges similar to those faced by the people in the community. This can include shared experiences like cultural backgrounds, socioeconomic status, health conditions, or barriers accessing the health and social service systems.

"Medicaid agency" - See WAC 182-500-0070.

"Postpartum period" - The period lasting until the end of the 12th month after the pregnancy ends.

"Washington apple health" - See WAC 182-500-0120.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2025 c 424 s 211(35). WSR 25-16-016, s 182-533-0620, filed 7/25/25, effective 8/25/25.*

##### **Wash. Admin. Code § 182-533-0630** Birth doula services—Client eligibility. {#sec-182-533-0630 omnilex-key=us-wa-regs-official--title-182--182-533-0630}

To receive birth doula services, a client must:

(1) Be eligible for one of the Washington apple health programs listed in the table in WAC 182-501-0060; and

(2) Be within one of the following eligibility periods:

(a) During pregnancy;

(b) Birth, inclusive of any end of pregnancy outcome; or

(c) The postpartum period as defined in WAC 182-533-0620.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2025 c 424 s 211(35). WSR 25-16-016, s 182-533-0630, filed 7/25/25, effective 8/25/25.*

##### **Wash. Admin. Code § 182-533-0640** Birth doula services—Provider requirements. {#sec-182-533-0640 omnilex-key=us-wa-regs-official--title-182--182-533-0640}

To be eligible to provide birth doula services to Washington apple health clients, a birth doula must:

(1) Be 18 years of age or older;

(2) Be a resident of the state of Washington or a bordering city as specified in WAC 182-501-0175;

(3) Possess current certification as a birth doula with the Washington state department of health under chapter 246-835 WAC;

(4) Be enrolled as an eligible birth doula provider with the medicaid agency (see WAC 182-502-0010);

(5) Meet the requirements in this chapter, chapter 182-502 WAC, and the billing and documentation requirements found in the agency's current birth doula services billing guide;

(6) Meet the standards required by state and federal laws governing the privacy and security of personally identifying information;

(7) Participate in care coordination activities throughout pregnancy and the postpartum period with the client's prenatal clinical care provider and, if applicable, their maternity support services (MSS) provider (see WAC 182-533-0310 through 182-533-0345);

(8) Provide culturally congruent care to the client and client's family; and

(9) Have lived experience that aligns with and provides a connection between the birth doula and the community being served.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2025 c 424 s 211(35). WSR 25-16-016, s 182-533-0640, filed 7/25/25, effective 8/25/25.*

##### **Wash. Admin. Code § 182-533-0650** Birth doula services—Documentation requirements. {#sec-182-533-0650 omnilex-key=us-wa-regs-official--title-182--182-533-0650}

(1) Providers must fulfill the documentation requirements found in WAC 182-502-0020 and the medicaid agency's current birth doula services billing guide.

(2) Each provider must maintain a client health care record for each client that states the services provided and justifies how those services support provider reimbursement.

(3) The following must be documented in the client's health record:

(a) Consent to services to be signed at the initiation of care;

(b) The date and time/duration of services and information substantiating the time/duration of services;

(c) The nature of the care and service(s) provided;

(d) Any coordination with medical or other care providers;

(e) Any referrals and coordination efforts with community resources or community supports;

(f) If screening is provided using a validated screening tool, the name of the tool, the score, and any communication following a positive screening including referrals to community resources, coordination with clinical team, etc.;

(g) If the client changes their birth doula; and

(h) The following required components of the prenatal intake visit:

(i) The date and time/duration of services, minimum two-hour visit;

(ii) A completed and signed consent for services form;

(iii) Provide an overview of the apple health birth doula benefit;

(iv) Co-design a plan of care across antepartum, delivery, and postpartum periods, as appropriate;

(v) Initiate discussion and implementation of birth plan or client/family preferences for care;

(vi) Support the client in establishing care as needed, including clinical pregnancy care, behavioral health services, dental services, etc. Coordinate with the managed care organization if needed to assist the client in accessing desired services, timely appointments, or any other care coordination or case management need;

(vii) Review the client's health history including any previous pregnancies, births, and loss of life;

(viii) Coordinate with medical providers regarding mental and emotional health screenings, and if appropriate, support symptom reduction through care navigation or peer support;

(ix) Review social determinants of health (SDOH) and other social-related health needs. Provide resources and support guided by client or family priorities; and

(x) Assess family and other relational support networks.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2025 c 424 s 211(35). WSR 25-16-016, s 182-533-0650, filed 7/25/25, effective 8/25/25.*

##### **Wash. Admin. Code § 182-533-0660** Birth doula services—Covered services. {#sec-182-533-0660 omnilex-key=us-wa-regs-official--title-182--182-533-0660}

(1) To be covered, birth doula services must:

(a) Be preventive in nature according to 42 C.F.R. 440.130(c); and

(b) Provide physical, emotional, and informational support to pregnant, birthing, and postpartum people.

(2) The medicaid agency covers the birth doula services described in this section. The agency pays for:

(a) One prenatal intake visit billed only once per client, per pregnancy. The visit must take place in person. Required components of the prenatal visit are listed in WAC 182-533-0650;

(b) Continuous labor and delivery support billed once per client, per pregnancy. This must take place in person and be provided to one client at a time;

(c) One comprehensive postpartum visit per pregnancy; and

(d) Additional prenatal and postpartum visits per client, per pregnancy across the prenatal and postpartum periods.

(3) The agency determines the maximum number of units of services allowed per client when directed by the legislature to achieve targeted expenditure levels for payment of birth doula services for any specific biennium. The maximum number of units allowed per client is published in the agency's current birth doula services billing guide.

(4) The agency evaluates requests for authorization of covered services that exceed limitations on a case-by-case basis in accordance with WAC 182-501-0169.

(5) For birth doula services not allowed via telemedicine, see WAC 182-533-0680.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2025 c 424 s 211(35). WSR 25-16-016, s 182-533-0660, filed 7/25/25, effective 8/25/25.*

##### **Wash. Admin. Code § 182-533-0665** Birth doula services—Noncovered services. {#sec-182-533-0665 omnilex-key=us-wa-regs-official--title-182--182-533-0665}

Under this chapter, the medicaid agency does not cover the following services when provided by birth doulas:

(1) Childcare;

(2) Chore services including, but not limited to, shopping and cooking;

(3) Group services;

(4) Phone calls, text messages, and emails;

(5) Documentation time; and

(6) Travel time and mileage.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2025 c 424 s 211(35). WSR 25-16-016, s 182-533-0665, filed 7/25/25, effective 8/25/25.*

##### **Wash. Admin. Code § 182-533-0670** Birth doula services—Payment. {#sec-182-533-0670 omnilex-key=us-wa-regs-official--title-182--182-533-0670}

(1) The medicaid agency pays for the birth doula services described in WAC 182-533-0660 when they are:

(a) Provided to a client who meets the eligibility requirements in WAC 182-533-0630;

(b) Provided to a client during a face-to-face encounter, including audio-visual telemedicine (see WAC 182-533-0680);

(c) Provided and billed according to the agency's current birth doula services billing guide; and

(d) Documented in the client's health care record or chart per WAC 182-533-0650.

(2) The agency's payment for birth doula services is as follows:

(a) Prenatal intake visit, flat rate with a minimum of two hours of one-to-one service delivered face-to-face;

(b) Labor and delivery support, flat rate with one-to-one service delivered face-to-face; and

(c) Additional prenatal and postpartum visits, per unit of time, with one unit being equal to 15 minutes. Providers must bill for the direct service delivery at the minimum time equivalent.

(3) For clients enrolled in managed care or fee-for-service (FFS) who are eligible for birth doula services, the agency pays for covered birth doula services through FFS using the agency's published fee schedule.

(4) The agency uses the appropriate payment methodology found in WAC 182-531-1850 for birth doula services.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2025 c 424 s 211(35). WSR 25-16-016, s 182-533-0670, filed 7/25/25, effective 8/25/25.*

##### **Wash. Admin. Code § 182-533-0680** Birth doula services—Telemedicine. {#sec-182-533-0680 omnilex-key=us-wa-regs-official--title-182--182-533-0680}

The medicaid agency pays for birth doula services provided via telemedicine according to WAC 182-501-0300 and the limitations in this section.

(1) The agency pays for birth doula services provided via telemedicine when one of the following are met:

(a) The prenatal intake visit is provided in person;

(b) The first visit with a new birth doula is provided in person if the client changes their birth doula;

(c) When initiating care postpartum, the first visit is in person; and

(d) The servicing provider for the telemedicine service uses the same billing provider's national provider identifier (NPI) used to bill for any of the visits referenced in this subsection.

(2) The agency does not pay for the following birth doula services provided via telemedicine:

(a) The prenatal intake visit;

(b) The first visit with a new birth doula if the client changes their birth doula;

(c) Labor and delivery support; and

(d) The first visit with a birth doula when initiating care postpartum.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2025 c 424 s 211(35). WSR 25-16-016, s 182-533-0680, filed 7/25/25, effective 8/25/25.*

##### **Wash. Admin. Code § 182-533-0701** Substance-using pregnant people (SUPP) program—Purpose. {#sec-182-533-0701 omnilex-key=us-wa-regs-official--title-182--182-533-0701}

The substance-using pregnant people (SUPP) program provides immediate access to medical care in a hospital setting to substance-using or substance-dependent pregnant people and their fetuses. The purpose of the immediate access to medical care is to reduce harm to and improve birth outcomes for birthing parents and their fetuses by preventing obstetric and prenatal complications related to substance use disorder.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-17-168, § 182-533-0701, filed 8/24/22, effective 9/24/22. WSR 11-14-075, recodified as § 182-533-0701, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.800. WSR 04-11-008, § 388-533-701 (codified as WAC 388-533-0701), filed 5/5/04, effective 6/5/04.*

##### **Wash. Admin. Code § 182-533-0710** Substance-using pregnant people (SUPP) program—Client eligibility. {#sec-182-533-0710 omnilex-key=us-wa-regs-official--title-182--182-533-0710}

(1) To be eligible for the substance-using pregnant people (SUPP) program, a person must be:

(a) Pregnant; and

(b) Eligible for medicaid.

(2) A client eligible under subsection (1) of this section who is enrolled in an agency-contracted managed care plan is eligible for SUPP services outside their plan. SUPP services and reimbursement are delivered outside a managed care plan and are subject to fee-for-services rules.

(3) A client receiving withdrawal management services or secure withdrawal management services through the agency is not eligible for the SUPP program.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-17-168, § 182-533-0710, filed 8/24/22, effective 9/24/22*
- *WSR 15-14-038, § 182-533-0710, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-533-0710, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 05-08-061, § 388-533-0710, filed 3/31/05, effective 5/1/05*
- *WSR 04-11-008, § 388-533-710 (codified as WAC 388-533-0710), filed 5/5/04, effective 6/5/04.*

##### **Wash. Admin. Code § 182-533-0720** Substance-using pregnant people (SUPP) program—Provider requirements. {#sec-182-533-0720 omnilex-key=us-wa-regs-official--title-182--182-533-0720}

(1) The agency pays only those providers who:

(a) Have been approved by the agency to provide substance-using pregnant people (SUPP) program services;

(b) Have been licensed and certified as a behavioral health agency by the department of health (DOH) under chapter 246-341 WAC;

(c) Meet the department of health hospital licensing regulations in chapter 246-320 WAC; and

(d) Meet the general provider requirements in chapter 182-502 WAC.

(2) Providers must:

(a) Report any changes in their certification, level of care, or program operations to the agency SUPP program manager;

(b) Have written policies and procedures that include a working statement describing the purpose and methods of treatment for substance-using or substance-dependent pregnant people;

(c) Provide guidelines and resources for current medical treatment methods by specific substance type;

(d) Have linkages with state and community providers to ensure a working knowledge exists of current medical and substance use disorder resources; and

(e) Ensure that an assessment for substance use disorders of the client has been completed:

(i) By a substance use disorder professional under chapter 246-811 WAC;

(ii) Using the latest criteria of the American Society of Addiction Medicine (ASAM); and

(iii) No earlier than six months before, and no later than five days after, the client's admission to the SUPP program.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-17-168, § 182-533-0720, filed 8/24/22, effective 9/24/22*
- *WSR 15-14-038, § 182-533-0720, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-533-0720, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 05-08-061, § 388-533-0720, filed 3/31/05, effective 5/1/05*
- *WSR 04-11-008, § 388-533-720 (codified as WAC 388-533-0720), filed 5/5/04, effective 6/5/04.*

##### **Wash. Admin. Code § 182-533-0730** Substance-using pregnant people (SUPP) program—Covered services. {#sec-182-533-0730 omnilex-key=us-wa-regs-official--title-182--182-533-0730}

(1) The agency pays for the following covered services for a pregnant client and their fetus under the substance-using pregnant people (SUPP) program:

(a) Primary acute withdrawal management and medical stabilization;

(b) Secondary subacute withdrawal management and medical stabilization; and

(c) Rehabilitation treatment and services as determined by the provider.

(2) The maximum length of treatment per inpatient stay that the agency will pay for is 26 days, unless additional days have been preauthorized by the agency (SUPP) program manager.

(3) If a client's pregnancy ends before inpatient treatment is completed, a provider may continue treatment through the 26th day.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-17-168, § 182-533-0730, filed 8/24/22, effective 9/24/22*
- *WSR 15-14-038, § 182-533-0730, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-533-0730, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.800. WSR 05-08-061, § 388-533-0730, filed 3/31/05, effective 5/1/05*
- *WSR 04-11-008, § 388-533-730 (codified as WAC 388-533-0730), filed 5/5/04, effective 6/5/04.*

## **Chapter 182-534** Early periodic screening, diagnosis and treatment (EPSDT). {#struct-chapter-182-534}

##### **Wash. Admin. Code § 182-534-0010** Purpose. {#sec-182-534-0010 omnilex-key=us-wa-regs-official--title-182--182-534-0010}

The purpose of the early periodic screening, diagnosis, and treatment program is to ensure that children and adolescents receive comprehensive preventive, diagnostic, and treatment services.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-048, s 182-534-0010, filed 6/11/25, effective 7/12/25.*

##### **Wash. Admin. Code § 182-534-0050** Definitions. {#sec-182-534-0050 omnilex-key=us-wa-regs-official--title-182--182-534-0050}

The following definitions and those found in chapter 182-500 WAC apply to this chapter:

"Early periodic screening, diagnosis, and treatment (EPSDT)" means the federally mandated health care benefit for clients from birth through age 20 that ensures access to medically necessary services. Federal statutes and rules govern EPSDT services; see, e.g., 42 U.S.C. § 1396d(r) and 42 C.F.R. Part 441, Subpart B.

"Well-child checkup" means the same as "screening" in 42 C.F.R. § 441.56(b).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-048, s 182-534-0050, filed 6/11/25, effective 7/12/25.*

##### **Wash. Admin. Code § 182-534-0100** Standard for coverage. {#sec-182-534-0100 omnilex-key=us-wa-regs-official--title-182--182-534-0100}

(1) People age 20 and younger who are enrolled in medicaid are eligible for coverage through the early periodic screening, diagnosis, and treatment (EPSDT) program. See WAC 182-501-0060, Health care coverage—Program benefit packages—Scope of service categories.

(2) Under the EPSDT program, the medicaid agency pays for health care services that fall under any of the categories listed in 42 C.F.R. Part 441, Subpart B, when they are:

(a) Medically necessary, as defined in WAC 182-500-0070;

(b) Safe and effective; and

(c) Not experimental.

(3) Services under the EPSDT program are exempt from specific coverage or service limitations, including amount, duration, and scope of services applicable to the Washington apple health categorically needy and medically needy programs.

(a) The agency may establish utilization controls to safeguard against unnecessary use of care and services. These limits may be exceeded through a process in which the agency reviews medical necessity in a manner consistent with federal EPSDT requirements.

(b) The agency conducts reviews of prior authorization requests on a case-by-case basis, evaluating each client's needs individually, so that delivery of needed treatment services is not delayed. The agency evaluates these requests using the process described in WAC 182-501-0165.

(c) Services not otherwise covered under the medicaid program, including optional services under 42 U.S.C. § 1396d, are available to children through EPSDT when the agency determines the services are medically necessary.

(4) Under the EPSDT program, the agency evaluates requests for noncovered services, as defined by WAC 182-500-0020 and 182-500-0075, under WAC 182-501-0165.

(5) Providers must document all EPSDT services furnished to each client as required by WAC 182-502-0020.

(6) To ensure clients have transportation to medically necessary services, the agency covers various modes of transportation under chapter 182-546 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-048, s 182-534-0100, filed 6/11/25, effective 7/12/25. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-019, § 182-534-0100, filed 7/24/14, effective 8/24/14. Statutory Authority: RCW 41.05.021 and section 1115 (a)(2) of the Social Security Act. WSR 12-22-046, § 182-534-0100, filed 11/2/12, effective 12/3/12. WSR 11-14-075, recodified as § 182-534-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090, 42 C.F.R., Part 441, Subpart B. WSR 02-07-016, § 388-534-0100, filed 3/8/02, effective 4/8/02. Statutory Authority: RCW 74.08.090. WSR 01-02-076, § 388-534-0100, filed 12/29/00, effective 1/29/01. WSR 00-11-183, recodified as § 388-534-0100, filed 5/24/00, effective 5/24/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-86-027, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090. WSR 90-12-061 (Order 3019), § 388-86-027, filed 5/31/90, effective 7/1/90*
- *WSR 82-01-001 (Order 1725), § 388-86-027, filed 12/3/81*
- *WSR 81-10-015 (Order 1647), § 388-86-027, filed 4/27/81*
- *WSR 80-15-034 (Order 1554), § 388-86-027, filed 10/9/80*
- *WSR 79-12-047 (Order 1457), § 388-86-027, filed 11/26/79*
- *Order 1112, § 388-86-027, filed 4/15/76*
- *Order 738, § 388-86-027, filed 11/22/72.*

##### **Wash. Admin. Code § 182-534-0200** Enhanced payments for EPSDT well-child checkups for children in out-of-home placement. {#sec-182-534-0200 omnilex-key=us-wa-regs-official--title-182--182-534-0200}

The medicaid agency covers early periodic screening, diagnosis, and treatment (EPSDT) services, as described in WAC 182-534-0100, for children in out-of-home placement to ensure medically necessary needs are promptly addressed.

(1) For the purposes of this section, out-of-home placement means temporary, 24 hour-per-day, substitute care for a child age 20 and younger:

(a) Placed away from the child's parents or guardians in licensed, paid, out-of-home care; and

(b) For whom the department of children, youth, and families or a tribe has placement and care authority.

(2) The agency pays an enhanced fee only for well-child checkups provided to children in out-of-home placement when the placement meets the federal requirements under 42 C.F.R. Part 441, Subpart B.

(3) For children in out-of-home placement, the agency exempts well-child checkups from coverage limitations, regardless of the periodicity schedule recommended by the American Academy of Pediatrics' Bright Futures guidelines or a comparable standard. The periodicity schedule is found in the agency's EPSDT well-child program billing guide.

(4) The agency pays for initial health screenings for children transitioning to out-of-home placement to identify and address immediate health needs.

(a) The agency pays for an initial health screening in addition to well-child checkups.

(b) Children must have an initial health screen within five days of entering out-of-home placement and a required well-child checkup within 30 days of entering out-of-home placement.

(c) The provider must document the initial health screening using the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Out-of-Home Placement Initial Health Screen Form (HCA 13-843).

(5) The agency evaluates client files and payments made under this program. The agency may recover the enhanced payment amount when:

(a) The child was not in out-of-home placement as defined in subsection (1) of this section when the EPSDT screen was provided; or

(b) Documentation was not in the child's medical file.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-048, s 182-534-0200, filed 6/11/25, effective 7/12/25*
- *WSR 24-21-163, s 182-534-0200, filed 10/23/24, effective 11/23/24*
- *WSR 15-12-074, § 182-534-0200, filed 5/29/15, effective 7/1/15. WSR 11-14-075, recodified as § 182-534-0200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-534-0200, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090, 42 C.F.R., Part 441, Subpart B. WSR 02-07-016, § 388-534-0200, filed 3/8/02, effective 4/8/02.*

## **Chapter 182-535** Dental-related services. {#struct-chapter-182-535}

##### **Wash. Admin. Code § 182-535-1050** Definitions. {#sec-182-535-1050 omnilex-key=us-wa-regs-official--title-182--182-535-1050}

The following definitions and abbreviations and those found in chapter 182-500 WAC apply to this chapter. The medicaid agency also uses dental definitions found in the American Dental Association's Current Dental Terminology (CDT) and the American Medical Association's Physician's Current Procedural Terminology (CPT). Where there is any discrepancy between the CDT or CPT and this section, this section prevails. (CPT is a trademark of the American Medical Association, and CDT is a trademark of the American Dental Association.)

"Access to baby and child dentistry (ABCD)" is a program to increase access to dental services for medicaid eligible infants, toddlers, and preschoolers through age five. See WAC 182-535-1245 for specific information.

"Alternate living facility" is defined in WAC 182-513-1100.

"American Dental Association (ADA)" is a national organization for dental professionals and dental societies.

"Anterior" refers to teeth (maxillary and mandibular incisors and canines) and tissue in the front of the mouth. Permanent maxillary anterior teeth include teeth six, seven, eight, nine, 10, and 11. Permanent mandibular anterior teeth include teeth 22, 23, 24, 25, 26, and 27. Primary maxillary anterior teeth include teeth C, D, E, F, G, and H. Primary mandibular anterior teeth include teeth M, N, O, P, Q, and R.

"Asynchronous" means two or more events not happening at the same time.

"Alveoloplasty" means a distinct (separate procedure) from extractions. Usually in preparation for a prosthesis or other treatments such as radiation therapy and transplant surgery.

"Behavior management" means using one additional professional staff, who is employed by the dental provider or clinic and who is not delivering dental treatment to the client, to manage the client's behavior to facilitate dental treatment delivery.

"By-report" means a method of reimbursement in which the department determines the amount it will pay for a service when the rate for that service is not included in the agency's published fee schedules. Upon request the provider must submit a "report" that describes the nature, extent, time, effort and/or equipment necessary to deliver the service.

"Caries" means carious lesions or tooth decay through the enamel or decay on the root surface.

• "Incipient caries" means the beginning stages of caries or decay, or subsurface demineralization.

• "Rampant caries" means a sudden onset of widespread caries that affects most of the teeth and penetrates quickly to the dental pulp.

"Comprehensive oral evaluation" means a thorough evaluation and documentation of a client's dental and medical history to include extra-oral and intra-oral hard and soft tissues, dental caries, missing or unerupted teeth, restorations, occlusal relationships, periodontal conditions, (may include periodontal screening and/or charting), hard and soft tissue anomalies, and oral cancer screening.

"Conscious sedation" means a drug-induced depression of consciousness during which a client responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, spontaneous ventilation is adequate, and cardiovascular function is maintained.

"Core buildup" means the building up of clinical crowns, including pins.

"Coronal" means the portion of a tooth that is covered by enamel.

"Crown" means a restoration covering or replacing the whole clinical crown of a tooth.

"Current dental terminology (CDT)" means a systematic listing of descriptive terms and identifying codes for reporting dental services and procedures performed by dental practitioners. CDT is published by the Council on Dental Benefit Programs of the American Dental Association (ADA).

"Current procedural terminology (CPT)" means a systematic listing of descriptive terms and identifying codes for reporting medical services, procedures, and interventions performed by physicians and other practitioners who provide physician-related services. CPT is copyrighted and published annually by the American Medical Association (AMA).

"Decay" means a term for caries or carious lesions and means decomposition of tooth structure.

"Deep sedation" means a drug-induced depression of consciousness during which a client cannot be easily aroused, ventilatory function may be impaired, but the client responds to repeated or painful stimulation.

"Dental general anesthesia" see "general anesthesia."

"Dentures" means an artificial replacement for natural teeth and adjacent tissues, and includes complete dentures, immediate dentures, overdentures, and partial dentures.

"Denturist" means a person licensed under chapter 18.30 RCW to make, construct, alter, reproduce, or repair a denture.

"Distant site (location of dental provider)" means the physical location of the dentist or authorized dental provider providing the dental service to a client through teledentistry.

"Early periodic screening, diagnosis, and treatment (EPSDT)" is defined under WAC 182-534-0050.

"Edentulous" means lacking teeth.

"Endodontic" means the etiology, diagnosis, prevention and treatment of diseases and injuries of the pulp and associated periradicular conditions.

"Extraction" see "simple extraction" and "surgical extraction."

"Fluoride varnish, rinse, foam or gel" means a substance containing dental fluoride which is applied to teeth, not including silver diamine fluoride.

"General anesthesia" means a drug-induced loss of consciousness during which a client is not arousable even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Clients may require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

"Interim therapeutic restoration (ITR)" means the placement of an adhesive restorative material following caries debridement by hand or other method for the management of early childhood caries. It is not considered a definitive restoration.

"Limited oral evaluation" means an evaluation limited to a specific oral health condition or problem. Typically a client receiving this type of evaluation has a dental emergency, such as trauma or acute infection.

"Limited visual oral assessment" means an assessment by a dentist or dental hygienist provided in a setting other than a dental office or dental clinic to identify signs of disease and the potential need for referral for diagnosis.

"Medically necessary" see WAC 182-500-0070.

"Mobile anesthesiologist" means a provider qualified to deliver moderate and deep sedation in an office setting other than their own. The mobile anesthesiologist is a separate provider from the clinician delivering dental treatment.

"Oral evaluation" see "comprehensive oral evaluation."

"Oral hygiene instruction" means instruction for home oral hygiene care, such as tooth brushing techniques or flossing.

"Originating site (location of client)" means the physical location of the medicaid client as it relates to teledentistry.

"Partials" or "partial dentures" mean a removable prosthetic appliance that replaces missing teeth on either arch.

"Periodic oral evaluation" means an evaluation performed on a patient of record to determine any changes in the client's dental or medical status since a previous comprehensive or periodic evaluation.

"Periodontal maintenance" means a procedure performed for clients who have previously been treated for periodontal disease with surgical or nonsurgical treatment. It includes the removal of supragingival and subgingival microorganisms, calculus, and deposits with hand and mechanical instrumentation, an evaluation of periodontal conditions, and a complete periodontal charting as appropriate.

"Periodontal scaling and root planing" means a procedure to remove plaque, calculus, microorganisms, and rough cementum and dentin from tooth surfaces. This includes hand and mechanical instrumentation, an evaluation of periodontal conditions, and a complete periodontal charting as appropriate.

"Posterior" means the teeth (maxillary and mandibular premolars and molars) and tissue towards the back of the mouth. Permanent maxillary posterior teeth include teeth one, two, three, four, five, 12, 13, 14, 15, and 16. Permanent mandibular posterior teeth include teeth 17, 18, 19, 20, 21, 28, 29, 30, 31, and 32. Primary maxillary posterior teeth include teeth A, B, I, and J. Primary mandibular posterior teeth include teeth K, L, S, and T.

"Prophylaxis" means the dental procedure of scaling and polishing which includes removal of calculus, plaque, and stains from tooth structures and implants and is intended to control local irritation factors.

"Proximal" means the surface of the tooth near or next to the adjacent tooth.

"Radiograph (X-ray)" means an image or picture produced on a radiation sensitive film emulsion or digital sensor by exposure to ionizing radiation.

"Reline" means to resurface the tissue side of a denture with new base material or soft tissue conditioner in order to achieve a more accurate fit.

"Resin-based composite restorations" means resin-based composite refers to a broad category of materials including, but not limited to, composites. The category may include bonded composite, light-cured composite, etc. Tooth preparation, acid-etching, adhesives (including resin-bonding agents), liners and bases, and curing are included as part of the restoration. Glass ionomers, when used as definitive restorations, should be reported with resin-based composite codes.

"Root canal" means the chamber within the root of the tooth that contains the pulp.

"Root canal therapy" means the treatment of the pulp and associated periradicular conditions.

"Root planing" means a procedure to remove plaque, calculus, microorganisms, and rough cementum and dentin from tooth surfaces. This includes hand and mechanical instrumentation.

"Scaling" means a procedure to remove plaque, calculus, and stain deposits from tooth surfaces.

"Sealant" means a dental material applied to teeth to prevent dental caries.

"Simple extraction" means the extraction of an erupted or exposed tooth to include the removal of tooth structure, minor smoothing of socket bone, and closure, as necessary.

"Standard of care" means what reasonable and prudent practitioners would do in the same or similar circumstances.

"Surgical extraction" means the extraction of an erupted or impacted tooth requiring removal of bone and/or sectioning of the tooth, and including elevation of mucoperiosteal flap if indicated. This includes related cutting of gingiva and bone, removal of tooth structure, minor smoothing of socket bone, and closure.

"Synchronous" means existing or occurring at the same time.

"Teledentistry" means the variety of technologies and tactics used to deliver HIPAA-compliant, interactive, real-time audio and video telecommunications (including web-based applications) or store-and-forward technology to deliver covered services within the dental care provider's scope of practice to a client at a site other than the site where the provider is located.

"Temporomandibular joint dysfunction (TMJ/TMD)" means an abnormal functioning of the temporomandibular joint or other areas secondary to the dysfunction.

"Therapeutic pulpotomy" means the surgical removal of a portion of the pulp (inner soft tissue of a tooth), to retain the healthy remaining pulp.

"Usual and customary" means the fee that the provider usually charges nonmedicaid customers for the same service or item. This is the maximum amount that the provider may bill the agency.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-21-142, s 182-535-1050, filed 10/21/25, effective 11/21/25*
- *WSR 21-14-055, § 182-535-1050, filed 7/1/21, effective 8/1/21. Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 415 §§ 211 (1)(c) and 1111 (1)(c). WSR 19-20-047, § 182-535-1050, filed 9/25/19, effective 10/26/19. Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 3rd sp.s. c 1 § 213 (1)(c). WSR 19-09-058, § 182-535-1050, filed 4/15/19, effective 7/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-20-097, § 182-535-1050, filed 10/3/17, effective 11/3/17*
- *WSR 16-13-110, § 182-535-1050, filed 6/20/16, effective 8/1/16. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1050, filed 3/25/14, effective 4/30/14. WSR 11-14-075, recodified as § 182-535-1050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 07-06-041, § 388-535-1050, filed 3/1/07, effective 4/1/07. Statutory Authority: RCW 74.04.050, 74.04.057, and 74.09.530. WSR 04-14-100, § 388-535-1050, filed 7/6/04, effective 8/6/04. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. WSR 03-19-077, § 388-535-1050, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. WSR 02-13-074, § 388-535-1050, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090. WSR 01-02-076, § 388-535-1050, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 440.225. WSR 99-07-023, § 388-535-1050, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. WSR 96-01-006 (Order 3931), § 388-535-1050, filed 12/6/95, effective 1/6/96.*

##### **Wash. Admin. Code § 182-535-1060** Client eligibility. {#sec-182-535-1060 omnilex-key=us-wa-regs-official--title-182--182-535-1060}

(1) Refer to WAC 182-501-0060 to see which apple health programs include dental-related services in their benefit package.

(2) Managed care clients are eligible under apple health fee-for-service for covered dental-related services not covered by their managed care organization (MCO), subject to the provisions of this chapter and other applicable agency rules.

(3) See WAC 182-507-0115 for rules for clients eligible under the alien emergency medical program.

(4) Exception to rule procedures as described in WAC 182-501-0160 are not available for services that are excluded from a client's benefit package.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 415 §§ 211 (1)(c) and 1111 (1)(c). WSR 19-20-047, § 182-535-1060, filed 9/25/19, effective 10/26/19. Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 3rd sp.s. c 1 § 213 (1)(c). WSR 19-09-058, § 182-535-1060, filed 4/15/19, effective 7/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-20-097, § 182-535-1060, filed 10/3/17, effective 11/3/17. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1060, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1060, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1060, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. WSR 03-19-077, § 388-535-1060, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. WSR 02-13-074, § 388-535-1060, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 440.225. WSR 99-07-023, § 388-535-1060, filed 3/10/99, effective 4/10/99.*

##### **Wash. Admin. Code § 182-535-1070** Dental-related services—Provider information. {#sec-182-535-1070 omnilex-key=us-wa-regs-official--title-182--182-535-1070}

(1) The following providers are eligible to enroll with the medicaid agency to furnish and bill for dental-related services provided to eligible clients:

(a) Persons currently licensed by the state of Washington to:

(i) Practice dentistry or specialties of dentistry.

(ii) Practice as dental hygienists.

(iii) Practice as denturists.

(iv) Practice as dental therapists.

(v) Practice anesthesia by:

(A) Providing conscious sedation with parenteral or multiple oral agents, deep sedation, or general anesthesia as an anesthesiologist or dental anesthesiologist;

(B) Providing conscious sedation with parenteral or multiple oral agents, deep sedation, or general anesthesia as a qualified professional under chapter 246-817 WAC; or

(C) Providing conscious sedation with parenteral or multiple oral agents as a dentist, when the dentist has a conscious sedation permit issued by the department of health (DOH) that is current at the time the billed service(s) is provided; or

(D) Providing deep sedation or general anesthesia as a dentist when the dentist has a general anesthesia permit issued by DOH that is current at the time the billed service(s) is provided.

(vi) Practice medicine and osteopathy for:

(A) Oral surgery procedures; or

(B) Providing fluoride varnish under EPSDT.

(b) Facilities that are:

(i) Hospitals currently licensed by the DOH;

(ii) Federally qualified health centers (FQHCs);

(iii) Medicare-certified ambulatory surgical centers (ASCs);

(iv) Medicare-certified rural health clinics (RHCs); or

(v) Community health centers.

(c) Participating local health jurisdictions.

(d) Bordering city or out-of-state providers of dental-related services who are qualified in their states to provide these services.

(2) Subject to the restrictions and limitations in this section and other applicable WAC, the agency pays licensed providers participating in the agency's dental program for only those services that are within their scope of practice.

(3) For the dental specialty of oral and maxillofacial surgery, the agency requires a dentist to meet the following requirements in order to be reimbursed for oral and maxillofacial surgery:

(a) The provider's professional organization guidelines;

(b) The department of health (DOH) requirements in chapter 246-817 WAC; and

(c) Any applicable DOH medical, dental, and nursing anesthesia regulations.

(4) See WAC 182-502-0020 for provider documentation and record retention requirements. The agency requires additional dental documentation under specific sections in this chapter and as required by DOH under chapter 246-817 WAC.

(5) See WAC 182-502-0100 and 182-502-0150 for provider billing and payment requirements. Enrolled dental providers who do not meet the conditions in subsection (3) of this section must bill all claims using only the CDT codes for services that are identified in WAC and the agency's published billing instructions and provider notices. The agency does not reimburse for billed CPT codes when the dental provider does not meet the requirements in subsection (3)(a) of this section.

(6) See WAC 182-502-0160 for regulations concerning charges billed to clients.

(7) See WAC 182-502-0230 for provider payment reviews and dispute rights.

(8) See chapter 182-502A WAC for provider audits and the audit appeal process.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-12-065, s 182-535-1070, filed 5/30/25, effective 6/30/25*
- *WSR 17-20-097, § 182-535-1070, filed 10/3/17, effective 11/3/17. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1070, filed 3/25/14, effective 4/30/14. WSR 11-14-075, recodified as § 182-535-1070, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 05-06-092, § 388-535-1070, filed 3/1/05, effective 4/1/05. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. WSR 03-19-077, § 388-535-1070, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. WSR 02-13-074, § 388-535-1070, filed 6/14/02, effective 7/15/02.*

##### **Wash. Admin. Code § 182-535-1079** Dental-related services—General. {#sec-182-535-1079 omnilex-key=us-wa-regs-official--title-182--182-535-1079}

(1) Clients described in WAC 182-535-1060 are eligible to receive the dental-related services described in this chapter, subject to coverage limitations, restrictions, and client age requirements identified for a specific service. The medicaid agency pays for dental-related services and procedures provided to eligible clients when the services and procedures:

(a) Are part of the client's dental benefit package;

(b) Are within the scope of an eligible client's Washington apple health program;

(c) Are medically necessary;

(d) Meet the agency's authorization requirements, if any;

(e) Are documented in the client's dental record in accordance with chapter 182-502 WAC and meet the department of health's requirements in WAC 246-817-305 and 246-817-310;

(f) Are within accepted dental or medical practice standards;

(g) Are consistent with a diagnosis of a dental disease or dental condition;

(h) Are reasonable in amount and duration of care, treatment, or service; and

(i) Are listed as covered in the agency's rules and published billing instructions and fee schedules.

(2) For orthodontic services, see chapter 182-535A WAC.

(3) The agency requires site-of-service prior authorization, in addition to prior authorization of the procedure, if applicable, for nonemergency dental-related services performed in a hospital or an ambulatory surgery center when:

(a) A client is not a client of the developmental disabilities community services division of the department of social and health services (DSHS) according to WAC 182-535-1099;

(b) A client is age nine or older;

(c) The service is not listed as exempt from the site-of-service authorization requirement in the agency's current published dental-related services fee schedule or billing instructions; and

(d) The service is not listed as exempt from the prior authorization requirement for deep sedation or general anesthesia (see WAC 182-535-1098 (1)(c)(v)).

(4) To be eligible for payment, dental-related services performed in a hospital or an ambulatory surgery center must be listed in the agency's current published outpatient fee schedule or ambulatory surgery center fee schedule. The claim must be billed with the correct procedure code for the site-of-service.

(5) For clients age 20 and younger, providers must follow the rules for the early periodic screening, diagnosis, and treatment (EPSDT) program, see chapter 182-534 WAC.

(6) The agency evaluates a request for dental-related services that are:

(a) In excess of the dental program's limitations or restrictions, according to WAC 182-501-0169; and

(b) Listed as noncovered, according to WAC 182-501-0160.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-21-142, s 182-535-1079, filed 10/21/25, effective 11/21/25*
- *WSR 17-20-097, § 182-535-1079, filed 10/3/17, effective 11/3/17*
- *WSR 16-18-033, § 182-535-1079, filed 8/26/16, effective 9/26/16. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1079, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1079, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1079, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 07-06-042, § 388-535-1079, filed 3/1/07, effective 4/1/07.*

##### **Wash. Admin. Code § 182-535-1080** Covered—Diagnostic. {#sec-182-535-1080 omnilex-key=us-wa-regs-official--title-182--182-535-1080}

Clients described in WAC 182-535-1060 are eligible to receive the dental-related diagnostic services listed in this section, subject to coverage limitations, restrictions, and client age requirements identified for a specific service.

(1) Clinical oral evaluations. The medicaid agency covers the following oral health evaluations and assessments, per client, per provider or clinic:

(a) Periodic oral evaluations as defined in WAC 182-535-1050, once every six months. Six months must elapse between the comprehensive oral evaluation and the first periodic oral evaluation.

(b) Limited oral evaluations as defined in WAC 182-535-1050, only when the provider performing the limited oral evaluation is not providing routine scheduled dental services for the client on the same day. The limited oral evaluation:

(i) Must be to evaluate the client for a:

(A) Specific dental problem or oral health complaint;

(B) Dental emergency; or

(C) Referral for other treatment.

(ii) When performed by a denturist, is limited to the initial examination appointment. The agency does not cover any additional limited examination by a denturist for the same client until three months after a removable prosthesis has been delivered.

(c) Comprehensive oral evaluations as defined in WAC 182-535-1050, once per client, per provider or clinic, as an initial examination. The agency covers an additional comprehensive oral evaluation if the client has not been treated by the same provider or clinic within the past five years.

(d) Limited visual oral assessments as defined in WAC 182-535-1050, two times per client, per provider in a twelve-month period only when the assessment is:

(i) Not performed in conjunction with other clinical oral evaluation services; and

(ii) Performed by a licensed dentist or dental hygienist to determine the need for sealants or fluoride treatment or when triage services are provided in settings other than dental offices or clinics.

(2) Radiographs (X-rays). The agency:

(a) Covers radiographs per client, per provider or clinic, that are of diagnostic quality, dated, and labeled with the client's name. The agency requires:

(i) Original radiographs to be retained by the provider as part of the client's dental record; and

(ii) Duplicate radiographs to be submitted:

(A) With requests for prior authorization; or

(B) When the agency requests copies of dental records.

(b) Uses the prevailing standard of care to determine the need for dental radiographs.

(c) Covers an intraoral complete series once in a three-year period for clients age fourteen and older only if the agency has not paid for a panoramic radiograph for the same client in the same three-year period. The intraoral complete series typically includes fourteen to twenty-two periapical and posterior bitewings. The agency limits reimbursement for all radiographs to a total payment of no more than payment for a complete series.

(d) Covers medically necessary periapical radiographs for diagnosis in conjunction with definitive treatment, such as root canal therapy. Documentation supporting medical necessity must be included in the client's record.

(e) Covers an occlusal intraoral radiograph, per arch, once in a two-year period, for clients age twenty and younger.

(f) Covers a maximum of four bitewing radiographs once every twelve months.

(g) Covers panoramic radiographs in conjunction with four bitewings, once in a three-year period, only if the agency has not paid for an intraoral complete series for the same client in the same three-year period.

(h) Covers one preoperative and postoperative panoramic radiograph per surgery without prior authorization. The agency considers additional radiographs on a case-by-case basis with prior authorization. For orthodontic services, see chapter 182-535A WAC.

(i) Covers one preoperative and postoperative cephalometric film per surgery without prior authorization. The agency considers additional radiographs on a case-by-case basis with prior authorization. For orthodontic services, see chapter 182-535A WAC.

(j) Covers radiographs not listed as covered in this subsection, only on a case-by-case basis and when prior authorized.

(k) Covers oral and facial photographic images, only on a case-by-case basis and when requested by the agency.

(3) Tests and examinations. The agency covers the following for clients who are age twenty and younger:

One pulp vitality test per visit (not per tooth):

(a) For diagnosis only during limited oral evaluations; and

(b) When radiographs or documented symptoms justify the medical necessity for the pulp vitality test.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-14-055, § 182-535-1080, filed 7/1/21, effective 8/1/21. Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 3rd sp.s. c 1 § 213 (1)(c). WSR 19-09-058, § 182-535-1080, filed 4/15/19, effective 7/1/19. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-18-033, § 182-535-1080, filed 8/26/16, effective 9/26/16. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1080, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1080, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1080, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 07-06-042, § 388-535-1080, filed 3/1/07, effective 4/1/07. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. WSR 03-19-078, § 388-535-1080, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. WSR 02-13-074, § 388-535-1080, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 440.225. WSR 99-07-023, § 388-535-1080, filed 3/10/99, effective 4/10/99.*

##### **Wash. Admin. Code § 182-535-1082** Covered—Preventive services. {#sec-182-535-1082 omnilex-key=us-wa-regs-official--title-182--182-535-1082}

Clients described in WAC 182-535-1060 are eligible for the dental-related preventive services listed in this section, subject to coverage limitations and client-age requirements identified for a specific service.

(1) Prophylaxis. The medicaid agency covers prophylaxis as follows. Prophylaxis:

(a) Includes scaling and polishing procedures to remove coronal plaque, calculus, and stains when performed on tooth structures and implants.

(b) Is limited to once every:

(i) Six months for clients:

(A) Age 18 and younger; or

(B) Of any age residing in an alternate living facility or nursing facility;

(ii) Twelve months for clients age 19 and older.

(c) Is reimbursed according to (b) of this subsection when the service is performed:

(i) At least six months after periodontal scaling and root planing, or periodontal maintenance services, for clients:

(A) Age 13 through 18; or

(B) Of any age residing in an alternate living facility or nursing facility; or

(ii) At least 12 months after periodontal scaling and root planing, periodontal maintenance services, for clients age 19 and older.

(d) Is not reimbursed separately when performed on the same date of service as periodontal scaling and root planing, periodontal maintenance, gingivectomy, gingivoplasty, or scaling in the presence of generalized moderate or severe gingival inflammation.

(e) Is covered for clients of the developmental disabilities community services division of the department of social and health services (DSHS) according to (a), (c), and (d) of this subsection and WAC 182-535-1099.

(2) Topical fluoride treatment. The agency covers the following per client, per provider or clinic:

(a) Fluoride rinse, foam or gel, fluoride varnish, including disposable trays, three times within a 12-month period with a minimum of 110 days between applications for clients:

(i) Age six and younger;

(ii) During orthodontic treatment.

(b) Fluoride rinse, foam or gel, fluoride varnish, including disposable trays, two times within a 12-month period with a minimum of 170 days between applications for clients:

(i) From age seven through 18; or

(ii) Of any age residing in alternate living facilities or nursing facilities.

(c) Fluoride rinse, foam or gel, fluoride varnish, including disposable trays, for clients age 19 and older, once within a 12-month period.

(d) Additional topical fluoride applications only on a case-by-case basis and when prior authorized.

(e) Topical fluoride treatment for clients of the developmental disabilities community services division of DSHS according to WAC 182-535-1099.

(3) Silver diamine fluoride.

(a) The agency covers silver diamine fluoride as follows:

(i) When used for stopping the progression of caries or as a topical preventive agent;

(ii) Allowed two times per client per tooth in a 12-month period; and

(iii) Cannot be billed with interim therapeutic restoration on the same tooth when arresting caries or as a preventive agent.

(b) The dental provider or office must have a signed informed consent form on file for each client receiving a silver diamine fluoride application. The form must include the following:

(i) Benefits and risks of silver diamine fluoride application;

(ii) Alternatives to silver diamine fluoride application; and

(iii) A color photograph example that demonstrates the post-procedure blackening of a tooth with silver diamine fluoride application.

(4) Oral hygiene instruction. Includes instruction for home care such as tooth brushing technique, flossing, and use of oral hygiene aids. Oral hygiene instruction is included as part of the global fee for prophylaxis for clients age nine and older. The agency covers individualized oral hygiene instruction for clients age eight and younger when all of the following criteria are met:

(a) Only once per client every six months within a 12-month period.

(b) Only when not performed on the same date of service as prophylaxis or within six months from a prophylaxis by the same provider or clinic.

(c) Only when provided by a licensed dentist or a licensed dental hygienist and the instruction is provided in a setting other than a dental office or clinic.

(5) Tobacco/nicotine cessation counseling for the control and prevention of oral disease. The agency covers tobacco/nicotine cessation counseling for pregnant individuals only. See WAC 182-531-1720.

(6) Sealants. The agency covers:

(a) Sealants for clients age 20 and younger and clients any age of the developmental disabilities community services division of DSHS.

(b) Sealants once per tooth:

(i) In a three-year period for clients age 20 and younger; and

(ii) In a two-year period for clients any age of the developmental disabilities community services division of DSHS according to WAC 182-535-1099.

(c) Sealants only when used on the occlusal surfaces of:

(i) Permanent teeth two, three, 14, 15, 18, 19, 30, and 31; and

(ii) Primary teeth A, B, I, J, K, L, S, and T.

(d) Sealants on noncarious teeth or teeth with incipient caries.

(e) Sealants only when placed on a tooth with no preexisting occlusal restoration, or any occlusal restoration placed on the same day.

(f) Sealants are included in the agency's payment for occlusal restoration placed on the same day.

(g) Additional sealants not described in this subsection on a case-by-case basis and when prior authorized.

(7) Space maintenance. The agency covers:

(a) One fixed unilateral space maintainer per quadrant or one fixed bilateral space maintainer per arch, including recementation, for missing primary molars A, B, I, J, K, L, S, and T, when:

(i) Evidence of pending permanent tooth eruption exists; and

(ii) The service is not provided during approved orthodontic treatment.

(b) Replacement space maintainers on a case-by-case basis when authorized.

(c) The removal of fixed space maintainers when removed by a different provider.

(i) Space maintainer removal is allowed once per appliance.

(ii) Reimbursement for space maintainer removal is included in the payment to the original provider that placed the space maintainer.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-535-1082, filed 11/4/25, effective 12/5/25*
- *WSR 22-16-070, § 182-535-1082, filed 7/29/22, effective 8/29/22*
- *WSR 21-14-055, § 182-535-1082, filed 7/1/21, effective 8/1/21. Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 3rd sp.s. c 1 § 213 (1)(c). WSR 19-09-058, § 182-535-1082, filed 4/15/19, effective 7/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-20-097, § 182-535-1082, filed 10/3/17, effective 11/3/17*
- *WSR 16-18-033, § 182-535-1082, filed 8/26/16, effective 9/26/16. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1082, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1082, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1082, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 07-06-042, § 388-535-1082, filed 3/1/07, effective 4/1/07.*

##### **Wash. Admin. Code § 182-535-1084** Dental-related services—Covered—Restorative services. {#sec-182-535-1084 omnilex-key=us-wa-regs-official--title-182--182-535-1084}

Clients described in WAC 182-535-1060 are eligible for the dental-related restorative services listed in this section, subject to coverage limitations, restrictions, and client age requirements identified for a specific service.

(1) Amalgam, resin, and glass ionomer restorations for primary and permanent teeth. The medicaid agency considers:

(a) Tooth preparation, acid etching, all adhesives (including bonding agents), liners and bases, indirect and direct pulp capping, polishing, and curing as part of the restoration.

(b) Occlusal adjustment of either the restored tooth or the opposing tooth or teeth as part of the restoration.

(c) Restorations placed within six months of a crown preparation by the same provider or clinic to be included in the payment for the crown.

(2) Limitations for all restorations. The agency:

(a) Considers multiple restoration involving the proximal and occlusal surfaces of the same tooth as a multisurface restoration, and limits reimbursement to a single multisurface restoration.

(b) Considers multiple restorative resins, flowable composite resins, resin-based composites, or glass ionomer restorations for the occlusal, buccal, lingual, mesial, and distal fissures and grooves on the same tooth as a one-surface restoration.

(c) Considers multiple restorations of fissures and grooves of the occlusal surface of the same tooth as a one-surface restoration.

(d) Considers resin-based composite restorations of teeth where the decay does not penetrate the dentinoenamel junction (DEJ) to be sealants. (See WAC 182-535-1082 for sealant coverage.)

(e) Covers only one buccal and one lingual surface per tooth. The agency reimburses buccal or lingual restorations, regardless of size or extension, as a one-surface restoration.

(f) Does not cover preventative restorations.

(g) Covers replacement restorations between six and 24 months of original placement, with approved prior authorization, if the restoration is cracked or broken. The client's record must include X-rays or documentation supporting the medical necessity for the replacement restoration.

(h) Replacement of a cracked or broken restoration within a six-month period by the same provider is considered part of the global payment of the initial restoration and will not pay separately.

(3) Additional limitations for restorations on permanent teeth. The agency covers:

(a) Two occlusal restorations for the upper molars on teeth one, two, three, 14, 15, and 16 if, the restorations are anatomically separated by sound tooth structure.

(b) A maximum of five surfaces per tooth for permanent posterior teeth, except for upper molars. The agency allows a maximum of six surfaces per tooth for teeth one, two, three, 14, 15, and 16.

(c) A maximum of six surfaces per tooth for resin-based composite restorations for permanent anterior teeth.

(4) Crowns. The agency:

(a) Covers the following indirect crowns once every five years, per tooth, for permanent anterior teeth for clients age 15 through 20 when the crowns meet prior authorization criteria in WAC 182-535-1220 and the provider follows the prior authorization requirements in (c) of this subsection:

(i) Porcelain/ceramic crowns to include all porcelains, glasses, glass-ceramic, and porcelain fused to metal crowns; and

(ii) Resin crowns and resin metal crowns to include any resin-based composite, fiber, or ceramic reinforced polymer compound.

(b) Considers the following to be included in the payment for a crown:

(i) Tooth and soft tissue preparation;

(ii) Amalgam and resin-based composite restoration, or any other restorative material placed within six months of the crown preparation. Exception: The agency covers a one-surface restoration on an endodontically treated tooth, or a core buildup or cast post and core;

(iii) Temporaries including, but not limited to, temporary restoration, temporary crown, provisional crown, temporary prefabricated stainless steel crown, ion crown, or acrylic crown;

(iv) Packing cord placement and removal;

(v) Diagnostic or final impressions;

(vi) Crown seating (placement), including cementing and insulating bases;

(vii) Occlusal adjustment of crown or opposing tooth or teeth; and

(viii) Local anesthesia.

(c) Requires the provider to submit the following with each prior authorization request:

(i) Radiographs to assess all remaining teeth;

(ii) Documentation and identification of all missing teeth;

(iii) Caries diagnosis and treatment plan for all remaining teeth, including a caries control plan for clients with rampant caries;

(iv) Pre- and post-endodontic treatment radiographs for requests on endodontically treated teeth; and

(v) Documentation supporting a five-year prognosis that the client will retain the tooth or crown if the tooth is crowned.

(d) Requires a provider to bill for a crown only after delivery and seating of the crown, not at the impression date.

(5) Other restorative services. The agency covers the following restorative services:

(a) All recementations of permanent indirect crowns.

(b) Prefabricated stainless steel crowns, including stainless steel crowns with resin window, resin-based composite crowns (direct), prefabricated esthetic coated stainless steel crowns, and prefabricated resin crowns for primary anterior teeth once every three years only for clients age 20 and younger.

(c) Prefabricated stainless steel crowns, including stainless steel crowns with resin window, resin-based composite crowns (direct), prefabricated esthetic coated stainless steel crowns, and prefabricated resin crowns, for primary posterior teeth once every three years without prior authorization for clients ages zero through 12 and with prior authorization for clients age 13 through 20 if:

(i) The tooth had a pulpotomy; or

(ii) Evidence of Class II caries with rampant decay; or

(iii) Evidence of extensive caries; or

(iv) Treatment of decay requires sedation or general anesthesia.

(d) Prefabricated stainless steel crowns, including stainless steel crowns with resin window, and prefabricated resin crowns, for permanent posterior teeth excluding one, 16, 17, and 32 once every three years, for clients age 20 and younger, without prior authorization.

(e) Prefabricated stainless steel crowns, for permanent posterior teeth, excluding one, 16, 17, and 32 for clients age 21 and older in lieu of a restoration requiring three or more surfaces.

(f) Prefabricated stainless steel crowns for clients of the developmental disabilities community services division of the department of social and health services (DSHS) without prior authorization in accordance with WAC 182-535-1099.

(g) Core buildup, including pins, only on permanent teeth, only for clients age 20 and younger, and only allowed in conjunction with crowns and when prior authorized. For indirect crowns, prior authorization must be obtained from the agency at the same time as the crown. Providers must submit pre- and post-endodontic treatment radiographs to the agency with the authorization request for endodontically treated teeth.

(h) Cast post and core or prefabricated post and core, only on permanent teeth, only for clients age 20 and younger, and only when in conjunction with a crown and when prior authorized.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-535-1084, filed 11/4/25, effective 12/5/25*
- *WSR 21-14-055, § 182-535-1084, filed 7/1/21, effective 8/1/21. Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 3rd sp.s. c 1 § 213 (1)(c). WSR 19-09-058, § 182-535-1084, filed 4/15/19, effective 7/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-12-033, § 182-535-1084, filed 5/29/18, effective 7/1/18*
- *WSR 17-20-097, § 182-535-1084, filed 10/3/17, effective 11/3/17*
- *WSR 16-18-033, § 182-535-1084, filed 8/26/16, effective 9/26/16*
- *WSR 15-10-043, § 182-535-1084, filed 4/29/15, effective 5/30/15. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1084, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1084, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1084, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 07-06-042, § 388-535-1084, filed 3/1/07, effective 4/1/07.*

##### **Wash. Admin. Code § 182-535-1086** Dental-related services—Covered—Endodontic services. {#sec-182-535-1086 omnilex-key=us-wa-regs-official--title-182--182-535-1086}

Clients described in WAC 182-535-1060 are eligible to receive the dental-related endodontic services listed in this section, subject to coverage limitations, restrictions, and client age requirements identified for a specific service.

(1) Pulp capping. The medicaid agency considers pulp capping to be included in the payment for the restoration.

(2) Pulpotomy. The agency covers:

(a) Therapeutic pulpotomy on primary teeth only for clients age twenty and younger.

(b) Pulpal debridement on permanent teeth only, excluding teeth one, sixteen, seventeen, and thirty-two. The agency does not pay for pulpal debridement when performed with palliative treatment of dental pain or when performed on the same day as endodontic treatment.

(3) Endodontic treatment on primary teeth. The agency covers endodontic treatment with resorbable material for primary teeth, if the entire root is present at treatment.

(4) Endodontic treatment on permanent teeth. The agency:

(a) Covers endodontic treatment for permanent anterior teeth for all clients.

(b) Covers endodontic treatment for permanent bicuspid and molar teeth, excluding teeth one, sixteen, seventeen, and thirty-two for clients age twenty and younger.

(c) Considers the following included in endodontic treatment:

(i) Pulpectomy when part of root canal therapy;

(ii) All procedures necessary to complete treatment; and

(iii) All intra-operative and final evaluation radiographs (X-rays) for the endodontic procedure.

(d) Pays separately for the following services that are related to the endodontic treatment:

(i) Initial diagnostic evaluation;

(ii) Initial diagnostic radiographs; and

(iii) Post treatment evaluation radiographs if taken at least three months after treatment.

(5) Endodontic retreatment on permanent anterior teeth. The agency:

(a) Covers endodontic retreatment for clients age twenty and younger when prior authorized.

(b) Covers endodontic retreatment of permanent anterior teeth for clients twenty-one years of age and older when prior authorized.

(c) Considers endodontic retreatment to include:

(i) The removal of post(s), pin(s), old root canal filling material, and all procedures necessary to prepare the canals;

(ii) Placement of new filling material; and

(iii) Retreatment for permanent anterior, bicuspid, and molar teeth, excluding teeth one, sixteen, seventeen, and thirty-two.

(d) Pays separately for the following services that are related to the endodontic retreatment:

(i) Initial diagnostic evaluation;

(ii) Initial diagnostic radiographs; and

(iii) Post treatment evaluation radiographs if taken at least three months after treatment.

(e) Does not pay for endodontic retreatment when provided by the original treating provider or clinic unless prior authorized by the agency.

(6) Apexification/apicoectomy. The agency covers:

(a) Apexification for apical closures for anterior permanent teeth only. Apexification is limited to the initial visit and three interim treatment visits per tooth and is limited to clients age twenty and younger.

(b) Apicoectomy and a retrograde fill for anterior teeth only for clients age twenty and younger.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-20-097, § 182-535-1086, filed 10/3/17, effective 11/3/17. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1086, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1086, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1086, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 07-06-042, § 388-535-1086, filed 3/1/07, effective 4/1/07.*

##### **Wash. Admin. Code § 182-535-1088** Dental-related services—Covered—Periodontic services. {#sec-182-535-1088 omnilex-key=us-wa-regs-official--title-182--182-535-1088}

Clients described in WAC 182-535-1060 are eligible to receive the dental-related periodontic services listed in this section, subject to coverage limitations, restrictions, and client-age requirements identified for a specified service.

(1) Surgical periodontal services. The medicaid agency covers the following surgical periodontal services, including all postoperative care:

(a) Gingivectomy/gingivoplasty (does not include distal wedge procedures on erupting molars) only on a case-by-case basis and when prior authorized and only for clients age 20 and younger; and

(b) Gingivectomy/gingivoplasty (does not include distal wedge procedures on erupting molars) for clients of the developmental disabilities community services division of the department of social and health services (DSHS) according to WAC 182-535-1099.

(2) Nonsurgical periodontal services. The agency:

(a) Covers periodontal scaling and root planing for clients age 13 through 18, once per quadrant per client, in a two-year period on a case-by-case basis, when prior authorized, and only when:

(i) The client has radiographic evidence of periodontal disease;

(ii) The client's record includes supporting documentation for the medical necessity, including complete periodontal charting done within the past 12 months from the date of the prior authorization request and a definitive diagnosis of periodontal disease;

(iii) The client's clinical condition meets current published periodontal guidelines; and

(iv) Performed at least two years from the date of completion of periodontal scaling and root planing or surgical periodontal treatment, or at least 12 calendar months from the completion of periodontal maintenance.

(b) Covers periodontal scaling and root planing once per quadrant per client in a two-year period for clients age 19 and older. Criteria in (a)(i) through (iv) of this subsection must be met.

(c) Considers ultrasonic scaling, gross scaling, or gross debridement to be included in the procedure and not a substitution for periodontal scaling and root planing.

(d) Covers periodontal scaling and root planing only when the services are not performed on the same date of service as prophylaxis, periodontal maintenance, gingivectomy, or gingivoplasty.

(e) Covers periodontal scaling and root planing for clients of the developmental disabilities community services division of DSHS according to WAC 182-535-1099.

(f) Covers periodontal scaling and root planing, one time per quadrant in a 12-month period for clients residing in an alternate living facility or nursing facility.

(3) Other periodontal services. The agency:

(a) Covers periodontal maintenance for clients age 13 through 18 once per client in a 12-month period on a case-by-case basis, when prior authorized, and only when:

(i) The client has radiographic evidence of periodontal disease;

(ii) The client's record includes supporting documentation for the medical necessity, including complete periodontal charting done within the past 12 months with location of the gingival margin and clinical attachment loss and a definitive diagnosis of periodontal disease;

(iii) The client's clinical condition meets current published periodontal guidelines; and

(iv) The client has had periodontal scaling and root planing but not within 12 months of the date of completion of periodontal scaling and root planing, or surgical periodontal treatment.

(b) Covers periodontal maintenance once per client in a 12-month period for clients age 19 and older. Criteria in (a)(i) through (iv) of this subsection must be met.

(c) Covers periodontal maintenance only if performed at least 12 calendar months after receiving prophylaxis, periodontal scaling and root planing, gingivectomy, or gingivoplasty.

(d) Covers periodontal maintenance for clients of the developmental disabilities community services division of DSHS according to WAC 182-535-1099.

(e) Covers periodontal maintenance for clients residing in an alternate living facility or nursing facility:

(i) Periodontal maintenance (four quadrants) substitutes for an eligible periodontal scaling or root planing once every six months.

(ii) Periodontal maintenance allowed six months after scaling or root planing.

(f) Covers periodontal maintenance for clients 21 and older with a diagnosis of diabetes:

(i) Periodontal maintenance allowed once every three months. Criteria in (a)(i) through (iii) of this subsection must be met.

(ii) Periodontal maintenance allowed three months after scaling or root planing.

(g) Covers full-mouth scaling in the presence of generalized moderate or severe gingival inflammation and only:

(i) For clients age 19 and older once in a 12-month period after an oral evaluation; and

(ii) For clients age 13 through 18 once in a 12-month period after an oral evaluation and when prior authorized.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-535-1088, filed 11/4/25, effective 12/5/25. Statutory Authority: RCW 41.05.021, 41.05.160, and 2023 c 475 § 211(60). WSR 23-20-129, § 182-535-1088, filed 10/4/23, effective 1/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-20-097, § 182-535-1088, filed 10/3/17, effective 11/3/17*
- *WSR 16-18-033, § 182-535-1088, filed 8/26/16, effective 9/26/16. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1088, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1088, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1088, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 07-06-042, § 388-535-1088, filed 3/1/07, effective 4/1/07.*

##### **Wash. Admin. Code § 182-535-1090** Dental-related services—Covered—Prosthodontics (removable). {#sec-182-535-1090 omnilex-key=us-wa-regs-official--title-182--182-535-1090}

Clients described in WAC 182-535-1060 are eligible to receive the prosthodontics (removable) and related services, subject to the coverage limitations, restrictions, and client-age requirements identified for a specific service.

(1) Prosthodontics. The medicaid agency requires prior authorization for removable prosthodontic and prosthodontic-related procedures, except as otherwise noted in this section. Prior authorization requests must meet the criteria in WAC 182-535-1220. In addition, the agency requires the dental provider to submit:

(a) Appropriate and diagnostic radiographs of all remaining teeth.

(b) A dental record which identifies:

(i) All missing teeth for both arches;

(ii) Teeth that are to be extracted; and

(iii) Dental restorative and periodontal services completed on all remaining teeth in the arch(es) being requested.

(2) Complete dentures. The agency covers complete dentures, including overdentures, when prior authorized, except as otherwise noted in this section.

The agency considers three-month post-delivery care (e.g., adjustments, soft relines, and repairs) from the delivery (placement) date of the complete denture as part of the complete denture procedure and does not pay separately for this care.

(a) The agency covers complete dentures only as follows:

(i) One initial maxillary complete denture and one initial mandibular complete denture per client.

(ii) Replacement of a partial denture with a complete denture only when the replacement occurs three or more years after the delivery (placement) date of the last resin partial denture.

(iii) One replacement maxillary complete denture and one replacement mandibular complete denture per client, per client's lifetime. The replacement must occur at least five years after the delivery (placement) date of the initial complete denture or overdenture and the replacement is medically necessary. Prior authorization is required for all replacement dentures with evidence of medical necessity.

(b) The agency reviews requests for replacement that exceed the limits in this subsection (2) under WAC 182-501-0050(7).

(c) The provider must obtain a current signed Denture Agreement of Acceptance (HCA 13-809) form from the client at the conclusion of the final denture try-in and at the time of delivery for an agency-authorized complete denture. If the client abandons the complete denture after signing the agreement of acceptance, the agency will deny subsequent requests for the same type of dental prosthesis if the request occurs prior to the dates specified in this section. A copy of the signed agreement must be kept in the provider's files and be available upon request by the agency. Failure to submit the completed, signed Denture Agreement of Acceptance form when requested may result in recoupment of the agency's payment.

(3) Resin partial dentures. The agency covers resin partial dentures only as follows:

(a) For anterior and posterior teeth only when the following criteria are met:

(i) The remaining teeth in the arch must be periodontally stable and have a reasonable periodontal prognosis.

(ii) The client has established caries control.

(iii) The client has one or more missing anterior teeth or four or more missing posterior teeth (excluding teeth one, two, fifteen, and sixteen) on the upper arch to qualify for a maxillary partial denture. Pontics on an existing fixed bridge do not count as missing teeth. The agency does not consider closed spaces of missing teeth to qualify as a missing tooth.

(iv) The client has one or more missing anterior teeth or four or more missing posterior teeth (excluding teeth seventeen, eighteen, thirty-one, and thirty-two) on the lower arch to qualify for a mandibular partial denture. Pontics on an existing fixed bridge do not count as missing teeth. The agency does not consider closed spaces of missing teeth to qualify as a missing tooth.

(v) There is a minimum of four functional, stable teeth remaining per arch.

(vi) There is a three-year prognosis for retention of the remaining teeth.

(b) Prior authorization is required.

(c) The agency considers three-month post-delivery care (e.g., adjustments, soft relines, and repairs) from the delivery (placement) date of the resin partial denture as part of the resin partial denture procedure and does not pay separately for this care.

(d) Replacement of a resin-based partial denture with a new resin partial denture or a complete denture if it occurs at least three years after the delivery (placement) date of the resin-based partial denture and is medically necessary. Prior authorization is required for all replacement dentures with evidence of medical necessity and meet agency coverage criteria in (a) of this subsection.

(e) The agency reviews requests for replacement that exceed the limits in this subsection (3) under WAC 182-501-0050(7).

(f) The provider must obtain a signed Partial Denture Agreement of Acceptance (HCA 13-965) form from the client at the time of delivery for an agency-authorized partial denture. A copy of the signed agreement must be kept in the provider's files and be available upon request by the agency. Failure to submit the completed, signed Partial Denture Agreement of Acceptance form when requested may result in recoupment of the agency's payment.

(4) Provider requirements.

(a) The agency requires a provider to bill for a removable partial or complete denture only after the delivery of the prosthesis, not at the impression date. Refer to subsection (5)(e) of this section for what the agency may pay if the removable partial or complete denture is not delivered and inserted.

(b) The agency requires a provider to submit the following with a prior authorization request for a removable resin partial or complete denture for a client residing in an alternate living facility or nursing facility:

(i) The client's medical diagnosis or prognosis;

(ii) The attending physician's request for prosthetic services;

(iii) The attending dentist's or denturist's statement documenting medical necessity;

(iv) A written and signed consent for treatment from the client's legal guardian when a guardian has been appointed; and

(v) A completed copy of the Denture/Partial Appliance Request for Skilled Nursing Facility Client (HCA 13-788) form available from the agency's published billing instructions which can be downloaded from the agency's website.

(c) The agency limits removable partial dentures to resin-based partial dentures for all clients residing in one of the facilities listed in (b) of this subsection.

(d) The agency requires a provider to deliver services and procedures that are of acceptable quality to the agency. The agency may recoup payment for services that are determined to be below the standard of care or of an unacceptable product quality.

(5) Other services for removable prosthodontics. The agency covers:

(a) Adjustments to complete and partial dentures three months after the date of delivery.

(b) Repairs:

(i) To complete dentures, once in a twelve-month period, per arch. The cost of repairs cannot exceed the cost of the replacement denture. The agency covers additional repairs on a case-by-case basis and when prior authorized.

(ii) To partial dentures, once in a twelve-month period, per arch. The cost of the repairs cannot exceed the cost of the replacement partial denture. The agency covers additional repairs on a case-by-case basis and when prior authorized.

(c) A laboratory reline or rebase to a complete or partial denture, once in a three-year period when performed at least six months after the delivery (placement) date. The agency does not pay for a denture reline and a rebase in the same three-year period. An additional reline or rebase may be covered for complete or partial dentures on a case-by-case basis when prior authorized.

(d) Laboratory fees, subject to the following:

(i) The agency does not pay separately for laboratory or professional fees for complete and partial dentures; and

(ii) The agency may pay part of billed laboratory fees when the provider obtains prior authorization, and the client:

(A) Is not eligible at the time of delivery of the partial or complete denture;

(B) Moves from the state;

(C) Cannot be located;

(D) Does not participate in completing the partial or complete denture; or

(E) Dies.

(iii) A provider must submit copies of laboratory prescriptions and receipts or invoices for each claim when billing for laboratory fees.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-14-055, § 182-535-1090, filed 7/1/21, effective 8/1/21*
- *WSR 18-04-028, § 182-535-1090, filed 1/30/18, effective 3/2/18*
- *WSR 17-20-097, § 182-535-1090, filed 10/3/17, effective 11/3/17*
- *WSR 16-18-033, § 182-535-1090, filed 8/26/16, effective 9/26/16*
- *WSR 15-10-043, § 182-535-1090, filed 4/29/15, effective 5/30/15. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1090, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1090, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1090, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 07-06-042, § 388-535-1090, filed 3/1/07, effective 4/1/07.*

##### **Wash. Admin. Code § 182-535-1092** Dental-related services—Covered—Maxillofacial prosthetic services. {#sec-182-535-1092 omnilex-key=us-wa-regs-official--title-182--182-535-1092}

Clients described in WAC 182-535-1060 are eligible to receive the maxillofacial prosthetic services listed in this section, subject to the following:

(1) Maxillofacial prosthetics are covered on a case-by-case basis and when prior authorized; and

(2) The medicaid agency must preapprove a provider qualified to furnish maxillofacial prosthetics.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-18-033, § 182-535-1092, filed 8/26/16, effective 9/26/16. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1092, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1092, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1092, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 07-06-042, § 388-535-1092, filed 3/1/07, effective 4/1/07.*

##### **Wash. Admin. Code § 182-535-1094** Dental-related services—Covered—Oral and maxillofacial surgery services. {#sec-182-535-1094 omnilex-key=us-wa-regs-official--title-182--182-535-1094}

Clients described in WAC 182-535-1060 are eligible to receive the oral and maxillofacial surgery services listed in this section, subject to the coverage limitations, restrictions, and client-age requirements identified for a specific service.

(1) Oral and maxillofacial surgery services. The medicaid agency:

(a) Requires enrolled providers who do not meet the conditions in WAC 182-535-1070(3) to bill claims for services that are listed in this subsection using only the current dental terminology (CDT) codes.

(b) Requires enrolled providers (oral and maxillofacial surgeons) who meet the conditions in WAC 182-535-1070(3) to bill claims using current procedural terminology (CPT) codes unless the procedure is specifically listed in the agency's current published billing guide as a CDT covered code (e.g., extractions).

(c) Covers nonemergency oral surgery performed in a hospital or ambulatory surgery center only for:

(i) Clients age eight and younger;

(ii) Clients age nine through 20. Prior authorization is required for the site of service; and

(iii) Clients any age of the developmental disabilities community services division of the department of social and health services (DSHS).

(d) For site-of-service and oral surgery CPT codes that require prior authorization, the agency requires the dental provider to submit current records (within the past 12 months), including:

(i) Documentation used to determine medical appropriateness;

(ii) Cephalometric films;

(iii) Radiographs (X-rays);

(iv) Photographs; and

(v) Written narrative/letter of medical necessity, including proposed billing codes.

(e) Requires the client's dental record to include supporting documentation for each type of extraction or any other surgical procedure billed to the agency. The documentation must include:

(i) Appropriate consent form signed by the client or the client's legal representative;

(ii) Appropriate radiographs;

(iii) Medical justification with diagnosis;

(iv) Client's blood pressure, when appropriate;

(v) A surgical narrative and complete description of each service performed beyond surgical extraction or beyond code definition;

(vi) A copy of the post-operative instructions; and

(vii) A copy of all pre- and post-operative prescriptions.

(f) Covers simple and surgical extractions.

(g) Covers unusual, complicated surgical extractions with prior authorization.

(h) Covers tooth reimplantation/stabilization of accidentally evulsed or displaced teeth.

(i) Covers surgical extraction of unerupted teeth.

(j) Covers debridement of a granuloma or cyst that is five millimeters or greater in diameter. The agency includes debridement of a granuloma or cyst that is less than five millimeters as part of the global fee for the extraction.

(k) Covers biopsy of soft oral tissue, brush biopsy, and surgical excision of soft tissue lesions. Providers must keep all biopsy reports or findings in the client's dental record.

(l) Covers only the following excisions of bone tissue in conjunction with placement of complete or partial dentures:

(i) Removal of lateral exostosis;

(ii) Removal of torus palatinus or torus mandibularis;

(iii) Surgical reduction of osseous tuberosity.

(2) Alveoloplasty. The agency covers alveoloplasty only in conjunction with the preparation of dentures or partials. Documentation supporting the medical necessity for the procedure must be maintained in the client's record. Supporting documentation must include current radiographs and medical justification narrative.

(3) Surgical incisions. The agency covers the following surgical incision-related services:

(a) Uncomplicated intraoral and extraoral soft tissue incision and drainage of abscess. The agency does not cover this service when combined with an extraction or root canal treatment. Documentation supporting the medical necessity must be in the client's record.

(b) Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue. Documentation supporting the medical necessity for the service must be in the client's record.

(c) Frenuloplasty/frenulectomy for clients age 12 and younger. Prior authorization is required.

(d) Surgical access of unerupted teeth for clients age 20 and younger. Prior authorization is required.

(4) Occlusal orthotic devices. (Refer to WAC 182-535-1098 (4)(c) for occlusal guard coverage and limitations on coverage.) The agency covers:

(a) Occlusal orthotic devices for clients age 12 through 20. Prior authorization is required.

(b) An occlusal orthotic device only as a laboratory processed full arch appliance.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-24-047, s 182-535-1094, filed 11/26/25, effective 12/27/25*
- *WSR 21-14-055, § 182-535-1094, filed 7/1/21, effective 8/1/21*
- *WSR 19-06-003, § 182-535-1094, filed 2/21/19, effective 3/24/19*
- *WSR 17-20-097, § 182-535-1094, filed 10/3/17, effective 11/3/17*
- *WSR 16-18-033, § 182-535-1094, filed 8/26/16, effective 9/26/16*
- *WSR 15-10-043, § 182-535-1094, filed 4/29/15, effective 5/30/15. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1094, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1094, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1094, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 07-06-042, § 388-535-1094, filed 3/1/07, effective 4/1/07.*

##### **Wash. Admin. Code § 182-535-1096** Dental-related services—Covered—Orthodontic services. {#sec-182-535-1096 omnilex-key=us-wa-regs-official--title-182--182-535-1096}

(1) The agency covers orthodontic services, subject to the coverage limitations listed, for clients twenty years of age and younger, according to chapter 182-535A WAC.

(2) The agency does not cover orthodontic services for clients twenty-one years of age and older.

**History**
- *Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1096, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1096, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1096, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 07-06-042, § 388-535-1096, filed 3/1/07, effective 4/1/07.*

##### **Wash. Admin. Code § 182-535-1098** Covered—Adjunctive general services. {#sec-182-535-1098 omnilex-key=us-wa-regs-official--title-182--182-535-1098}

Clients described in WAC 182-535-1060 are eligible to receive the adjunctive general services listed in this section, subject to coverage limitations, restrictions, and client-age requirements identified for a specific service.

(1) Adjunctive general services. The medicaid agency:

(a) Covers palliative (emergency) treatment, not to include pupal debridement (see WAC 182-535-1086 (2)(b)), for treatment of dental pain, limited to once per day, per client, as follows:

(i) The treatment must occur during limited evaluation appointments;

(ii) A comprehensive description of the diagnosis and services provided must be documented in the client's record; and

(iii) Appropriate radiographs must be in the client's record supporting the medical necessity of the treatment.

(b) Covers local anesthesia and regional blocks as part of the global fee for any procedure being provided to clients.

(c) Covers office-based deep sedation/general anesthesia services:

(i) For all eligible clients age eight and younger and clients any age of the developmental disabilities community services division of the department of social and health services (DSHS). Documentation supporting the medical necessity of the anesthesia service must be in the client's record.

(ii) For clients age nine through 20 on a case-by-case basis and when prior authorized, except for oral surgery services. For oral surgery services listed in WAC 182-535-1094 (1)(f) through (l) and clients with cleft palate diagnoses, the agency does not require prior authorization for deep sedation/general anesthesia services.

(iii) For clients age 21 and older when prior authorized. The agency considers these services for only those clients:

(A) With medical conditions such as tremors, seizures, or asthma;

(B) Whose records contain documentation of tried and failed treatment under local anesthesia or other less costly sedation alternatives due to behavioral health conditions; or

(C) With other conditions for which general anesthesia is medically necessary, as defined in WAC 182-500-0070.

(d) Covers moderate sedation with parenteral agents:

(i) For any dental service for clients age 20 and younger, and for clients any age of the developmental disabilities community services division of DSHS. Documentation supporting the medical necessity of the service must be in the client's record.

(ii) For clients age 21 and older when prior authorized. The agency considers these services for only those clients:

(A) With medical conditions such as tremors, seizures, or asthma;

(B) Whose records contain documentation of tried and failed treatment under local anesthesia, or other less costly sedation alternatives due to behavioral health conditions; or

(C) With other conditions for which general anesthesia or moderate sedation is medically necessary, as defined in WAC 182-500-0070.

(e) Covers moderate sedation with enteral agents:

(i) For any dental service for clients age 20 and younger, and for clients any age of the developmental disabilities community services division of DSHS. Documentation supporting the medical necessity of the service must be in the client's record.

(ii) For clients age 21 and older, only when prior authorized.

(f) Requires providers to bill anesthesia services using the current dental terminology (CDT) codes listed in the agency's current published billing instructions.

(g) Requires providers to have a current anesthesia permit on file with the agency.

(h) Covers administration of nitrous oxide once per day, per client per provider.

(i) Requires providers of minimal sedation, enteral, or parenteral moderate sedation, deep sedation, or general anesthesia to meet:

(i) The prevailing standard of care;

(ii) The provider's professional organizational guidelines;

(iii) The requirements in chapter 246-817 WAC; and

(iv) Relevant department of health (DOH) medical, dental, or nursing anesthesia regulations.

(j) Pays for dental anesthesia services according to WAC 182-535-1350.

(k) Covers professional consultation/diagnostic services as follows:

(i) A dentist or a physician other than the practitioner providing treatment must provide the services; and

(ii) A client must be referred by the agency for the services to be covered.

(2) Professional visits. The agency covers:

(a) Up to two house/extended care facility calls (visits) per facility, per provider. The agency limits payment to two facilities per day, per provider.

(b) One hospital visit, including emergency care, per day, per provider, per client, and not in combination with a surgical code unless the decision for surgery is a result of the visit.

(c) Emergency office visits after regularly scheduled hours. The agency limits payment to one emergency visit per day, per client, per provider.

(3) Drugs and medicaments (pharmaceuticals).

(a) The agency covers oral sedation medications only when prescribed and the prescription is filled at a pharmacy. The agency does not cover oral sedation medications that are dispensed in the provider's office for home use.

(b) The agency covers therapeutic parenteral drugs as follows:

(i) Includes antibiotics, steroids, anti-inflammatory drugs, or other therapeutic medications. This does not include sedative, anesthetic, or reversal agents.

(ii) Only one single-drug injection or one multiple-drug injection per date of service.

(c) The agency covers other drugs and medicaments under the client's pharmacy benefit. This includes, but is not limited to, oral antibiotics and oral analgesics. The agency does not cover the time spent writing prescriptions.

(d) For clients enrolled in an agency-contracted managed care organization (MCO), the client's MCO pays for dental prescriptions.

(4) Miscellaneous services. The agency covers:

(a) Behavior management provided by a dental provider or clinic. The agency does not cover assistance with managing a client's behavior provided by a dental provider or staff member delivering the client's dental treatment.

(i) Documentation supporting the need for behavior management must be in the client's record and including the following:

(A) A description of the behavior to be managed;

(B) The behavior management technique used; and

(C) The identity of the additional professional staff used to provide the behavior management.

(ii) Clients, who meet one of the following criteria and whose documented behavior requires the assistance of one additional professional staff employed by the dental provider or clinic to protect the client and the professional staff from injury while treatment is rendered, may receive behavior management:

(A) Clients age eight and younger;

(B) Clients age nine through 20, only on a case-by-case basis and when prior authorized;

(C) Clients any age of the developmental disabilities community services division of DSHS;

(D) Clients diagnosed with autism;

(E) Clients who reside in an alternate living facility (ALF) as defined in WAC 182-513-1100, or in a nursing facility as defined in WAC 182-500-0075.

(iii) Behavior management can be performed in the following settings:

(A) Clinics (including independent clinics, tribal health clinics, federally qualified health centers, rural health clinics, and public health clinics);

(B) Offices;

(C) Homes (including private homes and group homes); and

(D) Facilities (including nursing facilities and alternate living facilities).

(b) Treatment of post-surgical complications (e.g., dry socket). Documentation supporting the medical necessity of the service must be in the client's record.

(c) Occlusal guards when medically necessary and prior authorized. (Refer to WAC 182-535-1094(4) for occlusal orthotic device coverage and coverage limitations.) The agency covers:

(i) An occlusal guard only for clients age 12 through 20 when the client has permanent dentition; and

(ii) An occlusal guard only as a laboratory processed full arch appliance.

(5) Nonclinical procedures.

(a) The agency covers teledentistry according to the department of health, health systems quality assurance office of health professions, current guidelines, appropriate use of teledentistry, and as follows (see WAC 182-531-1730 for coverage limitations not listed in this section):

(i) Synchronous teledentistry at the distant site for clients of all ages; and

(ii) Asynchronous teledentistry at the distant site for clients of all ages.

(b) The client's record must include the following supporting documentation regarding teledentistry:

(i) Service provided via teledentistry;

(ii) Location of the client;

(iii) Location of the provider; and

(iv) Names and credentials of all persons involved in the teledentistry visit and their role in providing the service at both the originating and distant sites.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-05-030, s 182-535-1098, filed 2/11/26, effective 3/14/26*
- *WSR 25-22-083, s 182-535-1098, filed 11/4/25, effective 12/5/25*
- *WSR 23-08-080, § 182-535-1098, filed 4/5/23, effective 5/6/23*
- *WSR 21-14-055, § 182-535-1098, filed 7/1/21, effective 8/1/21*
- *WSR 20-08-103, § 182-535-1098, filed 3/30/20, effective 4/30/20. Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 3rd sp.s. c 1 § 213 (1)(c). WSR 19-09-058, § 182-535-1098, filed 4/15/19, effective 7/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-20-097, § 182-535-1098, filed 10/3/17, effective 11/3/17*
- *WSR 16-18-033, § 182-535-1098, filed 8/26/16, effective 9/26/16*
- *WSR 15-10-043, § 182-535-1098, filed 4/29/15, effective 5/30/15. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1098, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1098, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1098, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 07-06-042, § 388-535-1098, filed 3/1/07, effective 4/1/07.*

##### **Wash. Admin. Code § 182-535-1099** Dental-related services for clients of the developmental disabilities community services division of the department of social and health services. {#sec-182-535-1099 omnilex-key=us-wa-regs-official--title-182--182-535-1099}

Subject to coverage limitations and restrictions identified for a specific service, the medicaid agency pays for the additional dental-related services listed in this section that are provided to clients of the developmental disabilities community services division of the department of social and health services (DSHS), regardless of age.

(1) Preventive services. The agency covers:

(a) Periodic oral evaluations once every four months per client, per provider.

(b) Prophylaxis once every four months.

(c) Periodontal maintenance once every six months (see subsection (3) of this section for limitations on periodontal scaling and root planing).

(d) Topical fluoride varnish, rinse, foam or gel, once every four months, per client, per provider or clinic.

(e) Sealants (see WAC 182-535-1082 for sealant coverage):

(i) Only when used on the occlusal surfaces of:

(A) Primary teeth A, B, I, J, K, L, S, and T; or

(B) Permanent teeth two, three, four, five, 12, 13, 14, 15, 18, 19, 20, 21, 28, 29, 30, and 31.

(ii) Once per tooth in a two-year period.

(2) Other restorative services. The agency covers:

(a) All recementations of permanent indirect crowns.

(b) Prefabricated stainless steel crowns, including stainless steel crowns with resin window, resin-based composite crowns (direct), prefabricated esthetic coated stainless steel crowns, and prefabricated resin crowns for primary anterior teeth once every two years only for clients age 20 and younger without prior authorization.

(c) Prefabricated stainless steel crowns, including stainless steel crowns with resin window, resin-based composite crowns (direct), prefabricated esthetic coated stainless steel crowns, and prefabricated resin crowns for primary posterior teeth once every two years for clients age 20 and younger without prior authorization if:

(i) Decay involves three or more surfaces for a primary first molar;

(ii) Decay involves four or more surfaces for a primary second molar; or

(iii) The tooth had a pulpotomy.

(d) Prefabricated stainless steel crowns, including stainless steel crowns with resin window, and prefabricated resin crowns for permanent posterior teeth excluding one, 16, 17, and 32 once every two years without prior authorization for any age.

(3) Periodontic services.

(a) Surgical periodontal services. The agency covers:

(i) Gingivectomy/gingivoplasty once every three years. Documentation supporting the medical necessity of the service must be in the client's record (e.g., drug induced gingival hyperplasia).

(ii) Gingivectomy/gingivoplasty with periodontal scaling and root planing or periodontal maintenance when the services are performed:

(A) In a hospital or ambulatory surgical center; or

(B) For clients under conscious sedation, deep sedation, or general anesthesia.

(b) Nonsurgical periodontal services. The agency covers:

(i) Periodontal scaling and root planing, one time per quadrant in a 12-month period.

(ii) Periodontal maintenance (four quadrants) substitutes for an eligible periodontal scaling or root planing, twice in a 12-month period.

(iii) Periodontal maintenance allowed six months after scaling or root planing.

(iv) Full-mouth or quadrant debridement allowed once in a 12-month period.

(v) Full-mouth scaling in the presence of generalized moderate or severe gingival inflammation allowed once in a 12-month period.

(4) Adjunctive general services. The agency covers:

(a) Oral parenteral conscious sedation, deep sedation, or general anesthesia for any dental services performed in a dental office or clinic. Documentation supporting the medical necessity must be in the client's record.

(b) Sedation services according to WAC 182-535-1098 (1)(c) and (e).

(5) Nonemergency dental services. The agency covers nonemergency dental services performed in a hospital or an ambulatory surgical center for services listed as covered in WAC 182-535-1082, 182-535-1084, 182-535-1086, 182-535-1088, and 182-535-1094. Documentation supporting the medical necessity of the service must be included in the client's record.

(6) Miscellaneous services - Behavior management. The agency covers behavior management according to WAC 182-535-1098.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-535-1099, filed 11/4/25, effective 12/5/25*
- *WSR 21-14-055, § 182-535-1099, filed 7/1/21, effective 8/1/21*
- *WSR 17-20-097, § 182-535-1099, filed 10/3/17, effective 11/3/17*
- *WSR 16-18-033, § 182-535-1099, filed 8/26/16, effective 9/26/16*
- *WSR 15-10-043, § 182-535-1099, filed 4/29/15, effective 5/30/15. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1099, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1099, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1099, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 07-06-042, § 388-535-1099, filed 3/1/07, effective 4/1/07.*

##### **Wash. Admin. Code § 182-535-1100** Dental-related services—Not covered. {#sec-182-535-1100 omnilex-key=us-wa-regs-official--title-182--182-535-1100}

(1) The medicaid agency does not cover the following under the dental program:

(a) The dental-related services described in subsection (2) of this section unless the services are covered under the early periodic screening, diagnostic, and treatment (EPSDT) program described in chapter 182-534 WAC.

(b) Any service specifically excluded by statute.

(c) More costly services when less costly, equally effective services as determined by the agency are available.

(d) Services, procedures, treatment, devices, drugs, or application of associated services:

(i) That the agency or the Centers for Medicare and Medicaid Services (CMS) considers investigative or experimental on the date the services were provided.

(ii) That are not listed as covered in one or both of the following:

(A) Washington Administrative Code (WAC).

(B) The agency's current published documents.

(2) The agency does not cover dental-related services listed under the following categories of service (see subsection (1)(a) of this section for services provided under the EPSDT program):

(a) Diagnostic services. The agency does not cover:

(i) Detailed and extensive oral evaluations or reevaluations.

(ii) Posterior-anterior or lateral skull and facial bone survey films.

(iii) Any temporomandibular joint films.

(iv) Tomographic surveys/3-D imaging.

(v) Comprehensive periodontal evaluations.

(vi) Viral cultures, genetic testing, caries susceptibility tests, or adjunctive prediagnostic tests.

(b) Preventive services. The agency does not cover:

(i) Nutritional counseling for control of dental disease.

(ii) Removable space maintainers of any type.

(iii) Sealants placed on a tooth with the same-day occlusal restoration, preexisting occlusal restoration, or a tooth with occlusal decay.

(iv) Custom fluoride trays of any type.

(v) Bleach trays.

(c) Restorative services. The agency does not cover:

(i) Restorations for wear on any surface of any tooth without evidence of decay through the dentinoenamel junction (DEJ) or on the root surface.

(ii) Preventative restorations.

(iii) Labial veneer resin or porcelain laminate restorations.

(iv) Sedative fillings.

(v) Crowns and crown related services.

(A) Gold foil restorations.

(B) Metallic, resin-based composite, or porcelain/ceramic inlay/onlay restorations.

(C) Crowns for cosmetic purposes (e.g., peg laterals and tetracycline staining).

(D) Permanent indirect crowns for posterior teeth.

(E) Permanent indirect crowns on permanent anterior teeth for clients age 14 and younger.

(F) Temporary or provisional crowns (including ion crowns).

(G) Any type of coping.

(H) Crown repairs.

(I) Crowns on teeth one, 16, 17, and 32.

(vi) Polishing or recontouring restorations or overhang removal for any type of restoration.

(vii) Any services other than extraction on supernumerary teeth.

(d) Endodontic services. The agency does not cover:

(i) Indirect or direct pulp caps.

(ii) Any endodontic treatment on primary teeth, except as described in WAC 182-535-1086(3).

(e) Periodontic services. The agency does not cover:

(i) Surgical periodontal services including, but not limited to:

(A) Gingival flap procedures.

(B) Clinical crown lengthening.

(C) Osseous surgery.

(D) Bone or soft tissue grafts.

(E) Biological material to aid in soft and osseous tissue regeneration.

(F) Guided tissue regeneration.

(G) Pedicle, free soft tissue, apical positioning, subepithelial connective tissue, soft tissue allograft, combined connective tissue and double pedicle, or any other soft tissue or osseous grafts.

(H) Distal or proximal wedge procedures.

(ii) Nonsurgical periodontal services including, but not limited to:

(A) Intracoronal or extracoronal provisional splinting.

(B) Full mouth or quadrant debridement (except for clients of the developmental disabilities community services division of the department of social and health services (DSHS)).

(C) Localized delivery of chemotherapeutic agents.

(D) Any other type of surgical periodontal service.

(f) Removable prosthodontics. The agency does not cover:

(i) Removable unilateral partial dentures.

(ii) Any interim complete or partial dentures.

(iii) Flexible base partial dentures.

(iv) Any type of permanent soft reline (e.g., molloplast).

(v) Precision attachments.

(vi) Replacement of replaceable parts for semi-precision or precision attachments.

(vii) Replacement of second or third molars for any removable prosthesis.

(viii) Immediate dentures.

(ix) Cast-metal framework partial dentures.

(g) Implant services. The agency does not cover:

(i) Any type of implant procedures, including, but not limited to, any tooth implant abutment (e.g., periosteal implants, eposteal implants, and transosteal implants), abutments or implant supported crowns, abutment supported retainers, and implant supported retainers.

(ii) Any maintenance or repairs to procedures listed in (g)(i) of this subsection.

(iii) The removal of any implant as described in (g)(i) of this subsection.

(h) Fixed prosthodontics. The agency does not cover any type of:

(i) Fixed partial denture pontic.

(ii) Fixed partial denture retainer.

(iii) Precision attachment, stress breaker, connector bar, coping, cast post, or any other type of fixed attachment or prosthesis.

(i) Oral maxillofacial prosthetic services. The agency does not cover any type of oral or facial prosthesis other than those listed in WAC 182-535-1092.

(j) Oral and maxillofacial surgery. The agency does not cover:

(i) Any oral surgery service not listed in WAC 182-535-1094.

(ii) Vestibuloplasty.

(k) Adjunctive general services. The agency does not cover:

(i) Anesthesia, including, but not limited to:

(A) Local anesthesia as a separate procedure.

(B) Regional block anesthesia as a separate procedure.

(C) Trigeminal division block anesthesia as a separate procedure.

(D) Medication for oral sedation, or therapeutic intramuscular (IM) drug injections, including antibiotic and injection of sedative.

(E) Application of any type of desensitizing medicament or resin.

(ii) Other general services including, but not limited to:

(A) Fabrication of an athletic mouthguard.

(B) Sleep apnea devices or splints.

(C) Occlusion analysis.

(D) Occlusal adjustment, tooth or restoration adjustment or smoothing, or odontoplasties.

(E) Enamel microabrasion.

(F) Dental supplies such as toothbrushes, toothpaste, floss, and other take home items.

(G) Dentist's or dental hygienist's time writing or calling in prescriptions.

(H) Dentist's or dental hygienist's time consulting with clients on the phone.

(I) Educational supplies.

(J) Nonmedical equipment or supplies.

(K) Personal comfort items or services.

(L) Provider mileage or travel costs.

(M) Fees for no-show, canceled, or late arrival appointments.

(N) Service charges of any type, including fees to create or copy charts.

(O) Office supplies used in conjunction with an office visit.

(P) Teeth whitening services or bleaching, or materials used in whitening or bleaching.

(Q) Botox or dermal fillers.

(3) The agency does not cover the following dental-related services for clients age 21 and older:

(a) The following diagnostic services:

(i) Occlusal intraoral radiographs;

(ii) Diagnostic casts;

(iii) Sealants (for clients of the developmental disabilities administration, see WAC 182-535-1099);

(iv) Pulp vitality tests.

(b) The following restorative services:

(i) Prefabricated resin crowns;

(ii) Any type of core buildup, cast post and core, or prefabricated post and core.

(c) The following endodontic services:

(i) Endodontic treatment on permanent bicuspids or molar teeth;

(ii) Any apexification/recalcification procedures;

(iii) Any apicoectomy/periradicular surgical endodontic procedures including, but not limited to, retrograde fillings (except for anterior teeth), root amputation, reimplantation, and hemisections.

(d) The following adjunctive general services:

(i) Occlusal guards, occlusal orthotic splints or devices, bruxing or grinding splints or devices, or temporomandibular joint splints or devices; and

(ii) Analgesia or anxiolysis as a separate procedure except for administration of nitrous oxide.

(4) The agency evaluates a request for any dental-related services listed as noncovered in this chapter under the provisions of WAC 182-501-0160.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-21-142, s 182-535-1100, filed 10/21/25, effective 11/21/25*
- *WSR 23-08-080, § 182-535-1100, filed 4/5/23, effective 5/6/23*
- *WSR 17-20-097, § 182-535-1100, filed 10/3/17, effective 11/3/17*
- *WSR 15-10-043, § 182-535-1100, filed 4/29/15, effective 5/30/15. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1100, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1100, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 07-06-042, § 388-535-1100, filed 3/1/07, effective 4/1/07. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. WSR 03-19-078, § 388-535-1100, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. WSR 02-13-074, § 388-535-1100, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 440.225. WSR 99-07-023, § 388-535-1100, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. WSR 96-01-006 (Order 3931), § 388-535-1100, filed 12/6/95, effective 1/6/96.*

##### **Wash. Admin. Code § 182-535-1220** Obtaining prior authorization for dental-related services. {#sec-182-535-1220 omnilex-key=us-wa-regs-official--title-182--182-535-1220}

(1) The medicaid agency uses the determination process for payment described in WAC 182-501-0165 for covered dental-related services that require prior authorization.

(2) The agency requires a dental provider who is requesting prior authorization to submit sufficient, current (within the past twelve months), objective clinical information to establish medical necessity. The request must be submitted in writing on the General Information for Authorization (HCA 13-835) form, available on the agency's website.

(3) The agency may request additional information as follows:

(a) Additional radiographs (X-rays) (refer to WAC 182-535-1080(2));

(b) Photographs; and

(c) Any other information as determined by the agency.

(4) The agency may require second opinions and/or consultations by a licensed independent doctor of dental surgery (DDS)/doctor of medicine in dentistry (DMD) before authorizing any procedure.

(5) When the agency authorizes a dental-related service for a client, that authorization indicates only that the specific service is medically necessary; it is not a guarantee of payment. The authorization is valid for six to twelve months as indicated in the agency's authorization letter and only if the client is eligible for covered services on the date of service.

(6) The agency denies a request for a dental-related service when the requested service:

(a) Is covered by another state agency program;

(b) Is covered by an entity outside the agency; or

(c) Fails to meet the program criteria, limitations, or restrictions in this chapter.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-14-055, § 182-535-1220, filed 7/1/21, effective 8/1/21*
- *WSR 17-20-097, § 182-535-1220, filed 10/3/17, effective 11/3/17*
- *WSR 16-18-033, § 182-535-1220, filed 8/26/16, effective 9/26/16. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1220, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1220, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1220, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 07-06-042, § 388-535-1220, filed 3/1/07, effective 4/1/07. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. WSR 03-19-078, § 388-535-1220, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. WSR 02-13-074, § 388-535-1220, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 440.225. WSR 99-07-023, § 388-535-1220, filed 3/10/99, effective 4/10/99.*

##### **Wash. Admin. Code § 182-535-1245** Access to baby and child dentistry (ABCD) program. {#sec-182-535-1245 omnilex-key=us-wa-regs-official--title-182--182-535-1245}

The access to baby and child dentistry (ABCD) program increases access to dental services for certain medicaid-eligible clients.

(1) A client is eligible for the ABCD program if the client is:

(a) Eligible for one of the following medical assistance programs:

(i) Categorically needy program (CNP);

(ii) Limited casualty program-medically needy program (LCP-MNP);

(iii) Children's health program; or

(iv) State children's health insurance program (SCHIP); and

(b) Follow the age requirements:

(i) Under age six; or

(ii) Under age 13 and has one or more disabilities as defined by RCW 74.09.390.

(2) If the eligible client is enrolled in an agency-contracted managed care organization (MCO):

(a) Dental providers must bill the agency's fee-for-service payment system for ABCD program services.

(b) Medical providers must bill the MCO for ABCD program services.

(3) If the eligible client is not enrolled in an agency-contracted managed care organization (MCO):

(a) Dental providers must bill the agency's fee-for-service payment system for ABCD program services.

(b) Medical providers must bill the agency's fee-for-service payment system for ABCD program services.

(4) Health care providers and community service programs identify and refer eligible clients to the ABCD program. If the eligible client is treated by an ABCD certified provider, the client and an adult family member may receive:

(a) Oral health education;

(b) "Anticipatory guidance" (expectations of the client and the client's family members, including the importance of keeping appointments); and

(c) Assistance with transportation, interpreter services, and other issues related to dental services.

(5) Only ABCD-certified dental providers and primary care providers certified in ABCD are paid an enhanced fee for furnishing ABCD program services. ABCD program services include, when appropriate:

(a) Family oral health education. An oral health education visit:

(i) Is limited to one visit per day per family, up to two visits per client in a 12-month period, per provider or clinic; and

(ii) Must include all of the following services, provision of which must be documented in the client's record:

(A) "Lift the lip" training;

(B) Oral hygiene training;

(C) Risk assessment for early childhood caries;

(D) Dietary counseling; and

(E) Benefits of fluoride.

(b) Comprehensive oral evaluations as defined in WAC 182-535-1050, once per client, per provider or clinic, as an initial examination. The agency covers an additional comprehensive oral evaluation if the client has not been treated by the same provider or clinic within the past five years;

(c) Periodic oral evaluations as defined in WAC 182-535-1050, once every six months. Six months must elapse between the comprehensive oral evaluation and the first periodic oral evaluation;

(d) Topical application of fluoride varnish;

(e) Amalgam, resin, and glass ionomer restorations on primary teeth, as specified in the agency's current published documents;

(f) Interim therapeutic restorations (ITRs) for primary teeth. The agency pays an enhanced rate for these restorations to ABCD-certified, ITR-trained dentists as follows:

(i) A one-surface, resin-based composite, or glass ionomer restoration with a maximum of five teeth per visit; and

(ii) Restorations on a tooth can be done every 12 months or until the client can be definitively treated for a restoration.

(g) Therapeutic pulpotomy;

(h) Prefabricated stainless steel crowns on primary teeth, as specified in the agency's current published documents;

(i) Resin-based composite crowns on anterior primary teeth; and

(j) Other dental-related services, as specified in the agency's current published documents.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 242. WSR 21-22-051, § 182-535-1245, filed 10/28/21, effective 11/28/21. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-14-055, § 182-535-1245, filed 7/1/21, effective 8/1/21*
- *WSR 20-04-096, § 182-535-1245, filed 2/5/20, effective 3/7/20. Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 415 §§ 211 (1)(c) and 1111 (1)(c). WSR 19-20-047, § 182-535-1245, filed 9/25/19, effective 10/26/19. Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 3rd sp.s. c 1 § 213 (1)(c). WSR 19-09-058, § 182-535-1245, filed 4/15/19, effective 7/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-20-097, § 182-535-1245, filed 10/3/17, effective 11/3/17*
- *WSR 16-13-110, § 182-535-1245, filed 6/20/16, effective 8/1/16. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1245, filed 3/25/14, effective 4/30/14. WSR 11-14-075, recodified as § 182-535-1245, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 08-16-009, § 388-535-1245, filed 7/24/08, effective 8/24/08. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 07-06-042, § 388-535-1245, filed 3/1/07, effective 4/1/07. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and .225. WSR 02-11-136, § 388-535-1245, filed 5/21/02, effective 6/21/02.*

##### **Wash. Admin. Code § 182-535-1270** Oral health connections pilot project. {#sec-182-535-1270 omnilex-key=us-wa-regs-official--title-182--182-535-1270}

(1) The oral health connections pilot project is effective for dates of service from January 1, 2019, through December 31, 2023.

(2) The purpose of the oral health connections pilot project is to test the effect that enhanced oral health services have on the overall health of diabetic or pregnant medicaid clients receiving services in Cowlitz, Spokane, and Thurston counties.

(3) To be eligible for the oral health connections pilot project, a client must:

(a) Be diabetic and age 21 or older; or

(b) Be pregnant and 16 years of age or older; and

(c) Be receiving services under subsection (6) of this section in Cowlitz, Spokane, or Thurston counties; and

(d) Be referred by a nondental primary health care provider, managed care organization, or a designated community organization to a qualified oral health connections pilot project dental provider. For the purposes of this section, a designated community organization is defined as an auxiliary group or groups that partner with the agency and Arcora foundation to implement the oral health connections pilot project or provide an attestation showing the client has been diagnosed with diabetes or pregnancy, or both.

(4) A client who qualifies for the oral health connections pilot project due to pregnancy may continue receiving services through the duration of the maternity cycle as defined in WAC 182-533-0315, but must be pregnant at the start of services.

(5) The following are excluded from the oral health connections pilot project:

(a) Family planning only programs under chapter 182-532 WAC; and

(b) Medical care services (MCS) program under WAC 182-508-0005.

(6) Under the oral health connections pilot project, the medicaid agency pays an enhanced rate for the following services:

(a) One comprehensive oral exam, per client, per provider in a five-year period;

(b) One periodic exam, per client, per provider, every six months;

(c) One complete series of intraoral radiographic images per client in a three-year period;

(d) Four bitewing X-rays (radiographs) once per client in a 12-month period;

(e) One adult prophylaxis, per client, every six months;

(f) Periodontal scaling and root planing – Four or more teeth per quadrant, once per quadrant per client in a two-year period;

(g) Periodontal scaling and root planing - Three or more teeth per quadrant, once per quadrant per client in a two-year period;

(h) Up to three additional periodontal maintenance visits in a 12-month period. At least 90 days must elapse following periodontal scaling and root planing or at least 90 days must elapse following initial periodontal maintenance, and then every 90 days afterwards for a total of three additional periodontal maintenance visits per eligible client in a 12-month period;

(i) One fluoride varnish application, per client, every six months; and

(j) One silver diamine fluoride treatment, per tooth, per client, every six months.

(7) The services listed in subsection (6) of this section are the only services the agency pays at the enhanced rate. The agency pays for all other covered dental services at the standard rate.

(8) To receive the enhanced rate, dental providers must:

(a) Be enrolled to participate in the oral health connections pilot project;

(b) Meet the qualifications in WAC 182-535-1070;

(c) Provide the services in Cowlitz, Spokane, or Thurston counties; and

(d) Complete training designed specifically for the oral health connections pilot project.

(9) The agency assigns a special identifier to providers who complete the training in subsection (8)(d) of this section which allows them to receive the enhanced rate.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-06-035, § 182-535-1270, filed 2/23/22, effective 3/26/22. Statutory Authority: RCW 41.05.021, 41.05.160, and 2017 c 1. WSR 18-24-077, § 182-535-1270, filed 11/30/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-535-1350** Payment methodology for dental-related services. {#sec-182-535-1350 omnilex-key=us-wa-regs-official--title-182--182-535-1350}

The agency uses the description of dental services described in the American Dental Association's Current Dental Terminology (CDT), and the American Medical Association's Physician's Current Procedural Terminology (CPT).

(1) For covered dental-related services provided to eligible clients, the agency pays dentists and other eligible providers on a fee-for-service or contractual basis, subject to the exceptions and restrictions listed under WAC 182-535-1100 and 182-535-1400.

(2) The agency sets maximum allowable fees for dental services as follows:

(a) The agency's historical reimbursement rates for various procedures are compared to usual and customary charges.

(b) The agency consults with representatives of the provider community to identify program areas and concerns that need to be addressed.

(c) The agency consults with dental experts and public health professionals to identify and prioritize dental services and procedures for their effectiveness in improving or promoting dental health.

(d) Legislatively authorized vendor rate increases and/or earmarked appropriations for dental services are allocated to specific procedures based on the priorities identified in (c) of this subsection and considerations of access to services.

(e) Larger percentage increases may be given to those procedures which have been identified as most effective in improving or promoting dental health.

(f) Budget-neutral rate adjustments are made as appropriate based on the agency's evaluation of utilization trends, effectiveness of interventions, and access issues.

(3) The agency pays eligible fee-for-service providers listed in WAC 182-535-1070 for conscious sedation with parenteral and multiple oral agents, or for general anesthesia when the provider meets the criteria in this chapter and other applicable WAC. For clients enrolled in an agency-contracted managed care organization (MCO), the client's MCO pays for dental prescriptions.

(4) Dental hygienists who have a contract with the agency are paid at the same rate as dentists who have a contract with the agency, for services allowed under the Dental Hygienist Practice Act.

(5) Licensed denturists who have a contract with the agency are paid at the same rate as dentists who have a contract with the agency, for providing dentures and partials.

(6) The agency makes fee schedule changes whenever the legislature authorizes vendor rate increases or decreases.

(7) The agency may adjust maximum allowable fees to reflect changes in services or procedure code descriptions.

(8) The agency does not pay separately for chart or record setup, or for completion of reports, forms, or charting. The fees for these services are included in the agency's reimbursement for comprehensive oral evaluations or limited oral evaluations.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-08-103, § 182-535-1350, filed 3/30/20, effective 4/30/20. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1350, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1350, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1350, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. WSR 03-19-080, § 388-535-1350, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. WSR 02-13-074, § 388-535-1350, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 440.225. WSR 99-07-023, § 388-535-1350, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. WSR 96-01-006 (Order 3931), § 388-535-1350, filed 12/6/95, effective 1/6/96.*

##### **Wash. Admin. Code § 182-535-1400** Payment for dental-related services. {#sec-182-535-1400 omnilex-key=us-wa-regs-official--title-182--182-535-1400}

(1) The agency considers that a provider who furnishes covered dental services to an eligible client has accepted the agency's rules and fees.

(2) Participating providers must bill the agency their usual and customary fees.

(3) Payment for dental services is based on the agency's schedule of maximum allowances. Fees listed in the agency's fee schedule are the maximum allowable fees.

(4) The agency pays the provider the lesser of the billed charge (usual and customary fee) or the agency's maximum allowable fee.

(5) The agency pays dental general anesthesia services for eligible clients as follows:

(a) Fifteen-minute increments are billed as one unit of time. When a dental procedure requires multiple fifteen-minute units and there is a remainder (less than fifteen minutes), the remainder is considered one unit.

(b) When billing for anesthesia, the provider must show the actual beginning and ending times in the client's medical record. Anesthesia time begins when the provider starts to physically prepare the client for the induction of anesthesia in the operating room area (or its equivalent), and ends when the provider is no longer in constant attendance (i.e., when the client can be safely placed under postoperative supervision).

(6) The agency pays "by report" on a case-by-case basis, for a covered service that does not have a set fee.

(7) Participating providers must bill a client according to WAC 182-502-0160, unless otherwise specified in this chapter.

(8) If the client's eligibility for dental services ends before the conclusion of the dental treatment, payment for any remaining treatment is the client's responsibility. The exceptions to this are complete dentures and resin partial dentures as described in WAC 182-535-1090.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-13-110, § 182-535-1400, filed 6/20/16, effective 8/1/16. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1400, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1400, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. WSR 03-19-080, § 388-535-1400, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. WSR 02-13-074, § 388-535-1400, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 440.225. WSR 99-07-023, § 388-535-1400, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. WSR 96-01-006 (Order 3931), § 388-535-1400, filed 12/6/95, effective 1/6/96.*

##### **Wash. Admin. Code § 182-535-1450** Payment for denture laboratory services. {#sec-182-535-1450 omnilex-key=us-wa-regs-official--title-182--182-535-1450}

This section applies to payment for denture laboratory services. The agency does not directly reimburse denture laboratories. The agency's reimbursement for complete dentures, partial dentures, and overdentures includes laboratory fees. The provider is responsible to pay a denture laboratory for services furnished at the request of the provider.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1450, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1450, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. WSR 03-19-080, § 388-535-1450, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. WSR 02-13-074, § 388-535-1450, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 440.225. WSR 99-07-023, § 388-535-1450, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. WSR 96-01-006 (Order 3931), § 388-535-1450, filed 12/6/95, effective 1/6/96.*

##### **Wash. Admin. Code § 182-535-1500** Payment for dental-related hospital services. {#sec-182-535-1500 omnilex-key=us-wa-regs-official--title-182--182-535-1500}

The agency pays for medically necessary dental-related services provided in an inpatient or outpatient hospital setting according to WAC 182-550-1100.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1500, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. WSR 02-13-074, § 388-535-1500, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 440.225. WSR 99-07-023, § 388-535-1500, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. WSR 96-01-006 (Order 3931), § 388-535-1500, filed 12/6/95, effective 1/6/96.*

##### **Wash. Admin. Code § 182-535-1550** Payment for dental care provided out-of-state. {#sec-182-535-1550 omnilex-key=us-wa-regs-official--title-182--182-535-1550}

See WAC 182-501-0180, 182-501-0182, and 182-501-0184 for services provided outside the state of Washington. See WAC 182-501-0175 for designated bordering cities.

**History**
- *Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1550, filed 3/25/14, effective 4/30/14. WSR 11-14-075, recodified as § 182-535-1550, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035. WSR 08-08-064, § 388-535-1550, filed 3/31/08, effective 5/1/08. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. WSR 02-13-074, § 388-535-1550, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 440.225. WSR 99-07-023, § 388-535-1550, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. WSR 96-01-006 (Order 3931), § 388-535-1550, filed 12/6/95, effective 1/6/96.*

## **Chapter 182-535A** Orthodontic services. {#struct-chapter-182-535a}

##### **Wash. Admin. Code § 182-535A-0010** Definitions. {#sec-182-535a-0010 omnilex-key=us-wa-regs-official--title-182--182-535A-0010}

The following definitions and those found in chapter 182-500 WAC apply to this chapter.

"Adolescent dentition" means teeth that are present after the loss of primary teeth and prior to the cessation of growth that affects orthodontic treatment.

"Appliance placement" means the application of orthodontic attachments to the teeth for the purpose of correcting dentofacial abnormalities.

"Cleft" means an opening or fissure involving the dentition and supporting structures, especially one occurring in utero. These can be:

(a) Cleft lip;

(b) Cleft palate (involving the roof of the mouth); or

(c) Facial clefts (e.g., macrostomia).

"Comprehensive full orthodontic treatment" means utilizing fixed orthodontic appliances for treatment of adolescent dentition leading to the improvement of a client's severe handicapping craniofacial dysfunction and/or dentofacial deformity, including anatomical and functional relationships.

"Craniofacial anomalies" means abnormalities of the head and face, either congenital or acquired, involving disruption of the dentition and supporting structures.

"Craniofacial team" means a cleft palate/maxillofacial team or an American Cleft Palate Association-certified craniofacial team. These teams are responsible for the management (review, evaluation, and approval) of patients with cleft palate craniofacial anomalies to provide integrated management, promote parent-professional partnership, and make appropriate referrals to implement and coordinate treatment plans.

"Crossbite" means an abnormal relationship of a tooth or teeth to the opposing tooth or teeth, in which normal buccolingual or labiolingual relations are reversed.

"Dental dysplasia" means an abnormality in the development of the teeth.

"Early periodic screening, diagnosis, and treatment (EPSDT)" is defined under WAC 182-534-0050.

"Ectopic eruption" means a condition in which a tooth erupts in an abnormal position or is fifty percent blocked out of its normal alignment in the dental arch.

"Hemifacial microsomia" means a developmental condition involving the first and second brachial arch. This creates an abnormality of the upper and lower jaw, ear, and associated structures (half or part of the face is smaller in size).

"Limited orthodontic treatment" means orthodontic treatment with a limited objective, not involving the entire dentition. It may be directed only at the existing problem, or at only one aspect of a larger problem in which a decision is made to defer or forego more comprehensive therapy.

"Malocclusion" means improper alignment of biting or chewing surfaces of upper and lower teeth or abnormal relationship of the upper and lower dental arches.

"Maxillofacial" means relating to the jaws and face.

"Occlusion" means the relation of the upper and lower teeth when in functional contact during jaw movement.

"Orthodontics" means treatment involving the use of any appliance, in or out of the mouth, removable or fixed, or any surgical procedure designed to redirect teeth and surrounding tissues.

"Orthodontist" means a dentist who specializes in orthodontics, who is a graduate of a postgraduate program in orthodontics that is accredited by the American Dental Association, and who meets the licensure requirements of the department of health.

"Permanent dentition" means those teeth that succeed the primary teeth and the additional molars that erupt.

"Primary dentition" means teeth that develop and erupt first in order of time and are normally shed and replaced by permanent teeth.

"Transitional dentition" means the final phase from primary to permanent dentition, in which most primary teeth have been lost or are in the process of exfoliating and the permanent successors are erupting.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-21-142, s 182-535A-0010, filed 10/21/25, effective 11/21/25*
- *WSR 21-18-006, § 182-535A-0010, filed 8/18/21, effective 1/1/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 415 §§ 211 (1)(c) and 1111 (1)(c). WSR 19-20-047, § 182-535A-0010, filed 9/25/19, effective 10/26/19. Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 3rd sp.s. c 1 § 213 (1)(c). WSR 19-09-058, § 182-535A-0010, filed 4/15/19, effective 7/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-20-097, § 182-535A-0010, filed 10/3/17, effective 11/3/17. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535A-0010, filed 3/25/14, effective 4/30/14. WSR 11-14-075, recodified as § 182-535A-0010, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 08-17-009, § 388-535A-0010, filed 8/7/08, effective 9/7/08. Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. WSR 05-01-064, § 388-535A-0010, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520, 74.09.500, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 225. WSR 02-01-050, § 388-535A-0010, filed 12/11/01, effective 1/11/02.*

##### **Wash. Admin. Code § 182-535A-0020** Client eligibility. {#sec-182-535a-0020 omnilex-key=us-wa-regs-official--title-182--182-535A-0020}

(1) Subject to the limitations of this chapter, the medicaid agency covers medically necessary orthodontic treatment and orthodontic-related services for severe handicapping malocclusions, craniofacial anomalies, or cleft lip or palate, for eligible clients through age twenty. Refer to WAC 182-501-0060 to see which Washington apple health programs include orthodontic services in their benefit package.

(2) Eligible clients may receive the same orthodontic treatment and orthodontic-related services in recognized out-of-state bordering cities on the same basis as if provided in-state. See WAC 182-501-0175.

(3) Eligible clients may receive the same orthodontic treatment and orthodontic-related services for continued orthodontic treatment when originally rendered by a nonmedicaid or out-of-state provider as follows:

(a) The provider must submit the initial orthodontic case study and treatment plan records with the request for continued treatment.

(b) The agency evaluates the initial orthodontic case study and treatment plan to determine if the client met the agency's orthodontic criteria per WAC 182-535A-0040 (1) through (3).

(c) The agency determines continued treatment duration based on the client's current orthodontic conditions.

(d) The agency does not cover continued treatment if the client's initial condition did not meet the agency's criteria for the initial orthodontic treatment. The agency pays a deband and retainer fee if the client does not meet the initial orthodontic treatment criteria.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 415 §§ 211 (1)(c) and 1111 (1)(c). WSR 19-20-047, § 182-535A-0020, filed 9/25/19, effective 10/26/19. Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 3rd sp.s. c 1 § 213 (1)(c). WSR 19-09-058, § 182-535A-0020, filed 4/15/19, effective 7/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-20-097, § 182-535A-0020, filed 10/3/17, effective 11/3/17. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535A-0020, filed 3/25/14, effective 4/30/14. WSR 11-14-075, recodified as § 182-535A-0020, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 08-17-009, § 388-535A-0020, filed 8/7/08, effective 9/7/08. Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. WSR 05-01-064, § 388-535A-0020, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520, 74.09.500, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 225. WSR 02-01-050, § 388-535A-0020, filed 12/11/01, effective 1/11/02.*

##### **Wash. Admin. Code § 182-535A-0030** Orthodontic treatment and orthodontic-related services—Provider eligibility. {#sec-182-535a-0030 omnilex-key=us-wa-regs-official--title-182--182-535A-0030}

The following provider types may furnish and be paid for providing covered orthodontic treatment and orthodontic-related services to eligible medical assistance clients:

(1) Orthodontists;

(2) Pediatric dentists;

(3) General dentists; and

(4) Agency-recognized craniofacial teams or other orthodontic specialists approved by the agency.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-10-064, § 182-535A-0030, filed 5/2/16, effective 6/2/16. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535A-0030, filed 3/25/14, effective 4/30/14. WSR 11-14-075, recodified as § 182-535A-0030, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 08-17-009, § 388-535A-0030, filed 8/7/08, effective 9/7/08. Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. WSR 05-01-064, § 388-535A-0030, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520, 74.09.500, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 225. WSR 02-01-050, § 388-535A-0030, filed 12/11/01, effective 1/11/02.*

##### **Wash. Admin. Code § 182-535A-0040** Orthodontic treatment and orthodontic-related services—Covered, noncovered, and limitations to coverage. {#sec-182-535a-0040 omnilex-key=us-wa-regs-official--title-182--182-535A-0040}

Orthodontic treatment and orthodontic-related services require prior authorization.

(1) The medicaid agency covers orthodontic treatment and orthodontic-related services for a client who has one of the medical conditions listed in (a) and (b) of this subsection. Treatment and follow-up care must be performed by a provider who is part of a craniofacial team that includes, but is not limited to, a general or pediatric dentist, orthodontist, and an oral maxillofacial surgeon or specialist.

(a) Cleft lip and palate, cleft palate, or cleft lip.

(b) The following craniofacial anomalies including, but not limited to:

(i) Hemifacial microsomia;

(ii) Craniosynostosis syndromes;

(iii) Cleidocranial dental dysplasia;

(iv) Arthrogryposis;

(v) Marfan syndrome;

(vi) Treacher Collins syndrome;

(vii) Ectodermal dysplasia; or

(viii) Achondroplasia.

(2) The agency authorizes orthodontic treatment and orthodontic-related services when the following criteria are met:

(a) Severe malocclusions with a Washington Modified Handicapping Labiolingual Deviation (HLD) Index Score of 25 or higher as determined by the agency;

(b) The client has established caries control; and

(c) The client has established plaque control.

(3) The agency covers orthodontic treatment for dental malocclusions other than those listed in subsections (1) and (2) of this section on a case-by-case basis when the agency determines medical necessity based on documentation submitted by the provider.

(4) The agency does not cover the following orthodontic treatment or orthodontic-related services:

(a) Orthodontic treatment for cosmetic purposes;

(b) Orthodontic treatment that is not medically necessary;

(c) Orthodontic treatment provided out-of-state, except as stated in WAC 182-501-0180 (see also WAC 182-501-0175 for medical care provided in bordering cities); or

(d) Orthodontic treatment and orthodontic-related services that do not meet the requirements of this section or other applicable WAC.

(5) The agency covers the following orthodontic treatment and orthodontic-related services:

(a) Limited orthodontic treatment.

(b) Comprehensive full orthodontic treatment on adolescent dentition.

(c) A case study when done in conjunction with orthodontic treatment.

(d) Other orthodontic treatment subject to review for medical necessity as determined by the agency.

(6) The agency covers the following orthodontic-related services:

(a) Clinical oral evaluations according to WAC 182-535-1080.

(b) Cephalometric films that are of diagnostic quality, dated, and labeled with the client's name.

(c) Orthodontic appliance removal as a stand-alone service only when:

(i) The client's appliance was placed by a different provider or dental clinic; and

(ii) The provider has not furnished any other orthodontic treatment or orthodontic-related services to the client.

(7) The treatment must meet industry standards and correct the medical issue. If treatment is discontinued prior to completion, or treatment objectives are not achieved, the provider must:

(a) Document in the client's record why treatment was discontinued or not completed, or why treatment goals were not achieved.

(b) Notify the agency by submitting the Orthodontic Discontinuation of Service form (HCA 13-0039).

(8) The agency evaluates a request for orthodontic treatment or orthodontic-related services:

(a) That are in excess of the limitations or restrictions listed in this section, according to WAC 182-501-0169; and

(b) That are listed as noncovered according to WAC 182-501-0160.

(9) For children age 20 and younger, providers must follow the rules for the early periodic screening, diagnosis, and treatment (EPSDT) program, see chapter 182-534 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-21-142, s 182-535A-0040, filed 10/21/25, effective 11/21/25*
- *WSR 23-24-099, § 182-535A-0040, filed 12/6/23, effective 1/6/24*
- *WSR 23-08-009, § 182-535A-0040, filed 3/23/23, effective 4/23/23*
- *WSR 21-18-006, § 182-535A-0040, filed 8/18/21, effective 1/1/22*
- *WSR 20-03-042, § 182-535A-0040, filed 1/8/20, effective 2/8/20*
- *WSR 19-11-028, § 182-535A-0040, filed 5/7/19, effective 7/1/19*
- *WSR 17-20-097, § 182-535A-0040, filed 10/3/17, effective 11/3/17*
- *WSR 16-10-064, § 182-535A-0040, filed 5/2/16, effective 6/2/16. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535A-0040, filed 3/25/14, effective 4/30/14. WSR 11-14-075, recodified as § 182-535A-0040, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 08-17-009, § 388-535A-0040, filed 8/7/08, effective 9/7/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-535A-0040, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. WSR 05-01-064, § 388-535A-0040, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520, 74.09.500, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 225. WSR 02-01-050, § 388-535A-0040, filed 12/11/01, effective 1/11/02.*

##### **Wash. Admin. Code § 182-535A-0050** Orthodontic treatment and orthodontic-related services—Authorization and prior authorization. {#sec-182-535a-0050 omnilex-key=us-wa-regs-official--title-182--182-535A-0050}

When the medicaid agency authorizes a limited orthodontic treatment, full orthodontic treatment, or orthodontic-related services for a client, including a client eligible for services under the EPSDT program, that authorization indicates only that the specific service is medically necessary; authorization is not a guarantee of payment. The client must be eligible for the covered service at the time the service is provided.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-18-006, § 182-535A-0050, filed 8/18/21, effective 1/1/22*
- *WSR 20-03-042, § 182-535A-0050, filed 1/8/20, effective 2/8/20. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535A-0050, filed 3/25/14, effective 4/30/14. WSR 11-14-075, recodified as § 182-535A-0050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 08-17-009, § 388-535A-0050, filed 8/7/08, effective 9/7/08. Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. WSR 05-01-064, § 388-535A-0050, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520, 74.09.500, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 225. WSR 02-01-050, § 388-535A-0050, filed 12/11/01, effective 1/11/02.*

##### **Wash. Admin. Code § 182-535A-0060** Orthodontic treatment and orthodontic-related services—Payment. {#sec-182-535a-0060 omnilex-key=us-wa-regs-official--title-182--182-535A-0060}

(1) The medicaid agency pays providers for furnishing covered orthodontic treatment and orthodontic-related services described in WAC 182-535A-0040 according to this section and other applicable WAC.

(2) A provider who furnishes covered orthodontic treatment and orthodontic-related services to an eligible client accepts the agency's fees as published in the agency's fee schedules according to WAC 182-502-0010.

(3) Providers must deliver services and procedures that are of acceptable quality to the agency.

(4) The agency may recoup payment, not limited to services:

(a) Determined to be below the standard of care; or

(b) Of an unacceptable product quality; or

(c) That are not rendered; or

(d) That do not address medical issue(s) as listed in the prior authorization request.

(5) Limited orthodontic treatment. The agency pays for limited orthodontic treatment on transitional or adolescent dentition as follows:

(a) The first three months of treatment starts on the date the initial appliance is placed and includes active treatment for the first three months. The provider must bill the agency with the date of service that the initial appliance is placed.

(b) The agency's initial payment includes:

(i) The placement of orthodontic appliances;

(ii) Appliance removal;

(iii) The initial retainer fee; and

(iv) The final records (photos, a panoramic X-ray, a cephalometric film, and final trimmed study models).

(c) Continuing follow-up treatment must be billed as periodic orthodontic treatment visits.

(i) Payments are allowed once every three months during treatment.

(ii) Payment for treatment provided in addition to the three periodic orthodontic treatment visits requires a limitation extension. See WAC 182-535A-0040(8).

(iii) If treatment is discontinued or treatment objectives are not achieved, providers must notify the agency. See WAC 182-535A-0040(7).

(6) Comprehensive full orthodontic treatment. The agency pays for comprehensive full orthodontic treatment on adolescent dentition as follows:

(a) The first three months of treatment starts the date the initial appliance is placed and includes active treatment for the first three months. The provider must bill the agency with the date of service that the initial appliance is placed.

(b) The agency's initial payment includes:

(i) The placement of orthodontic appliances;

(ii) Appliance removal;

(iii) The initial retainer fee; and

(iv) The final records (photos, a panoramic X-ray, a cephalometric film, and final trimmed study models).

(c) Continuing follow-up treatment must be billed as periodic orthodontic treatment visits.

(i) Payments are allowed once every three months during treatment with the eighth periodic orthodontic treatment visit covering the last six months of treatment.

(ii) Payment for treatment provided in addition to the eight periodic orthodontic treatment visits requires a limitation extension. See WAC 182-535A-0040(8).

(iii) If treatment is discontinued or treatment objectives are not achieved, providers must notify the agency. See WAC 182-535A-0040(7).

(7) Case study. The agency pays for a case study, which includes:

(a) Preparation of comprehensive diagnostic records (additional photos, study casts, cephalometric examination film and panoramic film);

(b) Formation of diagnosis and treatment plan from such records; and

(c) Formal case conference.

(8) Payment for orthodontic treatment and orthodontic-related services is based on the agency's published fee schedule.

(9) Orthodontic providers who are in agency-designated bordering cities must:

(a) Meet the licensure requirements of their state; and

(b) Meet the same criteria for payment as in-state providers, including the requirements to contract with the agency.

(10) If the client's eligibility for orthodontic treatment under WAC 182-535A-0020 ends before the conclusion of the orthodontic treatment, payment for any remaining treatment is the client's responsibility. The agency does not pay for these services.

(11) The agency does not pay for orthodontic treatment provided after the client's twenty-first birthday. Payment for treatment that continues after the client's twenty-first birthday is the client's responsibility.

(12) The client is responsible for payment of any orthodontic service or treatment received during any period of medicaid ineligibility, even if the treatment was started when the client was eligible.

(13) See WAC 182-502-0160 and 182-501-0200 for when a provider or a client is responsible to pay for a covered service.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-18-006, § 182-535A-0060, filed 8/18/21, effective 1/1/22*
- *WSR 20-03-042, § 182-535A-0060, filed 1/8/20, effective 2/8/20*
- *WSR 19-11-028, § 182-535A-0060, filed 5/7/19, effective 7/1/19*
- *WSR 17-20-097, § 182-535A-0060, filed 10/3/17, effective 11/3/17*
- *WSR 16-10-064, § 182-535A-0060, filed 5/2/16, effective 6/2/16. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535A-0060, filed 3/25/14, effective 4/30/14. WSR 11-14-075, recodified as § 182-535A-0060, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 08-17-009, § 388-535A-0060, filed 8/7/08, effective 9/7/08. Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. WSR 05-01-064, § 388-535A-0060, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520, 74.09.500, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 225. WSR 02-01-050, § 388-535A-0060, filed 12/11/01, effective 1/11/02.*

## **Chapter 182-537** School-based health care services. {#struct-chapter-182-537}

##### **Wash. Admin. Code § 182-537-0100** Purpose. {#sec-182-537-0100 omnilex-key=us-wa-regs-official--title-182--182-537-0100}

The medicaid agency pays contracted school districts, educational service districts, charter schools, and tribal schools for school-based health care services provided to medicaid-eligible children who require early intervention or special education and related services consistent with Sections 1903(c) and 1905(a) of the Social Security Act. The agency pays school districts through fee-for-service. Covered services must:

(1) Identify, treat, and manage the disabilities of a child who requires early intervention or special education and related services;

(2) Be prescribed or recommended by licensed physicians or other licensed health care providers within their scope of practice under state law;

(3) Be medically necessary;

(4) Be included in the child's current individualized education program (IEP) or individualized family service plan (IFSP); and

(5) Be provided in a school setting, the natural environment, an alternate placement in accordance with the Individuals with Disabilities Education Act (IDEA), or by telemedicine.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-14-062, § 182-537-0100, filed 6/26/20, effective 7/27/20*
- *WSR 19-04-095, § 182-537-0100, filed 2/5/19, effective 3/8/19*
- *WSR 16-07-141, § 182-537-0100, filed 3/23/16, effective 4/23/16. Statutory Authority: RCW 41.05.021. WSR 13-05-017, § 182-537-0100, filed 2/7/13, effective 3/10/13. WSR 11-14-075, recodified as § 182-537-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 42 C.F.R. 440.110. WSR 09-07-004, § 388-537-0100, filed 3/4/09, effective 4/4/09. Statutory Authority: RCW 74.08.090. WSR 01-02-076, § 388-537-0100, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.04.050 and 74.08.090. WSR 00-01-088, § 388-537-0100, filed 12/14/99, effective 1/14/00.*

##### **Wash. Admin. Code § 182-537-0200** Definitions. {#sec-182-537-0200 omnilex-key=us-wa-regs-official--title-182--182-537-0200}

The following definitions and those found in chapter 182-500 WAC apply to this chapter:

"Agency" - See WAC 182-500-0010.

"Assessment" - For the purposes of this chapter, an assessment is made-up of medically necessary tests given to an individual child by a licensed health care provider to evaluate whether a child with a disability is in need of early intervention services or special education and related services. Assessments are a part of the individualized education program (IEP) and individualized family service plan (IFSP) evaluation and reevaluation processes.

"Charter school" - A public school governed by a charter school board and operated according to the terms of the charter school contract. Charter schools are open to all students, do not charge tuition, and do not have special entrance requirements.

"Child with a disability" - For purposes of this chapter, a child with a disability is a child evaluated and determined to need early intervention services or special education and related services because of a disability in one or more of the following eligibility categories:

• Autism;

• Deaf-blindness;

• Developmental delay for children ages three through nine, with an adverse educational impact, the results of which require special education and related direct services;

• Hearing loss (including deafness);

• Intellectual disability;

• Multiple disabilities;

• Orthopedic impairment;

• Other health impairment;

• Serious emotional disturbance (emotional behavioral disturbance);

• Specific learning disability;

• Speech or language impairment;

• Traumatic brain injury; and

• Visual impairment (including blindness).

"Core provider agreement" – See WAC 182-500-0020.

"Early intervention services" - Means developmental services provided to children ages birth through two. For the purposes of this chapter, early intervention services include:

• Audiology services;

• Health services;

• Nursing services;

• Occupational therapy;

• Physical therapy;

• Psychological services; and

• Speech-language pathology.

"Educational service district" - A regional agency which provides cooperative and informal services to local school districts within defined regions of the state.

"Electronic signature" - See WAC 182-500-0030.

"Evaluation" - Procedures used to determine whether a child has a disability, and the nature and extent of the early intervention or special education and related services needed. (See WAC 392-172A-01070 and 34 C.F.R. Sec. 303.321.)

"Fee-for-service" - See WAC 182-500-0035.

"Handwritten signature" - A scripted name or legal mark of an individual on a document to signify knowledge, approval, acceptance, or responsibility of the document.

"Health care-related services" - For the purposes of this chapter, means developmental, corrective, and other supportive services required to assist a student ages three through twenty eligible for special education and include:

• Audiology;

• Counseling;

• School health services and school nurse services;

• Occupational therapy;

• Physical therapy;

• Psychological assessments and services; and

• Speech-language therapy.

"Individualized education program (IEP)" - A written educational program for a child who is age three through twenty-one and eligible for special education. An IEP is developed, reviewed and revised according to WAC 392-172A-03090 through 392-172A-03115.

"Individualized family service plan (IFSP)" - A plan for providing early intervention services to a child birth through age two, with a disability or developmental delay and the child's family. The IFSP:

• Is based on the evaluation and assessment described in 34 C.F.R. Sec. 303.321;

• Includes the content specified in 34 C.F.R. Sec. 303.344; and

• Is developed under the IFSP procedures in 34 C.F.R. Secs. 303.342, 303.343, and 303.345.

"Medically necessary" - See WAC 182-500-0070.

"National provider identifier (NPI)" - See WAC 182-500-0075.

"Reevaluation" - Procedures used to determine whether a child continues to need early intervention services or special education and related services. (See WAC 392-172A-03015 and 34 C.F.R. Secs. 303.342 and 303.343.)

"Related services" – See WAC 392-172A-01155.

"School-based health care services contract" - A contract that describes and defines the relationship between the agency, the school-based health care services program, and the school district, ESD, charter, or tribal school.

"School-based health care services program" or "SBHS" - Is an agency-administered program that pays contracted school districts, educational service districts (ESDs), charter schools, and tribal schools for providing early intervention services or special education health-related services to children ages birth through twenty who have an IEP or IFSP.

"School district" - A group of schools administered by a particular authority within defined geographical division.

"Signature log" - A typed list that verifies a licensed provider's identity by associating each provider's signature with their name, handwritten initials, credentials, license and national provider identifier (NPI).

"Special education" - See WAC 392-172A-01175.

"Supervision" - Means supervision provided by a licensed health care provider either directly or indirectly to assist the supervisee in the administration of early intervention or health care-related services outlined in the IEP or IFSP.

"Telemedicine" - See WAC 182-501-0300.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2021 c 157. WSR 23-04-048, § 182-537-0200, filed 1/26/23, effective 2/26/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-14-062, § 182-537-0200, filed 6/26/20, effective 7/27/20*
- *WSR 19-04-095, § 182-537-0200, filed 2/5/19, effective 3/8/19*
- *WSR 16-07-141, § 182-537-0200, filed 3/23/16, effective 4/23/16. Statutory Authority: RCW 41.05.021, 34 C.F.R. 300.154(d), and chapter 182-502 WAC. WSR 13-21-079, § 182-537-0200, filed 10/17/13, effective 11/17/13. Statutory Authority: RCW 41.05.021. WSR 13-05-017, § 182-537-0200, filed 2/7/13, effective 3/10/13. WSR 11-14-075, recodified as § 182-537-0200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 42 C.F.R. 440.110. WSR 09-07-004, § 388-537-0200, filed 3/4/09, effective 4/4/09.*

##### **Wash. Admin. Code § 182-537-0300** Student eligibility. {#sec-182-537-0300 omnilex-key=us-wa-regs-official--title-182--182-537-0300}

(1) Contracted school districts may receive medicaid payment for students ages birth through twenty who:

(a) Have an active individualized family service plan (IFSP) or individualized education program (IEP); and

(b) Who are receiving Title XIX medicaid under a Washington apple health categorically needy program (CNP) or medically needy program (MNP).

(2) Eligible students enrolled in an agency-contracted managed care organization (MCO) are eligible to receive school-based health care services through fee-for-service.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-04-095, § 182-537-0300, filed 2/5/19, effective 3/8/19*
- *WSR 16-07-141, § 182-537-0300, filed 3/23/16, effective 4/23/16. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148). WSR 14-07-042, § 182-537-0300, filed 3/12/14, effective 4/12/14. WSR 11-14-075, recodified as § 182-537-0300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 42 C.F.R. 440.110. WSR 09-07-004, § 388-537-0300, filed 3/4/09, effective 4/4/09.*

##### **Wash. Admin. Code § 182-537-0350** Provider qualifications. {#sec-182-537-0350 omnilex-key=us-wa-regs-official--title-182--182-537-0350}

(1) School-based health care services (SBHS) must be delivered by or under the supervision of health care providers who are enrolled with the medicaid agency and who meet state licensure requirements, including active, unrestricted department of health (DOH) licensure. The following people may provide SBHS:

(a) Licensed audiologists;

(b) Licensed social workers;

(c) Licensed mental health counselors (LMHC);

(d) Licensed mental health counselor associates (LMHCA) practicing under the supervision of a licensed mental health provider;

(e) Advanced registered nurse practitioners (ARNP);

(f) Registered nurses (RN);

(g) Licensed practical nurses (LPN) practicing under the supervision of an ARNP or licensed RN;

(h) Licensed occupational therapists (OT);

(i) Licensed occupational therapist assistants (OTA) practicing under the supervision of a licensed OT;

(j) Licensed physical therapists (PT);

(k) Licensed physical therapist assistants (PTA) practicing under the supervision of a licensed PT;

(l) Licensed psychologists;

(m) Licensed speech-language pathologists (SLP);

(n) Speech-language pathology assistants (SLPA) practicing under the supervision of a licensed SLP;

(o) Audiologist and speech language pathologist interim permit holders practicing under the supervision of a licensed audiologist or SLP; and

(p) Nonlicensed people providing services under the supervision of a licensed provider.

(2) For services provided under the supervision of a licensed provider, the provider must:

(a) Ensure the child receives quality services by providing supervision in accordance with professional practice standards; and

(b) Review and cosign all treatment notes written by the supervisee before submitting claims for payment.

(3) The school district must ensure providers meet the professional licensing requirements described in the agency's SBHS billing guide and in this chapter.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-14-062, § 182-537-0350, filed 6/26/20, effective 7/27/20*
- *WSR 19-04-095, § 182-537-0350, filed 2/5/19, effective 3/8/19*
- *WSR 16-07-141, § 182-537-0350, filed 3/23/16, effective 4/23/16. Statutory Authority: RCW 41.05.021, 34 C.F.R. 300.154(d), and chapter 182-502 WAC. WSR 13-21-079, § 182-537-0350, filed 10/17/13, effective 11/17/13. Statutory Authority: RCW 41.05.021. WSR 13-05-017, § 182-537-0350, filed 2/7/13, effective 3/10/13. WSR 11-14-075, recodified as § 182-537-0350, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 42 C.F.R. 440.110. WSR 09-07-004, § 388-537-0350, filed 3/4/09, effective 4/4/09.*

##### **Wash. Admin. Code § 182-537-0400** Covered services. {#sec-182-537-0400 omnilex-key=us-wa-regs-official--title-182--182-537-0400}

Covered school-based health care (SBHS) services include:

(1) Evaluations when the child is determined to have a disability, and is in need of early intervention services or special education and health care-related services that result in an individualized education program (IEP) or individualized family service plan (IFSP);

(2) Health care-related services authorized in an IEP or IFSP limited to:

(a) Audiology;

(b) School health services and school nursing services;

(c) Occupational therapy;

(d) Physical therapy;

(e) Mental health services; and

(f) Speech-language therapy.

(3) Reevaluations, to determine whether a child continues to need early intervention services or special education and health care-related services.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-14-062, § 182-537-0400, filed 6/26/20, effective 7/27/20*
- *WSR 19-04-095, § 182-537-0400, filed 2/5/19, effective 3/8/19*
- *WSR 16-07-141, § 182-537-0400, filed 3/23/16, effective 4/23/16. Statutory Authority: RCW 41.05.021. WSR 13-05-017, § 182-537-0400, filed 2/7/13, effective 3/10/13. WSR 11-14-075, recodified as § 182-537-0400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 42 C.F.R. 440.110. WSR 09-07-004, § 388-537-0400, filed 3/4/09, effective 4/4/09.*

##### **Wash. Admin. Code § 182-537-0500** Noncovered services. {#sec-182-537-0500 omnilex-key=us-wa-regs-official--title-182--182-537-0500}

Noncovered services include, but are not limited to the following:

(1) Applied behavior analysis (ABA);

(2) Attending meetings;

(3) Charting;

(4) Instructional assistant contact;

(5) Observation not provided directly after service delivery;

(6) Parent consultation;

(7) Parent contact;

(8) Planning;

(9) Preparing and sending correspondence to parents or other professionals;

(10) Professional consultation;

(11) Report writing;

(12) Review of records;

(13) School district staff accompanying a child who requires special education services to and from school on the bus when direct services are not provided;

(14) Supervision;

(15) Teacher contact;

(16) Test interpretation; and

(17) Travel and transporting.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-04-095, § 182-537-0500, filed 2/5/19, effective 3/8/19*
- *WSR 16-07-141, § 182-537-0500, filed 3/23/16, effective 4/23/16. Statutory Authority: RCW 41.05.021. WSR 13-05-017, § 182-537-0500, filed 2/7/13, effective 3/10/13. WSR 11-14-075, recodified as § 182-537-0500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 42 C.F.R. 440.110. WSR 09-07-004, § 388-537-0500, filed 3/4/09, effective 4/4/09.*

##### **Wash. Admin. Code § 182-537-0600** School district requirements for billing and payment. {#sec-182-537-0600 omnilex-key=us-wa-regs-official--title-182--182-537-0600}

To receive payment from the medicaid agency for providing school-based health care services (SBHS) to eligible children, a school district must:

(1) Enroll as a billing provider in ProviderOne and have a current, signed core provider agreement (CPA) with the agency.

(2) Have a current, signed, and executed SBHS contract with the agency.

(3) Meet the applicable requirements in chapter 182-502 WAC.

(4) Comply with the applicable requirements in the agency's current, published ProviderOne billing and resource guide.

(5) Bill according to the agency's current SBHS billing guide and the SBHS fee schedule.

(6) Provide only early intervention or health care-related services identified through a current individualized education program (IEP) or individualized family service plan (IFSP).

(7) Use only licensed health care providers or nonlicensed people practicing under the supervision of a licensed provider under WAC 182-537-0350.

(8) Enroll licensed health care providers as servicing providers under the school district's ProviderOne account, and ensure providers have their own national provider identifier (NPI) number.

(9) Meet documentation requirements described in WAC 182-537-0700.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-14-019, § 182-537-0600, filed 6/24/22, effective 8/1/22*
- *WSR 20-14-062, § 182-537-0600, filed 6/26/20, effective 7/27/20*
- *WSR 19-04-095, § 182-537-0600, filed 2/5/19, effective 3/8/19*
- *WSR 16-07-141, § 182-537-0600, filed 3/23/16, effective 4/23/16. Statutory Authority: RCW 41.05.021, 34 C.F.R. 300.154(d), and chapter 182-502 WAC. WSR 13-21-079, § 182-537-0600, filed 10/17/13, effective 11/17/13. Statutory Authority: RCW 41.05.021. WSR 13-05-017, § 182-537-0600, filed 2/7/13, effective 3/10/13. WSR 11-14-075, recodified as § 182-537-0600, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 42 C.F.R. 440.110. WSR 09-07-004, § 388-537-0600, filed 3/4/09, effective 4/4/09.*

##### **Wash. Admin. Code § 182-537-0700** School district documentation requirements. {#sec-182-537-0700 omnilex-key=us-wa-regs-official--title-182--182-537-0700}

(1) Providers must document all school-based health care services as required in this section and the medicaid agency's school-based health care services (SBHS) billing guide.

(2) Documentation to justify billed claims must be maintained for at least six years from the date of service.

(3) Records for each student must include, but are not limited to:

(a) A referral or prescription for services by a physician or other licensed health care provider within their scope of practice;

(b) Assessment reports;

(c) Evaluation and reevaluation reports;

(d) Individualized education program (IEP) or individualized family service plan (IFSP);

(e) Attendance records; and

(f) Treatment notes. Treatment notes must include the:

(i) Child's name;

(ii) Child's ProviderOne client ID;

(iii) Child's date of birth;

(iv) Date of service, and for each date of service:

(A) Time-in;

(B) Time-out;

(C) A procedure code for and description of each service provided;

(D) The child's progress related to each service;

(E) Whether the occupational therapy, speech-language therapy, physical therapy or counseling service described in the note was individual or group therapy;

(F) The licensed provider's printed name, handwritten or electronic signature, and title; and

(G) Assistants and nonlicensed people, as defined in WAC 182-537-0350, who provide early intervention or health care-related services under supervision, must have a licensed provider review and cosign all treatment notes.

(4) The agency accepts electronic records and electronic signatures under chapter 1.80 RCW. Each school district is responsible for determining what standards are consistent with state and federal electronic record and electronic signature requirements.

(5) For a signature to be valid, it must be handwritten or electronic. Signature by stamp is acceptable only if the provider is unable to sign by hand due to a physical disability.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-07-133, § 182-537-0700, filed 3/22/23, effective 7/1/23*
- *WSR 20-14-062, § 182-537-0700, filed 6/26/20, effective 7/27/20*
- *WSR 19-04-095, § 182-537-0700, filed 2/5/19, effective 3/8/19*
- *WSR 16-07-141, § 182-537-0700, filed 3/23/16, effective 4/23/16*
- *WSR 14-20-090, § 182-537-0700, filed 9/29/14, effective 10/30/14. Statutory Authority: RCW 41.05.021. WSR 13-05-017, § 182-537-0700, filed 2/7/13, effective 3/10/13. WSR 11-14-075, recodified as § 182-537-0700, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 42 C.F.R. 440.110. WSR 09-07-004, § 388-537-0700, filed 3/4/09, effective 4/4/09.*

##### **Wash. Admin. Code § 182-537-0800** Program integrity. {#sec-182-537-0800 omnilex-key=us-wa-regs-official--title-182--182-537-0800}

(1) To ensure compliance with program rules, the medicaid agency conducts program integrity activities under chapters 182-502 and 182-502A WAC.

(2) School districts must participate in all program integrity activities.

(3) School districts are responsible for the accuracy, compliance, and completeness of all claims submitted for medicaid payment.

(4) The agency conducts reviews and recovers overpayments if a school district does not comply with agency requirements according to agency rules.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-04-095, § 182-537-0800, filed 2/5/19, effective 3/8/19*
- *WSR 16-07-141, § 182-537-0800, filed 3/23/16, effective 4/23/16. Statutory Authority: RCW 41.05.021. WSR 13-05-017, § 182-537-0800, filed 2/7/13, effective 3/10/13. WSR 11-14-075, recodified as § 182-537-0800, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 42 C.F.R. 440.110. WSR 09-07-004, § 388-537-0800, filed 3/4/09, effective 4/4/09.*

## **Chapter 182-538** Managed care. {#struct-chapter-182-538}

##### **Wash. Admin. Code § 182-538-040** Introduction. {#sec-182-538-040 omnilex-key=us-wa-regs-official--title-182--182-538-040}

(1) This chapter governs services provided under the Washington apple health integrated managed care (IMC) contract.

(2) IMC provides physical and behavioral health services to medicaid beneficiaries through managed care.

(3) IMC includes enrollees receiving behavioral health services only (BHSO).

(4) IMC medicaid services are available only through a contracted managed care organization (MCO) and its provider network, except as identified in this chapter.

(5) For nonmedicaid funded behavioral health wraparound services, see chapter 182-538B WAC.

(6) For crisis and crisis related behavioral health services, see chapter 182-538C WAC.

(7) For behavioral health services, also see chapter 182-538D WAC.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-040, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Parts 431, 433, 438, 440, 457, and 495. WSR 17-23-199, § 182-538-040, filed 11/22/17, effective 12/23/17. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-040, filed 12/1/15, effective 1/1/16.*

##### **Wash. Admin. Code § 182-538-050** Definitions. {#sec-182-538-050 omnilex-key=us-wa-regs-official--title-182--182-538-050}

The following definitions and abbreviations and those found in chapter 182-500 WAC apply to this chapter. If conflict exists, this chapter takes precedence.

"Administrative hearing" means an evidentiary adjudicative proceeding before an administrative law judge or presiding officer that is available to an enrollee under chapter 182-526 WAC according to RCW 74.09.741.

"Adverse benefit determination" means one or more of the following:

(a) The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit;

(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;

(e) The failure of a managed care organization (MCO) to act within the time frames provided in 42 C.F.R. Sec. 438.408 (a), (b)(1) and (2) for standard resolution of grievances and appeals; or

(f) For a resident of a rural area with only one MCO, the denial of an enrollee's request to exercise the enrollee's right to obtain services outside the network under 42 C.F.R. Sec. 438.52 (b)(2)(ii).

"Agency" - See WAC 182-500-0010.

"Appeal" means a review by an MCO of an adverse benefit determination.

"Apple health foster care (AHFC)" means the managed care program developed by the agency and the department of social and health services to serve children and youth in foster care and adoption support and young adult alumni of the foster care program.

"Assign" or "assignment" means the agency selects an MCO to serve a client who has not selected an MCO.

"Auto enrollment" means the agency has automatically enrolled a client into an MCO in the client's area of residence.

"Behavioral health" - See WAC 182-538D-0200.

"Behavioral health administrative service organization (BH-ASO)" means an entity selected by the medicaid agency to administer behavioral health services and programs, including crisis services for all people in an integrated managed care regional service area. The BH-ASO administers crisis services for all people in its defined regional service area, regardless of a person's ability to pay.

"Behavioral health services only (BHSO)" means the program in which enrollees only receive behavioral health benefits through a managed care delivery system.

"Child or youth with special health care needs" means a client under age 19 who is:

(a) Eligible for supplemental security income under Title XVI of the Social Security Act;

(b) Eligible for medicaid under section 1902 (e)(3) of the Social Security Act;

(c) In foster care or other out-of-home placement;

(d) Receiving foster care or adoption assistance; or

(e) Receiving services through a family-centered, community-based, coordinated care system that receives grant funds under section 501 (a)(1)(D) of Title V of the Social Security Act.

"Client" - See WAC 182-500-0020.

"Disenrollment" - See "end enrollment."

"Early periodic screening, diagnosis, and treatment (EPSDT)" - See WAC 182-534-0050.

"Emergency medical condition" means a condition meeting the definition in 42 C.F.R. Sec. 438.114(a).

"Emergency services" means services defined in 42 C.F.R. Sec. 438.114(a).

"End enrollment" means ending the enrollment of an enrollee for one of the reasons outlined in WAC 182-538-130.

"Enrollee" means a person eligible for any Washington apple health program enrolled in managed care with an MCO or PCCM provider that has a contract with the state.

"Enrollee's representative" means a person with a legal right or written authorization from the enrollee to act on behalf of the enrollee in making decisions.

"Enrollees with special health care needs" means enrollees having chronic and disabling conditions and the conditions:

(a) Have a biologic, psychologic, or cognitive basis;

(b) Have lasted or are virtually certain to last for at least one year; and

(c) Produce one or more of the following conditions stemming from a disease:

(i) Significant limitation in areas of physical, cognitive, or emotional function;

(ii) Dependency on medical or assistive devices to minimize limitation of function or activities; or

(iii) In addition, for children, any of the following:

(A) Significant limitation in social growth or developmental function;

(B) Need for psychological, educational, medical, or related services over and above the usual for the child's age; or

(C) Special ongoing treatments, such as medications, special diet, interventions, or accommodations at home or school.

"Exemption" means agency approval of a client's preenrollment request to remain in the fee-for-service delivery system for one of the reasons outlined in WAC 182-538-130.

"Fully integrated managed care (FIMC)" - See integrated managed care.

"Grievance" means an expression of dissatisfaction about any matter other than an adverse benefit determination.

"Grievance and appeal system" means the processes the MCO implements to handle appeals of adverse benefit determinations and grievances, as well as the processes to collect and track information about them.

"Health care service" or "service" means a service or item provided for the prevention, cure, or treatment of an illness, injury, disease, or condition.

"Integrated managed care (IMC)" means the program under which a managed care organization provides:

(a) Physical health services funded by medicaid; and

(b) Behavioral health services funded by medicaid, and other available resources provided for in chapters 182-538B, 182-538C, and 182-538D WAC.

"Managed care" means a comprehensive health care delivery system that includes preventive, primary, specialty, and ancillary services. These services are provided through either an MCO or PCCM provider.

"Managed care contract" means the agreement between the agency and an MCO to provide prepaid contracted services to enrollees.

"Managed care organization" or "MCO" means an organization having a certificate of authority or certificate of registration from the office of insurance commissioner that contracts with the agency under a comprehensive risk contract to provide prepaid health care services to enrollees under the agency's managed care programs.

"Mandatory enrollment" means the agency's requirement that a client enroll in managed care.

"Mandatory service area" means a service area in which eligible clients are required to enroll in an MCO.

"Nonparticipating provider" means a person, health care provider, practitioner, facility, or entity acting within their scope of practice and licensure that:

(a) Provides health care services to enrollees; and

(b) Does not have a written agreement with the managed care organization (MCO) to participate in the MCO's provider network.

"Participating provider" means a person, health care provider, practitioner, or entity acting within their scope of practice and licensure with a written agreement with the MCO to provide services to enrollees.

"Patient days of care" means all voluntary patients and involuntarily committed patients under chapter 71.05 RCW, regardless of where in the state hospital the patients reside. Patients who are committed to the state hospital under chapter 10.77 RCW are not included in the patient days of care. Patients who are committed under RCW 10.77.088 by municipal or district courts after failed competency restoration and dismissal of misdemeanor charges are not counted in the patient days of care until a petition for 90 days of civil commitment under chapter 71.05 RCW has been filed in court. Patients who are committed under RCW 10.77.086 by a superior court after failed competency restoration and dismissal of felony charges are not counted in the patient days of care until the patient is civilly committed under chapter 71.05 RCW.

"Primary care case management" or "PCCM" means the health care management activities of a provider that contracts with the agency to provide primary health care services and to arrange and coordinate other preventive, specialty, and ancillary health services.

"Primary care provider" or "PCP" means a person licensed or certified under Title 18 RCW including, but not limited to, a physician, an advanced registered nurse practitioner (ARNP), naturopath, or a physician assistant who supervises, coordinates, and provides health services to a client or an enrollee, initiates referrals for specialist and ancillary care, and maintains the client's or enrollee's continuity of care.

"Regional service area (RSA)" means a single county or multi-county grouping formed for the purpose of health care purchasing and designated by the agency and the department of social and health services.

"Timely" concerning the provision of services, means an enrollee has the right to receive medically necessary health care as expeditiously as the enrollee's health condition requires. Concerning authorization of services and grievances and appeals, "timely" means according to the agency's managed care program contracts and the time frames stated in this chapter.

"Wraparound with intensive services (WISe)" is a program that provides comprehensive behavioral health services and support to:

(a) Medicaid-eligible people age 20 or younger with complex behavioral health needs; and

(b) Their families.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-07-031, s 182-538-050, filed 3/11/26, effective 4/11/26. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. 438.50. WSR 22-07-107, § 182-538-050, filed 3/23/22, effective 4/23/22. Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-050, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Parts 431, 433, 438, 440, 457, and 495. WSR 17-23-199, § 182-538-050, filed 11/22/17, effective 12/23/17. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-050, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-050, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-050, filed 7/18/08, effective 8/18/08*
- *WSR 06-03-081, § 388-538-050, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 U.S.C. 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). WSR 05-01-066, § 388-538-050, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.522. WSR 03-18-109, § 388-538-050, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-050, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. WSR 00-04-080, § 388-538-050, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. WSR 95-18-046 (Order 3886), § 388-538-050, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. WSR 93-17-039 (Order 3621), § 388-538-050, filed 8/11/93, effective 9/11/93.*

##### **Wash. Admin. Code § 182-538-060** Managed care choice and assignment. {#sec-182-538-060 omnilex-key=us-wa-regs-official--title-182--182-538-060}

(1) The medicaid agency requires a client to enroll in integrated managed care (IMC) when that client:

(a) Is eligible for one of the Washington apple health programs for which enrollment is mandatory;

(b) Resides in an area where enrollment is mandatory; and

(c) Is not exempt from IMC enrollment and the agency has not ended the client's managed care enrollment, consistent with WAC 182-538-130.

(2) American Indian and Alaska native (AI/AN) clients and their descendants may choose one of the following:

(a) Enrollment with a managed care organization (MCO) available in their regional service area;

(b) Enrollment with a PCCM provider through a tribal clinic or urban Indian center available in their area; or

(c) The agency's fee-for-service system for physical health or behavioral health or both.

(3) To enroll with an MCO or PCCM provider, a client may:

(a) Enroll online via the Washington Healthplanfinder at https://www.wahealthplanfinder.org;

(b) Call the agency's toll-free enrollment line at 800-562-3022; or

(c) Go to the ProviderOne client portal at https://www.waproviderone.org/client and follow the instructions.

(4) An enrollee in IMC must enroll with an MCO available in the regional service area where the enrollee resides.

(5) All family members will be enrolled with the same MCO, except family members of an enrollee placed in the patient review and coordination (PRC) program under WAC 182-501-0135 need not enroll in the same MCO as the family member placed in the PRC program.

(6) An enrollee may be placed into the PRC program by the MCO or the agency. An enrollee placed in the PRC program must follow the enrollment requirements of the program as stated in WAC 182-501-0135.

(7) When a client requests enrollment with an MCO or PCCM provider, the agency enrolls a client effective the earliest possible date given the requirements of the agency's enrollment system.

(8) The agency assigns a client who does not choose an MCO or PCCM provider as follows:

(a) If the client was enrolled with an MCO or PCCM provider within the previous six months, the client is reenrolled with the same MCO or PCCM provider;

(b) If (a) of this subsection does not apply and the client has a family member enrolled with an MCO, the client is enrolled with that MCO;

(c) The client is reenrolled within the previous six months with their prior MCO plan if:

(i) The agency identifies the prior MCO and the program is available; and

(ii) The client does not have a family member enrolled with an agency-contracted MCO or PCCM provider.

(d) If the client has a break in eligibility of less than two months, the client will be automatically reenrolled with his or her previous MCO or PCCM provider and no notice will be sent; or

(e) If the client cannot be assigned according to (a), (b), (c), or (d) of this subsection, the agency:

(i) Assigns the client according to agency policy, or this rule, or both;

(ii) Does not assign clients to any MCO that has a total statewide market share of forty percent or more of clients who are enrolled in apple health IMC. On a quarterly basis, the agency reviews enrollment data to determine each MCO's statewide market share in apple health IMC;

(iii) Applies performance measures associated with increasing or reducing assignment consistent with this rule and agency policy or its contracts with MCOs.

(f) If the client cannot be assigned according to (a) or (b) of this subsection, the agency assigns the client as follows:

(i) If a client who is not AI/AN does not choose an MCO, the agency assigns the client to an MCO available in the area where the client resides. The MCO is responsible for primary care provider (PCP) choice and assignment.

(ii) For clients who are newly eligible or who have had a break in eligibility of more than six months, the agency sends a written notice to each household of one or more clients who are assigned to an MCO. The assigned client has ten calendar days to contact the agency to change the MCO assignment before enrollment is effective. The notice includes:

(A) The agency's toll-free number;

(B) The toll-free number and name of the MCO to which each client has been assigned;

(C) The effective date of enrollment; and

(D) The date by which the client must respond in order to change the assignment.

(9) An MCO enrollee's selection of a PCP or assignment to a PCP occurs as follows:

(a) An MCO enrollee may choose:

(i) A PCP or clinic that is in the enrollee's MCO and accepting new enrollees; or

(ii) A different PCP or clinic participating with the enrollee's MCO for different family members.

(b) The MCO assigns a PCP or clinic that meets the access standards set forth in the relevant managed care contract if the enrollee does not choose a PCP or clinic.

(c) An MCO enrollee may change PCPs or clinics in an MCO for any reason, with the change becoming effective no later than the beginning of the month following the enrollee's request.

(d) An MCO enrollee may file a grievance with the MCO if the MCO does not approve an enrollee's request to change PCPs or clinics.

(e) MCO enrollees required to participate in the agency's PRC program may be limited in their right to change PCPs (see WAC 182-501-0135).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-20-011, § 182-538-060, filed 9/24/20, effective 10/25/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-060, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-060, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-060, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-060, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-060, filed 7/18/08, effective 8/18/08*
- *WSR 06-03-081, § 388-538-060, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 U.S.C. 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). WSR 05-01-066, § 388-538-060, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.522. WSR 03-18-109, § 388-538-060, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-060, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. WSR 00-04-080, § 388-538-060, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-538-060, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. WSR 95-18-046 (Order 3886), § 388-538-060, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. WSR 93-17-039 (Order 3621), § 388-538-060, filed 8/11/93, effective 9/11/93.*

##### **Wash. Admin. Code § 182-538-067** Qualifications to become a managed care organization (MCO) in integrated managed care. {#sec-182-538-067 omnilex-key=us-wa-regs-official--title-182--182-538-067}

(1) To provide physical or behavioral health services under the apple health IMC contract, a managed care organization (MCO) must:

(a) Contract with the agency; and

(b) Contract with an agency-contracted behavioral health administrative service organization (BH-ASO) that maintains an adequate provider network to deliver services to clients in IMC regional service areas.

(2) An MCO must meet the following qualifications to be eligible to contract with the agency:

(a) Have a certificate of registration from the Washington state office of the insurance commissioner (OIC) that allows the MCO to provide health care services under a risk-based contract;

(b) Accept the terms and conditions of the agency's managed care contract;

(c) Meet the network and quality standards established by the agency; and

(d) Pass a readiness review, including an on-site visit conducted by the agency.

(3)(a) The agency may from time to time conduct a procurement for new apple health MCOs or to reduce or expand the use of existing apple health MCOs.

(b) The agency may conduct a procurement when the agency determines in its sole discretion there is a need to:

(i) Expand or reduce current MCO contracts;

(ii) Enhance current MCO provider networks; or

(iii) Establish new contracts for integrated managed care in one or more regional services areas; or

(iv) Adjust the program to ensure adherence to state and federal law.

(c) In accordance with RCW 74.09.522 and 74.09.871, the agency will give significant weight to the following factors in any procurement process:

(i) Demonstrated commitment to, and experience in, serving low-income populations;

(ii) Demonstrated commitment to, and experience in, serving persons who have mental illness, substance use disorders, or co-occurring disorders;

(iii) Demonstrated commitment to, and experience with, partnerships with county and municipal criminal justice systems, housing services, and other critical support services necessary to achieve the outcomes established in RCW 70.320.020, 71.24.435, and 71.36.025;

(iv) Recognition that meeting enrollees' physical and behavioral health care needs is a shared responsibility of contracted behavioral health administrative services organizations, MCOs, service providers, the state, and communities;

(v) Consideration of past and current performance and participation in other state or federal behavioral health programs as a contractor;

(vi) Quality of services provided to enrollees under previous contracts with the state of Washington or other states;

(vii) Accessibility, including appropriate utilization, of services offered to enrollees;

(viii) Demonstrated capability to perform contracted services, including the ability to supply an adequate provider network; and

(ix) The ability to meet any other requirements established by the agency.

(d) The agency may define and consider additional factors as part of any procurement including, but not limited to:

(i) Timely processing of, and payments to, providers in the MCO networks, including reconciliation of outstanding payments; and

(ii) The optimal number of MCOs per regional services area, based on population and in the manner that the agency determines most beneficial for the program, clients, and providers.

(4) The agency reserves the right not to contract with any otherwise qualified MCO.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-20-011, § 182-538-067, filed 9/24/20, effective 10/25/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-067, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-067, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-067, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-067, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-067, filed 7/18/08, effective 8/18/08*
- *WSR 06-03-081, § 388-538-067, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 U.S.C. 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). WSR 05-01-066, § 388-538-067, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.522. WSR 03-18-112, § 388-538-067, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, RCW 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-067, filed 12/14/01, effective 1/14/02.*

##### **Wash. Admin. Code § 182-538-068** Qualifications to become a primary care case management (PCCM) provider in integrated managed care regional service areas. {#sec-182-538-068 omnilex-key=us-wa-regs-official--title-182--182-538-068}

A primary care case management (PCCM) provider or the individual providers in a PCCM group or clinic must:

(1) Have a core provider agreement with the medicaid agency;

(2) Be a recognized urban Indian health center or tribal clinic;

(3) Accept the terms and conditions of the agency's PCCM contract;

(4) Be able to meet the quality standards established by the agency; and

(5) Accept the case management rate paid by the agency.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-068, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-068, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-068, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-068, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-068, filed 7/18/08, effective 8/18/08*
- *WSR 06-03-081, § 388-538-068, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-068, filed 12/14/01, effective 1/14/02.*

##### **Wash. Admin. Code § 182-538-070** Payments, corrective action, and sanctions for managed care organizations (MCOs). {#sec-182-538-070 omnilex-key=us-wa-regs-official--title-182--182-538-070}

(1) The medicaid agency pays apple health managed care organizations (MCOs) monthly capitated premiums that:

(a) Have been developed using generally accepted actuarial principles and practices;

(b) Are appropriate for the populations to be covered and the services to be furnished under the MCO contract;

(c) Have been certified by actuaries who meet the qualification standards established by the American Academy of Actuaries and follow the practice standards established by the Actuarial Standards Board;

(d) Are based on analysis of historical cost, rate information, or both; and

(e) Are paid based on legislative allocations.

(2) The MCO is solely responsible for payment of MCO-contracted health care services. The agency will not pay for a service that is the MCO's responsibility, even if the MCO has not paid the provider for the service.

(3) Home health services delivered through MCOs involving an in-home visit by a provider require the provider to comply with electronic visit verification requirements. See WAC 182-551-2220.

(4) The agency pays MCOs a service-based enhancement rate for wraparound with intensive services (WISe) administered by a certified WISe provider who holds a current behavioral health agency license issued by the department of health under chapter 246-341 WAC.

(5) For crisis services, the MCO must determine whether the person receiving the services is eligible for Washington apple health or if the person has other insurance coverage.

(6) The agency may require corrective action for:

(a) Substandard rates of clinical performance measures;

(b) Deficiencies found in audits and on-site visits; or

(c) Findings of noncompliance with any contractual, state, or federal requirements.

(7) The agency may:

(a) Impose sanctions for an MCO's noncompliance with any contractual, state, or federal requirements including, but not limited to, intermediate sanctions as described in 42 C.F.R. Sec. 438.700 and 42 C.F.R. Sec. 438.702; and

(b) Apply a monthly penalty assessment associated with poor performance on selected behavioral health performance measures.

(8) As authorized by 42 C.F.R. Sec. 438.702(b), if an MCO fails to meet any material obligation under the MCO contract including, but not limited to, the items listed in 42 C.F.R. Sec. 438.700 (b), (c), or (d), the agency may impose the maximum allowable sanction on a per-occurrence, per-day basis until the agency determines the MCO has:

(a) Corrected the violation; and

(b) Remedied any harm caused by the noncompliance.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-08-060, § 182-538-070, filed 3/29/24, effective 4/29/24. Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-538-070, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-03-063, § 182-538-070, filed 1/12/23, effective 2/12/23. Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-070, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-08-035, § 182-538-070, filed 3/27/18, effective 4/27/18*
- *WSR 15-24-098, § 182-538-070, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-070, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-070, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-070, filed 7/18/08, effective 8/18/08*
- *WSR 06-03-081, § 388-538-070, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 U.S.C. 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). WSR 05-01-066, § 388-538-070, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.522. WSR 03-18-109, § 388-538-070, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-070, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. WSR 00-04-080, § 388-538-070, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.08.090. WSR 96-24-073, § 388-538-070, filed 12/2/96, effective 1/2/97. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. WSR 95-18-046 (Order 3886), § 388-538-070, filed 8/29/95 effective 9/1/95. Statutory Authority: RCW 74.08.090. WSR 93-17-039 (Order 3621), § 388-538-070, filed 8/11/93, effective 9/11/93.*

##### **Wash. Admin. Code § 182-538-071** Payments for primary care case management (PCCM) providers in the integrated managed care for regional service areas. {#sec-182-538-071 omnilex-key=us-wa-regs-official--title-182--182-538-071}

(1) The medicaid agency pays PCCM providers a monthly case management fee according to contracted terms and conditions.

(2) The agency pays PCCM providers for health care services under the fee-for-service health care delivery system.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-071, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-071, filed 12/1/15, effective 1/1/16.*

##### **Wash. Admin. Code § 182-538-095** Scope of care for integrated managed care enrollees and managed care organization benefit administration requirements. {#sec-182-538-095 omnilex-key=us-wa-regs-official--title-182--182-538-095}

Scope of Care.

(1) An enrollee in integrated managed care (IMC) is eligible only for the scope of services that are covered based on the apple health program (eligibility program) in which they are enrolled.

(a) See the chart in WAC 182-501-0060 for category of covered services that are covered based on enrollee's apple health eligibility program, and the program rules to determine which specific services are covered. See WAC 182-501-0065 for a description of the category of covered services.

(b) The apple health eligibility programs for IMC includes the alternative benefit plan (ABP), categorically needy (CN), and medically needy (MN) programs.

(2) The managed care organization (MCO) covers the services included under the IMC medicaid contract for IMC enrollees based on their apple health eligibility program.

(3) If an IMC enrollee is enrolled in behavioral health services only (BHSO):

(a) The MCO will only cover the behavioral health benefit included in the IMC medicaid contract.

(b) The MCO is not responsible for coverage of the physical health benefit in the IMC contract.

(c) See WAC 182-538-190 regarding additional rules related to BHSO.

(4) The agency does not require the MCO to cover any services outside the scope of covered services in the MCO's contract with the agency. At its discretion, an MCO may cover services not required under the IMC medicaid contract.

(5) Services included in enrollees' medicaid eligibility program, and identified as covered based on program rules, may be excluded from coverage by the agency under the managed care contract. These excluded services that are covered based on program rules are available on a fee-for-service basis.

(6) The MCO is not required to authorize or pay for covered services if:

(a) Services are determined to be not medically necessary as defined in WAC 182-500-0070.

(b) Services are excluded from coverage under the managed care contract.

(c) Services received in a hospital emergency department for nonemergency medical conditions, except for a screening exam as described in WAC 182-538-100.

(d) Services received from a participating provider that require prior authorization from the MCO, but were not authorized by the MCO.

(e) All nonemergency services covered under the MCO contract and received from nonparticipating providers that were not prior authorized by the MCO.

MCO Benefit Administration Requirements.

(7) For services covered by the agency through contracts with MCOs:

(a) The agency requires the MCO to subcontract with enough providers to deliver the scope of contracted services in a timely manner;

(b) The agency requires MCOs to provide new enrollees with written information about how enrollees may obtain covered services;

(c) MCOs provide covered services to enrollees through their participating providers, unless an exception applies. An MCO covers services from a nonparticipating provider when an enrollee obtains:

(i) Emergency services; or

(ii) Authorization from the MCO to receive services from a nonparticipating provider.

(d) For nonemergency services, MCOs may require:

(i) The enrollee to obtain a referral from the primary care provider (PCP); or

(ii) The provider to obtain authorization from the MCO, according to the requirements of the MCO contract;

(e) MCOs and their contracted providers determine which services are medically necessary given the enrollee's condition, according to the requirements included in the MCO contract;

(f) The agency requires the MCO to coordinate benefits with other insurers in a manner that does not reduce benefits to the enrollee or result in costs to the enrollee;

(g) A managed care enrollee does not need a PCP referral to receive women's health care services, as described in RCW 48.42.100, from any women's health care provider participating with the MCO. Any covered services ordered or prescribed by a women's health care provider must meet the MCO's service authorization requirements for the specific service;

(h) For enrollees outside their MCO services area, the MCO must cover enrollees for emergency care and medically necessary covered benefits that cannot wait until the enrollees return to their MCO services area.

(8)(a) An MCO enrollee may obtain specific services described in the managed care contract from either an MCO-contracted provider or a provider with a separate agreement with the agency without a referral from the PCP or MCO. These services are communicated to enrollees by the agency and MCOs as described in (b) of this subsection.

(b) The agency sends each enrollee written information about covered services when the client must enroll in managed care and any time there is a change in covered services. The agency requires MCOs to provide new enrollees with written information about covered services.

(9) An enrollee is entitled to timely access to covered services that are medically necessary as defined in WAC 182-500-0070.

(10) All nonemergency services covered under the MCO contract and received from nonparticipating providers require prior authorization from the MCO.

(11) A provider may bill an enrollee for services only if the requirements of WAC 182-502-0160 are met.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-095, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-095, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-095, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-095, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-095, filed 7/18/08, effective 8/18/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-538-095, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 06-03-081, § 388-538-095, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 U.S.C. 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). WSR 05-01-066, § 388-538-095, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.522. WSR 03-18-109, § 388-538-095, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-095, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090. WSR 01-02-076, § 388-538-095, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. WSR 00-04-080, § 388-538-095, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-538-095, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. WSR 95-18-046 (Order 3886), § 388-538-095, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. WSR 93-17-039 (Order 3621), § 388-538-095, filed 8/11/93, effective 9/11/93.*

##### **Wash. Admin. Code § 182-538-096** Scope of service for PCCM enrollees. {#sec-182-538-096 omnilex-key=us-wa-regs-official--title-182--182-538-096}

(1) An enrollee is entitled to timely access to covered services that are medically necessary.

(2) A primary care case management (PCCM) enrollee is eligible for the scope of services that are covered based on the enrollee's apple health eligibility program. See WAC 182-501-0060 and 182-501-0065 for categories of services that are covered and program rules for specific services that are covered.

(3) The agency covers services through the fee-for-service system for enrollees with a primary care case management (PCCM) provider.

(a) The PCCM provider must either provide the covered services or refer the enrollee to other providers who are contracted with the agency for covered services, except for emergency services.

(b) The PCCM provider is responsible for explaining to the enrollee how to obtain the services for which the PCCM provider is referring the enrollee.

(c) Services that require PCCM provider referral are described in the PCCM contract.

(d) The agency sends each enrollee written information about covered services when the client enrolls in managed care and when there is a change in covered services. This information describes covered services, which services are covered by the agency, and how to access services through the PCCM provider.

(4) The agency will not authorize or pay for the following services:

(a) Services that are not medically necessary as defined in WAC 182-500-0070.

(b) Services not included in the scope of covered services for the client's apple health eligibility program.

(c) Services received in a hospital emergency department for nonemergency medical conditions, other than a screening exam as described in WAC 182-538-100(3).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-096, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-096, filed 12/1/15, effective 1/1/16.*

##### **Wash. Admin. Code § 182-538-100** Managed care emergency services. {#sec-182-538-100 omnilex-key=us-wa-regs-official--title-182--182-538-100}

(1) A managed care enrollee may obtain emergency services for emergency medical conditions from any qualified medicaid provider.

(a) The managed care organization (MCO) covers emergency services for MCO enrollees.

(b) The agency covers emergency services for primary care case management (PCCM) enrollees.

(2) Emergency services for emergency medical conditions do not require prior authorization by the MCO, primary care provider (PCP), PCCM provider, or the agency.

(3) MCOs must cover all emergency services provided to an enrollee by a provider who is qualified to furnish medicaid services, without regard to whether the provider is a participating or nonparticipating provider.

(4) An enrollee who requests emergency services may receive an exam to determine if the enrollee has an emergency medical condition. What constitutes an emergency medical condition may not be limited on the basis of diagnosis or symptoms.

(5) The MCO must cover emergency services provided to an enrollee when:

(a) The enrollee had an emergency medical condition, including cases in which the absence of immediate medical attention would not have had the outcomes specified in the definition of an emergency medical condition; and

(b) The plan provider or other MCO representative instructs the enrollee to seek emergency services.

(6) In any disagreement between a hospital and the MCO about whether the enrollee is stable enough for discharge or transfer, or whether the medical benefits of an unstabilized transfer outweigh the risks, the judgment of the attending physician(s) actually caring for the enrollee at the treating facility prevails.

(7) Under 42 C.F.R. 438.114, the enrollee's MCO must cover and pay for:

(a) Emergency services provided to enrollees by an emergency room provider, hospital or provider outside the managed care system; and

(b) Any screening and treatment the enrollee requires after the provision of the emergency services.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-100, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-100, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-100, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-100, filed 7/18/08, effective 8/18/08*
- *WSR 06-03-081, § 388-538-100, filed 1/12/06, effective 2/12/06*
- *WSR 03-18-110, § 388-538-100, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-100, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. WSR 00-04-080, § 388-538-100, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. WSR 95-18-046 (Order 3886), § 388-538-100, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. WSR 95-04-033 (Order 3826), § 388-538-100, filed 1/24/95, effective 2/1/95*
- *WSR 93-17-039 (Order 3621), § 388-538-100, filed 8/11/93, effective 9/11/93.*

##### **Wash. Admin. Code § 182-538-110** The grievance and appeal system and agency administrative hearing for managed care organization (MCO) enrollees. {#sec-182-538-110 omnilex-key=us-wa-regs-official--title-182--182-538-110}

(1) Introduction. This section contains information about the grievance and appeal system and the right to an agency administrative hearing for MCO enrollees. See WAC 182-538-111 for information about PCCM enrollees.

(2) Statutory basis and framework.

(a) Each MCO must have a grievance and appeal system in place for enrollees.

(b) Once an MCO enrollee has completed the MCO appeals process, the MCO enrollee has the option of requesting an agency administrative hearing regarding any adverse benefit determination upheld by the MCO. See chapter 182-526 WAC.

(3) MCO grievance and appeal system - General requirements.

(a) The MCO grievance and appeal system must include:

(i) A process for addressing complaints about any matter that is not an adverse benefit determination, which is a grievance;

(ii) An appeal process to address enrollee requests for review of an MCO adverse benefit determination; and

(iii) Access to the agency's administrative hearing process for review of an MCO's resolution of an appeal.

(b) MCOs must provide information describing the MCO's grievance and appeal system to all providers and subcontractors.

(c) An MCO must have agency approval for written materials sent to enrollees regarding the grievance and appeal system and the agency's administrative hearing process under chapter 182-526 WAC.

(d) MCOs must inform enrollees in writing within 15 calendar days of enrollment about enrollees' rights with instructions on how to use the MCO's grievance and appeal system and the agency's administrative hearing process.

(e) An MCO must give enrollees any reasonable assistance in completing forms and other procedural steps for grievances and appeals (e.g., interpreter services and toll-free numbers).

(f) An MCO must allow enrollees and their authorized representatives to file grievances and appeals orally as well as in writing.

(g) Methods to file either a grievance or appeal include, but are not limited to, U.S. mail, commercial delivery services, hand delivery, fax, telephone, and email.

(h) MCOs may not require enrollees to provide written follow-up for a grievance the MCO received orally.

(i) The MCO must resolve each grievance and appeal and provide notice of the resolution as expeditiously as the enrollee's health condition requires, and within the time frames identified in this section.

(j) The MCO must ensure that the people who make decisions on grievances and appeals:

(i) Neither were involved in any previous level of review or decision making, nor a subordinate of any person who was so involved; and

(ii) Are health care professionals with appropriate clinical expertise in treating the enrollee's condition or disease if deciding any of the following:

(A) An appeal of an adverse benefit determination concerning medical necessity;

(B) A grievance concerning denial of an expedited resolution of an appeal; or

(C) A grievance or appeal that involves any clinical issues.

(iii) Take into account all comments, documents, records, and other information submitted by the enrollee or the enrollee's representative without regard to whether the information was submitted or considered in the initial adverse benefit determination.

(4) The MCO grievance process.

(a) Only an enrollee or enrollee's authorized representative may file a grievance with the MCO. A provider may not file a grievance on behalf of an enrollee without the enrollee's written consent.

(b) The MCO must acknowledge receipt of each grievance within two business days. Acknowledgment may be orally or in writing.

(c) The MCO must complete the resolution of a grievance and provide notice to the affected parties as expeditiously as the enrollee's health condition requires, but no later than 45 days after receiving the grievance.

(d) The MCO must notify enrollees of the resolution of grievances within five business days of determination.

(i) Notices of resolution of grievances not involving clinical issues can be oral or in writing.

(ii) Notices of resolution of grievances for clinical issues must be in writing.

(e) Enrollees do not have a right to an agency administrative hearing to dispute the resolution of a grievance unless the MCO fails to adhere to the notice and timing requirements for grievances.

(f) If the MCO fails to adhere to the notice and timing requirements for grievances, the enrollee is deemed to have completed the MCO's appeals process and may initiate an agency administrative hearing.

(5) MCO's notice of adverse benefit determination.

(a) Language and format requirements. The notice of adverse benefit determination must be in writing in the enrollee's primary language, and in an easily understood format, in accordance with 42 C.F.R. Sec. 438.404.

(b) Content of notice. The notice of MCO adverse benefit determination must explain:

(i) The adverse benefit determination the MCO has made or intends to make, and any pertinent effective date;

(ii) The reasons for the adverse benefit determination, including citation to rules or regulations and the MCO criteria that were the basis of the decision;

(iii) The enrollee's right to receive upon request, free of charge, reasonable access to and copies of all documents, records, and other information relevant to the enrollee's adverse benefit determination, including medical necessity criteria and any processes, strategies, or evidentiary standards used in setting coverage limits;

(iv) The enrollee's right to file an appeal of the MCO adverse benefit determination, including information on the MCO appeal process and the right to request an agency administrative hearing;

(v) The procedures for exercising the enrollee's rights;

(vi) The circumstances under which an appeal can be expedited and how to request it;

(vii) The enrollee's right to have benefits continued pending resolution of an appeal, how to request that benefits be continued, and the circumstances under which the enrollee may be required to pay the costs of these services.

(c) Timing of notice. The MCO must mail the notice of adverse benefit determination within the following time frames:

(i) For termination, suspension, or reduction of previously authorized services, at least 10 calendar days prior to the effective date of the adverse benefit determination in accordance with 42 C.F.R. Sec. 438.404 and 431.211. This time period does not apply if the criteria in 42 C.F.R. Sec. 431.213 or 431.214 are met. This notice must be mailed by a method that certifies receipt and assures delivery within three calendar days.

(ii) For denial of payment, at the time of any adverse benefit determination affecting the claim. This applies only when the enrollee can be held liable for the costs associated with the adverse benefit determination.

(iii) For standard service authorization decisions that deny or limit services, as expeditiously as the enrollee's health condition requires not to exceed 14 calendar days following receipt of the request for service. An extension of up to 14 additional days may be allowed if:

(A) The enrollee or enrollee's provider requests the extension.

(B) The MCO determines and justifies to the agency upon request, a need for additional information and that the extension is in the enrollee's interest.

(iv) If the MCO extends the time frame for standard service authorization decisions, the MCO must:

(A) Give the enrollee written notice of the reason for the decision to extend and inform the enrollee of the right to file a grievance if the enrollee disagrees with that decision; and

(B) Issue and carry out its determination as expeditiously as the enrollee's health condition requires and no later than the date the extension expires.

(v) For expedited authorization decisions:

(A) In cases involving mental health drug authorization decisions, or where the provider indicates or the MCO determines that following the standard time frame could seriously jeopardize the enrollee's life or health or ability to attain, maintain, or regain maximum function, the MCO must make an expedited authorization decision and provide notice no later than 72 hours after receipt of the request for service.

(B) The MCO may extend the 72-hour time frame up to 14 calendar days if:

(I) The enrollee requests the extension; or

(II) The MCO determines and justifies to the agency, upon request, there is a need for additional information and it is in the enrollee's interest.

(6) The MCO appeal process.

(a) Authority to appeal. An enrollee, the enrollee's authorized representative, or the provider acting with the enrollee's written consent may appeal an adverse benefit determination from the MCO.

(b) Oral appeals. An MCO must treat oral inquiries about appealing an adverse benefit determination as an appeal to establish the earliest possible filing date for the appeal.

(c) Acknowledgment letter. The MCO must acknowledge in writing receipt of each standard appeal to both the enrollee and the requesting provider within five calendar days of receiving the appeal request. The appeal acknowledgment letter sent by the MCO serves as written confirmation of a standard appeal filed orally by an enrollee. The MCO must acknowledge receipt of each expedited appeal either orally or in writing within two business days.

(d) Standard service authorization - 60-day deadline. For appeals involving standard service authorization decisions, an enrollee must file an appeal within 60 calendar days of the date on the MCO's notice of adverse benefit determination. This time frame also applies to a request for an expedited appeal.

(e) Previously authorized service - 10-day deadline. For appeals of adverse benefit determinations involving termination, suspension, or reduction of a previously authorized service, and the enrollee is requesting continuation of the service, the enrollee must file an appeal within 10 calendar days of the MCO mailing notice of the adverse benefit determination.

(f) Untimely service authorization decisions. When the MCO does not make a service authorization decision within required time frames, it is considered a denial. In this case, the MCO sends a formal notice of adverse benefit determination, including the enrollee's right to an appeal.

(g) Appeal process requirements. The MCO appeal process must:

(i) Provide the enrollee a reasonable opportunity to present evidence and allegations of fact or law, in person, by telephone, or in writing. The MCO must inform the enrollee of the limited time available for this in the case of expedited resolution;

(ii) Provide the enrollee and the enrollee's representative opportunity before and during the appeal process to examine the enrollee's case file, including medical records, other relevant documents and records, and any new or additional evidence considered, relied upon, or generated by the MCO (or at the direction of the MCO) in connection with the appeal of the adverse benefit determination. This information must be provided free of charge and sufficiently in advance of the resolution time frame for appeals as specified in this section; and

(iii) Include as parties to the appeal:

(A) The enrollee and the enrollee's representative; or

(B) The legal representative of the deceased enrollee's estate.

(h) Level of appeal. There will only be one level of review in the MCO appeals process.

(i) Time frames for resolution of appeals and notice to the enrollee. MCOs must resolve each appeal and provide notice as expeditiously as the enrollee's health condition requires, and within the following time frames:

(i) For standard resolution of appeals, including notice to the affected parties, no longer than 30 calendar days from the day the MCO receives the appeal. This includes appeals involving termination, suspension, or reduction of previously authorized services.

(ii) For expedited resolution of appeals, including notice to the affected parties, no longer than 72 hours after the MCO receives the appeal. The MCO may extend the 72-hour time frame up to 14 calendar days if:

(A) The enrollee requests the extension; or

(B) The MCO determines and shows to the satisfaction of the agency, upon request, there is a need for additional information and it is in the enrollee's interest.

(iii) If the MCO fails to adhere to the notice and timing requirements for appeals, the enrollee is deemed to have completed the MCO's appeals process and may request an agency administrative hearing.

(j) Language and format requirements - Notice of resolution of appeal.

(i) The notice of the resolution of the appeal must be in writing in the enrollee's primary language and in an easily understood format, in accordance with 42 C.F.R. Sec. 438.10.

(ii) The notice of the resolution of the appeal must be sent to the enrollee and the requesting provider.

(iii) For notice of an expedited resolution, the MCO must also make reasonable efforts to provide oral notice.

(k) Content of resolution of appeal.

(i) The notice of resolution must include the results of the resolution process and the date it was completed;

(ii) For appeals not resolved wholly in favor of the enrollee, the notice of resolution must include:

(A) The right to request an agency administrative hearing under RCW 74.09.741 and chapter 182-526 WAC, and how to request the hearing;

(B) The right to request and receive benefits while an agency administrative hearing is pending, and how to make the request in accordance with subsection (9) of this section and the agency's administrative hearing rules in chapter 182-526 WAC;

(C) That the enrollee may be held liable for the cost of those benefits received for the first 60 days after the agency or the office of administrative hearings (OAH) receives an agency administrative hearing request, if the hearing decision upholds the MCO's adverse benefit determination. See RCW 74.09.741 (5)(g).

(7) MCO expedited appeal process.

(a) Each MCO must establish and maintain an expedited appeal process when the MCO determines or the provider indicates that taking the time for a standard resolution of an appeal could seriously jeopardize the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum function.

(b) The enrollee may file an expedited appeal either orally, according to WAC 182-526-0095, or in writing. No additional follow-up is required of the enrollee.

(c) The MCO must issue a final decision and provide notice as expeditiously as the enrollee's physical or mental health condition requires, but not later than 72 hours after receiving the appeal. The MCO may extend the time frame for an expedited appeal, up to 14 days, if:

(i) The enrollee requests the extension; or

(ii) The MCO determines and shows to the satisfaction of the agency, upon its request, that there is a need for additional information and the delay is in the enrollee's interest.

(d) The MCO must provide written notice for any extension not requested by the enrollee within two calendar days of the decision and inform the enrollee of the reason for the delay and the enrollee's right to file a grievance.

(e) If the MCO denies a request for expedited resolution of an appeal, it must:

(i) Process the appeal based on the time frame for standard resolution;

(ii) Make reasonable efforts to give the enrollee prompt oral notice of the denial; and

(iii) Provide written notice within two calendar days.

(f) The MCO must ensure that punitive action is not taken against a provider who requests an expedited resolution or supports an enrollee's appeal.

(8) The right to an agency administrative hearing for managed care (MCO) enrollees.

(a) Authority to file. Only an enrollee, the enrollee's authorized representative, or a provider with the enrollee's or authorized representative's written consent may request an administrative hearing. See RCW 74.09.741, WAC 182-526-0090, and 182-526-0155.

(b) Right to agency administrative hearing. If an enrollee has completed the MCO appeal process and does not agree with the MCO's resolution of the appeal, the enrollee may file a request for an agency administrative hearing based on the rules in this section and the agency administrative hearing rules in chapter 182-526 WAC.

(c) Deadline – 120 days. An enrollee's request for an agency administrative hearing must be filed no later than 120 calendar days from the date of the written notice of resolution of appeal from the MCO.

(d) Independent party. The MCO is an independent party and responsible for its own representation in any agency administrative hearing, appeal to the board of appeals, and any subsequent judicial proceedings.

(e) Applicable rules. The agency's administrative hearing rules in chapter 182-526 WAC apply to agency administrative hearings requested by enrollees to review the resolution of an enrollee appeal of an MCO adverse benefit determination.

(9) Continuation of previously authorized services.

(a) The MCO must continue the enrollee's services if all of the following apply:

(i) The enrollee, or enrollee's authorized representative, or provider with written consent files the appeal on or before the later of the following:

(A) Within 10 calendar days of the MCO mailing the notice of adverse benefit determination; or

(B) The intended effective date of the MCO's proposed adverse benefit determination.

(ii) The appeal involves the termination, suspension, or reduction of previously authorized services;

(iii) The services were ordered by an authorized provider; and

(iv) The original period covered by the original authorization has not expired.

(b) If the MCO continues or reinstates the enrollee's services while the appeal is pending at the enrollee's request, the services must be continued until one of the following occurs:

(i) The enrollee withdraws the MCO appeal;

(ii) The enrollee fails to request an agency administrative hearing within 10 calendar days after the MCO sends the notice of an adverse resolution to the enrollee's appeal;

(iii) The enrollee withdraws the request for an agency administrative hearing; or

(iv) The office of administrative hearings (OAH) issues a hearing decision adverse to the enrollee.

(c) If the final resolution of the appeal upholds the MCO's adverse benefit determination, the MCO may recover from the enrollee the amount paid for the services provided to the enrollee for the first 60 calendar days after the agency or the office of administrative hearings (OAH) received a request for an agency administrative hearing, to the extent that services were provided solely because of the requirement for continuation of services.

(10) Effect of reversed resolutions of appeals.

(a) Services not furnished while an appeal is pending. If the MCO or a final order entered by the HCA board of appeals, as defined in chapter 182-526 WAC, or an independent review organization (IRO) reverses a decision to deny, limit, or delay services that were not provided while the appeal was pending, the MCO must authorize or provide the disputed services promptly, and as expeditiously as the enrollee's health condition requires, but not later than 72 hours from the date it receives notice reversing the determination.

(b) Services furnished while the appeal is pending. If the MCO reverses a decision to deny authorization of services or the denial is reversed through an IRO or a final order of OAH or the board of appeals and the enrollee received the disputed services while the appeal was pending, the MCO must pay for those services.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-05-061, s 182-538-110, filed 2/14/25, effective 3/17/25. Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-110, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Parts 431, 433, 438, 440, 457, and 495. WSR 17-23-199, § 182-538-110, filed 11/22/17, effective 12/23/17. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-110, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-110, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-110, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-110, filed 7/18/08, effective 8/18/08*
- *WSR 06-03-081, § 388-538-110, filed 1/12/06, effective 2/12/06*
- *WSR 03-18-110, § 388-538-110, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-110, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. WSR 00-04-080, § 388-538-110, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.08.090. WSR 97-04-004, § 388-538-110, filed 1/24/97, effective 2/24/97. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. WSR 95-18-046 (Order 3886), § 388-538-110, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. WSR 94-04-038 (Order 3701), § 388-538-110, filed 1/26/94, effective 2/26/94*
- *WSR 93-17-039 (Order 3621), § 388-538-110, filed 8/11/93, effective 9/11/93.*

##### **Wash. Admin. Code § 182-538-111** The administrative hearing process for primary care case management (PCCM). {#sec-182-538-111 omnilex-key=us-wa-regs-official--title-182--182-538-111}

PCCM enrollees follow the same administrative hearing rules and processes as fee-for-service clients under chapter 182-526 WAC.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-111, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-111, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-111, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-111, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-111, filed 7/18/08, effective 8/18/08*
- *WSR 06-03-081, § 388-538-111, filed 1/12/06, effective 2/12/06*
- *WSR 03-18-110, § 388-538-111, filed 9/2/03, effective 10/3/03.*

##### **Wash. Admin. Code § 182-538-120** Enrollee request for a second medical opinion. {#sec-182-538-120 omnilex-key=us-wa-regs-official--title-182--182-538-120}

(1) A managed care enrollee has the right to a timely referral for a second opinion upon request when:

(a) The enrollee needs more information about treatment recommended by the provider or managed care organization (MCO); or

(b) The enrollee believes the MCO is not authorizing medically necessary care.

(2) A managed care enrollee has a right to a second opinion from a participating provider. At the MCO's discretion, a clinically appropriate nonparticipating provider who is agreed upon by the MCO and the enrollee may provide the second opinion.

(3) Primary care case management (PCCM) enrollees have a right to a timely referral for a second opinion by another provider who has a core provider agreement with the agency.

**History**
- *Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-120, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-120, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-120, filed 7/18/08, effective 8/18/08*
- *WSR 06-03-081, § 388-538-120, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 § 201(4), 2004 c 276 § 201(4), 42 U.S.C. 1396N (section 1915 (b) and (c) of the Social Security Act of 1924). WSR 05-01-066, § 388-538-120, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-120, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. WSR 00-04-080, § 388-538-120, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. WSR 95-18-046 (Order 3886), § 388-538-120, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. WSR 93-17-039 (Order 3621), § 388-538-120, filed 8/11/93, effective 9/11/93.*

##### **Wash. Admin. Code § 182-538-130** Exemptions and ending enrollment in managed care. {#sec-182-538-130 omnilex-key=us-wa-regs-official--title-182--182-538-130}

The medicaid agency enrolls clients into integrated managed care (IMC) based on the rules in WAC 182-538-060. IMC is mandatory in all regional service areas.

(1) Authority to request. The following people may request that the agency approve an exemption or end enrollment in managed care:

(a) A client or enrollee;

(b) A client or enrollee's authorized representative under WAC 182-503-0130; or

(c) A client or enrollee's representative as defined in RCW 7.70.065.

(2) Standards to exempt or end enrollment.

(a) The agency exempts or ends enrollment from mandatory managed care when any of the following apply:

(i) The client or enrollee is eligible for medicare;

(ii) The client or enrollee is not eligible for managed care enrollment, for Washington apple health programs, or both.

(b) The agency grants a request to exempt or to end enrollment in managed care, with the change effective the earliest possible date given the requirements of the agency's enrollment system, when the client or enrollee:

(i) Is American Indian or Alaska native or is a descendant of an AI/AN client and requests not to be in managed care;

(ii) Lives in an area or is enrolled in a Washington apple health program in which participation in managed care is voluntary;

(iii) Requires care that meets the criteria in subsection (3) of this section for case-by-case clinical exemptions or to end enrollment; or

(iv) Is a child or youth with special health care needs as defined in WAC 182-538-050.

(3) Case-by-case clinical criteria. Clinical criteria for an enrollee or client to be exempted or end enrollment in IMC.

(a) The agency may approve a request for exemption or to end enrollment when the following criteria are met:

(i) The care must be medically necessary;

(ii) The medically necessary care at issue is covered under the agency's managed care contracts and is not a benefit under the behavioral health services only (BHSO) program;

(iii) The client is receiving the medically necessary care at issue from an established provider or providers who are not available through any contracted MCO; and

(iv) It is medically necessary to continue that care from the established provider or providers.

(b) If a client requests exemption prior to enrollment, the client is not enrolled until the agency approves or denies the request.

(c) If an enrollee request to end enrollment is received after the enrollment effective date, the enrollee remains enrolled pending the agency's decision.

(4) Approved request.

(a) When the agency approves a request for exemption or to end enrollment, the agency will notify the client or enrollee of its decision by telephone or in writing.

(b) For clients who are not AI/AN, the following rules apply:

(i) If the agency approves the request for a limited time, the client or enrollee is notified of the time limitation and the process for renewing the exemption.

(ii) The agency limits the period of time based on the circumstances or how long the conditions described are expected to exist.

(iii) The agency may periodically review those circumstances or conditions to determine if they continue to exist.

(iv) Any authorized exemption will continue only until the client can be enrolled in managed care.

(5) BHSO.

(a) When a client is exempt from mandatory IMC or their enrollment in the mandatory IMC program ends, the exemption is for the physical health benefit only. The client remains enrolled in behavioral health services only (BHSO) for the behavioral health benefit.

(b) AI/AN clients are an exception in that they can choose to receive their behavioral health benefit on a fee-for-service basis.

(6) Denied request. When the agency denies a request for exemption or to end enrollment:

(a) The agency will notify the client or enrollee of its decision by telephone or in writing and confirms a telephone notification in writing.

(b) When a client or enrollee is limited-English proficient, the written notice must be available in the client's or enrollee's primary language under 42 C.F.R. 438.10.

(c) The written notice must contain all the following information:

(i) The agency's decision;

(ii) The reason for the decision;

(iii) The specific rule or regulation supporting the decision; and

(iv) The right to request an agency administrative hearing.

(7) Administrative hearing request. If a client or enrollee does not agree with the agency's decision regarding a request for exemption or to end enrollment, the client or enrollee may file a request for an agency administrative hearing based on RCW 74.09.741, the rules in this chapter, and the agency hearing rules in chapter 182-526 WAC.

(8) MCO request. The agency will grant a request from an MCO to end enrollment of an enrollee when the request is submitted to the agency in writing and includes sufficient documentation for the agency to determine that the criteria to end enrollment in this subsection is met.

(a) All of the following criteria must be met to end enrollment:

(i) The enrollee puts the safety or property of the contractor or the contractor's staff, providers, patients, or visitors at risk and the enrollee's conduct presents the threat of imminent harm to others, except for enrollees described in (c) of this subsection;

(ii) A clinically appropriate evaluation was conducted to determine whether there was a treatable problem contributing to the enrollee's behavior and there was not a treatable problem or the enrollee refused to participate;

(iii) The enrollee's health care needs have been coordinated as contractually required and the safety concerns cannot be addressed; and

(iv) The enrollee has received written notice from the MCO of its intent to request to end enrollment of the enrollee, unless the requirement for notification has been waived by the agency because the enrollee's conduct presents the threat of imminent harm to others. The MCO's notice to the enrollee includes the enrollee's right to use the MCO's grievance process to review the request to end enrollment.

(b) The agency will not approve a request to end enrollment when the request is solely due to any of the following:

(i) An adverse change in the enrollee's health status;

(ii) The cost of meeting the enrollee's health care needs or because of the enrollee's utilization of services;

(iii) The enrollee's diminished mental capacity; or

(iv) Uncooperative or disruptive behavior resulting from the enrollee's special needs or behavioral health condition, except when continued enrollment in the MCO or PCCM seriously impairs the entity's ability to furnish services to either this particular enrollee or other enrollees.

(c) The agency will not approve a request to end enrollment of an enrollee's behavioral health services. The agency may determine to transition the enrollee to behavioral health services only (BHSO).

(d) When the agency receives a request from an MCO to end enrollment of an enrollee, the agency reviews each request on a case-by-case basis. The agency will respond to the MCO in writing with the decision. If the agency grants the request to end enrollment:

(i) The MCO will notify the enrollee in writing of the decision. The notice must include:

(A) The enrollee's right to use the MCO's grievance system as described in WAC 182-538-110; and

(B) The enrollee's right to use the agency's hearing process (see WAC 182-526-0200 for the hearing process for enrollees).

(ii) The agency will send a written notice to the enrollee at least 10 calendar days in advance of the effective date that enrollment will end. The notice to the enrollee includes the information in subsection (3)(c) of this section.

(e) The MCO will continue to provide services to the enrollee until the date the person is no longer enrolled.

(f) The agency may exempt the client for the period of time the circumstances are expected to exist. The agency may periodically review those circumstances to determine if they continue to exist. Any authorized exemption will continue only until the client can be enrolled in IMC.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. 438.50. WSR 22-07-107, § 182-538-130, filed 3/23/22, effective 4/23/22. Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-130, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-23-021, § 182-538-130, filed 11/4/16, effective 1/1/17*
- *WSR 15-24-098, § 182-538-130, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-130, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-130, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-130, filed 7/18/08, effective 8/18/08*
- *WSR 06-03-081, § 388-538-130, filed 1/12/06, effective 2/12/06*
- *WSR 03-18-111, § 388-538-130, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-130, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. WSR 00-04-080, § 388-538-130, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-538-130, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. WSR 95-18-046 (Order 3886), § 388-538-130, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. WSR 93-17-039 (Order 3621), § 388-538-130, filed 8/11/93, effective 9/11/93.*

##### **Wash. Admin. Code § 182-538-140** Quality of care. {#sec-182-538-140 omnilex-key=us-wa-regs-official--title-182--182-538-140}

To assure that managed care enrollees receive quality health care services, the agency requires managed care organizations (MCOs) to comply with quality improvement standards detailed in the agency's managed care contract. MCOs must:

(1) Have a clearly defined quality organizational structure and operation, including a fully operational quality assessment, measurement, and improvement program;

(2) Have effective means to detect overutilization and underutilization of services;

(3) Maintain a system for provider and practitioner credentialing and recredentialing;

(4) Ensure that MCO subcontracts and the delegation of MCO responsibilities align with agency standards;

(5) Ensure MCO oversight of delegated entities responsible for any delegated activity to include:

(a) A delegation agreement with each entity describing the responsibilities of the MCO and the entity;

(b) Evaluation of the entity before delegation;

(c) An annual evaluation of the entity; and

(d) Evaluation or regular reports and follow-up on issues that are not compliant with the delegation agreement or the agency's managed care contract specifications;

(6) Cooperate with an agency-contracted, qualified independent external quality review organization (EQRO) conducting review activities as described in 42 C.F.R. Sec. 438.358;

(7) Have an effective mechanism to assess the quality and appropriateness of care furnished to enrollees with special health care needs;

(8) Assess and develop individualized treatment plans for enrollees with special health care needs which ensure integration of clinical and nonclinical disciplines and services in the overall plan of care;

(9) Submit annual reports to the agency on performance measures as specified by the agency;

(10) Maintain a health information system that:

(a) Collects, analyzes, integrates, and reports data as requested by the agency;

(b) Provides information on utilization, grievances and appeals, enrollees ending enrollment for reasons other than the loss of medicaid eligibility, and other areas as defined by the agency;

(c) Retains enrollee grievance and appeal records described in 42 C.F.R. Sec. 438.416, base data as required by 42 C.F.R. Sec. 438.5(c), MLR reports as required by 42 C.F.R. Sec. 438.8(k), and the data, information, and documentation specified in 42 C.F.R. Secs. 438.604, 438.606, 438.408, and 438.610 for a period of no less than 10 years;

(d) Collects data on enrollees, providers, and services provided to enrollees through an encounter data system, in a standardized format as specified by the agency; and

(e) Ensures data received from providers is adequate and complete by verifying the accuracy and timeliness of reported data and screening the data for completeness, logic, and consistency;

(11) Conduct performance improvement projects designed to achieve significant improvement, sustained over time, in clinical care outcomes and services, and that involve the following:

(a) Measuring performance using objective quality indicators;

(b) Implementing system changes to achieve improvement in service quality;

(c) Evaluating the effectiveness of system changes;

(d) Planning and initiating activities for increasing or sustaining performance improvement;

(e) Reporting each project status and the results as requested by the agency; and

(f) Completing each performance improvement project timely so as to generally allow aggregate information to produce new quality of care information every year;

(12) Ensure enrollee access to health care services;

(13) Ensure continuity and coordination of enrollee care;

(14) Maintain and monitor availability of health care services for enrollees;

(15) Perform client satisfaction surveys; and

(16) Obtain and maintain national committee on quality assurance (NCQA) accreditation.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-03-063, § 182-538-140, filed 1/12/23, effective 2/12/23. Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-140, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Parts 431, 433, 438, 440, 457, and 495. WSR 17-23-199, § 182-538-140, filed 11/22/17, effective 12/23/17. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-140, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-140, filed 12/19/12, effective 2/1/13. WSR 11-14-075, recodified as § 182-538-140, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. WSR 08-15-110, § 388-538-140, filed 7/18/08, effective 8/18/08*
- *WSR 06-03-081, § 388-538-140, filed 1/12/06, effective 2/12/06*
- *WSR 03-18-111, § 388-538-140, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522, 74.09.450, 1115 Waiver, 42 U.S.C. 1396. WSR 02-01-075, § 388-538-140, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. WSR 00-04-080, § 388-538-140, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. WSR 95-18-046 (Order 3886), § 388-538-140, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. WSR 93-17-039 (Order 3621), § 388-538-140, filed 8/11/93, effective 9/11/93.*

##### **Wash. Admin. Code § 182-538-150** Apple health foster care program. {#sec-182-538-150 omnilex-key=us-wa-regs-official--title-182--182-538-150}

(1) Unless otherwise stated in this section, all of the provisions of chapter 182-538 WAC apply to apple health foster care (AHFC).

(2) The following sections of chapter 182-538 WAC do not apply to AHFC:

(a) WAC 182-538-068;

(b) WAC 182-538-071;

(c) WAC 182-538-096; and

(d) WAC 182-538-111.

(3)(a) Enrollment in AHFC is voluntary for eligible people.

(b) The agency will enroll eligible people in the single MCO that serves children and youth in foster care and adoption support, and young adult alumni of the foster care system.

(c) An AHFC enrollee may request to end enrollment in AHFC without cause if the client is in the adoption support or young adult alumni programs. WAC 182-538-130 does not apply to these requests as enrollment in AHFC is voluntary.

(4) AHFC coordinates health care services for enrollees. This includes services with the department of social and health services community mental health system and other health care systems as needed.

(5) The agency sends written information about covered services when the person becomes eligible to enroll in AHFC and at any time there is a change in covered services. In addition, the agency requires MCOs to provide new enrollees with written information about:

(a) Covered services;

(b) The right to grievances and appeals through the MCO; and

(c) Hearings through the agency.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-150, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-23-021, § 182-538-150, filed 11/4/16, effective 1/1/17*
- *WSR 15-24-098, § 182-538-150, filed 12/1/15, effective 1/1/16.*

##### **Wash. Admin. Code § 182-538-170** Notice requirements. {#sec-182-538-170 omnilex-key=us-wa-regs-official--title-182--182-538-170}

The notice requirements in chapter 182-518 WAC apply to integrated managed care (IMC).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-170, filed 11/27/19, effective 1/1/20.*

##### **Wash. Admin. Code § 182-538-180** Rights and protections. {#sec-182-538-180 omnilex-key=us-wa-regs-official--title-182--182-538-180}

(1) People have medicaid-specific rights when applying for, eligible for, or receiving medicaid-funded health care services.

(2) All applicable statutory and constitutional rights apply to all medicaid people including, but not limited to:

(a) The participant rights under WAC 246-341-0600;

(b) Applicable necessary supplemental accommodation services including, but not limited to:

(i) Arranging for or providing help to complete and submit forms to the agency;

(ii) Helping people give or get the information the agency needs to decide or continue eligibility;

(iii) Helping to request continuing benefits;

(iv) Explaining the reduction in or ending of benefits;

(v) Assisting with requests for administrative hearings; and

(vi) On request, reviewing the agency's decision to terminate, suspend, or reduce benefits.

(c) Receiving the name, address, telephone number, and any languages offered other than English of providers in a managed care organization (MCO);

(d) Receiving information about the structure and operation of the MCO and how health care services are delivered;

(e) Receiving emergency care, urgent care, or crisis services;

(f) Receiving poststabilization services after receiving emergency care, urgent care, or crisis services that result in admittance to a hospital;

(g) Receiving age-appropriate and culturally appropriate services;

(h) Being provided a qualified interpreter and translated material at no cost to the person;

(i) Receiving requested information and help in the language or format of choice;

(j) Having available treatment options and explanation of alternatives;

(k) Refusing any proposed treatment;

(l) Receiving care that does not discriminate against a person;

(m) Being free of any sexual exploitation or harassment;

(n) Making an advance directive that states the person's choices and preferences for health care services under 42 C.F.R. Sec. 489 Subpart I;

(o) Choosing a contracted health care provider;

(p) Requesting and receiving a copy of health care records;

(q) Being informed the cost for copying, if any;

(r) Being free from retaliation;

(s) Requesting and receiving policies and procedures of the MCO as they relate to health care rights;

(t) Receiving services in an accessible location;

(u) Receiving medically necessary services in accordance with the early periodic screening, diagnosis, and treatment (EPSDT) program under chapter 182-534 WAC, if the person is age 20 or younger;

(v) Being treated with dignity, privacy, and respect;

(w) Receiving treatment options and alternatives in a manner that is appropriate to a person's condition;

(x) Being free from seclusion and restraint;

(y) Receiving a second opinion from a qualified health care professional within an MCO provider network at no cost or having one arranged outside the network at no cost, as provided in 42 C.F.R. Sec. 438.206(b)(3);

(z) Receiving medically necessary health care services outside of the MCO if those services cannot be provided adequately and timely within the MCO;

(aa) Filing a grievance with the MCO if the person is not satisfied with a service;

(bb) Receiving a notice of action so that a person may appeal any decision by the MCO that:

(i) Denies or limits authorization of a requested service;

(ii) Reduces, suspends, or terminates a previously authorized service; or

(iii) Denies payment for a service, in whole or in part.

(cc) Filing an appeal if the MCO fails to provide health care services in a timely manner as defined by the state or act within the time frames in 42 C.F.R. Sec. 438.408(b); and

(dd) Requesting an administrative hearing if an appeal is not resolved in a person's favor.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-21-142, s 182-538-180, filed 10/21/25, effective 11/21/25. Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-180, filed 11/27/19, effective 1/1/20.*

##### **Wash. Admin. Code § 182-538-190** Behavioral health services only (BHSO). {#sec-182-538-190 omnilex-key=us-wa-regs-official--title-182--182-538-190}

This section applies to enrollees receiving behavioral health services only (BHSO) under the integrated managed care (IMC) medicaid contract.

(1) IMC is mandatory for clients in eligible programs, but the agency may end enrollment or exempt clients from IMC based on WAC 182-538-130.

(2) If the agency ends enrollment or exempts a client from IMC, the client is required to enroll in behavioral health services only (BHSO). An exception to this requirement exists for American Indian and Alaskan native (AI/AN) clients. IMC including BHSO is optional for AI/AN clients.

(3) For BHSO enrollees, the MCO covers the behavioral health benefits included in the IMC medicaid contract, and the agency covers physical health services on a fee-for-service basis.

(4) The agency assigns the BHSO enrollee to an MCO available in the area where the client resides.

(5) A BHSO enrollee may change MCOs at any time for any reason with the change becoming effective the earliest possible date given the requirements of the agency's enrollment system.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-190, filed 11/27/19, effective 1/1/20.*

##### **Wash. Admin. Code § 182-538-195** Telemedicine and store and forward technology. {#sec-182-538-195 omnilex-key=us-wa-regs-official--title-182--182-538-195}

The medicaid agency's rules related to the authorized use of telemedicine and store and forward technology are found in WAC 182-501-0300 and are applicable to the benefits (including behavioral health services) administered by agency-contracted managed care entities (managed care organizations and behavioral health administrative service organizations) and fee-for-service programs.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2021 c 157. WSR 23-04-048, § 182-538-195, filed 1/26/23, effective 2/26/23.*

## **Chapter 182-538B** Behavioral health wraparound services. {#struct-chapter-182-538b}

##### **Wash. Admin. Code § 182-538B-040** Behavioral health wraparound services. {#sec-182-538b-040 omnilex-key=us-wa-regs-official--title-182--182-538B-040}

(1) This chapter governs nonmedicaid funded behavioral health services provided under the medicaid agency's behavioral health services wraparound contract. See also chapter 182-538D WAC for rules applicable to nonmedicaid behavioral health services.

(2) Washington apple health integrated managed care (IMC) behavioral health wraparound services are available only through a managed care organization (MCO) contracted to provide IMC services.

(3) The MCO provides contracted nonmedicaid funded behavioral health wraparound services to medicaid enrollees in an IMC regional service area:

(a) Within available resources;

(b) Based on medical necessity; and

(c) In order of priority to populations as identified by state and federal authorities.

(4) When nonmedicaid funding is exhausted, behavioral health wraparound services are no longer paid for and cannot be authorized regardless of medical necessity.

(5) For clients age 20 and younger, see the early periodic screening, diagnosis, and treatment (EPSDT) program described in chapter 182-534 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-07-031, s 182-538B-040, filed 3/11/26, effective 4/11/26. Statutory Authority: RCW 41.05.021 and 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538B-040, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-05-051, § 182-538B-040, filed 2/11/16, effective 4/1/16.*

##### **Wash. Admin. Code § 182-538B-050** Definitions. {#sec-182-538b-050 omnilex-key=us-wa-regs-official--title-182--182-538B-050}

The following definitions and those found in chapters 182-500 and 182-538 WAC apply to this chapter, unless otherwise stated.

"Action" means the denial or limited authorization of a service covered under the behavioral health services wraparound contract based on medical necessity.

"Available resources" means funds appropriated for the purpose of providing behavioral health wraparound services.

(a) This includes:

(i) Federal funds, except those provided according to Title XIX of the Social Security Act; and

(ii) State funds appropriated by the legislature for the purpose of providing services under the behavioral health administrative services organization contract.

(b) This does not include funds appropriated for the purpose of operating and administering the state psychiatric hospitals.

"Integrated managed care (IMC)" See WAC 182-538-050.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538B-050, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-05-051, § 182-538B-050, filed 2/11/16, effective 4/1/16.*

##### **Wash. Admin. Code § 182-538B-110** Grievance and appeal system and agency administrative hearing. {#sec-182-538b-110 omnilex-key=us-wa-regs-official--title-182--182-538B-110}

(1) Introduction. This section contains information about the managed care organization (MCO) grievance and appeal system and the agency's administrative hearing process for enrollees under the behavioral health services wraparound contract in integrated managed care (IMC) regional service areas.

(a) The MCO must have a grievance and appeal system and access to an agency administrative hearing to allow enrollees to file grievances and seek review of an MCO action as defined in this chapter.

(b) The agency's administrative hearing rules in chapter 182-526 WAC apply to agency administrative hearings requested by an enrollee to review the resolution of an enrollee's appeal of an MCO action.

(c) If a conflict exists between the requirements of this chapter and other rules, the requirements of this chapter take precedence.

(d) The MCO's policies and procedures regarding the grievance system must be approved by the agency.

(2) MCO grievance and appeal system. The MCO grievance and appeal system includes:

(a) A grievance process for addressing complaints about any matter that is not an action;

(b) An appeals process to address an enrollee's request for review of an MCO action;

(c) Access to an independent review by an independent review organization (IRO) under RCW 48.43.535 and WAC 182-526-0200;

(d) Access to the agency's administrative hearing process for review of an MCO's resolution of an appeal; and

(e) Allowing enrollees and the enrollee's authorized representatives to file grievances and appeals orally or in writing. An MCO cannot require enrollees to provide written follow-up for a grievance or an appeal the MCO received orally.

(3) The MCO grievance process.

(a) An enrollee or enrollee's authorized representative may file a grievance with an MCO. A provider may not file a grievance on behalf of an enrollee without the enrollee's written consent.

(b) An enrollee does not have a right to an agency administrative hearing in regards to the resolution of a grievance.

(c) The MCO must acknowledge receipt of each grievance either orally or in writing within two business days.

(d) The MCO must notify enrollees of the resolution of grievances within five business days of determination.

(4) The MCO appeals process.

(a) An enrollee, the enrollee's authorized representative, or a provider acting on behalf of the enrollee with the enrollee's written consent may appeal an MCO action.

(b) An MCO treats oral inquiries about appealing an action as an appeal to establish the earliest possible filing date for the appeal. The MCO confirms the oral appeal in writing.

(c) An MCO must acknowledge in writing receipt of each appeal to both the enrollee and the requesting provider within five calendar days of receiving the appeal request. The appeal acknowledgment letter sent by the MCO serves as written confirmation of an appeal filed orally by an enrollee.

(d) The enrollee must file an appeal of an MCO action within sixty calendar days of the date on the MCO's notice of action.

(e) The MCO is not obligated to continue services pending the results of an appeal or subsequent agency administrative hearing.

(f) The MCO appeal process:

(i) Provides the enrollee a reasonable opportunity to present evidence and allegations of fact or law, both in person and in writing;

(ii) Provides the enrollee and the enrollee's representative the enrollee's case file, including medical records, other documents and records, and any new or additional evidence considered, relied upon, or generated by the MCO, PIHP or PAHP (or at the direction of the MCO, PIHP or PAHP) in connection with the action. This information must be provided free of charge and sufficiently in advance of the resolution time frame for appeals as specified in this section; and

(iii) Includes as parties to the appeal:

(A) The enrollee and the enrollee's authorized representative; and

(B) The legal representative of the deceased enrollee's estate.

(g) The MCO ensures that the people making decisions on appeals:

(i) Were not involved in any previous level of review or decision making; and

(ii) Are health care professionals who have appropriate clinical expertise in treating the enrollee's condition or disease if deciding either of the following:

(A) An appeal of an action involving medical necessity; or

(B) An appeal that involves any clinical issues.

(h) Time frames for resolution of appeals.

(i) An MCO resolves each appeal and provides notice as expeditiously as the enrollee's health condition requires and no longer than seventy-two hours after the day the MCO receives the appeal.

(ii) The MCO may extend the time frame by an additional fourteen calendar days if:

(A) The enrollee requests the extension; or

(B) The MCO determines additional information is needed and delay is in the interests of the enrollee.

(i) Notice of resolution of appeal. The notice of the resolution of the appeal must:

(i) Be in writing and be sent to the enrollee and the requesting provider;

(ii) Include the results of the resolution of the appeal process and the date it was completed; and

(iii) Include information on the enrollee's right to request an agency administrative hearing and how to do so as provided in the agency hearing rules in WAC 182-526-0200, if the appeal is not resolved wholly in favor of the enrollee.

(j) Deemed completion of the appeals process. If the MCO fails to adhere to the notice and timing requirements for appeals, the enrollee is deemed to have completed the MCO's appeals process and may request an agency administrative hearing under WAC 182-526-0200.

(5) Agency administrative hearing.

(a) Only an enrollee or enrollee's authorized representative may request an agency administrative hearing. A provider may not request a hearing on behalf of an enrollee.

(b) If an enrollee does not agree with the MCO's resolution of an appeal and has completed the MCO appeal process, the enrollee may file a request for an agency administrative hearing based on the rules in this section and the agency hearing rules in WAC 182-526-0200. The enrollee must request an agency administrative hearing within ninety calendar days of the notice of resolution of appeal.

(c) An MCO is an independent party and responsible for its own representation in any agency administrative hearing, independent review, appeal to the board of appeals, and any subsequent judicial proceedings.

(6) Effect of reversed resolutions of appeals. If an MCO, a final order as defined in chapter 182-526 WAC, or an independent review organization (IRO) reverses a decision to deny or limit services, the MCO must authorize or provide the disputed services promptly and as expeditiously as the enrollee's health condition requires.

(7) Available resources exhausted. When available resources are exhausted, any appeals process, independent review, or agency administrative hearing process related to a request to authorize a service will be terminated, since services cannot be authorized without funding regardless of medical necessity.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538B-110, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Parts 431, 433, 438, 440, 457, and 495. WSR 17-23-199, § 182-538B-110, filed 11/22/17, effective 12/23/17. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-05-051, § 182-538B-110, filed 2/11/16, effective 4/1/16.*

##### **Wash. Admin. Code § 182-538B-170** Notice requirements. {#sec-182-538b-170 omnilex-key=us-wa-regs-official--title-182--182-538B-170}

Chapter 182-518 WAC applies to notice requirements in integrated managed care (IMC) regional service areas.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538B-170, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-05-051, § 182-538B-170, filed 2/11/16, effective 4/1/16.*

## **Chapter 182-538C** Crisis and noncrisis behavioral health services. {#struct-chapter-182-538c}

##### **Wash. Admin. Code § 182-538C-040** Behavioral health services. {#sec-182-538c-040 omnilex-key=us-wa-regs-official--title-182--182-538C-040}

(1) This chapter governs crisis-related and other behavioral health services provided under the medicaid agency's behavioral health administrative services organization (BH-ASO) contract. See also chapter 182-538D WAC for rules applicable to nonmedicaid behavioral health services.

(2) The BH-ASO contracts with the agency to provide behavioral health services within an integrated managed care (IMC) regional service area.

(a) The BH-ASO provides the following services to all people, regardless of insurance status, income level, ability to pay, and county of residence:

(i) Mental health crisis services;

(ii) Operation of a behavioral health ombuds (ombudsman); and

(iii) Implementation of the Involuntary Treatment Act for both mental health and substance use disorders.

(b) The BH-ASO may provide substance use disorder crisis services within available resources to all people, regardless of the person's insurance status, income level, ability to pay, and county of residence.

(c) The BH-ASO provides the following services to people who are not eligible for medicaid coverage and are involuntarily or voluntarily detained under chapter 71.05, 71.24, or 71.34 RCW, or a less restrictive alternative (LRA) court order:

(i) Evaluation and treatment services;

(ii) Substance use disorder residential treatment services; and

(iii) Outpatient behavioral services, under an LRA court order.

(d) To be eligible to contract with the agency, the BH-ASO must:

(i) Accept the terms and conditions of the agency's contracts; and

(ii) Be able to meet the network and quality standards established by the agency.

(e) Services related to the administration of chapters 71.05, 71.24, and 71.34 RCW.

(3) The BH-ASO may provide contracted noncrisis behavioral health services to people in an IMC regional service area:

(a) Within available resources;

(b) Based on medical necessity; and

(c) In order of priority to populations as identified by state and federal authorities.

(4) Within an IMC regional service area, the BH-ASO is a subcontractor with all IMC managed care organizations (MCOs) to provide crisis services for medicaid enrollees and the administration of involuntary treatment acts under chapter 71.05, 71.24, or 71.34 RCW.

(5) For medicaid-funded services subcontracted for by IMC managed care organizations (MCOs) to the BH-ASO:

(a) Grievances and appeals must be filed with the IMC MCO; and

(b) The grievance and appeal system and the agency's administrative hearing rules in chapter 182-538 WAC apply instead of the grievance and appeal system and hearing rules in this chapter.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538C-040, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 17-23-200, § 182-538C-040, filed 11/22/17, effective 12/23/17*
- *WSR 16-05-051, § 182-538C-040, filed 2/11/16, effective 4/1/16.*

##### **Wash. Admin. Code § 182-538C-050** Definitions. {#sec-182-538c-050 omnilex-key=us-wa-regs-official--title-182--182-538C-050}

The definitions in this section and those found in chapters 182-500 and 182-538 WAC apply to this chapter.

"Action" means the denial or limited authorization of a service covered under the behavioral health administrative services organization (BH-ASO) contract based on medical necessity.

"Available resources" means funds appropriated for the purpose of providing community behavioral health programs.

(a) This includes:

(i) Federal funds, except those provided according to Title XIX of the Social Security Act; and

(ii) State funds appropriated by the legislature for the purpose of providing services under the BH-ASO contract.

(b) This does not include funds appropriated for the purpose of operating and administering the state psychiatric hospitals.

"Behavioral health" - See WAC 182-538-050.

"Behavioral health administrative services organization (BH-ASO)" - See WAC 182-538-050.

"Complaint" - See "grievance."

"Crisis" - See WAC 182-538D-0200.

"Grievance" - See WAC 182-538-050.

"Integrated managed care (IMC)" - See WAC 182-538-050.

"Less restrictive alternative (LRA)" means court-ordered outpatient treatment in a setting less restrictive than total confinement.

"Noncrisis services" means services funded by nonmedicaid funding sources that are provided to people who are not enrolled in Washington apple health or otherwise eligible for medicaid. These services may be provided at the discretion of the behavioral health administrative services organization (BH-ASO) within available resources, such as:

(a) Crisis stabilization;

(b) Outpatient mental health or substance use disorder services; and

(c) Withdrawal management.

"Patient days of care" - See WAC 182-538-050.

"Regional service area" - See WAC 182-538-050.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538C-050, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-05-051, § 182-538C-050, filed 2/11/16, effective 4/1/16.*

##### **Wash. Admin. Code § 182-538C-070** Payment. {#sec-182-538c-070 omnilex-key=us-wa-regs-official--title-182--182-538C-070}

(1) For crisis services, the behavioral health administrative services organization (BH-ASO) must determine whether the person receiving the services is eligible for Washington apple health or if the person has any other form of insurance coverage.

(2) For people receiving crisis services who do not have other insurance coverage, the BH-ASO is responsible for the cost of those services.

(3) The BH-ASO administers and pays for the evaluation of involuntary detention or involuntary treatment under chapters 71.05, 71.24, and 71.34 RCW.

(4) The BH-ASO pays a reimbursement for each state hospital patient day of care that exceeds the BH-ASO daily allocation of state hospital beds based on a quarterly calculation of the bed usage by the BH-ASO.

(a) The medicaid agency bills the BH-ASO quarterly for state hospital patient days of care exceeding the BH-ASO daily allocation of state hospital beds and the established rate of reimbursement.

(b) The BH-ASO using fewer patient days of care than its quarterly allocation of state hospital beds will receive a portion of the reimbursement collected proportional to its share of the total number of patient days of care that were not used at the appropriate state hospital.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538C-070, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-05-051, § 182-538C-070, filed 2/11/16, effective 4/1/16.*

##### **Wash. Admin. Code § 182-538C-110** Grievance and appeal system and agency administrative hearing for behavioral health administrative services organizations (BH-ASOs). {#sec-182-538c-110 omnilex-key=us-wa-regs-official--title-182--182-538C-110}

(1) General. This section applies to the behavioral health administrative service organization (BH-ASO) grievance system for people within integrated managed care (IMC) regional service areas.

(a) The BH-ASO must have a grievance and appeal system to allow a person to file a grievance and request a review of a BH-ASO action as defined in this chapter.

(b) The agency's administrative hearing rules in chapter 182-526 WAC apply to agency administrative hearings requested by a person to review the resolution of an appeal of a BH-ASO action.

(c) If a conflict exists between the requirements of this chapter and other rules, the requirements of this chapter take precedence.

(d) The BH-ASO must maintain records of grievances and appeals.

(e) The BH-ASO is not obligated to continue services pending the results of an appeal or subsequent agency administrative hearing.

(2) The BH-ASO grievance and appeal system. The BH-ASO grievance system includes:

(a) A process for addressing complaints about any matter that is not an action;

(b) An appeal process to address a person's request for a review of a BH-ASO action as defined in this chapter; and

(c) Access to the agency's administrative hearing process for a person to request a review of a BH-ASO's resolution of an appeal.

(3) The BH-ASO grievance process.

(a) A person or a person's authorized representative may file a grievance with a BH-ASO. A provider may not file a grievance on behalf of a person without the written consent of the person or the person's authorized representative.

(b) There is no right to an agency administrative hearing regarding the BH-ASO's decision on a grievance, since a grievance is not an action.

(c) The BH-ASO must notify a person of the decision regarding the person's grievance within five business days of the decision.

(4) The BH-ASO appeal process.

(a) Parties to the appeal include:

(i) The person and the person's authorized or legal representative; or

(ii) The authorized representative of the deceased person's estate.

(b) A person, the person's authorized representative, or the provider acting with the person's written consent may appeal a BH-ASO action.

(c) A BH-ASO must treat oral inquiries about appealing an action as an appeal in order to establish the earliest possible filing date for the appeal.

(d) The BH-ASO must confirm any oral appeal in writing to the person or provider acting on behalf of the person.

(e) The person or provider acting on behalf of the person must file an appeal, either orally or in writing, within sixty calendar days of the date on the BH-ASO's notice of action.

(f) The BH-ASO must acknowledge receipt of each appeal to both the person and the provider requesting the service within three calendar days of receipt.

(g) If the person requests an expedited appeal for a crisis-related service, the BH-ASO must make a decision on whether to grant the person's request for expedited appeal and provide written notice as expeditiously as the person's health condition requires, within three calendar days after the BH-ASO receives the appeal. The BH-ASO must make reasonable efforts to provide oral notice.

(h) The BH-ASO appeal process:

(i) Provides the person a reasonable opportunity to present evidence and allegations of fact or law in writing.

(ii) Provides the person and the person's authorized representative opportunity before and during the appeals process to examine the person's case file, including medical records and any other documents and records considered during the appeal process free of charge.

(iii) If the person requests an expedited appeal, the BH-ASO must inform the person that it may result in the person having limited time to review records and prepare for the appeal.

(i) The BH-ASO ensures the staff making decisions on appeals:

(i) Were not involved in any previous level of review or decision making; and

(ii) Are health care professionals with appropriate clinical expertise in treating the person's condition or disease if deciding any of the following:

(A) An appeal of an action; or

(B) An appeal that involves any clinical issues.

(j) Time frames for standard resolution of appeals.

(i) For appeals involving termination, suspension, or reduction of previously authorized noncrisis services, the BH-ASO must make a decision within fourteen calendar days after receipt of the appeal.

(ii) If the BH-ASO cannot resolve an appeal within fourteen calendar days, the BH-ASO must notify the person that an extension is necessary to complete the appeal.

(k) Time frames for expedited appeals for crisis-related services.

(i) The BH-ASO must resolve the expedited appeal and provide notice of the decision no later than three calendar days after the BH-ASO receives the appeal.

(ii) The BH-ASO may extend the time frame by fourteen additional calendar days if:

(A) The person requests the extension; or

(B) The BH-ASO determines additional information is needed and the delay is in the interests of the person.

(iii) If the BH-ASO denies a request for expedited resolution of a noncrisis related service appeal, it must:

(A) Process the appeal based on the time frame for standard resolution;

(B) Make reasonable efforts to give the person prompt oral notice of the denial; and

(C) Follow-up within two calendar days of the oral notice with a written notice of denial.

(l) Extension of a standard resolution or expedited appeal not requested by the person.

(i) The BH-ASO must notify the person in writing of the reason for the delay, if not requested by that person.

(ii) The extension cannot delay the decision beyond twenty-eight calendar days of the request for appeal, without the informed written consent of the person.

(m) Notice of resolution of appeal. The notice of the resolution of the appeal must:

(i) Be in writing and be sent to the person and the provider requesting the services;

(ii) Include the results of the resolution process and the date it was completed; and

(iii) Include notice of the right to request an agency administrative hearing and how to do so as provided in the agency hearing rules in chapter 182-526 WAC, if the appeal is not resolved wholly in favor of the person.

(5) Agency administrative hearings.

(a) Only a person or a person's authorized representative may request an agency administrative hearing. A provider may not request a hearing on behalf of a person.

(b) If a person does not agree with the BH-ASO's resolution of an appeal, the person may file a request for an agency administrative hearing based on this section and the agency hearing rules in chapter 182-526 WAC.

(c) The BH-ASO is an independent party and responsible for its own representation in any agency administrative hearing, appeal to the board of appeals, and any subsequent judicial proceedings.

(6) Effect of reversed resolutions of appeals. If the BH-ASO's decision not to provide services is reversed on appeal by the BH-ASO or through a final order from the agency administrative hearing process, the BH-ASO must authorize or provide the disputed services promptly and as expeditiously as the person's health condition requires.

(7) Available resources exhausted. When available resources are exhausted, any appeals or administrative hearing process related to a request for authorization of a noncrisis service will be terminated, since noncrisis services cannot be authorized without funding, regardless of medical necessity.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538C-110, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 17-23-200, § 182-538C-110, filed 11/22/17, effective 12/23/17*
- *WSR 16-15-030, § 182-538C-110, filed 7/13/16, effective 8/13/16*
- *WSR 16-05-051, § 182-538C-110, filed 2/11/16, effective 4/1/16.*

##### **Wash. Admin. Code § 182-538C-220** Covered crisis mental health services. {#sec-182-538c-220 omnilex-key=us-wa-regs-official--title-182--182-538C-220}

(1) Crisis mental health services are intended to stabilize a person in crisis to:

(a) Prevent further deterioration;

(b) Provide immediate treatment and intervention in a location best suited to meet the needs of the person; and

(c) Provide treatment services in the least restrictive environment available.

(2) Crisis mental health services include:

(a) Crisis telephone support;

(b) Crisis outreach services;

(c) Crisis stabilization services;

(d) Crisis peer support services; and

(e) Emergency involuntary detention services.

(3) A facility providing any crisis mental health service to a person must:

(a) Be licensed by the department of health as a behavioral health agency;

(b) Be certified by the department of health to provide crisis mental health services;

(c) Have policies and procedures to support and implement the:

(i) Program-specific requirements for each crisis mental health service provided; and

(ii) Department of corrections access to confidential mental health information requirements in WAC 182-538D-0600 through 182-538D-0640.

(4) A BH-ASO or its subcontractor providing crisis mental health services only is not required to meet the initial assessment, individual service plan, and clinical record requirements in WAC 246-341-0610, 246-341-0620, and 246-341-0640.

(5) A BH-ASO or its subcontractor must ensure crisis mental health services:

(a) Are, with the exception of stabilization services, available twenty-four hours a day, seven days a week;

(b) Include family members, significant others, and other relevant treatment providers, as necessary, to provide support to the person in crisis; and

(c) Are provided in a setting that is safe for the person and staff members of the BH-ASO and its subcontractor.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538C-220, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-05-051, § 182-538C-220, filed 2/11/16, effective 4/1/16.*

##### **Wash. Admin. Code § 182-538C-230** Covered substance use disorder detoxification services. {#sec-182-538c-230 omnilex-key=us-wa-regs-official--title-182--182-538C-230}

(1) Chemical dependency detoxification services are provided to a person to assist in the process of withdrawal from psychoactive substances in a safe and effective manner.

(2) A facility providing detoxification services to a person must:

(a) Be a facility licensed by the department of health under one of the following:

(i) Chapter 246-320 WAC;

(ii) Chapter 246-322 WAC;

(iii) Chapter 246-324 WAC; or

(iv) Chapter 246-337 WAC.

(b) Be licensed by the department of health as a behavioral health agency;

(c) Meet the applicable behavioral health agency licensure, certification, administration, personnel, clinical requirements, and behavioral health services administrative requirements; and

(d) Have policies and procedures to support and implement the applicable requirements in WAC 246-341-1100 and 246-341-1102.

(3) A BH-ASO or its subcontractor agency must:

(a) Provide counseling to each person that addresses the person's:

(i) Chemical dependency and motivation; and

(ii) Continuing care needs and need for referral to other services.

(b) Maintain a list of resources and referral options that can be used by staff members to refer a person to appropriate services.

(c) Post any rules and responsibilities for people receiving treatment, including information on potential use of increased motivation interventions or sanctions, in a public place in the facility.

(d) Provide tuberculosis screenings to people for the prevention and control of tuberculosis.

(e) Provide HIV/AIDS information and include a brief risk intervention and referral as indicated.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538C-230, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-05-051, § 182-538C-230, filed 2/11/16, effective 4/1/16.*

##### **Wash. Admin. Code § 182-538C-252** Behavioral health administrative services organizations—Advisory board membership. {#sec-182-538c-252 omnilex-key=us-wa-regs-official--title-182--182-538C-252}

(1) A behavioral health administrative services organization (BH-ASO) must appoint advisory board members and maintain an advisory board in order to:

(a) Promote active engagement with people with behavioral health disorders, their families, and behavioral health agencies; and

(b) Solicit and use the advisory board members input to improve service delivery and outcome.

(2) The BH-ASO must appoint advisory board members and maintain an advisory board that:

(a) Broadly represents the demographic character of the service area;

(b) Is composed of at least fifty-one percent representation of one or more of the following:

(i) People with lived experience;

(ii) Parents or legal guardians of people with lived experience; or

(iii) Self-identified as people in recovery from a behavioral health disorder.

(c) Includes law enforcement representation; and

(d) Includes tribal representation, upon request of a tribe.

(3) When the BH-ASO is not a function of county government, the advisory board must include no more than four county elected officials.

(4) The advisory board:

(a) May have members who are employees of subcontracted agencies, as long as there are written rules that address potential conflicts of interest.

(b) Has the discretion to set rules in order to meet the requirements of this section.

(c) Membership is limited to three years per term for time served, per each advisory board member. Multiple terms may be served by a member if the advisory board rules allow it.

(5) The advisory board independently reviews and provides comments to the BH-ASO, on plans, budgets, and policies developed by the BH-ASO to implement the requirements of this section, chapters 71.05, 71.24, 71.34 RCW, and applicable federal laws.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538C-252, filed 11/27/19, effective 1/1/20.*

## **Chapter 182-538D** Behavioral health services. {#struct-chapter-182-538d}

##### **Wash. Admin. Code § 182-538D-0200** Behavioral health services—Definitions. {#sec-182-538d-0200 omnilex-key=us-wa-regs-official--title-182--182-538D-0200}

The following definitions and those found in chapters 182-500, 182-538, and 182-538C WAC apply to this chapter. If conflict exists, this chapter takes precedence.

"Adult" means a person age 18 or older.

"Assessment" means the process of obtaining all pertinent bio-psychosocial information, as identified by the person, and family and collateral sources, for determining a diagnosis and to plan individualized services and supports.

"Behavioral health" means the prevention, treatment of, and recovery from substance use disorders, mental health disorders or problem and pathological gambling disorders.

"Behavioral health administrative service organization (BH-ASO)" - See WAC 182-538-050.

"Behavioral health agency" means an entity licensed by the department of health (DOH) to provide behavioral health services, including services for mental health disorders and substance use disorders.

"Certified behavioral health support specialist (BHSS)" means a person who delivers brief behavioral health services under the supervision of a provider outlined in WAC 246-821-410. To provide services as a BHSS, this person must have a bachelor's degree and have completed the BHSS educational program recognized by DOH.

"Certified peer counselor" - See chapter 182-115 WAC.

"Certified peer support specialist" or "CPSS" - See chapter 246-929 WAC.

"Certified peer support specialist trainee" or "CPSST" - See chapter 246-929 WAC.

"Child" means the same as in RCW 71.24.025. For clients age 20 and younger, see the early periodic screening, diagnosis, and treatment (EPSDT) program described in chapter 182-534 WAC.

"Clinical record" means a paper or electronic file that is maintained by the provider and contains pertinent psychological, medical, and clinical information for each person served.

"Community support services" means the same as in RCW 71.24.025.

"Complaint" - See "grievance" in WAC 182-538-050.

"Consent" means agreement given by a person after the person is provided with a description of the nature, character, anticipated results of proposed treatments and the recognized serious possible risks, complications, and anticipated benefits, including alternatives and nontreatment. Informed consent must be provided in a terminology that the person can reasonably be expected to understand.

"Consultation" means the clinical review and development of recommendations regarding activities, or decisions of, clinical staff, contracted employees, volunteers, or students by people with appropriate knowledge and experience to make recommendations.

"Crisis" means an actual or perceived urgent or emergent situation that occurs when a person's stability or functioning is disrupted and there is an immediate need to resolve the situation to prevent a serious deterioration in the person's mental or physical health, or to prevent the need for referral to a significantly higher level of care.

"Cultural competence" or "culturally competent" means the ability to recognize and respond to health-related beliefs and cultural values, disease incidence and prevalence, and treatment efficacy. Examples of culturally competent care include striving to overcome cultural, language, and communications barriers, providing an environment in which people from diverse cultural backgrounds feel comfortable discussing their cultural health beliefs and practices in the context of negotiating treatment options, encouraging people to express their spiritual beliefs and cultural practices, and being familiar with and respectful of various traditional healing systems and beliefs and, where appropriate, integrating these approaches into treatment plans.

"Designated crisis responder (DCR)" means a mental health professional appointed by the county, or an entity appointed by the county, to perform the duties described in chapter 71.05 RCW.

"Disability" means a physical or mental impairment that substantially limits one or more major life activities of a person and the person:

(a) Has a record of such an impairment; or

(b) Is regarded as having such impairment.

"Ethnic minority" or "racial/ethnic groups" means, for the purposes of this chapter, any of the following general population groups:

(a) African American;

(b) An American Indian or Alaskan native, which includes:

(i) A person who is a member or considered to be a member in a federally recognized tribe;

(ii) A person determined eligible to be found Indian by the secretary of interior;

(iii) An Eskimo, Aleut, or other Alaskan native; and

(iv) An unenrolled Indian meaning a person considered Indian by a federally or nonfederally recognized Indian tribe or off-reservation Indian/Alaskan native community organization.

(c) Asian/Pacific Islander; or

(d) Hispanic.

"Housing services" means the active search and promotion of individual access to, and choice in, safe and affordable housing that is appropriate to the person's age, culture, and needs.

"Integrated managed care (IMC)" - See WAC 182-538-050.

"Less restrictive alternative (LRA)" - See WAC 182-538C-050.

"Mental health professional" means a person who meets the following:

(a) A psychiatrist, psychologist, psychological associate, physician assistant working with a supervising psychiatrist, psychiatric advanced registered nurse practitioner (ARNP), psychiatric nurse, or social worker as defined in chapters 71.05 and 71.34 RCW;

(b) A person who is licensed by DOH as a mental health counselor, mental health counselor associate, marriage and family therapist, or marriage and family therapist associate; or

(c) A person with a master's degree or further advanced degree in counseling or one of the social sciences from an accredited college or university who has at least two years of experience in direct treatment of people with mental illness or emotional disturbance, experience that was gained under the supervision of a mental health professional recognized by DOH or attested to by the licensed behavioral health agency.

"Mental health specialist" means:

(a) A "child mental health specialist" is defined as a mental health professional with the following education and experience:

(i) A minimum of 100 actual hours (not quarter or semester hours) of special training in child development and the treatment of children and youth with serious emotional disturbance and their families; and

(ii) The equivalent of one year of full-time experience in the treatment of seriously emotionally disturbed children and youth and their families under the supervision of a child mental health specialist.

(b) A "geriatric mental health specialist" is defined as a mental health professional who has the following education and experience:

(i) A minimum of 100 actual hours (not quarter or semester hours) of specialized training devoted to the mental health problems and treatment of people age 60 and older; and

(ii) The equivalent of one year of full-time experience in the treatment of people age 60 and older, under the supervision of a geriatric mental health specialist.

(c) An "ethnic minority mental health specialist" is defined as a mental health professional who has demonstrated cultural competence attained through major commitment, ongoing training, experience and/or specialization in serving ethnic minorities, including:

(i) Evidence of one year of service specializing in serving the ethnic minority group under the supervision of an ethnic minority mental health specialist; and

(ii) One of the following:

(A) Evidence of support from the ethnic minority community attesting to the person's commitment to that community; or

(B) A minimum of 100 actual hours (not quarter or semester hours) of specialized training devoted to ethnic minority issues and treatment of ethnic minorities.

(d) A "disability mental health specialist" is defined as a mental health professional with special expertise in working with an identified disability group. For purposes of this chapter only, "disabled" means a person with a disability other than a mental illness, including a developmental disability, serious physical handicap, or sensory impairment.

(i) If the consumer is deaf, the specialist must be a mental health professional with:

(A) Knowledge about the deaf culture and psychosocial problems faced by people who are deaf; and

(B) Ability to communicate fluently in the preferred language system of the consumer.

(ii) The specialist for people with developmental disabilities must be a mental health professional who:

(A) Has at least one year experience working with people with developmental disabilities; or

(B) Is a developmental disabilities professional as defined in RCW 71.05.020.

"Quality plan" means an overarching system or process, or both, whereby quality assurance and quality improvement activities are incorporated and infused into all aspects of a BH-ASO's or MCO's operations.

"Residential services" means a complete range of residences and supports authorized by resource management services and which may involve a facility, a distinct part thereof, or services which support community living, for people who are acutely mentally ill, adults who are chronically mentally ill, children who are severely emotionally disturbed, or adults who are seriously disturbed and determined by the behavioral health organization to be at risk of becoming acutely or chronically mentally ill.

"Resource management services" means the same as in RCW 71.24.025.

"Substance use disorder" means a cluster of cognitive, behavioral, and physiological symptoms indicating that a person continues using the substance despite significant substance-related problems. The diagnosis of a substance use disorder is based on a pathological pattern of behaviors related to the use of the substances.

"Substance use disorder professional" or "SUDP" - See WAC 182-500-0100.

"Substance use disorder professional trainee" or "SUDPT" - See WAC 246-811-010.

"Supervision" means the regular monitoring of the administrative, clinical, or clerical work performance of a staff member, trainee, student, volunteer, or employee on contract by a person with the authority to give direction and require change.

"Youth" means a person age 13 through age 17. For clients age 20 and younger, see the early periodic screening, diagnosis, and treatment (EPSDT) program described in chapter 182-534 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-07-031, s 182-538D-0200, filed 3/11/26, effective 4/11/26. Statutory Authority: RCW 41.05.021, 41.05.160, 2024 c 371, and chapter 246-929 WAC. WSR 25-22-061, s 182-538D-0200, filed 10/30/25, effective 1/1/26. Statutory Authority: RCW 18.227.100, 41.05.021, and 41.05.160. WSR 25-04-011, s 182-538D-0200, filed 1/23/25, effective 2/23/25. Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538D-0200, filed 11/27/19, effective 1/1/20.*

##### **Wash. Admin. Code § 182-538D-0234** Behavioral health administrative service organizations—When the medicaid agency administers regional behavioral health services. {#sec-182-538d-0234 omnilex-key=us-wa-regs-official--title-182--182-538D-0234}

(1) If a currently operating behavioral health administrative service organization (BH-ASO) chooses to stop functioning as a BH-ASO, fails to perform contract requirements and fails to correct the issue to the medicaid agency's satisfaction when corrective action is issued, or does not meet the requirements under RCW 71.24.045, the following is implemented:

(a) Under RCW 71.24.035(16), the director of the medicaid agency:

(i) Is designated as the BH-ASO until a new BH-ASO is designated; and

(ii) Assumes the duties assigned to the region without a participating BH-ASO.

(b) The medicaid agency:

(i) Administers behavioral health services within the region without a participating BH-ASO; and

(ii) Continues to apply the BH-ASO requirements in chapter 182-538C WAC.

(2) A person who resides within the service area of a region without a participating BH-ASO may receive services, within available resources as defined in RCW 71.24.025(2), from any provider of behavioral health services that is contracted with the medicaid agency and licensed by the department of health.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538D-0234, filed 11/27/19, effective 1/1/20.*

##### **Wash. Admin. Code § 182-538D-0246** Behavioral health administrative service organizations and managed care organizations—Public awareness of behavioral health services. {#sec-182-538d-0246 omnilex-key=us-wa-regs-official--title-182--182-538D-0246}

A behavioral health administrative service organization (BH-ASO), or a managed care organization (MCO), or a BH-ASO's or MCO's designee must provide public information on the availability of mental health and substance use disorder services. The BH-ASO or MCO must:

(1) Maintain information on available services, including crisis services and the recovery help line in telephone directories, public websites, and other public places in easily accessible formats; and

(2) Publish and disseminate brochures and other materials or methods for describing services and hours of operation that are appropriate for all people, including those who may be visually impaired, limited-English proficient, or unable to read.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538D-0246, filed 11/27/19, effective 1/1/20.*

##### **Wash. Admin. Code § 182-538D-0254** Behavioral health administrative service organizations and managed care organizations—Voluntary and involuntary inpatient evaluation and treatment services. {#sec-182-538d-0254 omnilex-key=us-wa-regs-official--title-182--182-538D-0254}

(1) A behavioral health administrative service organization (BH-ASO) and managed care organization (MCO) must develop and implement age and culturally competent behavioral health services that are consistent with chapters 71.24, 71.05, and 71.34 RCW.

(2) For involuntary evaluation and treatment services, the BH-ASO or MCO:

(a) Must ensure that people in their regional service area have access to involuntary inpatient care; and

(b) Is responsible for coordinating discharge planning with the treating inpatient facility.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538D-0254, filed 11/27/19, effective 1/1/20.*

##### **Wash. Admin. Code § 182-538D-0258** Behavioral health administrative service organizations—Administration of the Mental Health Involuntary Treatment Act and Substance Use Disorders Involuntary Treatment Act. {#sec-182-538d-0258 omnilex-key=us-wa-regs-official--title-182--182-538D-0258}

Behavioral health administrative service organizations (BH-ASOs) are responsible for administration of the Mental Health Involuntary Treatment Act and Substance Use Disorders Involuntary Treatment Act, including investigation, detention, transportation for people not eligible for medicaid, due process and other court-related services, and other services required by chapters 71.05, 71.24, and 71.34 RCW. This includes:

(1) BH-ASOs ensuring that designated crisis responders (DCRs) perform the duties of involuntary investigation and detention in accordance with the requirements of chapters 71.05, 71.24, and 71.34 RCW.

(2) BH-ASOs and managed care organizations documenting the person's compliance with the conditions of mental health less restrictive alternative court orders by:

(a) Ensuring periodic evaluation of each committed person for release from or continuation of an involuntary treatment order. Evaluations must be recorded in the clinical record, and must occur at least monthly for ninety-day commitments and one hundred eighty-day commitments.

(b) Notifying the DCR if noncompliance with the less restrictive alternative order impairs the person sufficiently to warrant detention or evaluation for detention and petitioning for revocation of the less restrictive alternative court order.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538D-0258, filed 11/27/19, effective 1/1/20.*

##### **Wash. Admin. Code § 182-538D-0264** Behavioral health administrative service organizations and managed care organizations—Quality plan. {#sec-182-538d-0264 omnilex-key=us-wa-regs-official--title-182--182-538D-0264}

A behavioral health administrative service organization (BH-ASO) and managed care organization (MCO) must have a quality plan for continuous quality improvement in the delivery of culturally competent behavioral health services. See WAC 182-538-140 for MCOs and WAC 182-538C-040 for BH-ASOs.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538D-0264, filed 11/27/19, effective 1/1/20.*

##### **Wash. Admin. Code § 182-538D-0380** Managed care organization—Choice of primary behavioral health provider. {#sec-182-538d-0380 omnilex-key=us-wa-regs-official--title-182--182-538D-0380}

The managed care organization (MCO) must:

(1) Ensure that each person receiving nonemergency behavioral health rehabilitation services has a primary behavioral health provider who is responsible to carry out the individual service plan; and

(2) Allow people, parents of people age twelve and younger, and guardians of people of all ages to select a primary behavioral health provider from the available primary behavioral health provider staff within the MCO.

(3) Assign a primary behavioral health provider not later than fifteen working days after the person requests services if the person does not select a primary behavioral health provider.

(4) Allow a person to change primary behavioral health providers at any time for any reason. The person must notify the MCO or its designee of the request for a change, and inform the MCO or designee of the name of the new primary behavioral health provider.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538D-0380, filed 11/27/19, effective 1/1/20.*

##### **Wash. Admin. Code § 182-538D-0600** Purpose. {#sec-182-538d-0600 omnilex-key=us-wa-regs-official--title-182--182-538D-0600}

In order to enhance and facilitate the department of corrections' ability to carry out its responsibility of planning and ensuring community protection, mental health records and information, as defined in this section, that are otherwise confidential shall be released by any mental health service provider to the department of corrections personnel for whom the information is necessary to carry out the responsibilities of their office as authorized in RCW 71.05.445. Department of corrections personnel must use records only for the stated purpose and must assure that records remain confidential and subject to the limitations on disclosure outlined in chapter 71.05 RCW, except as provided in RCW 72.09.585.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538D-0600, filed 11/27/19, effective 1/1/20.*

##### **Wash. Admin. Code § 182-538D-0620** Scope. {#sec-182-538d-0620 omnilex-key=us-wa-regs-official--title-182--182-538D-0620}

Many records and reports are updated on a regular or as needed basis. The scope of the records and reports to be released to the department of corrections are dependent upon the reason for the request.

(1) For the purpose of a presentence investigation release only the most recently completed or received records of those completed or received within the twenty-four-month period before the date of the request; or

(2) For all other purposes including risk assessments release all versions of records and reports that were completed or received within the ten year period prior to the date of the request that are still available.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538D-0620, filed 11/27/19, effective 1/1/20.*

##### **Wash. Admin. Code § 182-538D-0630** Time frame. {#sec-182-538d-0630 omnilex-key=us-wa-regs-official--title-182--182-538D-0630}

The mental health service provider will provide the requested relevant records, reports and information to the authorized department of corrections person in a timely manner, according to the purpose of the request:

(1) Presentence investigation - Within seven days of the receipt of the request. If some or all of the requested relevant records, reports and information are not available within that time period the mental health service provider shall notify the authorized department of corrections person prior to the end of the seven-day-period and provide the requested relevant records, reports or information within a mutually agreed to time period; or

(2) All other purposes - Within thirty days of the receipt of the request. If some or all of the requested relevant records, reports and information are not available within that time period the mental health service provider shall notify the authorized department of corrections person prior to the end of the thirty-day period and provide the requested relevant records, reports or information within a mutually agreed to time period; or

(3) Emergent situation requests - When an offender subject has failed to report for department of corrections supervision or in an emergent situation that poses a significant risk to the public, the mental health provider shall upon request, release information related to mental health services delivered to the offender and, if known, information regarding the whereabouts of the offender. Requests if oral must be subsequently confirmed in writing the next working day, which includes email or facsimile so long as the requesting person at the department of corrections is clearly defined. The request must specify the information being requested. Disclosure of the information requested does not require the consent of consumer.

Information that can be released is limited to:

(a) A statement as to whether the offender is or is not being treated by the mental health services provider; and

(b) Address or information about the location or whereabouts of the offender.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538D-0630, filed 11/27/19, effective 1/1/20.*

##### **Wash. Admin. Code § 182-538D-0640** Written requests. {#sec-182-538d-0640 omnilex-key=us-wa-regs-official--title-182--182-538D-0640}

The written request for relevant records, reports and information must include:

(1) Verification that the person for whom records, reports and information are being requested is under the authority of the department of corrections, per chapter 9.94A RCW, and the expiration date of that authority;

(2) Sufficient information to identify the person for whom records, reports and information are being requested including name and other identifying data;

(3) Specification as to which records and reports are being requested and the purpose for the request;

(4) Specification as to what relevant information is requested and the purpose for the request;

(5) Identification of the department of corrections person to whom the records, reports and information shall be sent, including the person's name, title and address;

(6) Name, title and signature of the requestor and date of the request.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538D-0640, filed 11/27/19, effective 1/1/20.*

## **Chapter 182-539** HIV/AIDS related services. {#struct-chapter-182-539}

##### **Wash. Admin. Code § 182-539-0200** AIDS—Health insurance premium payment program. {#sec-182-539-0200 omnilex-key=us-wa-regs-official--title-182--182-539-0200}

(1) The purpose of the AIDS health insurance premium payment program is to help people who are not eligible for the medicaid agency's Washington apple health medical programs and who are diagnosed with AIDS pay their health insurance premiums.

(2) To be eligible for the AIDS health insurance premium payment program:

(a) A person must be:

(i) Diagnosed with AIDS as defined in WAC 246-100-011;

(ii) A resident of the state of Washington;

(iii) Responsible for all or part of the health insurance premium payment (without the agency's help);

(b) A person must not:

(i) Be eligible for one of the agency's other medical programs;

(ii) Have personal income that exceeds three hundred seventy percent of the federal poverty level; and

(iii) Have personal assets, after exemptions, exceeding fifteen thousand dollars, except for:

(A) A home used as the person's primary residence; and

(B) A vehicle used as personal transportation.

(3) The agency may contract with a not-for-profit community agency to administer the AIDS health insurance premium payment program. The agency or its contractor determines a person's initial eligibility and redetermines eligibility on a periodic basis. To be eligible, a person must:

(a) Cooperate with the agency's contractor;

(b) Cooperate with the eligibility determination and redetermination process; and

(c) Initially meet and continue to meet the eligibility criteria in subsection (2) of this section.

(4) People diagnosed with AIDS who are eligible for an agency medical program may ask the agency to pay their health insurance premiums under a separate process. The client's community services office (CSO) can assist the client with this process.

(5) When a person is eligible for the AIDS health insurance premium payment program, eligibility ceases only when the person:

(a) Is deceased;

(b) Voluntarily quits the program;

(c) No longer meets the requirements of subsection (2) of this section; or

(d) Has benefits terminated because the legislature terminated the funding for this program.

(6) The agency sets a reasonable payment limit for health insurance premiums by tracking the charges billed to the agency for clients with AIDS. The agency does not pay health insurance premiums that exceed fifty percent of the average of charges billed to the agency for clients with AIDS.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-17-054, § 182-539-0200, filed 8/13/15, effective 9/13/15. WSR 11-14-075, recodified as § 182-539-0200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-539-0200, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.757. WSR 00-14-070, § 388-539-0200, filed 7/5/00, effective 8/5/00.*

##### **Wash. Admin. Code § 182-539-0300** Case management for people living with HIV/AIDS. {#sec-182-539-0300 omnilex-key=us-wa-regs-official--title-182--182-539-0300}

The medicaid agency provides HIV/AIDS case management to assist people infected with HIV to: Live as independently as possible; maintain and improve health; reduce behaviors that put the person and others at risk; and gain access to needed medical, social, and educational services.

(1) To be eligible for agency-reimbursed HIV/AIDS case management services, a person must:

(a) Have a current medical diagnosis of HIV or AIDS;

(b) Be eligible for Title XIX (medicaid) coverage under either the categorically needy program (CNP) or the medically needy program (MNP); and

(c) Require:

(i) Assistance to obtain and effectively use necessary medical, social, and educational services; or

(ii) Ninety days of continued monitoring under WAC 182-539-0350(2).

(2) The agency has an interagency agreement with the Washington state department of health (DOH) to administer the HIV/AIDS case management program for Title XIX (medicaid) clients.

(3) HIV/AIDS case management agencies who serve Washington apple health clients must be approved by HIV client services, DOH.

(4) HIV/AIDS case management providers must:

(a) Notify HIV positive people of their statewide choice of available HIV/AIDS case management providers and document that notification in the client's record. This notification requirement does not obligate HIV/AIDS case management providers to accept all clients who request their services.

(b) Have a current, client-signed authorization form to release and obtain information. The provider must have a valid authorization on file for the months that case management services are billed to the agency (see RCW 70.02.030). The fee referenced in RCW 70.02.030 is included in the agency's payment to providers. Clients must not be charged for services or documents related to covered services.

(c) Maintain enough contact to ensure effective, ongoing services under subsection (5) of this section. The agency requires a minimum of one contact per month between the HIV/AIDS case manager and the client. However, contact frequency must be enough to ensure the individual service plan (ISP) is implemented and maintained.

(5) HIV/AIDS case management providers must document services as follows:

(a) Providers must start a comprehensive assessment within two working days of the client's referral to HIV/AIDS case management services.

(b) Providers must complete the assessment before billing for ongoing case management services.

(c) If the assessment does not meet requirements under this subsection, the provider must document the reason or reasons for failure to do so.

(d) The assessment must include the following elements as reported by the client:

(i) Demographic information (for example, age, gender, education, family composition, housing);

(ii) Physical status, the client's primary care provider, and current information on the client's medications and treatments;

(iii) HIV diagnosis (both the documented diagnosis from the assessment and historical diagnosis information);

(iv) Psychological, social, and cognitive functioning and mental health history;

(v) Ability to perform daily activities;

(vi) Financial and employment status;

(vii) Medical benefits and insurance coverage;

(viii) Informal support systems (for example, family, friends, and spiritual support);

(ix) Legal status, durable power of attorney, and any self-reported criminal history; and

(x) Self-reported behaviors that could lead to HIV transmission or re-infection (for example, drug or alcohol use).

(e) Providers must develop, monitor, and revise the client's ISP. The ISP identifies and documents the client's unmet needs and the resources needed to assist in meeting the client's needs. The case manager and the client must develop the ISP within two days of the comprehensive assessment, or the provider must document the reason this is not possible. An ISP must be:

(i) Signed by the client, documenting that the client is voluntarily requesting and receiving the agency-reimbursed HIV/AIDS case management services; and

(ii) Reviewed monthly by the case manager through in-person or telephone contact with the client. The case manager must note the review and any changes:

(A) In the case record narrative; or

(B) By entering notations in, initialing, and dating the ISP.

(f) Providers must maintain ongoing narrative records and must document case management services provided in each month the provider bills the agency. Records must:

(i) Be entered in chronological order and signed by the case manager;

(ii) Document the reason for the case manager's interaction with the client; and

(iii) Describe the plans in place or to be developed to meet unmet client needs.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-17-054, § 182-539-0300, filed 8/13/15, effective 9/13/15. WSR 11-14-075, recodified as § 182-539-0300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-539-0300, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.755, 74.09.800, 42 U.S.C. Section 1915(g). WSR 00-23-070, § 388-539-0300, filed 11/16/00, effective 12/17/00.*

##### **Wash. Admin. Code § 182-539-0350** HIV/AIDS case management reimbursement information. {#sec-182-539-0350 omnilex-key=us-wa-regs-official--title-182--182-539-0350}

(1) The medicaid agency pays HIV/AIDS case management providers for the following three services:

(a) Comprehensive assessment. The assessment must cover the areas outlined in WAC 182-539-0300 (1) and (5).

(i) The agency pays for only one comprehensive assessment unless the client's situation changes as follows:

(A) There is a fifty percent change in need from the initial assessment; or

(B) The client transfers to a new case management provider.

(ii) If a comprehensive assessment is completed during a month the client is medicaid eligible and ongoing case management has been provided, the agency pays for the assessment and the monthly case management charge (either full-month or partial-month).

(b) HIV/AIDS case management, full-month. Providers may request the full-month payment for any month when the requirements of WAC 182-539-0300 have been met and the case manager has an individual service plan (ISP) in place for twenty or more days in that month. The agency pays only one full-month case management fee per client in any one month.

(c) HIV/AIDS case management, partial-month. Providers may request the partial-month payment for any month when the requirements of WAC 182-539-0300 have been met and the case manager has an ISP in place for fewer than twenty days in that month. Using the partial-month reimbursement, the agency may pay two different case management providers for services to a client who changes from one provider to a new provider during that month.

(2) The agency limits payments to HIV/AIDS case managers when a client becomes stabilized and no longer needs an ISP with active service elements. The agency limits payment for monitoring to ninety days after the last active service element of the ISP is completed. To bill the agency for a maximum of ninety days of monitoring, a provider must:

(a) Document the client's history of recurring need;

(b) Assess the client for possible future instability; and

(c) Provide monthly monitoring contacts.

(3) The agency reinstates payment for ongoing case management if a client shifts from monitoring status to active case management status due to documented need or needs. Providers must meet the requirements in WAC 182-539-0300 when a client is reinstated to active case management.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-17-054, § 182-539-0350, filed 8/13/15, effective 9/13/15. WSR 11-14-075, recodified as § 182-539-0350, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-539-0350, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.755, 74.09.800, 42 U.S.C. Section 1915(g). WSR 00-23-070, § 388-539-0350, filed 11/16/00, effective 12/17/00.*

## **Chapter 182-540** Kidney disease program and kidney center services. {#struct-chapter-182-540}

##### **Wash. Admin. Code § 182-540-001** Purpose. {#sec-182-540-001 omnilex-key=us-wa-regs-official--title-182--182-540-001}

This chapter (WAC 182-540-001 through 182-540-065) contains rules for the state-funded kidney disease program (KDP) administered by the health care authority (the agency). The KDP is available for persons who have end-stage renal disease requiring dialysis or kidney transplant, or persons who have received a kidney transplant but who do not meet the eligibility standards for any other Washington apple health program including medicaid or state-only funded medical programs.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 13-23-065, § 182-540-001, filed 11/18/13, effective 1/1/14. WSR 11-14-075, recodified as § 182-540-001, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-001, filed 10/8/03, effective 11/8/03. Statutory Authority: RCW 74.04.050 and 74.08.090. WSR 00-01-088, § 388-540-001, filed 12/14/99, effective 1/14/00. Statutory Authority: RCW 74.08.090. WSR 93-16-039 (Order 3600), § 388-540-001, filed 7/28/93, effective 8/28/93.*

##### **Wash. Admin. Code § 182-540-005** Kidney disease program (KDP)—Definitions. {#sec-182-540-005 omnilex-key=us-wa-regs-official--title-182--182-540-005}

The following definitions and those found in chapter 182-500 WAC, apply to this chapter for the purpose of administering the kidney disease program.

"Affiliate" - A facility, hospital, unit, business, or person having an agreement with a kidney center to provide specified services to ESRD patients;

"Applicant for KDP" - A person who submits a new application for assistance under the kidney disease program (KDP), or an existing client who has had a break in eligibility of over thirty days;

"Application documentation" - A "medical eligibility determination" letter from the department of social and health services (DSHS) and/or a Washington apple health (WAH) eligibility determination letter from the health care authority (the agency) either approving or denying an application for WAH;

"Certification" - The kidney center or affiliate has determined a person eligible for the KDP for a defined period of time;

"End-stage renal disease (ESRD)" - The stage of renal impairment which is irreversible and permanent, and requires dialysis or kidney transplant to ameliorate uremic symptoms and maintain life. For purposes of the KDP, this includes persons who have received a transplant;

"KDP application" - The agency Form 13-566 which the person completes and submits to the KDP contractor to determine KDP eligibility;

"KDP client" - A person who has a diagnosis of ESRD or had a diagnosis of ESRD and has received a kidney transplant and has been determined eligible for the kidney disease program as determined by a KDP contractor;

"KDP contractor" - A kidney center or other ESRD facility that has contracted with the health care authority (the agency), kidney disease program to provide ESRD services to KDP clients;

"KDP manual" - A manual that describes the KDP contract guidelines and procedures for a KDP contractor;

"Kidney center" - A facility as defined and certified by the federal government to provide ESRD services.

"Kidney disease program (KDP)" - A state-funded program managed by the Washington state health care authority that provides financial assistance to eligible persons for the costs of ESRD medical care;

"Spenddown" - The process by which a person uses incurred medical expenses to offset income to meet the financial standards established by the agency. (See WAC 182-519-0110.)

**History**
- *Statutory Authority: RCW 41.05.021. WSR 13-23-065, § 182-540-005, filed 11/18/13, effective 1/1/14. WSR 11-14-075, recodified as § 182-540-005, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-005, filed 10/8/03, effective 11/8/03. Statutory Authority: RCW 74.04.050 and 74.08.090. WSR 00-01-088, § 388-540-005, filed 12/14/99, effective 1/14/00. Statutory Authority: RCW 74.08.090, 74.04.005 and 74.08.025. WSR 98-06-025, § 388-540-005, filed 2/24/98, effective 3/27/98. Statutory Authority: RCW 74.08.090. WSR 93-16-039 (Order 3600), § 388-540-005, filed 7/28/93, effective 8/28/93.*

##### **Wash. Admin. Code § 182-540-015** Kidney disease program (KDP)—General eligibility criteria. {#sec-182-540-015 omnilex-key=us-wa-regs-official--title-182--182-540-015}

(1) Persons must meet the following criteria to be eligible for the kidney disease program (KDP):

(a) Reside in the state of Washington as required under WAC 182-503-0520 or 182-503-0525;

(b) Be diagnosed with end-stage renal disease (ESRD) requiring dialysis or kidney transplant as defined in WAC 182-540-005 or have received a kidney transplant;

(c) Be determined ineligible for any other Washington apple health (WAH) program, including medicaid; the alien medical program described in WAC 182-507-0110; the medical care services (MCS) program described in WAC 182-508-0005; and another state-funded medical program with the following exceptions:

(i) Persons who are found eligible for the medically needy (MN) program but are required to meet the spenddown liability under WAC 182-519-0110 or who are found or become eligible for the alien emergency medical programs described in WAC 182-507-0110, are eligible for KDP until the spenddown liability has been met;

(ii) A KDP contractor may use KDP funding as available to pay for medical expenses on behalf of a spenddown client as expenses are incurred by the person, and those expenses will be treated as if the person incurred the financial liability for the expense;

(iii) When a KDP contractor uses KDP funding to pay for monthly health insurance premiums (including WSHIP premiums) on behalf of a spenddown client, those committed funds may continue to be paid even if the person becomes eligible for MN coverage by meeting the spenddown liability. Payment may continue until the person is no longer otherwise eligible for KDP or until the person applies to the agency and is found eligible for assistance in paying the premiums;

(iv) A KDP contractor may use KDP funding to pay for premiums under the health care for workers with disabilities program described in chapter 182-511 WAC if it is cost-effective for the kidney center and KDP funds are available.

(d) Submit an application for medicare to the Social Security Administration (SSA) within thirty calendar days of applying for KDP and provide the KDP contractor with a copy of SSA's approval or denial determination notice with the following exceptions:

(i) Clients that have any employer group health plan (EGHP) or COBRA plan; and

(ii) Clients who are still within the thirty-month EGHP period.

(e) Have countable income which is equal to or less than two hundred twenty percent of the federal poverty level (FPL);

(f) Have countable resources in an amount that is equal to or less than the resource standards under the qualified medicare beneficiary (QMB) program. Resource rules are defined in WAC 182-540-030;

(g) Report changes in circumstances as required under WAC 182-540-023.

(2) Persons are not eligible for KDP if they:

(a) Become eligible for another WAH program, including medicaid, the alien emergency medical program described in WAC 182-507-0110, medical care services and any other state-funded medical program, with the exceptions described in subsection (1)(c) of this section;

(b) Fail to apply for medicare within thirty days of being approved for KDP, or fail to follow through with the medicare application process required by the Social Security Administration;

(c) Are in custody of, or confined in, a public institution such as a state penitentiary or county jail;

(d) Reside in an institution for mental disease and are twenty-one through sixty-four years of age.

(3) Applicants for KDP do not have to meet citizenship criteria described in WAC 182-503-0535 to qualify for KDP.

(4) When a Social Security number has been issued to a person, it must be provided to the KDP contractor. Rules governing Social Security numbers are described in WAC 182-503-0515.

(5) The effective date of eligibility for KDP is the first day of the month in which the person submits the KDP application form, if eligible. A person may be eligible for retroactive coverage for expenses incurred within the three months immediately prior to the KDP application if the person:

(a) Meets the KDP financial eligibility criteria in this section;

(b) Has a diagnosis of ESRD requiring dialysis or kidney transplant as defined in WAC 182-540-005 or has received a kidney transplant; and

(c) Has incurred medical expenses potentially payable by the kidney disease program during the three-month retroactive period.

(6) A person who is subsequently found retroactively eligible for another WAH program during the three-month retroactive period is not eligible for KDP reimbursement of expenses which are billable to the other WAH program. KDP funds spent on the person's behalf must be reimbursed to the KDP with the following exceptions:

(a) Transportation expenses;

(b) Health insurance premiums;

(c) Expenses paid by the KDP which were used to meet a spenddown liability.

(7) There is no time limit on how long a person may be eligible for KDP as long as the person continues to meet ESRD criteria. The KDP contractor is responsible for certifying that the person meets the functional criteria for ESRD at the time of application and at the time of review.

(8) Persons who have received a kidney transplant are eligible for KDP until they no longer meet the requirements as described in this section.

(9) Persons who are aggrieved by a decision affecting eligibility for KDP have the right to an administrative hearing. See WAC 182-540-0060.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 13-23-065, § 182-540-015, filed 11/18/13, effective 1/1/14. WSR 11-14-075, recodified as § 182-540-015, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-015, filed 10/8/03, effective 11/8/03.*

##### **Wash. Admin. Code § 182-540-021** Kidney disease program (KDP)—Household size. {#sec-182-540-021 omnilex-key=us-wa-regs-official--title-182--182-540-021}

(1) Household size is used to determine the appropriate income standard for KDP eligibility and also whose income must be counted or not counted.

(2) The following members of a person's household must be included when determining the household size:

(a) The applicant's spouse if living in the same home;

(b) Dependent children eighteen years of age and younger with no income who live in the same household and for whom the person is legally responsible;

(c) Children nineteen through twenty-one years of age who are attending full-time school or college; and

(d) Any other members of a person's household that the person claimed as a dependent on their most recent federal income tax return.

(3) Children eighteen years of age and younger who have income or separate resources which may make an applicant ineligible for KDP may be included or excluded from the household size determination, depending on what is most beneficial for the KDP applicant. If a child is included in the household size, then their income and/or resources are also counted.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 13-23-065, § 182-540-021, filed 11/18/13, effective 1/1/14.*

##### **Wash. Admin. Code § 182-540-022** Kidney disease program (KDP)—Income eligibility. {#sec-182-540-022 omnilex-key=us-wa-regs-official--title-182--182-540-022}

(1) A household must have countable income at or below two hundred twenty percent of the federal poverty level for a person to be eligible for the kidney disease program (KDP). See WAC 182-540-021 to determine who must be included in the household and whose income counts.

(2) The KDP contractor determines the household's income based upon the information reported in the KDP application and may request additional verification if the information in the application is not clear. A KDP applicant must provide verification of all household income (and expenses, if self-employed) to the KDP contractor for a KDP eligibility determination.

(3) The agency does not count the following income:

(a) The first twenty dollars per month of unearned income for the entire household;

(b) Cost-of-living adjustments (COLAs) to Social Security disability benefits and supplemental security income (SSI) benefits that take effect in the calendar year of a KDP eligibility determination and any subsequent COLAs to these benefits received by:

(i) The applicant;

(ii) The applicant's spouse; or

(iii) Other family members included in the household size.

(c) Fifty percent of the gross earned income of any person included in the household size;

(d) Income received by a dependent child age eighteen or younger who is not included in the household size; or

(e) Any income source which is specifically excluded by federal law.

(4) The agency follows rules for SSI-related medical described in chapter 182-512 WAC to determine what income types count when determining eligibility for KDP.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-21-001, § 182-540-022, filed 10/8/15, effective 11/8/15. Statutory Authority: RCW 41.05.021. WSR 13-23-065, § 182-540-022, filed 11/18/13, effective 1/1/14.*

##### **Wash. Admin. Code § 182-540-023** Kidney disease program (KDP)—Change of circumstances. {#sec-182-540-023 omnilex-key=us-wa-regs-official--title-182--182-540-023}

(1) A person who is approved for KDP is required to report changes in their circumstances to the KDP contractor within thirty days of the date of the change. The person is required to report the following changes:

(a) When total income for household members included in the KDP household size goes above two hundred twenty percent FPL and the change is expected to last for thirty calendar days or longer;

(b) When countable resources exceed the standards described in WAC 182-540-030;

(c) When there is a change in household members or household size;

(d) When the person is determined eligible for medicare; or

(e) When the person is no longer a resident in the state of Washington.

(2) If the change in circumstances reflects a change in the person's KDP eligibility, the person is required to fill out and submit a new KDP application, with a new effective date reflecting the changes made. The KDP contractor will end the person's previous application.

(3) If the person fails to report their change in circumstance which would result in the person's ineligibility for the program, the KDP contractor is not liable for paying expenses on the person's behalf. If expenses are paid on behalf of a person who is not eligible for KDP or eligible for Washington apple health, the requirements in WAC 182-502-0160 billing a client, do not apply.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 13-23-065, § 182-540-023, filed 11/18/13, effective 1/1/14.*

##### **Wash. Admin. Code § 182-540-025** Kidney disease program (KDP)—Application and recertification requirements—KDP contractor. {#sec-182-540-025 omnilex-key=us-wa-regs-official--title-182--182-540-025}

When a person applies for the kidney disease program (KDP), the KDP contractor must:

(1) Inform the applicant of the requirements for KDP eligibility as defined in this chapter, provide the applicant with the necessary forms and instructions to complete the KDP application, and provide the applicant with a copy of the person's rights and responsibilities.

(2) If required, help the applicant submit an application for medical benefits with the department of social and health services (DSHS) community services office or the health benefits exchange.

(a) The KDP contractor must obtain the person's application documentation from DSHS or the health benefits exchange and keep a copy in the person's record.

(b) The KDP contractor may authorize KDP payment pending the outcome of the medical application; however, if the person is subsequently approved for medical coverage for any month in which KDP funds were authorized, those expenses must not be billed to KDP. If KDP has already reimbursed those funds, the contractor must refund the KDP, subject to exceptions for transportation expenses, health insurance premiums, and expenses paid by the KDP which were used to meet a spenddown liability as described in WAC 182-540-015 (6)(a), (b), and (c).

(3) Inform the applicant of the requirement to apply for medicare and help with the application process. The KDP contractor must obtain a copy of the Social Security Administration's (SSA's) approval or denial of medicare entitlement and keep a copy in the person's record once a determination has been made by SSA.

(4) Determine eligibility using the agency's policies, rules, and instructions and provide the applicant with a timely written approval or denial notice within no more than sixty calendar days from the date of the KDP application.

(5) The KDP contractor may request an extension of the application time from the KDP program manager when extenuating circumstances prevent the person from completing the application or recertification process within the specified time limit.

(6) Forward the completed KDP application and the application documentation to the KDP program manager at the health care authority (HCA). The KDP program manager may amend or terminate a person's certification period within thirty calendar days of receipt if the application is incomplete or inaccurate.

(7) The KDP contractor certifies an eligible person for no more than one year from the first day of the month of application, unless the client:

(a) Needs medical coverage for less than one year; or

(b) Reports a change as described in WAC 182-540-0023 that makes the person ineligible for KDP.

(8) Within sixty calendar days prior to the end of a person's certification period, the KDP contractor must assist a person with completing a recertification for KDP. To be eligible for ongoing KDP funding, a person must meet the requirements described in WAC 182-540-026(2).

**History**
- *Statutory Authority: RCW 41.05.021. WSR 13-23-065, § 182-540-025, filed 11/18/13, effective 1/1/14. WSR 11-14-075, recodified as § 182-540-025, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-025, filed 10/8/03, effective 11/8/03.*

##### **Wash. Admin. Code § 182-540-026** Kidney disease program (KDP)—Application and recertification requirements—Client. {#sec-182-540-026 omnilex-key=us-wa-regs-official--title-182--182-540-026}

(1) An applicant for KDP must:

(a) Complete the KDP application form and submit any necessary documentation to the KDP contractor in order to make an eligibility determination;

(b) Do one of the following:

(i) Provide application documentation from the department of social and health services (DSHS) or the Washington Healthplanfinder verifying that the applicant applied for Washington apple health (WAH) within the six-month period prior to the month of application for KDP, and that the application for WAH was denied due to an eligibility requirement and not because the person failed to complete the application process; or

(ii) Submit an application for WAH to DSHS and/or via the Washington Healthplanfinder, as applicable, and provide the KDP contractor with a copy of the application documentation when an eligibility determination has been made; and

(c) Apply for medicare within thirty calendar days of applying for KDP and provide written proof from the Social Security Administration that the application was approved or denied. A copy of the proof must be kept in the person's record.

(2) At the end of the KDP certification period, a person may reapply for continued KDP eligibility. To complete the recertification, the client must:

(a) Complete a new KDP application no later than thirty calendar days beyond the end of the original certification period and submit any documentation necessary to determine eligibility to the KDP contractor; and

(b) Submit a new application for WAH and provide a copy to the KDP contractor.

(3) A person who fails to follow through with the required application or recertification processes or fails to provide requested verifications within the time limits requested by the KDP contractor is not eligible for KDP funding and the application will be denied.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 13-23-065, § 182-540-026, filed 11/18/13, effective 1/1/14.*

##### **Wash. Admin. Code § 182-540-030** Kidney disease program (KDP)—Resource eligibility. {#sec-182-540-030 omnilex-key=us-wa-regs-official--title-182--182-540-030}

(1) The person's household must have countable resources at or below the limits established in the federal low-income subsidy (LIS) program for the person to be eligible for the kidney disease program. LIS resource standards are listed at https://www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

(2) See WAC 182-540-021 to determine who must be included in the household when making a determination of whose resources count.

(3) The following resources are not counted:

(a) A home, defined as real property owned by a client as their principal place of residence together with surrounding and contiguous property;

(b) Household furnishings;

(c) One burial plot per household member or irrevocable burial plans with a mortuary;

(d) Up to $1,500 for a person or $3,000 for a couple set aside in a revocable burial account;

(e) Any resource which is specifically excluded by federal law.

(4) The agency follows rules for SSI-related medicaid determinations described in WAC 182-512-0200 through 182-512-0550 when determining whether any other resources are countable with the exception of subsection (5) of this section.

(5) The agency follows rules in chapter 182-516 WAC when a person owns a trust, an annuity, or a life estate.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-072, § 182-540-030, filed 6/29/23, effective 7/30/23*
- *WSR 16-01-033, § 182-540-030, filed 12/8/15, effective 1/8/16. Statutory Authority: RCW 41.05.021. WSR 13-23-065, § 182-540-030, filed 11/18/13, effective 1/1/14.*

##### **Wash. Admin. Code § 182-540-045** Kidney disease program (KDP) contractor requirements. {#sec-182-540-045 omnilex-key=us-wa-regs-official--title-182--182-540-045}

(1) The kidney disease program (KDP) contractor must:

(a) Be a medicare-certified end-stage renal disease (ESRD) facility; and

(b) Have a valid KDP client services contract with the agency.

(2) The KDP contractor must provide, directly or through an affiliate:

(a) Professional consultation, personal instructions, medical treatment and care, drug products and all supplies necessary for carrying out a medically sound end-stage renal disease (ESRD) treatment program;

(b) Dialysis for clients with ESRD when medically indicated;

(c) Coordination of care with a kidney transplant center;

(d) Treatment for conditions directly related to ESRD such as anemia, vascular, or peritoneal access care; and

(e) Supplies and equipment for home dialysis.

(3) The provider must maintain adequate records for audit and review purposes, including:

(a) Medical charts and records that meet the requirements of WAC 182-502-0020; and

(b) Documentation of expenses and amounts paid by the KDP to assist clients in meeting a spenddown requirement as described in WAC 182-519-0100.

(4) The contractor must meet other obligations as required by its contract with the KDP program.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 13-23-065, § 182-540-045, filed 11/18/13, effective 1/1/14. WSR 11-14-075, recodified as § 182-540-045, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-045, filed 10/8/03, effective 11/8/03.*

##### **Wash. Admin. Code § 182-540-055** Kidney disease program (KDP) covered services. {#sec-182-540-055 omnilex-key=us-wa-regs-official--title-182--182-540-055}

(1) The kidney disease program (KDP) covers the cost of health care services essential to the treatment of end-stage renal disease (ESRD) and its complications. Within available funding and at the discretion of the KDP contractor covered services include:

(a) Dialysis:

(i) Center dialysis - Covers the cost of dialysis, necessary supplies, and related services provided in a kidney center;

(ii) Home dialysis - Covers the cost of providing dialysis and related services in the home; and

(iii) Dialysis while hospitalized - Covers the cost of dialysis and related services while the KDP client is confined to an acute care facility and is unable to dialyze at his/her regular site.

(b) Medication - As defined in the approved drug list in the KDP manual;

(c) Access surgery (venous and peritoneal) - Covers costs associated with surgically preparing the client for dialysis and medical complications related to the access site;

(d) Laboratory tests and X-rays considered to be part of the overall treatment plan for ESRD;

(e) Pretransplant work-up including, but not limited to, transportation, lodging, and physician visits;

(f) Post-transplant visit to assess client's ESRD status to include, but is not limited to, transportation, lodging, and physician visits;

(g) Health insurance premium including copays and deductibles when found to be cost-effective;

(h) Spenddown expenses when found to be cost-effective; and

(i) Other services as approved by the agency's KDP program manager.

(2) If the KDP pays for medical and dental services required to receive a transplant, and the KDP client does not follow through with their recommended treatment plan in order to receive or make progress towards receiving a transplant, the KDP contractor must submit a request for a determination of noncompliance to the agency's KDP manager. If the request is approved, KDP funds must not be used for any follow-up or additional services. Once the KDP client makes progress with their treatment plan, the agency may rereview the request.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 13-23-065, § 182-540-055, filed 11/18/13, effective 1/1/14. WSR 11-14-075, recodified as § 182-540-055, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-055, filed 10/8/03, effective 11/8/03.*

##### **Wash. Admin. Code § 182-540-060** Kidney disease program (KDP) client appeal rights. {#sec-182-540-060 omnilex-key=us-wa-regs-official--title-182--182-540-060}

(1) Clients have the right to appeal:

(a) KDP eligibility decisions made by the person's KDP contractor;

(b) Coverage decisions made by the contractor or the first decision submitted by the agency for medical services or devices that are not considered to be for the treatment of the person's ESRD diagnosis; or

(c) The denial, made by the KDP contractor, of services found in WAC 182-540-055(1) which have been denied by a KDP contractor.

(2) Clients do not have the right to appeal:

(a) Reimbursement based on covered or noncovered procedure codes or rates; or

(b) The KDP contractor's decision to not cover services found in WAC 182-540-055(1) when the KDP contractor has gone over its KDP allotted funding.

(3) A client who is aggrieved by a decision made by the KDP contractor may request review of the decision to the agency within thirty days of receiving the notice of the decision by sending a written request for review to the agency's KDP Program Manager, Health Care Authority, P.O. Box 45510, Olympia, WA 98504-5510.

(4) The request for review must clearly identify the name and address of the client requesting the review.

(5) Within thirty days of receiving the request for review, the KDP program manager will send the client a written decision. Failure to request review does not prevent the client from appealing the decision under subsection (6) of this section.

(6) Within ninety days of receiving the KDP contractor's or the KDP program manager's written decision, the client can appeal the decision by sending a written request for hearing to the Health Care Authority, P.O. Box 45504, Olympia, WA 98504-5540.

(7) The request for hearing:

(a) Must clearly identify the name, address, and telephone number of the client requesting the hearing;

(b) Should include a copy of the KDP program manager's written decision which the client is appealing.

(8) The hearing is usually conducted by telephone by an agency presiding officer in accordance with WAC 182-526-0025(1). The client requesting the hearing is responsible for making sure that the agency's presiding officer has the correct telephone number to contact the party for the hearing.

(9) The agency's presiding officer may refer the case in writing to the office of administrative hearings when the:

(a) Client requests an in-person hearing to accommodate a disability; and

(b) The presiding officer determines that the agency does not have the resources needed to conduct the in-person hearing.

(10) When an administrative law judge (ALJ) employed by the office of administrative hearings conducts the hearing on behalf of the agency, the ALJ issues an initial order in accordance with WAC 182-526-0025(1) and 182-526-0215(4). Any party may appeal the initial order to an agency review judge in accordance with WAC 182-526-0575.

(11) When a presiding officer employed by the agency conducts the hearing, the agency's presiding officer issues a final order. Any party may request reconsideration of the final order in accordance with chapter 182-526 WAC. The party who requested the hearing, but not the agency, may file a petition for judicial review as provided in WAC 182-526-0605 and 182-526-0620.

(12) The hearing rules found in chapter 182-526 WAC apply to any administrative hearing requested in accordance with subsection (6) of this section. Where the program rules in this chapter conflict with the hearing rules contained in chapter 182-526 WAC, the program rules in this chapter prevail.

(13) Failure to timely request a hearing will result in the loss of right to appeal.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 13-23-065, § 182-540-060, filed 11/18/13, effective 1/1/14.*

##### **Wash. Admin. Code § 182-540-065** Kidney disease program (KDP)—Reimbursement. {#sec-182-540-065 omnilex-key=us-wa-regs-official--title-182--182-540-065}

(1) The agency reimburses KDP contractors:

(a) Within the limits of legislative funding for the program;

(b) According to the terms of each kidney center's contract with the agency; and

(c) According to the provisions of the KDP manual.

(2) The KDP contractor must submit the following documentation to the agency's KDP program manager within the time limits specified within the KDP contract:

(a) A description of the services for which reimbursement is requested; and

(b) The person's approved KDP application if the application had not previously been provided to the KDP program manager.

(3) A KDP client is not liable and must not be billed for charges incurred under KDP due to the failure of the KDP contractor to bill the agency within the time limits specified in the contract.

(4) The agency limits KDP reimbursement for out-of-state services to fourteen days per calendar year. Reimbursement is paid only to KDP contractors. Out-of-state dialysis providers must operate under subcontract or agreement with an in-state KDP contractor in order to receive reimbursement under this program.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 13-23-065, § 182-540-065, filed 11/18/13, effective 1/1/14. WSR 11-14-075, recodified as § 182-540-065, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-065, filed 10/8/03, effective 11/8/03.*

##### **Wash. Admin. Code § 182-540-101** Purpose and scope. {#sec-182-540-101 omnilex-key=us-wa-regs-official--title-182--182-540-101}

This section describes the medicaid agency reimbursement rules for free-standing kidney centers providing dialysis and end-stage renal disease services to agency clients.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-040, § 182-540-101, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-540-101, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-101, filed 10/8/03, effective 11/8/03.*

##### **Wash. Admin. Code § 182-540-105** Definitions. {#sec-182-540-105 omnilex-key=us-wa-regs-official--title-182--182-540-105}

The following definitions and those found in chapter 182-500 WAC, apply to this chapter.

"Affiliate" means a facility, hospital, unit, business, or person having an agreement with a kidney center to provide specified services to end stage renal disease (ESRD) patients.

"Agreement" means a written document executed between an ESRD facility and another facility in which the other facility agrees to assume responsibility for furnishing specified services to patients and for obtaining reimbursement for those services.

"Composite rate" means a payment method in which all standard equipment, supplies, and services are calculated into a blended rate. All in-facility dialysis and all home dialysis treatments are billed under the composite rate system.

"Continuous ambulatory peritoneal dialysis (CAPD)" means a type of dialysis where the patient's peritoneal membrane is used as the dialyzer. The patient dialyzes at home, using special supplies, but without the need for a machine. (See "Peritoneal dialysis.")

"Continuous cycling peritoneal dialysis (CCPD)" means a type of peritoneal dialysis where the patient dialyzes at home and uses an automated peritoneal cycler for delivering dialysis.

"Dialysate" means an electrolyte solution used in dialysis containing elements such as potassium and sodium chloride. It surrounds the membrane or fibers and allows the exchange of substances with the patient's blood in the dialyzer.

"Dialysis" means a process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semipermeable membrane.

"Dialysis session" means the period beginning when the patient arrives at the facility and ending when the patient departs from the facility. For home dialysis, it means the period beginning when the patient prepares for dialysis and ending when the patient is disconnected from the machine.

"Dialyzer" means the synthetic porous membrane or fibers contained in a supporting structure, through which blood flows to eliminate harmful substances and replace them with useful ones.

"Durable medical equipment (DME)" means equipment that:

(1) Can withstand repeated use;

(2) Is primarily and customarily used to serve a medical purpose;

(3) Generally is not useful to a person in the absence of illness or injury; and

(4) Is appropriate for use in the client's place of residence.

"End-stage renal disease (ESRD)" means the stage of renal impairment that is irreversible and permanent and requires dialysis or kidney transplant to ameliorate uremic symptoms and maintain life.

"Epoetin alpha (EPO)" means the biologically engineered protein that stimulates the bone marrow to make new red blood cells. It is used in the treatment of anemia.

"Free-standing kidney center" means a limited care facility not operated by a hospital that is certified by the federal government to provide ESRD services.

"Home dialysis" means any dialysis performed at home.

"Home dialysis helper" means a person trained to assist the client in home dialysis.

"In-facility dialysis" - For the purpose of this chapter only, "in-facility dialysis" means dialysis of any type performed on the premises of a kidney center or other free-standing ESRD facility.

"Intermittent peritoneal dialysis (IPD)" means a type of peritoneal dialysis in which dialysis solution is infused into the peritoneal cavity and then drained out. IPD is usually done in a kidney center or facility. It can be done at home with a trained home dialysis helper.

"Kidney center" means a facility as defined and certified by the federal government to:

(1) Provide ESRD services;

(2) Provide the services specified in this chapter; and

(3) Promote and encourage home dialysis for a client when medically indicated.

"Peritoneal dialysis" means a procedure that introduces dialysate into the abdominal cavity to remove waste products through the peritoneum. Three forms of peritoneal dialysis are continuous ambulatory peritoneal dialysis, continuous cycling peritoneal dialysis, and intermittent peritoneal dialysis.

"Standard ESRD lab tests" means certain laboratory tests that the Centers for medicare and medicaid include in their composite rate calculations. These tests are identified in the agency kidney center services billing instructions.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-040, § 182-540-105, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-540-105, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-105, filed 10/8/03, effective 11/8/03.*

##### **Wash. Admin. Code § 182-540-110** Eligibility. {#sec-182-540-110 omnilex-key=us-wa-regs-official--title-182--182-540-110}

(1) To be eligible for the kidney center services described in this section, a person must be diagnosed with end-stage renal disease (ESRD) or acute renal failure and be covered under:

(a) One of the Washington apple health programs listed in the table in WAC 182-501-0060;

(b) Alien emergency medical; or

(c) Qualified medicare beneficiary (QMB) - (The agency pays only for medicare premium, coinsurance and deductible).

(2) Managed care enrollees must have dialysis services arranged directly through their designated plan.

**History**
- *Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148). WSR 14-07-042, § 182-540-110, filed 3/12/14, effective 4/12/14. WSR 11-14-075, recodified as § 182-540-110, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-110, filed 10/8/03, effective 11/8/03.*

##### **Wash. Admin. Code § 182-540-120** Provider requirements. {#sec-182-540-120 omnilex-key=us-wa-regs-official--title-182--182-540-120}

To receive reimbursement from the medicaid agency for providing care to agency clients, a kidney center must:

(1) Be a medicare-certified end-stage renal disease (ESRD) facility and have a signed core provider agreement with the agency (see chapter 182-502 WAC);

(2) Meet requirements found in chapter 182-502 WAC;

(3) Provide only those services within the scope of their provider's license; and

(4) Provide, either directly or through an affiliate, all physical facilities, professional consultation, personal instructions, medical treatment, care, and all supplies necessary for carrying out an medically sound ESRD treatment program, including:

(a) Dialysis for ESRD clients;

(b) Kidney transplant treatment, either directly or by referral, for ESRD clients when medically indicated;

(c) Treatment for conditions directly related to ESRD;

(d) Training and supervision of supporting personnel and clients for home dialysis, medical care, and treatment; and

(e) Supplies and equipment for home dialysis.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-040, § 182-540-120, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-540-120, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-120, filed 10/8/03, effective 11/8/03.*

##### **Wash. Admin. Code § 182-540-130** Covered services. {#sec-182-540-130 omnilex-key=us-wa-regs-official--title-182--182-540-130}

(1) The medicaid agency covers the following services and supplies subject to the restrictions and limitations in this section and other applicable published WAC:

(a) In-facility dialysis;

(b) Home dialysis;

(c) Training for self-dialysis;

(d) Home dialysis helpers;

(e) Dialysis supplies;

(f) Diagnostic lab work;

(g) Treatment for anemia; and

(h) Intravenous drugs.

(2) Covered services are subject to the limitations specified by the agency. Providers must obtain prior authorization (PA) or expedited prior authorization (EPA) before providing services that exceed specified limits in quantity, frequency, or duration (refer to WAC 182-501-0165 and 182-501-0169).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-040, § 182-540-130, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-540-130, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-540-130, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-130, filed 10/8/03, effective 11/8/03.*

##### **Wash. Admin. Code § 182-540-140** Noncovered services. {#sec-182-540-140 omnilex-key=us-wa-regs-official--title-182--182-540-140}

(1) The medicaid agency does not reimburse kidney centers for the following:

(a) Blood and blood products (refer to WAC 182-540-190);

(b) Personal care items such as slippers and toothbrushes; or

(c) Additional staff time or personnel costs. Staff time is paid through the composite rate. Home dialysis helpers are the only personnel cost paid outside the composite rate (refer to WAC 182-540-160).

(2) The agency evaluates a request for any service listed as noncovered in this chapter under WAC 182-501-0160.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-040, § 182-540-140, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-540-140, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-540-140, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-140, filed 10/8/03, effective 11/8/03.*

##### **Wash. Admin. Code § 182-540-150** Reimbursement—General. {#sec-182-540-150 omnilex-key=us-wa-regs-official--title-182--182-540-150}

(1) Kidney center services described in this section are paid by one of two methods:

(a) Composite rate payments - This is a payment method in which all standard equipment, supplies, and services are calculated into a blended rate.

(i) A single dialysis session and related services are reimbursed through a single composite rate payment (refer to WAC 182-540-160).

(ii) Composite rate payments for continuous ambulatory peritoneal dialysis (CAPD) or continuous cycling peritoneal dialysis (CCPD) are limited to thirty-one per month for an individual client.

(iii) Composite rate payments for all other types of dialysis sessions are limited to fourteen per month for an individual client.

(b) Noncomposite rate payments - End-stage renal disease (ESRD) services and items covered by the medicaid agency but not included in the composite rate are billed and paid separately (refer to WAC 182-540-170).

(2) Limitation extension request - The agency evaluates billings for covered services that are subject to limitations or other restrictions, and approves the services beyond those limitations or restrictions when medically necessary under WAC 182-501-0165 and 182-501-0169.

(3) Take-home drugs - The agency reimburses kidney centers for take-home drugs only when they meet the conditions described in WAC 182-540-170(1). Other drugs for at-home use must be billed by a pharmacy and be subject to the agency's pharmacy rules.

(4) Medical nutrition - Medical nutrition products must be billed by a pharmacy or a durable medical equipment (DME) provider.

(5) Medicare eligible clients - The agency does not reimburse kidney centers as a primary payer for medicare eligible clients.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-040, § 182-540-150, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-540-150, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-540-150, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-150, filed 10/8/03, effective 11/8/03.*

##### **Wash. Admin. Code § 182-540-160** Items and services included in the composite rate. {#sec-182-540-160 omnilex-key=us-wa-regs-official--title-182--182-540-160}

(1) The following equipment, supplies, and services for in-facility and home dialysis are included in the composite rate:

(a) Medically necessary dialysis equipment;

(b) All dialysis services furnished by the facility's staff;

(c) Standard end-stage renal disease laboratory tests (refer to WAC 182-540-180);

(d) Home dialysis support services including delivery, installation, and maintenance of equipment;

(e) Purchase and delivery of all necessary dialysis supplies;

(f) Declotting of shunts and any supplies used to declot shunts;

(g) Oxygen and the administration of oxygen;

(h) Staff time used to administer blood and nonroutine parenteral items;

(i) Noninvasive vascular studies; and

(j) Training for self-dialysis and home dialysis helpers.

(2) The medicaid agency issues a composite rate payment only when all the items and services in subsection (1) of this section are furnished or available at each dialysis session.

(3) If the facility fails to furnish or have available any of the items in subsection (1) of this section, the agency does not pay for any part of the items and services that were furnished.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-040, § 182-540-160, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-540-160, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-160, filed 10/8/03, effective 11/8/03.*

##### **Wash. Admin. Code § 182-540-170** Items and services not included in the composite rate. {#sec-182-540-170 omnilex-key=us-wa-regs-official--title-182--182-540-170}

The following items and services are not included in the composite rate and must be billed separately, subject to the restrictions or limitations in this section and other applicable published WAC:

(1) Drugs related to treatment including, but not limited to, epoetin alpha (EPO) and diazepam. The drug must:

(a) Be prescribed by a physician;

(b) Meet the rebate requirements described in WAC 182-530-7500; and

(c) Meet the requirements of WAC 246-945-090 when provided for home use.

(2) Supplies used to administer drugs and blood;

(3) Blood processing fees charged by the blood bank (refer to WAC 182-540-190); and

(4) Home dialysis helpers.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-09-050, s 182-540-170, filed 4/10/25, effective 5/11/25*
- *WSR 15-14-040, § 182-540-170, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-540-170, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-170, filed 10/8/03, effective 11/8/03.*

##### **Wash. Admin. Code § 182-540-180** Laboratory services. {#sec-182-540-180 omnilex-key=us-wa-regs-official--title-182--182-540-180}

(1) Laboratory services included in the composite rate, performed by either the facility or an independent laboratory, must not be billed separately except as provided for in (b) of this subsection:

(a) Standard end-stage renal disease (ESRD) lab tests are included in the composite rate when performed at recommended intervals (see billing instructions for current list).

(b) The standard ESRD lab tests referred to in (a) of this subsection can be reimbursed separately from the composite rate only when it is medically necessary to test more frequently:

(i) Proof of medical necessity must be documented in the client's medical record when billing for more frequent testing. A diagnosis of end-stage renal disease is not sufficient;

(ii) The claim must include information on the nature of the illness or injury (diagnosis, complaint or symptom) requiring the performance of the test(s); or

(iii) An ICD-9CM diagnosis code may be shown in lieu of a narrative description.

(2) All separately billable, ESRD laboratory services must be billed by and reimbursed to the lab that performs the test.

**History**
- *WSR 11-14-075, recodified as § 182-540-180, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-180, filed 10/8/03, effective 11/8/03.*

##### **Wash. Admin. Code § 182-540-190** Blood products and services. {#sec-182-540-190 omnilex-key=us-wa-regs-official--title-182--182-540-190}

(1) The medicaid agency reimburses free-standing kidney centers for:

(a) Blood processing and other fees assessed by nonprofit blood centers that do not charge for the blood or blood products themselves; and

(b) Costs incurred by the center to administer its in-house blood procurement program.

(2) The agency does not reimburse centers for blood or blood products (refer to WAC 182-550-6500).

(3) Staff time used to administer blood or blood products is reimbursed only through the composite rate (refer to WAC 182-540-150 and 182-540-160).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-040, § 182-540-190, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-540-190, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-190, filed 10/8/03, effective 11/8/03.*

##### **Wash. Admin. Code § 182-540-200** Epoetin alpha (EPO) therapy. {#sec-182-540-200 omnilex-key=us-wa-regs-official--title-182--182-540-200}

The medicaid agency reimburses the kidney center for EPO therapy when:

(1) Administered in the kidney center to a client:

(a) With a hematocrit less than 33 percent or a hemoglobin less than 11 when therapy is initiated;

(b) Continuing EPO therapy with a hematocrit between 30 and 36 percent; or

(c) Medical justification documented in the client's record is required for hematocrits more than 36 or hemoglobins more than 12. Medical justification includes:

(i) Documentation that the dose is being titrated downward to bring a patient's hematocrit back within target range; or

(ii) Documentation that it is medically necessary for the client to have a target hematocrit more than 36 percent.

(2) Provided to a home dialysis client:

(a) Under the same hematocrit and hemoglobin guidelines as stated in (1)(a) and (b) of this section; and

(b) When permitted by Washington board of pharmacy rules. (Refer to WAC 246-945-090 Home dialysis program—Legend drugs.)

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-09-050, s 182-540-200, filed 4/10/25, effective 5/11/25*
- *WSR 15-14-040, § 182-540-200, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-540-200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-200, filed 10/8/03, effective 11/8/03.*

##### **Wash. Admin. Code § 182-540-210** Injectable drugs given in the kidney center. {#sec-182-540-210 omnilex-key=us-wa-regs-official--title-182--182-540-210}

Injectable drugs administered in the kidney center are reimbursed up to the medicaid agency published maximum fees.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-040, § 182-540-210, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-540-210, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-210, filed 10/8/03, effective 11/8/03.*

## **Chapter 182-543** Medical equipment, supplies, and appliances. {#struct-chapter-182-543}

##### **Wash. Admin. Code § 182-543-0500** General. {#sec-182-543-0500 omnilex-key=us-wa-regs-official--title-182--182-543-0500}

(1) The federal government considers medical equipment, supplies, and appliances, which the medicaid agency refers to throughout this chapter as medical equipment, services under the medicaid program.

(2) The agency pays for medical equipment, including modifications, accessories, and repairs, according to agency rules and subject to the limitations and requirements in this chapter when the medical equipment is:

(a) Medically necessary, as defined in WAC 182-500-0070;

(b) Authorized, as required within this chapter, chapters 182-501 and 182-502 WAC, and the agency's published billing instructions and provider notices; and

(c) Billed according to this chapter, chapters 182-501 and 182-502 WAC, and the agency's published billing instructions and provider notices.

(3) For the initiation of medical equipment under WAC 182-551-2122, the face-to-face encounter must be related to the primary reason the client requires medical equipment and must occur no later than six months prior to the start of services.

(4) The face-to-face encounter may be conducted by:

(a) A physician;

(b) A nurse practitioner;

(c) A clinical nurse specialist;

(d) A certified nurse midwife under 42 C.F.R. 440.70 when furnished by a home health agency that meets the conditions of participation for medicare;

(e) A physician assistant; or

(f) The attending acute, or post-acute physician, for beneficiaries admitted to home health immediately after an acute or post-acute stay.

(5) Services may be ordered by:

(a) Physicians;

(b) Nurse practitioners;

(c) Clinical nurse specialists; or

(d) Physician assistants.

(6) The agency requires prior authorization for covered medical equipment when the clinical criteria set forth in this chapter are not met, including the criteria associated with the expedited prior authorization process.

(a) The agency evaluates requests requiring prior authorization on a case-by-case basis to determine medical necessity as defined in WAC 182-500-0070, according to the process found in WAC 182-501-0165.

(b) Refer to WAC 182-543-7000, 182-543-7100, 182-543-7200, and 182-543-7300 for specific details regarding authorization.

(7) The agency bases its determination about which medical equipment requires prior authorization (PA) or expedited prior authorization (EPA) on utilization criteria (see WAC 182-543-7100 for PA and WAC 182-543-7300 for EPA). The agency considers all of the following when establishing utilization criteria:

(a) Cost;

(b) The potential for utilization abuse;

(c) A narrow therapeutic indication; and

(d) Safety.

(8) The agency evaluates a request for equipment that does not meet the definition of medical equipment or that is determined not medically necessary under the provisions of WAC 182-501-0160. When early and periodic screening, diagnosis and treatment (EPSDT) applies, the agency evaluates a noncovered service, equipment, or supply according to the process in WAC 182-501-0165 to determine if it is medically necessary, safe, effective, and not experimental (see WAC 182-543-0100 for EPSDT rules).

(9) The agency may terminate a provider's participation with the agency according to WAC 182-502-0030 and 182-502-0040.

(10) The agency evaluates a request for a service that meets the definition of medical equipment but has been determined to be experimental or investigational, under the provisions of WAC 182-501-0165.

(11) If the agency denies a requested service, the agency notifies the client in writing that the client may request an administrative hearing under chapter 182-526 WAC. (For MCO enrollees, see WAC 182-538-110.)

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. § 440.70. WSR 21-12-051, § 182-543-0500, filed 5/26/21, effective 6/26/21. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-0500, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-0500, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-0500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-0500, filed 6/29/11, effective 8/1/11.*

##### **Wash. Admin. Code § 182-543-1000** Definitions. {#sec-182-543-1000 omnilex-key=us-wa-regs-official--title-182--182-543-1000}

The following definitions and abbreviations and those found in chapter 182-500 WAC apply to this chapter.

"By-report (BR)" - See WAC 182-500-0015.

"Complex needs patient" - An individual with a diagnosis or medical condition that results in significant physical or functional needs and capacities.

"Complex rehabilitation technology (CRT)" - Wheelchairs and seating systems classified as durable medical equipment within the medicare program that:

(a) Are individually configured for individuals to meet their specific and unique medical, physical, and functional needs and capacities for basic activities as medically necessary to prevent hospitalization or institutionalization of a complex needs patient;

(b) Are primarily used to serve a medical purpose and generally not useful to a person in the absence of an illness or injury; and

(c) Require certain services necessary to allow for appropriate design, configuration, and use of such item, including patient evaluation and equipment fitting.

"Date of delivery" - The date the client actually took physical possession of an item or equipment.

"Digitized speech" (also referred to as devices with whole message speech output) - Words or phrases that have been recorded by an individual other than the speech generating device (SGD) user for playback upon command of the SGD user.

"Disposable supplies" - Supplies which are designed as single-use products to be discarded after initial use.

"EPSDT" - See WAC 182-500-0030.

"Expedited prior authorization (EPA)" - See WAC 182-500-0030.

"Fee-for-service (FFS)" - See WAC 182-500-0035.

"Health care common procedure coding system (HCPCS)" - A coding system established by the Health Care Financing Administration (HCFA) to define services and procedures. HCFA is now known as the Centers for Medicare and Medicaid Services (CMS).

"Home" - For the purposes of this chapter, means location, other than hospital or skilled nursing facility where the client resides and receives care.

"Hospital bed" - A bed designed for use in a hospital or similar facility, or for use at home. It is characterized by its adjustability and various features, including the ability to elevate or lower the head, foot, or entire bed frame, often using a motorized mechanism. Hospital beds may also have side rails and other features to support patient care and comfort. They are used to provide patients with therapeutic support and to facilitate easier medical care and treatment.

"House wheelchair" - A skilled nursing facility wheelchair that is included in the skilled nursing facility's per-patient-day rate under chapter 74.46 RCW.

"Individually configured" - 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.

"Manual wheelchair" - See "Wheelchair - Manual."

"Medical equipment" - Includes medical equipment and appliances, and medical supplies.

"Medical equipment and appliances" - Health care-related items that:

(a) Are primarily and customarily used to serve a medical purpose;

(b) Generally, are not useful to a person in the absence of a disability, illness, or injury;

(c) Can withstand repeated use;

(d) Can be reusable or removable; and

(e) Are suitable for use in any setting where normal life activities take place.

"Medical supplies" - Health care-related items that are:

(a) Consumable or disposable or cannot withstand repeated use by more than one person;

(b) Required to address an individual medical disability, illness, or injury;

(c) Suitable for use in any setting which is not a medical institution and in which normal life activities take place; and

(d) Generally not useful to a person in the absence of illness or injury.

"Medically necessary" - See WAC 182-500-0070.

"National provider indicator (NPI)" - See WAC 182-500-0075.

"Orthotic device" or "orthotic" - A corrective or supportive device that:

(a) Prevents or corrects physical deformity or malfunction; or

(b) Supports a weak or deformed portion of the body.

"Power-drive wheelchair" - See "Wheelchair - Power."

"Pricing cluster" - A group of manufacturers' list prices for brands/models of medical equipment that the agency considers when calculating the reimbursement rate for a procedure code that does not have a fee established by medicare.

"Prior authorization" - See WAC 182-500-0085.

"Prosthetic device" or "prosthetic" - See WAC 182-500-0085.

"Qualified complex rehabilitation technology supplier" - A company or entity that:

(a) Is accredited by a recognized accrediting organization as a supplier of CRT;

(b) Meets the supplier and quality standards established for durable medical equipment suppliers under the medicare program;

(c) For each site that it operates, employs at least one CRT professional, certified by the rehabilitation engineering and assistive technology society of North America as an assistive technology professional, to analyze the needs and capacities of clients, and provide training in the use of the selected covered CRT items;

(d) Has the CRT professional physically present for the evaluation and determination of the appropriate individually configured CRT for the complex needs patient;

(e) Provides service and repairs by qualified technicians for all CRT products it sells; and

(f) Provides written information to the complex needs patient at the time of delivery about how the individual may receive service and repair of the delivered CRT.

"Resource-based relative value scale (RBRVS)" - A scale that measures the relative value of a medical service or intervention, based on the amount of physician resources involved.

"Reusable supplies" - Supplies which are designed and intended for repeated use.

"Safety enclosure frame/canopy" - A passive bed enclosure that provides a solid framework and a soft canopy structure, which securely attaches to the bed. The enclosure provides access to the client through openings, allowing the caregiver the ability to provide routine care to the client. It is an integral part of, or accessory to, a hospital bed.

"Scooter" - A federally approved, motor-powered vehicle that:

(a) Has a seat on a long platform;

(b) Moves on either three or four wheels;

(c) Is controlled by a steering handle; and

(d) Can be independently driven by a client.

"Specialty bed" - A hospital bed used primarily in the treatment of individuals with a disability, illness, or injury, that has a pressure reducing or relieving support surface, or both, such as foam, air, water, or gel mattress or overlay.

"Speech generating device (SGD)" - An electronic device or system that compensates for the loss or impairment of a speech function due to a congenital condition, an acquired disability, or a progressive neurological disease. The term includes only that equipment used for the purpose of communication. Formerly known as "augmentative communication device (ACD)."

"Synthesized speech" - Is a technology that translates a user's input into device-generated speech using algorithms representing linguistic rules, unlike prerecorded messages of digitized speech. A SGD that has synthesized speech is not limited to prerecorded messages but rather can independently create messages as communication needs dictate.

"Three- or four-wheeled scooter" - A three- or four-wheeled vehicle meeting the definition of scooter (see "scooter") and which has the following minimum features:

(a) Rear drive;

(b) A 24 volt system;

(c) Electronic or dynamic braking;

(d) A high to low speed setting; and

(e) Tires designed for indoor/outdoor use.

"Trendelenburg position" - A position in which the patient is lying on his or her back on a plane inclined 30 to 40 degrees. This position makes the pelvis higher than the head, with the knees flexed and the legs and feet hanging down over the edge of the plane.

"Usual and customary charge" - See WAC 182-500-0110.

"Warranty-period" - A guarantee or assurance, according to manufacturers' or provider's guidelines, of set duration from the date of purchase.

"Wheelchair - Manual" - A federally approved, nonmotorized wheelchair that is capable of being independently propelled and fits one of the following categories:

(a) Standard:

(i) Usually is not capable of being modified;

(ii) Accommodates a person weighing up to 250 pounds; and

(iii) Has a warranty period of at least one year.

(b) Lightweight:

(i) Composed of lightweight materials;

(ii) Capable of being modified;

(iii) Accommodates a person weighing up to 250 pounds; and

(iv) Usually has a warranty period of at least three years.

(c) High-strength lightweight:

(i) Is usually made of a composite material;

(ii) Is capable of being modified;

(iii) Accommodates a person weighing up to 250 pounds;

(iv) Has an extended warranty period of over three years; and

(v) Accommodates the very active person.

(d) Hemi:

(i) Has a seat-to-floor height lower than 18 inches to enable an adult to propel the wheelchair with one or both feet; and

(ii) Is identified by its manufacturer as "Hemi" type with specific model numbers that include the "Hemi" description.

(e) Pediatric: Has a narrower seat and shorter depth more suited to pediatric patients, usually adaptable to modifications for a growing child.

(f) Recliner: Has an adjustable, reclining back to facilitate weight shifts and provide support to the upper body and head.

(g) Tilt-in-space: Has a positioning system, which allows both the seat and back to tilt to a specified angle to reduce shear or allow for unassisted pressure releases.

(h) Heavy duty:

(i) Specifically manufactured to support a person weighing up to 300 pounds; or

(ii) Accommodating a seat width of up to 22 inches wide (not to be confused with custom manufactured wheelchairs).

(i) Rigid: Is of ultra-lightweight material with a rigid (nonfolding) frame.

(j) Custom heavy duty:

(i) Specifically manufactured to support a person weighing over 300 pounds; or

(ii) Accommodates a seat width of over 22 inches wide (not to be confused with custom manufactured wheelchairs).

(k) Custom manufactured specially built:

(i) Ordered for a specific client from custom measurements; and

(ii) Is assembled primarily at the manufacturer's factory.

"Wheelchair - Power" - A federally approved, motorized wheelchair that can be independently driven by a client and fits one of the following categories:

(a) Custom power adaptable to:

(i) Alternative driving controls; and

(ii) Power recline and tilt-in-space systems.

(b) Noncustom power: Does not need special positioning or controls and has a standard frame.

(c) Pediatric: Has a narrower seat and shorter depth that is more suited to pediatric patients. Pediatric wheelchairs are usually adaptable to modifications for a growing child.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-18-019, § 182-543-1000, filed 8/23/24, effective 9/23/24. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-1000, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-1000, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-1000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-1000, filed 6/29/11, effective 8/1/11. Statutory Authority: RCW 74.08.090, 74.09.530. WSR 02-16-054, § 388-543-1000, filed 8/1/02, effective 9/1/02*
- *WSR 01-01-078, § 388-543-1000, filed 12/13/00, effective 1/13/01.*

##### **Wash. Admin. Code § 182-543-1100** Client eligibility. {#sec-182-543-1100 omnilex-key=us-wa-regs-official--title-182--182-543-1100}

(1) Refer to the table in WAC 182-501-0060 to see which Washington apple health programs include home health services, including medical equipment and related services, in their benefit package.

(2) For clients eligible under an alien emergency medical (AEM) program, see WAC 182-507-0115.

(3) Clients who are eligible for services under medicare and medicaid (medically needy program-qualified medicare beneficiaries) are eligible for medical equipment and related services.

(4) Clients who are enrolled in a medicaid agency-contracted managed care organization (MCO) must arrange for medical equipment and related services directly through the client's agency-contracted MCO. The agency does not pay for medical equipment or services provided to a client who is enrolled in an agency-contracted MCO, but chose not to use one of the MCO's participating providers.

(5) For clients who reside in a skilled nursing facility, see WAC 182-543-5700.

(6) Clients enrolled in the alternative benefits plan (defined in WAC 182-500-0010) are eligible for medical equipment when used as a habilitative service in accordance with WAC 182-545-400.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-03-072, § 182-543-1100, filed 1/10/20, effective 2/10/20. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-1100, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-1100, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-1100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-1100, filed 6/29/11, effective 8/1/11*
- *WSR 07-17-062, § 388-543-1100, filed 8/13/07, effective 9/13/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-543-1100, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.04.050, 74.04.57 [74.04.057], and 74.08.090. WSR 05-21-102, § 388-543-1100, filed 10/18/05, effective 11/18/05. Statutory Authority: RCW 74.08.090, 34.05.353. WSR 03-12-005, § 388-543-1100, filed 5/22/03, effective 6/22/03. Statutory Authority: RCW 74.08.090, 74.09.530. WSR 02-16-054, § 388-543-1100, filed 8/1/02, effective 9/1/02*
- *WSR 01-01-078, § 388-543-1100, filed 12/13/00, effective 1/13/01.*

##### **Wash. Admin. Code § 182-543-2000** Eligible providers and provider requirements. {#sec-182-543-2000 omnilex-key=us-wa-regs-official--title-182--182-543-2000}

(1) The medicaid agency pays, on a fee-for-service basis, providers (including providers who supply medical equipment and supplies in an outpatient clinical setting), pharmacies, and suppliers, for medical equipment, medical supplies, complex rehabilitation technology (CRT), and related repair services.

(a) Providers, pharmacies, and suppliers (including out-of-state providers, pharmacies, and suppliers) must:

(i) Be enrolled with medicare as a pharmacy, supplier of medical equipment, medical supplies, and related repair services, or as a CRT supplier (CRT suppliers must also comply with the requirements in WAC 182-543-4400); and

(ii) Possess a national provider identifier (NPI) for a pharmacy, supplier of medical equipment, medical supplies, and related repair services, or CRT supplier.

(b) Prosthetics and orthotics providers, and occupational therapists providing orthotics, must meet the licensing regulations of the state in which they practice.

(2) Providers and suppliers of medical equipment and supplies must:

(a) Meet the general provider requirements in chapter 182-502 WAC, except when the client is dual-eligible, medicare is the primary payer, and the agency is being billed only for one or more of the copay, coinsurance, or deductible;

(b) Have the proper business license and be certified, licensed and bonded if required, to perform the services billed to the agency;

(c) Have a valid prescription, which is referred to as a standard written order (SWO), for the medical equipment or supplies. A SWO is a written order communicated by the treating provider to the supplier that:

(i) Is written by an authorized practitioner as defined in WAC 182-551-2010 and meets the face-to-face encounter requirements described in WAC 182-551-2040;

(ii) Includes the following information:

(A) Client's full name;

(B) Order date, which is the date the order was written or electronically signed by the treating practitioner;

(C) General item description, which may be either a general description (for example, wheelchair or hospital bed), a HCPCS code, a HCPCS code narrative, or a brand name or model number;

(I) For equipment, in addition to the base item description, the SWO may include all concurrently ordered options, accessories, or additional features that are separately billed or require an upgraded code (list each separately);

(II) For supplies, in addition to the base item description, the order/prescription may include all concurrently ordered supplies that are separately billed (list each separately);

(D) If applicable, the quantity to be provided and the frequency of use;

(E) If applicable, the length of time the item is required; and

(F) The name, NPI, and signature of the treating practitioner, practitioner credentials, and the signature date.

(d) Provide instructions for use of equipment;

(e) Provide only new equipment to clients, which include full manufacturer and dealer warranties. See WAC 182-543-2250(3);

(f) Provide documentation of proof of delivery, upon agency request (see WAC 182-543-2200); and

(g) Bill the agency using only the allowed procedure codes that are listed in the agency's published billing guides.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-07-045, s 182-543-2000, filed 3/12/25, effective 5/1/25*
- *WSR 21-23-044, § 182-543-2000, filed 11/9/21, effective 12/10/21. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-2000, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-15-073, § 182-543-2000, filed 7/14/17, effective 8/14/17. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-2000, filed 3/25/14, effective 4/25/14. Statutory Authority: RCW 41.05.021 and Affordable Care Act (ACA) - 76 Fed. Reg. 5862, 42 C.F.R. Parts 405, 424, 447, 455, 457, and 498. WSR 12-15-015, § 182-543-2000, filed 7/10/12, effective 9/1/12. WSR 11-14-075, recodified as § 182-543-2000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-2000, filed 6/29/11, effective 8/1/11*
- *WSR 07-17-062, § 388-543-2000, filed 8/13/07, effective 9/13/07. Statutory Authority: RCW 74.08.090, 74.09.530. WSR 01-01-078, § 388-543-2000, filed 12/13/00, effective 1/13/01.*

##### **Wash. Admin. Code § 182-543-2100** Requests to include new medical equipment and technology. {#sec-182-543-2100 omnilex-key=us-wa-regs-official--title-182--182-543-2100}

(1) An interested party may request the medicaid agency to include new medical equipment in the agency's medical equipment billing guide.

(2) The request must include credible evidence, including but not limited to:

(a) Manufacturer's literature;

(b) Manufacturer's pricing;

(c) Clinical research/case studies (including FDA approval, if required);

(d) Proof of certification from the Centers for Medicare and Medicaid Services (CMS), if applicable; and

(e) Any additional information the requester feels would aid the agency in its determination.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-2100, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-2100, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-2100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-2100, filed 6/29/11, effective 8/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and Public Law 104-191. WSR 03-19-083, § 388-543-2100, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090, 74.09.530. WSR 01-01-078, § 388-543-2100, filed 12/13/00, effective 1/13/01.*

##### **Wash. Admin. Code § 182-543-2200** Proof of delivery. {#sec-182-543-2200 omnilex-key=us-wa-regs-official--title-182--182-543-2200}

(1) When a provider delivers an item directly to the client or the client's authorized representative, the provider must furnish the proof of delivery when the medicaid agency requests that information. All of the following apply:

(a) The agency requires a delivery slip as proof of delivery. The proof of delivery slip must:

(i) Include the client's name and a detailed description of the item(s) delivered, including the quantity and brand name; and

(ii) For medical equipment that may require future repairs, include the serial number.

(b) When the provider or supplier submits a claim for payment to the agency, the date of service on the claim must be one of the following:

(i) For a one-time delivery, the date the item was received by the client or the client's authorized representative; or

(ii) For nondurable medical supplies for which the agency has established a monthly maximum, on or after the date the item was received by the client or the client's authorized representative.

(2) When a provider uses a delivery/shipping service to deliver items which are not fitted to the client, the provider must furnish proof of delivery that the client received the equipment and/or supply, when the agency requests that information.

(a) If the provider uses a delivery/shipping service, the tracking slip is the proof of delivery. The tracking slip must include:

(i) The client's name or a reference to the client's package or packages;

(ii) The delivery service package identification number; and

(iii) The delivery address.

(b) If the provider/supplier does the delivering, the delivery slip is the proof of delivery. The delivery slip must include:

(i) The client's name;

(ii) The shipping service package identification number;

(iii) The quantity, detailed description(s), and brand name or names of the items being shipped; and

(iv) For medical equipment that may require future repairs, the serial number.

(c) When billing the agency, use:

(i) The shipping date as the date of service on the claim if the provider uses a delivery/shipping service; or

(ii) The actual date of delivery as the date of service on the claim if the provider/supplier does the delivery.

(3) A provider must not use a delivery/shipping service to deliver items which must be fitted to the client.

(4) Providers must obtain prior authorization when required before delivering the item to the client. The item must be delivered to the client before the provider bills the agency.

(5) The agency does not pay for medical equipment and related items furnished to the agency's clients when:

(a) The medical professional who provides medical justification to the agency for the item provided to the client is an employee of, has a contract with, or has any financial relationship with the provider of the item; or

(b) The medical professional who performs a client evaluation is an employee of, has a contract with, or has any financial relationship with a provider of medical equipment and related items.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-10-050, § 182-543-2200, filed 4/29/21, effective 5/30/21. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-2200, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-2200, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-2200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-2200, filed 6/29/11, effective 8/1/11. Statutory Authority: RCW 74.08.090, 74.09.530. WSR 02-16-054, § 388-543-2200, filed 8/1/02, effective 9/1/02*
- *WSR 01-01-078, § 388-543-2200, filed 12/13/00, effective 1/13/01.*

##### **Wash. Admin. Code § 182-543-2250** Rental or purchase. {#sec-182-543-2250 omnilex-key=us-wa-regs-official--title-182--182-543-2250}

(1) The medicaid agency bases its decision to rent or purchase medical equipment on the length of time the client needs the equipment.

(2) A provider must not bill the agency for the rental or purchase of equipment supplied to the provider at no cost by suppliers/manufacturers.

(3) The agency purchases new medical equipment only.

(a) A new medical equipment item that is placed with a client initially as a rental item is considered a new item by the agency at the time of purchase.

(b) A used medical equipment item that is placed with a client initially as a rental item must be replaced by the supplier with a new item prior to purchase by the agency.

(4) The agency requires a dispensing provider to ensure the medical equipment rented to a client is:

(a) In good working order; and

(b) Comparable to equipment the provider rents to individuals with similar medical equipment needs who are either private pay or who have other third-party coverage.

(5) The agency's minimum rental period for covered medical equipment is one day.

(6) The agency authorizes rental equipment for a specific period of time. The provider must request authorization from the agency for any extension of the rental period.

(7) The agency's reimbursement amount for rented medical equipment includes all of the following:

(a) Delivery to the client;

(b) Fitting, set-up, and adjustments;

(c) Maintenance, repair and/or replacement of the equipment; and

(d) Return pickup by the provider.

(8) The agency considers rented equipment to be purchased after twelve months' rental unless the equipment is restricted as rental only.

(9) Medical equipment purchased by the agency for a client is the client's property.

(10) The agency rents, but does not purchase, certain medical equipment for clients. This includes, but is not limited to, the following:

(a) Bilirubin lights for newborns with jaundice in any setting where normal life activities take place; and

(b) Electric hospital-grade breast pumps.

(11) The agency stops paying for any rented medical equipment effective the date of a client's death. The agency prorates monthly rentals as appropriate.

(12) For a client who is eligible for both medicare and medicaid, the agency only pays the client's coinsurance and deductibles when the medical equipment is covered by medicare. The agency discontinues paying client's coinsurance and deductibles for rental medical equipment covered by medicare when either of the following applies:

(a) The reimbursement amount reaches medicare's reimbursement cap for the medical equipment; or

(b) Medicare considers the medical equipment purchased.

(13) The agency does not obtain or pay for insurance coverage against liability, loss and/or damage to rental equipment that a provider supplies to a client.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-2250, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-2250, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-2250, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-2250, filed 6/29/11, effective 8/1/11.*

##### **Wash. Admin. Code § 182-543-3000** Covered—Hospital beds, mattresses, and related equipment. {#sec-182-543-3000 omnilex-key=us-wa-regs-official--title-182--182-543-3000}

(1) Hospital beds.

(a) The medicaid agency covers, with prior authorization, one hospital bed in a ten-year period, per client, with the following limitations:

(i) A manual hospital bed as the primary option when the client has full-time caregivers; or

(ii) A semi-electric hospital bed only when:

(A) The client's medical need requires the client to be positioned in a way that is not possible in a regular bed and the position cannot be attained through less costly alternatives (e.g., the use of bedside rails, a trapeze, pillows, bolsters, rolled up towels or blankets);

(B) The client's medical condition requires immediate position changes;

(C) The client is able to operate the controls independently; and

(D) The client needs to be in the Trendelenburg position.

(b) The agency bases the decision to rent or purchase a manual or semi-electric hospital bed on the length of time the client needs the bed.

(c) Rental - The agency pays up to eleven months continuous rental of a hospital bed in a twelve-month period as follows:

(i) A manual hospital bed with mattress, with or without bed rails. The client must meet all of the following clinical criteria:

(A) Has a length of need/life expectancy that is twelve months or less;

(B) Has a medical condition that requires positioning of the body that cannot be accomplished in a standard bed (reason must be documented in the client's file);

(C) Has tried pillows, bolsters, and/or rolled up blankets/towels in client's own bed, and these have been determined to not be effective in meeting the client's positioning needs (nature of ineffectiveness must be documented in the client's file);

(D) Has a medical condition that necessitates upper body positioning at no less than a thirty-degree angle the majority of time the client is in the bed;

(E) Does not have full-time caregivers; and

(F) Does not also have a rental wheelchair.

(ii) A semi-electric hospital bed with mattress, with or without bed rails. The client must meet all of the following clinical criteria:

(A) Has a length of need/life expectancy that is twelve months or less;

(B) Has tried pillows, bolsters, and/or rolled up blankets/towels in own bed, and these have been determined to be ineffective in meeting positioning needs (nature of ineffectiveness must be documented in the client's file);

(C) Has a chronic or terminal condition such as chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), lung cancer or cancer that has metastasized to the lungs, or other pulmonary conditions that cause the need for immediate upper body elevation;

(D) Must be able to independently and safely operate the bed controls; and

(E) Does not have a rental wheelchair.

(d) Purchase - The agency pays, with prior authorization, for the initial purchase of a semi-electric hospital bed with mattress, with or without bed rails, when the following criteria are met:

(i) The client:

(A) Has a length of need/life expectancy that is twelve months or more;

(B) Has tried positioning devices such as pillows, bolsters, foam wedges, and/or rolled up blankets/towels in own bed, and these have been determined to be ineffective in meeting positioning needs (nature of ineffectiveness must be documented in the client's file);

(C) Must be able to independently and safely operate the bed controls; and

(D) Is diagnosed:

(I) With quadriplegia;

(II) With tetraplegia;

(III) With duchenne muscular dystrophy;

(IV) With amyotrophic lateral sclerosis (ALS), often referred to as "Lou Gehrig's Disease";

(V) As ventilator-dependent; or

(VI) With COPD or CHF with aspiration risk or shortness of breath that causes the need for an immediate change of upper body positioning of more than thirty degrees.

(ii) Requests for prior authorization must be submitted in writing to the agency and be accompanied by:

(A) A completed General Information for Authorization form (HCA 13-835) and Hospital Bed Evaluation form (HCA 13-747). The agency's electronic forms are available online (see WAC 182-543-7000, Authorization);

(B) Documentation of the client's life expectancy, in months and/or years, the client's diagnosis, the client's date of delivery and serial number of the hospital bed; and

(C) Be accompanied by written documentation, from the client or caregiver, indicating the client has not been previously provided a hospital bed, purchase or rental.

(2) Mattresses and related equipment - The agency pays, with prior authorization, for the following:

(a) Pressure pad, alternating with pump - One in a five-year period;

(b) Dry pressure mattress - One in a five-year period;

(c) Gel or gel-like pressure pad for mattress - One in a five-year period;

(d) Gel pressure mattress - One in a five-year period;

(e) Water pressure pad for mattress - One in a five-year period;

(f) Dry pressure pad for mattress - One in a five-year period;

(g) Mattress, inner spring - One in a five-year period; and

(h) Mattress, foam rubber - One in a five-year period.

**History**
- *Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-3000, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-3000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-3000, filed 6/29/11, effective 8/1/11. Statutory Authority: RCW 74.08.090, 74.09.530. WSR 01-01-078, § 388-543-3000, filed 12/13/00, effective 1/13/01.*

##### **Wash. Admin. Code § 182-543-3100** Patient lifts/traction, equipment/fracture, and frames/transfer boards. {#sec-182-543-3100 omnilex-key=us-wa-regs-official--title-182--182-543-3100}

The medicaid agency covers the purchase of the following, with the stated limitations, without prior authorization:

(1) Patient lift, hydraulic, with seat or sling - One per client in a five-year period.

(2) Traction equipment - One per client in a five-year period.

(3) Trapeze bars - One per client in a five-year period. The agency requires prior authorization for rental.

(4) Fracture frames - One per client in a five-year period. The agency requires prior authorization for rental.

(5) Transfer board or devices - One per client in a five-year period.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-3100, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-3100, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-3100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-3100, filed 6/29/11, effective 8/1/11.*

##### **Wash. Admin. Code § 182-543-3300** Covered—Osteogenesis electrical stimulator (bone growth stimulator)—Noninvasive. {#sec-182-543-3300 omnilex-key=us-wa-regs-official--title-182--182-543-3300}

(1) The medicaid agency covers, with prior authorization, noninvasive osteogenesis electrical stimulators, also known as bone growth stimulators, limited to one per client, in a five-year period.

(2) The agency pays for the purchase of nonspinal bone growth stimulators, only when:

(a) The stimulators have pulsed electromagnetic field (PEMF) stimulation; and

(b) The client meets one or more of the following clinical criteria:

(i) Has a nonunion of a long bone fracture (which includes clavicle, humerus, phalanx, radius, ulna, femur, tibia, fibula, metacarpal and metatarsal) where three months have elapsed since the date of injury without healing; or

(ii) Has a failed fusion of a joint, other than in the spine, where a minimum of nine months has elapsed since the last surgery; or

(iii) Diagnosed with congenital pseudarthrosis.

(3) The agency pays for the purchase of spinal bone growth stimulators, when:

(a) Prescribed by a neurologist, an orthopedic surgeon, or a neurosurgeon; and

(b) The client meets one or more of the following clinical criteria:

(i) Has a failed spinal fusion where a minimum of nine months has elapsed since the last surgery; or

(ii) Is post-op from a multilevel spinal fusion surgery; or

(iii) Is post-op from spinal fusion surgery and there is a history of a previously failed spinal fusion.

(4) The agency pays for the purchase of ultrasonic noninvasive bone growth stimulators when:

(a) Prescribed by a neurologist, an orthopedic surgeon, or a neurosurgeon; and

(b) The client meets all the following clinical criteria:

(i) Nonunion confirmed by two radiographs minimum 90 days apart; and

(ii) Physician statement of no clinical evidence of fracture healing.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-17-001, § 182-543-3300, filed 8/8/24, effective 9/8/24. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-3300, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-3300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-3300, filed 6/29/11, effective 8/1/11.*

##### **Wash. Admin. Code § 182-543-3400** Covered—Communication devices/speech generating devices (SGD). {#sec-182-543-3400 omnilex-key=us-wa-regs-official--title-182--182-543-3400}

(1) The medicaid agency covers:

(a) One artificial larynx, any type, without prior authorization, per client in a five-year period; and

(b) One speech generating device (SGD), with prior authorization, per client every two years.

(2) The agency pays only for those approved SGDs that have:

(a) Digitized speech output, using prerecorded messages;

(b) Synthesized speech output requiring message formation by spelling and access by physical contact with the device; or

(c) Synthesized speech output, permitting multiple methods of message formulation and multiple methods of device access.

(3) The agency requires prior authorization for SGDs and reviews requests on a case-by-case basis. Requests to the agency for prior authorization must meet all of the following:

(a) The client must have a severe expressive speech impairment and the client's medical condition warrants the use of a device to replace verbal communication (e.g., to communicate medical information); and

(b) The request must be in writing and be accompanied by:

(i) A completed General Information for Authorization form (HCA 13-835). The agency's electronic forms are available online (see WAC 182-543-7000, Authorization); and

(ii) A completed Speech Language Pathologist (SLP) Evaluation for Speech Generating Devices (15-310) form. The agency requires, at a minimum, the following information:

(A) A detailed description of the client's therapeutic history;

(B) A written assessment by a licensed SLP; and

(C) Documentation of all of the following:

(I) The client has reliable and consistent motor response, which can be used to communicate with the help of an SGD;

(II) The client has demonstrated the cognitive and physical abilities to utilize the equipment effectively and independently to communicate; and

(III) The client's treatment plan includes a training schedule for the selected device.

(iii) A copy of the prescription for the SGD from the client's treating physician written on an agency Prescription Form (HCA 13-794) (see WAC 182-543-2000(2)).

(4) The agency may require trial-use rental of a SGD. The agency applies the rental costs for the trial-use to the purchase price.

(5) The agency pays for the repair or modification of an SGD when all of the following are met:

(a) All warranties are expired;

(b) The cost of the repair or modification is less than fifty percent of the cost of a new SGD and the provider has submitted supporting documentation; and

(c) The repair has a warranty for a minimum of ninety days.

(6) The agency does not pay for devices requested for the purpose of education.

(7) The agency pays for replacement batteries for a SGD in accordance with WAC 182-543-5500(3). The agency does not pay for back-up batteries for an SGD.

(8) Clients who are eligible for both medicare and medicaid must apply first to medicare for an SGD. If medicare denies the request and the client requests an SGD from the agency, the agency evaluates the request according to the rules of this section.

**History**
- *Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-3400, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-3400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-3400, filed 6/29/11, effective 8/1/11.*

##### **Wash. Admin. Code § 182-543-3500** Covered—Ambulatory aids (canes, crutches, walkers, related supplies). {#sec-182-543-3500 omnilex-key=us-wa-regs-official--title-182--182-543-3500}

(1) The medicaid agency covers the purchase of the following ambulatory aids with stated limitations, without prior authorization:

(a) Canes - One per client in a five-year period.

(b) Crutches - One per client in a five-year period.

(c) Walkers - One per client in a five-year period.

(2) The agency pays for replacement underarm pads for crutches and replacement handgrips and tips for canes, crutches, and walkers. Prior authorization is not required.

**History**
- *Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-3500, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-3500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-3500, filed 6/29/11, effective 8/1/11.*

##### **Wash. Admin. Code § 182-543-4000** Covered—Wheelchairs—General. {#sec-182-543-4000 omnilex-key=us-wa-regs-official--title-182--182-543-4000}

(1) The medicaid agency covers, with prior authorization, manual and power-drive wheelchairs for clients who reside at home. For clients who reside in a skilled nursing facility, see WAC 182-543-5700.

(2) For manual or power-drive wheelchairs for clients who reside at home, requests for prior authorization must include all of the following completed forms:

(a) General Information for Authorization form (HCA 13-835). The agency's electronic forms are available online (see WAC 182-543-7000, Authorization);

(b) A Prescription Form (HCA 13-794); and

(c) Medical Necessity for Wheelchair Purchase (for home clients only) form (HCA 13-727) from the client's physician or therapist. The date on this form (HCA 13-727) must not be prior to the date on the Prescription Form (HCA 13-794).

(3) The agency does not pay for manual or power-drive wheelchairs that have been delivered to a client without prior authorization from the agency.

(4) When the agency determines that a wheelchair is medically necessary, according to the process found in WAC 182-501-0165, the agency rents or purchases a wheelchair for clients who live at home. For clients who reside in a skilled nursing facility, see WAC 182-543-5700.

**History**
- *Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-4000, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-4000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-4000, filed 6/29/11, effective 8/1/11.*

##### **Wash. Admin. Code § 182-543-4100** Covered—Wheelchairs—Manual. {#sec-182-543-4100 omnilex-key=us-wa-regs-official--title-182--182-543-4100}

The medicaid agency covers the rental or purchase of a manual wheelchair for a home client who is nonambulatory or has limited mobility and requires a wheelchair to participate in normal daily activities. For clients who reside in a skilled nursing facility, see WAC 182-543-5700.

(1) The agency determines the type of manual wheelchair for a home client as follows:

(a) A standard wheelchair if the client's medical condition requires the client to have a wheelchair to participate in normal daily activities;

(b) A standard lightweight wheelchair if the client's medical condition is such that the client:

(i) Cannot self-propel a standard weight wheelchair; or

(ii) Requires custom modifications that cannot be provided on a standard weight wheelchair.

(c) A high-strength, lightweight wheelchair for a client:

(i) Whose medical condition is such that the client cannot self-propel a lightweight or standard weight wheelchair; or

(ii) Requires custom modifications that cannot be provided on a standard weight or lightweight wheelchair.

(d) A heavy duty wheelchair for a client who requires a specifically manufactured wheelchair designed to:

(i) Support a person weighing three hundred pounds or over; or

(ii) Accommodate a seat width up to twenty-two inches wide (not to be confused with custom heavy duty wheelchairs).

(e) A custom heavy duty wheelchair for a client who requires a specifically manufactured wheelchair designed to:

(i) Support a person weighing three hundred pounds or over; or

(ii) Accommodate a seat width over twenty-two inches wide.

(f) A rigid wheelchair for a client:

(i) With a medical condition that involves severe upper extremity weakness;

(ii) Who has a high level of activity; and

(iii) Who is unable to self-propel any of the above categories of wheelchair.

(g) A custom manufactured wheelchair for a client with a medical condition requiring wheelchair customization that cannot be obtained on any of the categories of wheelchairs listed in this section.

(h) Pediatric wheelchairs/positioning strollers having a narrower seat and shorter depths more suited to pediatric patients, usually adaptable to modifications for a growing child.

(2) The agency pays for both a manual wheelchair and a power-drive wheelchair only for noninstitutionalized clients in limited circumstances. See WAC 182-543-4200(5).

**History**
- *Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-4100, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-4100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-4100, filed 6/29/11, effective 8/1/11.*

##### **Wash. Admin. Code § 182-543-4200** Covered wheelchairs—Power-drive. {#sec-182-543-4200 omnilex-key=us-wa-regs-official--title-182--182-543-4200}

The medicaid agency pays for medically necessary power-drive wheelchairs when prior authorized.

(1) Adults. The medicaid agency pays for power-drive wheelchairs for clients age twenty-one and older when the prescribing physician certifies that the following clinical criteria are met:

(a) The client can independently and safely operate a power-drive wheelchair;

(b) The client's medical condition prevents the client from self-propelling any of the wheelchairs listed in the manual wheelchair category; and

(c) A power-drive wheelchair will provide the client the only means of independent mobility in any of the settings where the client's normal life activities take place.

The agency also pays for power wheelchairs on a case-by-case basis that are determined medically necessary and when prior authorized as described in WAC 182-501-0165. The agency determines medical necessity based on documentation submitted by the provider.

(2) Children. The agency reviews all requests for power wheelchairs for a person age twenty and younger using the standard for coverage under the EPSDT program according to the provisions of chapter 182-534 WAC. The agency determines medical necessity based on documentation submitted by the provider.

(3) Three or four wheeled power-drive scooters/power-operated vehicles (POV). Additionally, for a three or four-wheeled power-drive scooter/power-operated vehicle (POV) for an adult, the prescribing physician must certify the client's condition is unlikely to require a standard power-drive wheelchair within the next two years.

(4) Client's primary wheelchair. When the agency approves a power-drive wheelchair for a client who already has a manual wheelchair, the power-drive wheelchair becomes the client's primary chair, unless the client meets the criteria in subsection (6) of this section.

(5) Payment for primary wheelchair. The agency pays to maintain only the client's primary wheelchair, unless the conditions of subsection (7) of this section apply.

(6) Approval for more than one wheelchair. The agency pays for one manual wheelchair and one power-drive wheelchair for noninstitutionalized clients when medically necessary for the client to have mobility in all settings where the client's normal life activities take place. Situations that demonstrate medical necessity include, but are not limited to, the following:

(a) The architecture of locations where the client's normal life activities take place are completely unsuitable for a power-drive wheelchair, due to conditions such as narrow hallways, narrow doorways, steps at the entryway, and insufficient turning radius;

(b) The architecture of the bathroom in locations where the client's normal life activities take place is such that power-drive wheelchair access is not possible, and the client needs a manual wheelchair to safely and successfully complete bathroom activities and maintain personal cleanliness; or

(c) The client has a power-drive wheelchair, but also requires a manual wheelchair because the power-drive wheelchair cannot be transported to meet the client's community, workplace, or educational activities. In this case, the manual wheelchair would allow the caregiver to transport the client in a standard automobile or van. The agency requires the client's situation to meet the following conditions:

(i) The client's activities that require the second wheelchair must be located farther than one-fourth of a mile from the client's home or along a pathway that does not provide for safe use of a power wheelchair; and

(ii) Cabulance, public buses, or personal transit are not available, practical, or possible for financial or other reasons.

(7) Payment for more than one wheelchair. When the agency approves both a manual wheelchair and a power-drive wheelchair for a noninstitutionalized client, the agency pays to maintain both wheelchairs.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-03-072, § 182-543-4200, filed 1/10/20, effective 2/10/20. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-4200, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-4200, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-4200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-4200, filed 6/29/11, effective 8/1/11.*

##### **Wash. Admin. Code § 182-543-4300** Wheelchairs—Modifications, accessories, and repairs. {#sec-182-543-4300 omnilex-key=us-wa-regs-official--title-182--182-543-4300}

(1) The medicaid agency pays for, with prior authorization, wheelchair accessories and modifications that are specifically identified by the manufacturer as separate line item charges. To receive payment, providers must submit the following to the agency:

(a) A completed General Information for Authorization form (HCA 13-835). The agency's electronic forms are available online (see WAC 182-543-7000, Authorization);

(b) A completed Prescription Form (HCA 13-794);

(c) A completed Medical Necessity for Wheelchair Purchase (for home clients only) form (HCA 13-727). The date on this form (HCA 13-727) must not be dated prior to the date on the Prescription Form (HCA 13-794);

(d) The make, model, and serial number of the wheelchair to be modified;

(e) The modification requested; and

(f) Any specific information regarding the client's medical condition that necessitates the modification.

(2) The agency pays for transit option restraints only when used for client-owned vehicles.

(3) The agency pays for, with prior authorization, wheelchair repairs. To receive payment, providers must submit the following to the agency:

(a) General Information for Authorization form (HCA 13-835). The agency's electronic forms are available online (see WAC 182-543-7000);

(b) A completed Medical Necessity for Wheelchair Purchase form (for home clients only) (HCA 13-727);

(c) The make, model, and serial number of the wheelchair to be repaired; and

(d) The repair requested.

(4) Prior authorization is required for the repair and modification of client-owned equipment.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-4300, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-4300, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-4300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-4300, filed 6/29/11, effective 8/1/11.*

##### **Wash. Admin. Code § 182-543-4400** Complex rehabilitation technology. {#sec-182-543-4400 omnilex-key=us-wa-regs-official--title-182--182-543-4400}

(1) The medicaid agency pays for, with prior authorization, individually configured, complex rehabilitation technology (CRT) products.

(2) CRT must be supplied by a CRT supplier with the appropriate taxonomy number to bill for the items.

(3) Each site that a company operates must employ at least one CRT professional who has been certified by the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA).

(4) The client must be evaluated by a licensed health care provider who performs specialty evaluations within their scope of practice (occupational or physical therapists) and who does not have a financial relationship with the supplier.

(a) At the evaluation, a CRT professional must also be present from the company ordering the equipment; or

(b) The CRT provider must be present at the evaluation to:

(i) Assist in selection of the appropriate CRT item(s); and

(ii) Provide training in the use of the selected items.

(5) The CRT provider must:

(a) Provide service and repairs by qualified technicians for all CRT products it sells; and

(b) Provide written information to the client at the time of delivery as to how the client may receive services and repairs.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-4400, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-4400, filed 3/25/14, effective 4/25/14.*

##### **Wash. Admin. Code § 182-543-5000** Prosthetics/orthotics. {#sec-182-543-5000 omnilex-key=us-wa-regs-official--title-182--182-543-5000}

(1) The medicaid agency pays for, without prior authorization (PA), the following prosthetics and orthotics. Items that meet the definition of medical equipment may be covered under the requirements for medical equipment. Prosthetics and orthotics that do not meet those definitions are covered, with stated limitations:

(a) Thoracic-hip-knee-ankle orthosis (THKAO) standing frame - One every five years.

(b) Preparatory, above knee "PTB" type socket, nonalignable system, pylon, no cover, SACH foot plaster socket, molded to model - One per lifetime, per limb.

(c) Preparatory, below knee "PTB" type socket, nonalignable system, pylon, no cover, SACH foot thermoplastic or equal, direct formed - One per lifetime, per limb.

(d) Socket replacement, below the knee, molded to patient model - One per twelve-month period, per limb.

(e) Socket replacement, above the knee/knee disarticulation, including attachment plate, molded to patient model - One per twelve-month period, per limb.

(f) All other prosthetics and orthotics are limited to one per twelve-month period per limb.

(g) Prosthetics and orthotics beyond these limits may be prior authorized when medically necessary, as defined in WAC 182-500-0070.

(2) The agency pays only licensed prosthetic and orthotic providers to supply prosthetics and orthotics. This licensure requirement does not apply to the following:

(a) Providers who are not required to have specialized skills to provide select orthotics, but meet medical equipment and pharmacy provider licensure requirements;

(b) Occupational therapists providing orthotics who are licensed by the Washington state department of health in occupational therapy; and

(c) Out-of-state providers, who must meet the licensure requirements of that state.

(3) The agency pays only for prosthetics or orthotics that are listed as such by the Centers for Medicare and Medicaid Services (CMS), that meet the definition of prosthetic or orthotic in WAC 182-543-1000 and are prescribed under WAC 182-543-1100.

(4) The agency pays for repair or modification of a client's current prosthesis. To receive payment, all of the following must be met:

(a) All warranties are expired;

(b) The cost of the repair or modification is less than fifty percent of the cost of a new prosthesis and the provider has submitted supporting documentation; and

(c) The repair must have a warranty for a minimum of ninety days.

(5) Clients are responsible for routine maintenance of their prosthetic or orthotic. If a client does not have the physical or mental ability to perform this task, the client's caregiver is responsible for routine maintenance of the prosthetic or orthotic. The agency requires PA for extensive maintenance to a prosthetic or orthotic.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-5000, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-15-073, § 182-543-5000, filed 7/14/17, effective 8/14/17. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-5000, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-5000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-5000, filed 6/29/11, effective 8/1/11.*

##### **Wash. Admin. Code § 182-543-5500** Medical supplies and related services. {#sec-182-543-5500 omnilex-key=us-wa-regs-official--title-182--182-543-5500}

The medicaid agency pays for the following medical supplies and related services without prior authorization unless otherwise specified:

(1) Antiseptics and germicides:

(a) Alcohol (isopropyl) or peroxide (hydrogen) - One pint per month;

(b) Alcohol wipes (box of two hundred) - One box per month;

(c) Betadine or pHisoHex solution - One pint per month;

(d) Betadine or iodine swabs/wipes (box of one hundred) - One box per month;

(2) Bandages, dressings, and tapes;

(3) Batteries - Replacement batteries:

(a) The agency pays for the purchase of replacement batteries for wheelchairs with prior authorization.

(b) The agency does not pay for wheelchair replacement batteries that are used for speech generating devices (SGDs) or ventilators.

(4) Blood monitoring/testing supplies:

(a) Replacement battery of any type, used with a client-owned, medically necessary or specialized blood glucose monitor - One in a three-month period;

(b) Spring-powered device for lancet - One in a six-month period;

(c) Diabetic test strips as follows:

(i) For clients age twenty and younger, as follows:

(A) Insulin dependent, three hundred test strips and three hundred lancets per client, per month.

(B) For noninsulin dependent, one hundred test strips and one hundred lancets per client, per month.

(ii) For clients age twenty-one and older:

(A) Insulin dependent, one hundred test strips and one hundred lancets per client, per month.

(B) For noninsulin dependent, one hundred test strips and one hundred lancets per client, every three months.

(iii) For pregnant people with gestational diabetes, the agency pays for the quantity necessary to support testing as directed by the client's physician, up to sixty days postpartum.

(d) See WAC 182-543-5500(12) for blood glucose monitors.

(5) Braces, belts, and supportive devices:

(a) Knee brace (neoprene, nylon, elastic, or with a hinged bar) - Two per twelve-month period;

(b) Ankle, elbow, or wrist brace - Two per twelve-month period;

(c) Lumbosacral brace, rib belt, or hernia belt - One per twelve-month period;

(d) Cervical head harness/halter, cervical pillow, pelvic belt/harness/boot, or extremity belt/harness - One per twelve-month period.

(6) Decubitus care products:

(a) Cushion (gel, sacroiliac, or accuback) and cushion cover (any size) - One per twelve-month period;

(b) Synthetic or lamb's wool sheepskin pad - One per twelve-month period;

(c) Heel or elbow protectors - Four per twelve-month period.

(7) Ostomy supplies:

(a) Adhesive for ostomy or catheter: Cement; powder; liquid (e.g., spray or brush); or paste (any composition, e.g., silicone or latex) - Four total ounces per month.

(b) Adhesive or nonadhesive disc or foam pad for ostomy pouches - Ten per month.

(c) Adhesive remover or solvent - Three ounces per month.

(d) Adhesive remover wipes, fifty per box - One box per month.

(e) Closed pouch, with or without attached barrier, with a one- or two-piece flange, or for use on a faceplate - Sixty per month.

(f) Closed ostomy pouch with attached standard wear barrier, with built-in one-piece convexity - Ten per month.

(g) Continent plug for continent stoma - Thirty per month.

(h) Continent device for continent stoma - One per month.

(i) Drainable ostomy pouch, with or without attached barrier, or with one- or two-piece flange - Twenty per month.

(j) Drainable ostomy pouch with attached standard or extended wear barrier, with or without built-in one-piece convexity - Twenty per month.

(k) Drainable ostomy pouch for use on a plastic or rubber faceplate (only one type of faceplate allowed) - Ten per month.

(l) Drainable urinary pouch for use on a plastic, heavy plastic, or rubber faceplate (only one type of faceplate allowed) - Ten per month.

(m) Irrigation bag - Two every six months.

(n) Irrigation cone and catheter, including brush - Two every six months.

(o) Irrigation supply, sleeve - One per month.

(p) Ostomy belt (adjustable) for appliance - Two every six months.

(q) Ostomy convex insert - Ten per month.

(r) Ostomy ring - Ten per month.

(s) Stoma cap - Thirty per month.

(t) Ostomy faceplate - Ten per month. The agency does not pay for either of the following when billed in combination with an ostomy faceplate:

(i) Drainable pouches with plastic face plate attached; or

(ii) Drainable pouches with rubber face plate.

(8) Syringes and needles;

(9) Urological supplies - Diapers and related supplies:

(a) The standards and specifications in this subsection apply to all disposable incontinent products (e.g., briefs, diapers, pull-up pants, underpads for beds, liners, shields, guards, pads, and undergarments). See subsections (b), (c), (d), and (e) of this section for additional standards for specific products. All of the following apply to all disposable incontinent products:

(i) All materials used in the construction of the product must be safe for the client's skin and harmless if ingested;

(ii) Adhesives and glues used in the construction of the product must not be water-soluble and must form continuous seals at the edges of the absorbent core to minimize leakage;

(iii) The padding must provide uniform protection;

(iv) The product must be hypoallergenic;

(v) The product must meet the flammability requirements of both federal law and industry standards; and

(vi) All products are covered for client personal use only.

(b) In addition to the standards in subsection (a) of this section, diapers must meet all the following specifications. They must:

(i) Be hourglass shaped with formed leg contours;

(ii) Have an absorbent filler core that is at least one-half inch from the elastic leg gathers;

(iii) Have leg gathers that consist of at least three strands of elasticized materials;

(iv) Have an absorbent core that consists of cellulose fibers mixed with absorbent gelling materials;

(v) Have a back sheet that is moisture impervious and is at least 1.00 mm thick, designed to protect clothing and linens;

(vi) Have a top sheet that resists moisture returning to the skin;

(vii) Have an inner lining that is made of soft, absorbent material; and

(viii) Have either a continuous waistband, or side panels with a tear-away feature, or refastenable tapes, as follows:

(A) For child diapers, at least two tapes, one on each side.

(B) The tape adhesive must release from the back sheet without tearing it, and permit a minimum of three fastening/unfastening cycles.

(c) In addition to the standards in subsection (a) of this section, pull-up pants and briefs must meet the following specifications. They must:

(i) Be made like regular underwear with an elastic waist or have at least four tapes, two on each side or two large tapes, one on each side;

(ii) Have an absorbent core filler that is at least one-half inch from the elastic leg gathers;

(iii) Have an absorbent core that consists of cellulose fibers mixed with absorbent gelling;

(iv) Have leg gathers that consist of at least three strands of elasticized materials;

(v) Have a back sheet that is moisture impervious, is at least 1.00 mm thick, and is designed to protect clothing and linens;

(vi) Have an inner lining made of soft, absorbent material; and

(vii) Have a top sheet that resists moisture returning to the skin.

(d) In addition to the standards in subsection (a) of this section, underpads are covered only for incontinent purposes in a client's bed and must meet the following specifications:

(i) Have an absorbent layer that is at least one and one-half inches from the edge of the underpad;

(ii) Be manufactured with a waterproof backing material;

(iii) Be able to withstand temperatures not to exceed one hundred-forty degrees Fahrenheit;

(iv) Have a covering or facing sheet that is made of nonwoven, porous materials that have a high degree of permeability, allowing fluids to pass through and into the absorbent filler. The patient contact surface must be soft and durable;

(v) Have filler material that is highly absorbent. It must be heavy weight fluff filler or the equivalent; and

(vi) Have four-ply, nonwoven facing, sealed on all four sides.

(e) In addition to the standards in subsection (a) of this section, liners, shields, guards, pads, and undergarments are covered for incontinence only and must meet the following specifications:

(i) Have channels to direct fluid throughout the absorbent area, and leg gathers to assist in controlling leakage, and/or be contoured to permit a more comfortable fit;

(ii) Have a waterproof backing designed to protect clothing and linens;

(iii) Have an inner liner that resists moisture returning to the skin;

(iv) Have an absorbent core that consists of cellulose fibers mixed with absorbent gelling materials;

(v) Have pressure-sensitive tapes on the reverse side to fasten to underwear; and

(vi) For undergarments only, be contoured for good fit, have at least three elastic leg gathers, and may be belted or unbelted.

(f) The agency pays for urological products when they are used alone. The following are examples of products the agency does not pay for when used in combination with each other:

(i) Disposable diapers;

(ii) Disposable pull-up pants and briefs;

(iii) Disposable liners, shields, guards, pads, and undergarments;

(iv) Rented reusable diapers (e.g., from a diaper service); and

(v) Rented reusable briefs (e.g., from a diaper service), or pull-up pants.

(g) The agency approves a client's use of a combination of products only when the client uses different products for daytime and nighttime use. Example: pull-up pants for daytime use and disposable diapers for nighttime use. The total quantity of all products in this section used in combination cannot exceed the monthly limitation for the product with the highest limit.

(h) Purchased disposable diapers (any size) are limited to two hundred per month for clients age three and older.

(i) Reusable cloth diapers (any size) are limited to:

(i) Purchased - Thirty-six per year; and

(ii) Rented - Two hundred per month.

(j) Disposable briefs and pull-up pants (any size) are limited to:

(i) Two hundred per month for a client age three through age eighteen; and

(ii) One hundred fifty per month for a client age nineteen and older.

(k) Reusable briefs, washable protective underwear, or pull-up pants (any size) are limited to:

(i) Purchased - Four per year.

(ii) Rented - One hundred fifty per month.

(l) Disposable pant liners, shields, guards, pads, and undergarments are limited to two hundred per month.

(m) Underpads for beds are limited to:

(i) Disposable (any size) - One hundred eighty per month.

(ii) Purchased, reusable (large) - Forty-two per year.

(iii) Rented, reusable (large) - Ninety per month.

(10) Urological supplies - Urinary retention:

(a) Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube - Two per month. The agency does not pay for these when billed in combination with any of the following:

(i) With extension drainage tubing for use with urinary leg bag or urostomy pouch (any type, any length), with connector/adapter; and/or

(ii) With an insertion tray with drainage bag, and with or without catheter.

(b) Bedside drainage bottle, with or without tubing - Two per six month period.

(c) Extension drainage tubing (any type, any length), with connector/adapter, for use with urinary leg bag or urostomy pouch. The agency does not pay for these when billed in combination with a vinyl urinary leg bag, with or without tube.

(d) External urethral clamp or compression device (not be used for catheter clamp) - Two per twelve-month period.

(e) Indwelling catheters (any type) - Three per month.

(f) Insertion trays:

(i) Without drainage bag and catheter - One hundred and twenty per month. The agency does not pay for these when billed in combination with other insertion trays that include drainage bag, catheters, and/or individual lubricant packets.

(ii) With indwelling catheters - Three per month. The agency does not pay for these when billed in combination with other insertion trays without drainage bag and/or indwelling catheter, individual indwelling catheters, and/or individual lubricant packets.

(g) Intermittent urinary catheter - One hundred twenty per month. The agency does not pay for these when billed in combination with an insertion tray with or without drainage bag and catheter, or other individual intermittent urinary catheters.

(h) Irrigation syringe (bulb or piston). The agency does not pay for these when billed in combination with irrigation tray or tubing.

(i) Irrigation tray with syringe (bulb or piston) - Thirty per month. The agency does not pay for these when billed in combination with irrigation syringe (bulb or piston), or irrigation tubing set.

(j) Irrigation tubing set - Thirty per month. The agency does not pay for these when billed in combination with an irrigation tray or irrigation syringe (bulb or piston).

(k) Leg straps (latex foam and fabric), replacement only.

(l) Male external catheter, specialty type, or with adhesive coating or adhesive strip - Sixty per month.

(m) Urinary suspensory with leg bag, with or without tube - Two per month. The agency does not pay for these when billed in combination with a latex urinary leg bag, urinary suspensory without leg bag, extension drainage tubing, or a leg strap.

(n) Urinary suspensory without leg bag, with or without tube - Two per month.

(o) Urinary leg bag, vinyl, with or without tube - Two per month. The agency does not pay for these when billed in combination with drainage bag and without catheter.

(p) Urinary leg bag, latex - One per month. The agency does not pay for these when billed in combination with or without catheter.

(11) Miscellaneous supplies:

(a) Bilirubin light therapy supplies when provided with a bilirubin light which the agency prior authorized - Five days supply.

(b) Continuous passive motion (CPM) softgoods kit - One, with rental of CPM machine.

(c) Eye patch with elastic, tied band, or adhesive, to be attached to an eyeglass lens - One box of twenty.

(d) Eye patch (adhesive wound cover) - One box of twenty.

(e) Nontoxic gel (e.g., LiceOff TM) for use with lice combs - One bottle per twelve-month period.

(f) Nonsterile gloves - Two hundred, per client, per month.

(i) For clients residing in an assisted living facility, the agency pays, with prior authorization, for additional nonsterile gloves up to the quantity necessary as directed by the client's physician, not to exceed a total of four hundred per client, per month.

(ii) Prior authorization requests must include a completed:

(A) General Information for Authorization form (HCA 13-835). The agency's electronic forms are available online (see WAC 182-543-7000 Authorization); and

(B) Limitation Extension Request Incontinent Supplies and Gloves form (HCA 13-870).

(g) Sterile gloves - Thirty pair, per client, per month.

(12) Miscellaneous medical equipment:

(a) Bilirubin light or light pad - Five days rental per twelve-month period for at-home newborns with jaundice.

(b) Blood glucose monitor - One in a three-year period. See WAC 182-543-5500(4) for blood monitoring/testing supplies. The agency does not pay for continuous glucose monitoring systems including related equipment and supplies under the durable medical equipment benefit. See WAC 182-553-500 home infusion therapy/parenteral nutrition program.

(c) Continuous passive motion (CPM) machine - Up to ten days rental and requires prior authorization.

(d) Lightweight protective helmet/soft shell (including adjustable chin/mouth strap) - Two per twelve-month period.

(e) Lightweight ventilated hard-shell helmet (including unbreakable face bar, woven chin strap with adjustable buckle and snap fastener, and one set of cushion pads for adjusting fit to head circumference) - Two per twelve-month period.

(f) Pneumatic compressor - One in a five-year period.

(g) Positioning car seat - One in a five-year period.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-5500, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021. WSR 12-07-022, § 182-543-5500, filed 3/12/12, effective 4/12/12. WSR 11-14-075, recodified as § 182-543-5500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-5500, filed 6/29/11, effective 8/1/11.*

##### **Wash. Admin. Code § 182-543-5700** Medical equipment for clients in skilled nursing facilities. {#sec-182-543-5700 omnilex-key=us-wa-regs-official--title-182--182-543-5700}

(1) The medicaid agency's skilled nursing facility per diem rate, established in chapters 74.46 RCW, 388-96, and 388-97 WAC, includes any reusable and disposable medical supplies that may be required for a skilled nursing facility client, unless otherwise specified within this section.

(2) The agency pays for the following medical equipment outside of the skilled nursing facility per diem rate, subject to the limitations in this section:

(a) Manual or power-drive wheelchairs (including CRT);

(b) Speech generating devices (SGD); and

(c) Specialty beds.

(3) The agency pays for one manual or one power-drive wheelchair for clients who reside in a skilled nursing facility, with prior authorization, according to the requirements in WAC 182-543-4100, 182-543-4200, and 182-543-4300. Requests for prior authorization must:

(a) Be for the exclusive full-time use of a skilled nursing facility resident;

(b) Not be included in the skilled nursing facility's per diem rate;

(c) Include a completed General Information for Authorization form (HCA 13-835);

(d) Include a copy of the telephone order, signed by the physician, for the wheelchair assessment;

(e) Include a completed Medical Necessity for Wheelchair Purchase for Nursing Facility Clients form (HCA 19-0006).

(4) The agency pays for wheelchair accessories and modifications that are specifically identified by the manufacturer as separate line item charges, with prior authorization. To receive payment, providers must submit the following to the agency:

(a) A copy of the telephone order, signed by the physician for the wheelchair accessories and modifications;

(b) A completed Medical Necessity for Wheelchair Purchase for Nursing Facility Clients form (HCA 19-0006). The date on this form (HCA 19-0006) must not be prior to the date on the telephone order. The agency's electronic forms are available online (see WAC 182-543-7000, Authorization);

(c) The make, model, and serial number of the wheelchair to be modified;

(d) The modification requested; and

(e) Specific information regarding the client's medical condition that necessitates modification.

(5) The agency pays for wheelchair repairs with prior authorization. To receive payment, providers must submit the following to the agency:

(a) A completed Medical Necessity for Wheelchair Purchase for Nursing Facility Clients form (HCA 19-0006). The agency's electronic forms are available online (see WAC 182-543-7000, Authorization);

(b) The make, model, and serial number of the wheelchair to be repaired; and

(c) The repair requested.

(6) Prior authorization is required for the repair and modification of client-owned equipment.

(7) The skilled nursing facility must provide a house wheelchair as part of the per diem rate, when the client resides in a skilled nursing facility.

(8) When the client is eligible for both medicare and medicaid and is residing in a skilled nursing facility in lieu of hospitalization, the agency does not reimburse for medical equipment, related services, or related repairs or labor charges under fee-for-service (FFS).

(9) The agency pays for the purchase and repair of a speech generating device (SGD), with prior authorization. The agency pays for replacement batteries for SGDs in accordance with WAC 182-543-5500(3).

(10) The agency pays for the purchase or rental of a specialty bed (a heavy duty bariatric bed is not a specialty bed), with prior authorization, when:

(a) The specialty bed is intended to help the client heal; and

(b) The client's nutrition and laboratory values are within normal limits.

(11) The agency considers decubitus care products to be included in the skilled nursing facility per diem rate and does not reimburse for these separately.

(12) See WAC 182-543-9000 for reimbursement for wheelchairs and CRT.

(13) The agency pays for the following medical supplies for a client in a skilled nursing facility outside the skilled nursing facility per diem rate:

(a) Medical supplies or services that replace all or part of the function of a permanently impaired or malfunctioning internal body organ. This includes, but is not limited to, the following:

(i) Colostomy and other ostomy bags and necessary supplies (see WAC 388-97-1060(3)); and

(ii) Urinary retention catheters, tubes, and bags, excluding irrigation supplies.

(b) Supplies for intermittent catheterization programs, for the following purposes:

(i) Long term treatment of atonic bladder with a large capacity; and

(ii) Short term management for temporary bladder atony.

(c) Surgical dressings required as a result of a surgical procedure, for up to six weeks post-surgery.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-10-041, § 182-543-5700, filed 4/24/24, effective 5/25/24. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-5700, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-5700, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-5700, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-5700, filed 6/29/11, effective 8/1/11.*

##### **Wash. Admin. Code § 182-543-7000** Authorization. {#sec-182-543-7000 omnilex-key=us-wa-regs-official--title-182--182-543-7000}

(1) The medicaid agency requires providers to obtain authorization for medical equipment as required in this chapter, in chapters 182-501 and 182-502 WAC, and in published billing guides and provider notices or when the clinical criteria required in this chapter are not met.

(a) The agency considers requests for prior authorization (PA) for any item meeting the definition of medical equipment, and PA is granted when the service is medically necessary as defined in WAC 182-500-0070.

(b) For prior authorization (PA), a provider must submit a written request to the agency as specified in the agency's published billing guides (see WAC 182-543-7100). All requests for prior authorization must be accompanied by a completed General Information for Authorization form (HCA 13-835) in addition to any program specific forms as required within this chapter. The agency's electronic forms are available online at http://www.hca.wa.gov/medicaid/forms/Pages/index.aspx.

(c) For expedited prior authorization (EPA), a provider must meet the clinically appropriate EPA criteria outlined in the agency's published billing guides. The appropriate EPA number must be used when the provider bills the agency (see WAC 182-543-7200).

(2) When a service requires authorization, the provider must properly request authorization in accordance with the agency's rules, billing guides, and provider notices.

(3) The agency's authorization of services does not necessarily guarantee payment.

(4) When authorization is not properly requested, the agency rejects and returns the request to the provider for further action. The agency does not consider the rejection of the request to be a denial of service.

(5) Authorization requirements in this chapter are not a denial of service to the client.

(6) The agency may recoup any payment made to a provider if the agency later determines that the service was not properly authorized or did not meet the EPA criteria. Refer to WAC 182-502-0100 (1)(c).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-7000, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-7000, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-7000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-7000, filed 6/29/11, effective 8/1/11.*

##### **Wash. Admin. Code § 182-543-7100** Prior authorization. {#sec-182-543-7100 omnilex-key=us-wa-regs-official--title-182--182-543-7100}

(1) The medicaid agency requires providers to obtain prior authorization for certain medical equipment and services before delivering the equipment or service to the client, except for dual-eligible medicare/medicaid clients when medicare is the primary payer. The equipment or service must also be delivered to the client before the provider bills the agency.

(2) All prior authorization requests must be accompanied by a completed General Information for Authorization form (HCA 13-835), in addition to any program specific agency forms as required within this chapter. Agency forms are available online at http://www.hca.wa.gov/medicaid/forms/Pages/index.aspx.

(3) When the agency receives the initial request for prior authorization, the prescription for the medical equipment or services must not be older than six months from the date the agency receives the request.

(4) The agency requires certain information from providers in order to prior authorize the purchase or rental of equipment. This information includes, but is not limited to:

(a) The manufacturer's name;

(b) The equipment model and serial number;

(c) A detailed description of the item; and

(d) Any modifications required, including the product or accessory number as shown in the manufacturer's catalog.

(5) For prior authorization requests, the agency requires the prescribing provider to furnish patient-specific justification for base equipment and each requested line item accessory or modification as identified by the manufacturer as a separate charge. The agency does not accept general standards of care or industry standards for generalized equipment as justification.

(6) The agency considers requests for medical equipment that does not have assigned health care common procedure coding system (HCPCS) codes and are not listed in the agency's published issuances, including billing instructions or provider notices. These items require prior authorization. The provider must furnish all of the following information to the agency to establish medical necessity:

(a) A detailed description of the equipment or service to be provided;

(b) The cost or charge for the equipment;

(c) A copy of the manufacturer's invoice, price-list or catalog with the product description for the equipment being provided; and

(d) A detailed explanation of how the requested equipment differs from an already existing code description.

(7) The agency does not pay for the purchase, rental, or repair of medical equipment that duplicates equipment that the client already owns, rents, or that the agency has authorized for the client. If the provider believes the purchase, rental, or repair of medical equipment is not duplicative, the provider must request prior authorization and submit the following to the agency:

(a) Why the existing equipment no longer meets the client's medical needs; or

(b) Why the existing equipment could not be repaired or modified to meet the client's medical needs.

(c) Upon request, documentation showing how the client's condition met the criteria for PA or EPA.

(8) A provider may resubmit a request for prior authorization for equipment or services that the agency has denied. The agency requires the provider to include new documentation that is relevant to the request.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-7100, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-7100, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-7100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-7100, filed 6/29/11, effective 8/1/11.*

##### **Wash. Admin. Code § 182-543-7200** Prior authorization for limits on amount, frequency, or duration. {#sec-182-543-7200 omnilex-key=us-wa-regs-official--title-182--182-543-7200}

(1) The medicaid agency limits the amount, frequency, or duration of certain medical equipment and related services, and reimburses up to the stated limit without requiring prior authorization.

(2) Certain items have limitations on quantity and frequency. These limits are designed to avoid the need for prior authorization for items normally considered medically necessary and for quantities sufficient for a thirty-day supply for one client.

(3) The agency requires a provider to request prior authorization in order to exceed the stated limits for medical equipment and supplies that do not require prior authorization. All requests for prior authorization must be accompanied by a completed General Information for Authorization form (HCA 13-835) in addition to any program specific forms as required within this chapter. Agency forms are available online at http://www.hca.wa.gov/medicaid/forms/Pages/index.aspx.

(4) The agency evaluates such requests under the provisions of WAC 182-501-0169, and grants prior authorization when it is medically necessary, as defined in WAC 182-500-0070.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-7200, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-7200, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-7200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-7200, filed 6/29/11, effective 8/1/11.*

##### **Wash. Admin. Code § 182-543-7300** Expedited prior authorization (EPA). {#sec-182-543-7300 omnilex-key=us-wa-regs-official--title-182--182-543-7300}

(1) The expedited prior authorization process (EPA) is designed to eliminate the need for written and telephonic requests for prior authorization for selected medical equipment procedure codes.

(2) The medicaid agency requires a provider to create an authorization number for EPA for selected medical equipment procedure codes. The process and criteria used to create the authorization number is explained in the agency published medical equipment-related billing guide. The authorization number must be used when the provider bills the agency.

(3) Upon request, a provider must provide documentation to the agency showing how the client's condition met the criteria for EPA.

(4) A written or telephone request for prior authorization is required when a situation does not meet the EPA criteria for selected medical equipment procedure codes.

(5) The agency may recoup any payment made to a provider under this section if the provider did not follow the expedited authorization process and criteria.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-7300, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-7300, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-7300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-7300, filed 6/29/11, effective 8/1/11.*

##### **Wash. Admin. Code § 182-543-8000** Billing general. {#sec-182-543-8000 omnilex-key=us-wa-regs-official--title-182--182-543-8000}

(1) A provider must not bill the medicaid agency for the rental or purchase of medical equipment supplied to the provider at no cost by suppliers or manufacturers.

(2) The agency does not pay a medical equipment provider for medical supplies used in conjunction with a physician office visit. The agency pays the office physician for these supplies when appropriate. Refer to the agency's physician-related professional services billing guide.

(3) The agency does not pay for any prosthetics and orthotics required for surgery or placed during the hospital stay under this chapter. See chapter 182-550 WAC. In this situation, the prosthetics and orthotics are included in the hospital reimbursement rate.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-8000, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-8000, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-8000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-8000, filed 6/29/11, effective 8/1/11.*

##### **Wash. Admin. Code § 182-543-8100** Billing for managed care clients. {#sec-182-543-8100 omnilex-key=us-wa-regs-official--title-182--182-543-8100}

If a fee-for-service (FFS) client enrolls in a medicaid agency-contracted managed care organization (MCO), the following apply:

(1) The agency stops paying for any rented medical equipment on the last day of the month preceding the month in which the client becomes enrolled in the MCO.

(2) The plan determines the client's continuing need for the medical equipment and is responsible for paying the provider.

(3) A client may become an MCO enrollee before the agency completes the purchase of prescribed medical equipment. The agency considers the purchase complete when the product is delivered and the agency is notified of the serial number. If the client becomes an MCO enrollee before the agency completes the purchase:

(a) The agency rescinds the agency's authorization with the vendor until the MCO's primary care provider (PCP) evaluates the client; then

(b) The agency requires the PCP to write a new prescription if the PCP determines the equipment is still medically necessary as defined in WAC 182-500-0070; then

(c) The MCO's applicable reimbursement policies apply to the purchase or rental of the equipment.

(4) If a client is disenrolled from an MCO and placed into fee-for-service before the MCO completes the purchase of prescribed medical equipment:

(a) The agency rescinds the MCO's authorization with the vendor until the client's primary care provider (PCP) evaluates the client; then

(b) The agency requires the PCP to write a new prescription if the PCP determines the equipment is still medically necessary as defined in WAC 182-500-0070; then

(c) The agency does not pay for medical equipment and services provided to a client who is enrolled in an agency-contracted managed care organization (MCO), but who did not use one of the MCO's participating providers.

(d) The agency's applicable reimbursement policies apply to the purchase or rental of the equipment.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-8100, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-8100, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-8100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-8100, filed 6/29/11, effective 8/1/11.*

##### **Wash. Admin. Code § 182-543-8200** Billing for clients eligible for medicare and medicaid. {#sec-182-543-8200 omnilex-key=us-wa-regs-official--title-182--182-543-8200}

If a client is eligible for both medicare and medicaid, see WAC 182-502-0110 Conditions of payment and prior authorization requirements—Medicare coinsurance, copayments, and deductibles.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-06-025, § 182-543-8200, filed 2/22/23, effective 3/25/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-8200, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-8200, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-8200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-8200, filed 6/29/11, effective 8/1/11.*

##### **Wash. Admin. Code § 182-543-9000** General reimbursement. {#sec-182-543-9000 omnilex-key=us-wa-regs-official--title-182--182-543-9000}

(1) The medicaid agency pays qualified providers who meet all conditions in WAC 182-502-0100 for medical equipment, repairs, and related services provided on a fee-for-service (FFS) basis as follows:

(a) To agency-enrolled medical equipment providers, qualified complex rehabilitation technology (CRT) suppliers, pharmacies, and home health agencies under their national provider identifier (NPI) numbers, subject to the limitations of this chapter, and according to the procedures and codes in the agency's current medical equipment billing guide;

(b) In accordance with the health care common procedure coding system (HCPCS) guidelines for product classification and code assignation; and

(c) Providers must code the specific brand and model of wheelchair or CRT products dispensed according to the centers for medicare and medicaid services' (CMS) pricing, data analysis, and coding (PDAC) website.

(2) The agency sets, evaluates, and updates the maximum allowable fees for medical equipment and related services at least once yearly, unless otherwise directed by the legislature or determined necessary by the agency.

(3) The agency sets the rates for medical equipment codes subject to the federal financial participation (FFP) limitation at the lesser of medicare's prevailing payment rates in the Durable Medical Equipment Prosthetics/Orthotics, and Supplies (DMEPOS) Fee Schedule or Competitive Bid Area (CBA) rate. For all other procedure codes, the agency sets rates using one of the following:

(a) Medicare fee schedules;

(b) Legislative direction;

(c) Input from stakeholders or relevant sources that the agency determines to be reliable and appropriate;

(d) Pricing clusters; or

(e) A by-report (BR) basis.

(4) The medicaid agency evaluates a by-report (BR) item, procedure, or service for its medical necessity, appropriateness and reimbursement value on a case-by-case basis. The agency's reimbursement rate is a percentage of the manufacturer's list or manufacturer's suggested retail price (MSRP), or a percentage of the wholesale acquisition cost (AC). The MSRP or invoice must be dated within 12 months prior to the date of service and must substantiate the specific supply being billed. The agency uses the following percentages:

(a) For basic standard wheelchairs, 65 percent of MSRP or 140 percent of AC;

(b) For wheelchair parts and add-on CRT accessories and parts, 84 percent of MSRP or 140 percent of AC;

(c) For wheelchair seat and back cushions, CRT manual wheelchair base, and up-charge modifications and seating systems, 80 percent of MSRP or 140 percent of AC;

(d) For CRT power-drive wheelchair base, 85 percent of MSRP or 140 percent of AC;

(e) For prosthetics and orthotics and medical supplies and related services, 85 percent of MSRP or 125 percent of AC;

(f) For other medical equipment, 80 percent of MSRP or 125 percent of AC;

(g) For medical supplies, 85 percent of MSRP or 125 percent of AC.

(5) When establishing reimbursement rates for medical equipment based on pricing clusters for a specific HCPCS code, the maximum allowable fee is the median or average amount of all items in the cluster. The pricing cluster is comprised of all the brands/models for which the agency obtains pricing information. However, the agency may limit the number of brands/models included in the pricing cluster due to:

(a) A client's medical needs;

(b) Product quality;

(c) Introduction, substitution or discontinuation of certain brands/models; and/or

(d) Cost.

(6) When there is only a rental rate on the DMEPOS fee schedule, the agency sets the maximum allowable purchase rate at either the DMEPOS rate divided by 0.15 or multiplied by 10. The agency sets the maximum allowable fee for daily rental at one-three-hundredth of the new purchase price or one-thirtieth of the monthly rental rate on the DMEPOS fee schedule;

(7) The agency may adopt policies, procedure codes, and/or rates that are inconsistent with those set by medicare if the agency determines that such actions are necessary to:

(a) Assure that payments are sufficient to enlist providers and maintain access to care and services; or

(b) Comply with legislative budget directives.

(8) The agency's maximum payment for medical equipment and related services is the lesser of either the:

(a) Providers' usual and customary charges; or

(b) Established rates, except as provided in WAC 182-543-8200.

(9) The agency is the payor of last resort for clients with medicare or third-party insurance.

(10) The agency's reimbursement for a prosthetic or orthotic includes the cost of any necessary molds, fitting, shipping, handling or any other administrative expenses related to provision of the prosthetic or orthotic to the client.

(11) The agency's reimbursement rate for purchased or rented covered medical equipment and related services includes all of the following:

(a) Any adjustments or modifications to the medical equipment required within three months of the date of delivery or covered under the manufacturer's warranty. This does not apply to adjustments required because of changes in the client's medical condition;

(b) Any pick-up or delivery fees or associated costs (e.g., mileage, travel time, gas, etc.);

(c) Telephone calls;

(d) Shipping, handling, and/or postage;

(e) Routine maintenance that includes testing, cleaning, regulating, and assessing the client's equipment;

(f) Fitting and set-up; and

(g) Instruction to the client or client's caregiver in the appropriate use of the medical equipment.

(12) Medical equipment and related services supplied to eligible clients under the following reimbursement methodologies are included in those methodologies and are not reimbursed under fee-for-service:

(a) Hospice providers' per diem reimbursement;

(b) Hospitals' diagnosis-related group (DRG) reimbursement;

(c) Managed care plans' capitation rate;

(d) Skilled nursing facilities' per diem rate; and

(e) Professional services' resource-based relative value system reimbursement (RBRVS) rate.

(13) The provider must make warranty information, including date of purchase, applicable serial number, model number or other unique identifier of the equipment, and warranty period, available to the agency upon request.

(14) The dispensing provider who furnishes the medical equipment to a client is responsible for any costs incurred to have a different provider repair the equipment when:

(a) Any medical equipment the agency considers purchased requires repair during the applicable warranty period;

(b) The provider refuses or is unable to fulfill the warranty; and

(c) The equipment continues to be medically necessary.

(15) If the rental medical equipment must be replaced during the warranty period, the agency recoups 50 percent of the total amount previously paid toward rental and eventual purchase of the medical equipment delivered to the client if:

(a) The provider is unwilling or unable to fulfill the warranty; and

(b) The equipment continues to be medically necessary.

(16) The agency does not reimburse for medical equipment, related services, and related repairs and labor charges under fee-for-service when the client is:

(a) An inpatient hospital client;

(b) Eligible for both medicare and medicaid, and is staying in a skilled nursing facility in lieu of hospitalization;

(c) Terminally ill and receiving hospice care; or

(d) Enrolled in a risk-based managed care plan that includes coverage for such items and/or services.

(17) The agency rescinds any purchase order for a prescribed item if the equipment was not delivered to the client before the client:

(a) Dies;

(b) Loses medical eligibility;

(c) Becomes covered by a hospice agency; or

(d) Becomes covered by a managed care organization.

(18) A provider may incur extra costs for customized equipment that may not be easily resold. In these cases, for purchase orders rescinded in subsection (7) of this section, the agency may pay the provider an amount it considers appropriate to help defray these extra costs. The agency requires the provider to submit justification sufficient to support such a claim.

(19) For clients residing in skilled nursing facilities, see WAC 182-543-5700.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-01-207, s 182-543-9000, filed 12/24/25, effective 1/24/26. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70*
- *42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-9000, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-9000, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-9000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-9000, filed 6/29/11, effective 8/1/11.*

## **Chapter 182-544** Vision care. {#struct-chapter-182-544}

##### **Wash. Admin. Code § 182-544-0010** Vision care—General. {#sec-182-544-0010 omnilex-key=us-wa-regs-official--title-182--182-544-0010}

(1) The medicaid agency covers the vision care services listed in this chapter for clients age twenty and younger, according to agency rules and subject to the limitations and requirements in this chapter. The agency pays for vision care when it is:

(a) Covered;

(b) Within the scope of the client's benefit package;

(c) Medically necessary as defined in WAC 182-500-0070;

(d) Authorized, as required within this chapter, chapter 182-501 WAC, and the agency's published billing instructions; and

(e) Billed according to this chapter, chapters 182-501 and 182-502 WAC, and the agency's published billing instructions.

(2) The agency does not require prior authorization for covered vision care services that meet the clinical criteria set forth in this chapter.

(3) The agency requires prior authorization for covered vision care services when the clinical criteria set forth in this chapter are not met, including the criteria associated with the expedited prior authorization process.

(4) The agency evaluates requests for covered services that do not meet clinical criteria based on the definition of medical necessity in WAC 182-500-0070 and the process in WAC 182-501-0165.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0010, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0010, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0010, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-544-0010, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. WSR 05-13-038, § 388-544-0010, filed 6/6/05, effective 7/7/05.*

##### **Wash. Admin. Code § 182-544-0050** Vision care—Definitions. {#sec-182-544-0050 omnilex-key=us-wa-regs-official--title-182--182-544-0050}

The following definitions and those found in chapter 182-500 WAC apply to this chapter. Unless otherwise defined in this chapter, medical terms are used as commonly defined within the scope of professional medical practice in the state of Washington.

"Blindness" - A diagnosis of visual acuity for distance vision of twenty/two hundred or worse in the better eye with best correction or a limitation of the client's visual field (widest diameter) subtending an angle of less than twenty degrees from central.

"Conventional soft contact lenses" or "rigid gas permeable contact lenses" - FDA-approved contact lenses that do not have a scheduled replacement (discard and replace with new contacts) plan. The soft lenses usually last one year, and the rigid gas permeable lenses usually last two years. Although some of these lenses are designed for extended wear, the medicaid agency generally approves only those lenses that are designed to be worn as daily wear (remove at night).

"Disposable contact lenses" - FDA-approved contact lenses that have a planned replacement schedule (e.g., daily, every two weeks, monthly, quarterly). The contacts are then discarded and replaced with new ones as scheduled. Although many of these lenses are designed for extended wear, the agency generally approves only those lenses that are designed to be worn as daily wear (remove at night).

"Expedited prior authorization" - A form of authorization used by the provider to certify that the agency-published clinical criteria for a specific vision care service(s) have been met.

"Extended wear soft contacts" - Contact lenses that are designed to be worn for longer periods than daily wear (remove at night) lenses. These can be conventional soft contact lenses or disposable contact lenses designed to be worn for several days and nights before removal.

"Hardware" - Eyeglass frames and lenses and contact lenses.

"Prior authorization" - A form of authorization used by the provider to obtain the agency's written approval for a specific vision care service(s). The agency's approval is based on medical necessity and must be received before the service(s) are provided to clients as a precondition for payment.

"Specialty contact lens design" - Custom contact lenses that have a more complex design than a standard spherical lens. These specialty contact lenses (e.g., lenticular, aspheric, or myodisc) are designed for the treatment of specific disease processes, such as keratoconus, or are required due to high refractive errors. This definition of specialty contact lens does not include lenses used for surgical implantation.

"Stable visual condition" - A client's eye condition has no acute disease or injury; or the client has reached a point after any acute disease or injury where the variation in need for refractive correction has diminished or steadied. The client's vision condition has stabilized to the extent that eyeglasses or contact lenses are appropriate and that any prescription for refractive correction is likely to be sufficient for one year or more.

"Visual field exams or testing" - A process to determine defects in the field of vision and test the function of the retina, optic nerve and optic pathways. The process may include simple confrontation to increasingly complex studies with sophisticated equipment.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0050, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0050, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. WSR 05-13-038, § 388-544-0050, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. WSR 01-01-010, § 388-544-0050, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-544-0100** Vision care—Eligible persons—Twenty years of age and younger. {#sec-182-544-0100 omnilex-key=us-wa-regs-official--title-182--182-544-0100}

This section applies to eligible persons who are twenty years of age and younger.

(1) Vision care is available to persons who are eligible for services under one of the Washington apple health programs listed in the table in WAC 182-501-0060 or are eligible for the alien emergency medical (AEM) program as described in WAC 182-507-0110.

(2) Eligible persons who are enrolled in an agency-contracted managed care organization (MCO) are eligible under fee-for-service for covered vision care that is not covered by their plan, subject to the provisions of this chapter and other applicable WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148). WSR 14-07-042, § 182-544-0100, filed 3/12/14, effective 4/12/14. WSR 11-14-075, recodified as § 182-544-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-016, § 388-544-0100, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0100, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. WSR 05-13-038, § 388-544-0100, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. WSR 01-01-010, § 388-544-0100, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-544-0150** Vision care—Provider requirements. {#sec-182-544-0150 omnilex-key=us-wa-regs-official--title-182--182-544-0150}

(1) Enrolled/contracted eye care providers must:

(a) Meet the requirements in chapter 182-502 WAC;

(b) Provide only those services that are within the scope of the provider's license;

(c) Obtain all hardware (including the tinting of eyeglass lenses) and contact lenses for clients from the medicaid agency's designated supplier as published in the agency's current vision care billing instructions; and

(d) Return all unclaimed hardware and contact lenses to the agency's designated supplier using a postage-paid envelope furnished by the supplier.

(2) The following providers are to enroll/contract with the agency to provide and bill for vision care services furnished to clients:

(a) Ophthalmologists;

(b) Optometrists;

(c) Opticians; and

(d) Ocularists.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0150, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0150, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0150, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. WSR 05-13-038, § 388-544-0150, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. WSR 01-01-010, § 388-544-0150, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-544-0250** Vision care—Covered eye services (examinations, refractions, visual field testing, and vision therapy). {#sec-182-544-0250 omnilex-key=us-wa-regs-official--title-182--182-544-0250}

See WAC 182-531-1000 Ophthalmic services.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0250, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0250, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-016, § 388-544-0250, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0250, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. WSR 05-13-038, § 388-544-0250, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. WSR 01-01-010, § 388-544-0250, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-544-0300** Vision care—Covered eyeglasses (frames and lenses)—Clients age twenty and younger. {#sec-182-544-0300 omnilex-key=us-wa-regs-official--title-182--182-544-0300}

(1) The medicaid agency covers eyeglasses once every twelve months for clients when the following clinical criteria are met:

(a) The client has a stable visual condition;

(b) The client's treatment is stabilized;

(c) The prescription is less than eighteen months old; and

(d) One of the following minimum correction needs in at least one eye is documented in the client's file:

(i) Sphere power equal to, or greater than, plus or minus 0.50 diopter;

(ii) Astigmatism power equal to, or greater than, plus or minus 0.50 diopter; or

(iii) Add power equal to, or greater than, 1.0 diopter for bifocals and trifocals.

(2) If the client has a diagnosis of accommodative esotropia or any strabismus correction, the limitations of subsection (1) of this section do not apply.

(3) The agency covers one pair of back-up eyeglasses for clients who wear contact lenses as their primary visual correction aid (see WAC 182-544-0400(1)) limited to once every two years.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0300, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-016, § 388-544-0300, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0300, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. WSR 05-13-038, § 388-544-0300, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. WSR 01-01-010, § 388-544-0300, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-544-0325** Vision care—Covered eyeglass frames and repairs—Clients age twenty and younger. {#sec-182-544-0325 omnilex-key=us-wa-regs-official--title-182--182-544-0325}

(1) The medicaid agency covers durable or flexible frames when the client has a diagnosed medical condition that contributes to broken eyeglass frames. To receive payment, the provider must order the "durable" or "flexible" frames through the agency's designated supplier.

(2) The agency covers all of the following for clients:

(a) Coating contract eyeglass frames to make the frames nonallergenic. Clients must have a medically diagnosed and documented allergy to the materials in the available eyeglass frames.

(b) Four incidental repairs to a client's eyeglass frames in a calendar year. To receive payment, all of the following must be met:

(i) The provider typically charges the general public for the repair or adjustment;

(ii) The contractor's one year warranty period has expired; and

(iii) The cost of the repair does not exceed the agency's cost for replacement frames and a fitting fee.

(c) Up to two replacement eyeglass frames in a calendar year when the eyeglass frames have been lost or broken. Lost or broken eyeglass frames must be documented in the client's medical record.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0325, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0325, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-016, § 388-544-0325, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0325, filed 6/24/08, effective 7/25/08.*

##### **Wash. Admin. Code § 182-544-0350** Vision care—Covered eyeglass lenses—Clients age twenty and younger. {#sec-182-544-0350 omnilex-key=us-wa-regs-official--title-182--182-544-0350}

(1) The medicaid agency covers the following plastic scratch-resistant eyeglass lenses:

(a) Single vision lenses;

(b) Round or flat top D-style bifocals;

(c) Flat top trifocals;

(d) Slab-off and prism lenses (including Fresnel lenses);

(e) Plastic photochromatic lenses when the client's medical need is diagnosed and documented as ocular albinism or retinitis pigmentosa;

(f) Polycarbonate lenses when the client's medical need is diagnosed and documented as one of the following:

(i) Blind in one eye and needs protection for the other eye, regardless of whether a vision correction is required;

(ii) Infants and toddlers with motor ataxia;

(iii) Strabismus or amblyopia;

(iv) Seizure disorder, cerebral palsy, autism, attention deficit hyperactivity disorder (ADHD), developmental delay, Down syndrome, bipolar, schizophrenia, or multiple sclerosis.

(g) Bifocal lenses to be replaced with single vision or trifocal lenses, or trifocal lenses to be replaced with bifocal or single vision lenses when:

(i) The client has attempted to adjust to the bifocals or trifocals for at least sixty days;

(ii) The client is unable to make the adjustment; and

(iii) The trifocal lenses being replaced are returned to the provider.

(2) Eyeglass lenses covered under subsection (1) of this section must be placed into a frame that is, or was, purchased by the agency.

(3) The agency covers the following high index lenses for clients when clinical criteria are met. The client's medical need in at least one eye must be diagnosed and documented as:

(a) A spherical refractive correction of plus or minus six diopters or greater; or

(b) A cylinder correction of plus or minus three diopters or greater.

(4) The agency covers the tinting of plastic lenses when the client's medical need is diagnosed and documented as one or more of the following chronic (expected to last longer than three months) eye conditions causing photophobia:

(a) Blindness;

(b) Chronic corneal keratitis;

(c) Chronic iritis, iridocyclitis;

(d) Diabetic retinopathy;

(e) Fixed pupil;

(f) Glare from cataracts;

(g) Macular degeneration;

(h) Migraine disorder;

(i) Ocular albinism;

(j) Optic atrophy or optic neuritis;

(k) Rare photo-induced epilepsy conditions; or

(l) Retinitis pigmentosa.

(5) The agency covers up to four replacement lenses in a calendar year when the lenses are lost or broken. Lost or broken lenses must be documented in the client's medical record.

(6) The agency covers replacement lenses when the client meets one of the following clinical criteria:

(a) Eye surgery or the effects of prescribed medication or one or more diseases affecting vision:

(i) The client has a stable visual condition;

(ii) The client's treatment is stabilized;

(iii) The lens correction must have a 1.0 or greater diopter change between the sphere or cylinder correction in at least one eye; and

(iv) The previous and new refraction are documented in the client's medical record.

(b) Headaches, blurred vision, or visual difficulty in school or at work. In this case, all of the following must be documented in the client's medical record:

(i) Copy of current prescription (less than eighteen months old);

(ii) Date of last dispensing, if known;

(iii) Absence of a medical condition that is known to cause temporary visual acuity changes (e.g., diabetes, pregnancy, etc.); and

(iv) A refractive change of at least .75 diopter or greater between the sphere or cylinder correction in at least one eye.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0350, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0350, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-016, § 388-544-0350, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0350, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, and 42 C.F.R. 440.120 and 440.225. WSR 05-17-153, § 388-544-0350, filed 8/22/05, effective 9/22/05*
- *WSR 05-13-038, § 388-544-0350, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. WSR 01-01-010, § 388-544-0350, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-544-0400** Vision care—Covered contact lenses—Clients age twenty and younger. {#sec-182-544-0400 omnilex-key=us-wa-regs-official--title-182--182-544-0400}

(1) The medicaid agency covers contact lenses as the client's primary refractive correction method when the client has a spherical correction of plus or minus 6.0 diopters or greater in at least one eye. See subsection (4) of this section for exceptions to the plus or minus 6.0 diopter criteria. The spherical correction may be from the prescription for the glasses or the contact lenses and may be written in either "minus cyl" or "plus cyl" form.

(2) The agency covers the following contact lenses:

(a) Conventional soft contact lenses or rigid gas permeable contact lenses that are prescribed for daily wear; or

(b) Disposable contact lenses that are prescribed for daily wear and have a monthly or quarterly planned replacement schedule, as follows:

(i) Twelve pairs of monthly replacement contact lenses; or

(ii) Four pairs of three-month replacement contact lenses.

(3) The agency covers soft toric contact lenses for clients with astigmatism when the following clinical criteria are met:

(a) The client's cylinder correction is plus or minus 1.0 diopter in at least one eye; and

(b) The client meets the spherical correction listed in subsection (1) of this section.

(4) The agency covers contact lenses when the following clinical criteria are met. In these cases, the limitations in subsection (1) of this section do not apply.

(a) For clients diagnosed with high anisometropia.

(i) The client's refractive error difference between the two eyes is at least plus or minus 3.0 diopters between the sphere or cylinder correction; and

(ii) Eyeglasses cannot reasonably correct the refractive errors.

(b) Specialty contact lens designs for clients who are diagnosed with one or more of the following:

(i) Aphakia;

(ii) Keratoconus; or

(iii) Corneal softening.

(c) Therapeutic contact bandage lenses only when needed immediately after eye injury or eye surgery.

(5) The agency covers replacement contact lenses for clients when lost or damaged.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0400, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-016, § 388-544-0400, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0400, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. WSR 05-13-038, § 388-544-0400, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. WSR 01-01-010, § 388-544-0400, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-544-0500** Vision care—Covered ocular prosthetics. {#sec-182-544-0500 omnilex-key=us-wa-regs-official--title-182--182-544-0500}

See WAC 182-531-1000 Opthalmic services.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0500, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-016, § 388-544-0500, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0500, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. WSR 05-13-038, § 388-544-0500, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. WSR 01-01-010, § 388-544-0500, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-544-0550** Vision care—Covered eye surgery. {#sec-182-544-0550 omnilex-key=us-wa-regs-official--title-182--182-544-0550}

See WAC 182-531-1000 Ophthalmic services.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0550, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0550, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-016, § 388-544-0550, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0550, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. WSR 05-13-038, § 388-544-0550, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. WSR 01-01-010, § 388-544-0550, filed 12/6/00, effective 1/6/01.*

##### **Wash. Admin. Code § 182-544-0560** Vision care—Authorization. {#sec-182-544-0560 omnilex-key=us-wa-regs-official--title-182--182-544-0560}

(1) The medicaid agency requires providers to obtain authorization for covered vision care services as required in this chapter.

(a) For prior authorization (PA), a provider must submit a written request to the agency as specified in the agency's published vision care billing instructions.

(b) For expedited prior authorization (EPA), a provider must meet the clinically appropriate EPA criteria outlined in the agency's published vision care billing instructions. The appropriate EPA number must be used when the provider bills the agency.

(c) Upon request, a provider must provide documentation to the agency showing how the client's condition met the criteria for PA or EPA.

(2) Authorization requirements in this chapter are not a denial of service.

(3) When a service requires authorization, the provider must properly request authorization in accordance with the agency's rules and billing instructions.

(4) When authorization is not properly requested, the agency rejects and returns the request to the provider for further action. The agency does not consider the rejection of the request to be a denial of service.

(5) The agency's authorization of service(s) does not necessarily guarantee payment.

(6) The agency evaluates requests for authorization of covered vision care services that exceed limitations in this chapter on a case-by-case basis in accordance with WAC 182-501-0169.

(7) The agency may recoup any payment made to a provider if the agency later determines that the service was not properly authorized or did not meet the EPA criteria. Refer to WAC 182-502-0100.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0560, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0560, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0560, filed 6/24/08, effective 7/25/08.*

##### **Wash. Admin. Code § 182-544-0575** Vision care—Noncovered eyeglasses and contact lenses. {#sec-182-544-0575 omnilex-key=us-wa-regs-official--title-182--182-544-0575}

(1) The agency does not cover the following:

(a) Executive style eyeglass lenses;

(b) Bifocal contact lenses;

(c) Daily and two week disposable contact lenses;

(d) Extended wear soft contact lenses, except when used as therapeutic contact bandage lenses or for aphakic clients;

(e) Custom colored contact lenses;

(f) Glass lenses;

(g) Nonglare or anti-reflective lenses;

(h) Progressive lenses;

(i) Sunglasses and accessories that function as sunglasses (e.g., "clip-ons");

(j) Upgrades at private expense to avoid the medicaid agency's contract limitations (e.g., frames that are not available through the agency's contract or noncontract frames or lenses for which the client or other person pays the difference between the agency's payment and the total cost).

(2) A noncovered service may be requested as an exception to rule (ETR) as described in WAC 182-501-0160.

(3) For clients age 20 and younger, providers must follow the rules for the early periodic screening, diagnosis, and treatment (EPSDT) program, see chapter 182-534 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-21-142, s 182-544-0575, filed 10/21/25, effective 11/21/25*
- *WSR 17-14-067, § 182-544-0575, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0575, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-016, § 388-544-0575, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0575, filed 6/24/08, effective 7/25/08.*

##### **Wash. Admin. Code § 182-544-0600** Vision care—Payment methodology. {#sec-182-544-0600 omnilex-key=us-wa-regs-official--title-182--182-544-0600}

(1) To receive payment, vision care providers must bill the agency according to this chapter, chapters 182-501 and 182-502 WAC, and the medicaid agency's published billing instructions and numbered memoranda.

(2) The agency pays one hundred percent of the agency contract price for covered eyeglass frames, lenses, and contact lenses when these items are obtained through the agency's approved contractor.

(3) See WAC 182-531-1850 for professional fee payment methodology.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0600, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0600, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-014, § 388-544-0600, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. WSR 08-14-052, § 388-544-0600, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. WSR 05-13-038, § 388-544-0600, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. WSR 01-01-010, § 388-544-0600, filed 12/6/00, effective 1/6/01.*

## **Chapter 182-545** Therapies. {#struct-chapter-182-545}

##### **Wash. Admin. Code § 182-545-200** Outpatient rehabilitation (occupational therapy, physical therapy, and speech therapy). {#sec-182-545-200 omnilex-key=us-wa-regs-official--title-182--182-545-200}

(1) The following health professionals may enroll with the medicaid agency, as defined in WAC 182-500-0010, to provide outpatient rehabilitation (which includes occupational therapy, physical therapy, and speech therapy) within their scope of practice to eligible clients:

(a) A physiatrist;

(b) A licensed occupational therapist;

(c) A licensed occupational therapy assistant (OTA) supervised by a licensed occupational therapist;

(d) A licensed physical therapist;

(e) A physical therapist assistant supervised by a licensed physical therapist;

(f) A licensed speech-language pathologist; and

(g) A licensed optometrist to provide vision occupational therapy only.

(2) Clients covered by one of the Washington apple health programs listed in the table in WAC 182-501-0060 or receiving home health care services as described in chapter 182-551 WAC (subchapter II) are eligible to receive outpatient rehabilitation as described in this chapter.

(3) Clients enrolled in an agency-contracted managed care organization (MCO) must arrange for outpatient rehabilitation directly through their agency-contracted MCO.

(4) The agency pays for outpatient rehabilitation when the services are:

(a) Covered;

(b) Medically necessary;

(c) Within the scope of the eligible person's medical care program;

(d) Ordered by:

(i) A physician, physician assistant (PA), or an advanced registered nurse practitioner (ARNP); or

(ii) An optometrist, if the ordered services are for occupational therapy only.

(e) Within currently accepted standards of evidence-based medical practice;

(f) Authorized, as required within this chapter, under chapters 182-501 and 182-502 WAC and the agency's published billing instructions;

(g) Begun within 30 calendar days of the date ordered;

(h) Provided by one of the health professionals listed in subsection (1) of this section;

(i) Billed according to this chapter, chapters 182-501 and 182-502 WAC, and the agency's published billing instructions; and

(j) Provided as part of an outpatient treatment program:

(i) In an office or outpatient hospital setting;

(ii) In the home, by a home health agency as described in chapter 182-551 WAC;

(iii) In a neurodevelopmental center, as described in WAC 182-545-900;

(iv) For children with disabilities, age six or younger, in natural environments including the home and community setting in which children without disabilities participate, to the maximum extent appropriate to the needs of the child; or

(v) When provided by licensed and certified behavioral health agencies as part of a mental health or substance use disorder treatment program.

(5) For eligible clients age 20 and younger, the agency covers unlimited outpatient rehabilitation.

(6) For clients age 21 and older, the agency covers a limited outpatient rehabilitation benefit.

(7) Outpatient rehabilitation services for clients age 21 and older must:

(a) Restore, improve, or maintain the person's level of function that has been lost due to a clinically documented condition; and

(b) Include an ongoing management plan for the client or the client's caregiver to support timely discharge and continued progress.

(8) For eligible clients age 21 and older, the agency limits coverage of outpatient rehabilitation as follows:

(a) Occupational therapy, per person, per year:

(i) Without authorization:

(A) For clients needing occupational therapy to treat physical conditions:

(I) One occupational therapy evaluation;

(II) One occupational therapy reevaluation at time of discharge; and

(III) Twenty-four units of occupational therapy, which is approximately six hours; and

(B) For clients needing occupational therapy to treat behavioral health conditions:

(I) One occupational therapy evaluation;

(II) One occupational therapy reevaluation at time of discharge; and

(III) Twenty-four units of occupational therapy, which is approximately six hours.

(ii) With expedited prior authorization, up to 24 additional units of occupational therapy to treat either the client's physical or behavioral health conditions may be available to continue treatment initiated under the original 24 units when the criteria below is met:

(A) To continue treatment of the original qualifying condition; and

(B) The client's diagnosis is any of the following:

(I) Acute, open, or chronic nonhealing wounds;

(II) Behavioral health conditions;

(III) Brain injury, which occurred within the past 24 months, with residual cognitive or functional deficits;

(IV) Burns - Second or third degree only;

(V) Cerebral vascular accident, which occurred within the past 24 months, with residual cognitive or functional deficits;

(VI) Lymphedema;

(VII) Major joint surgery - Partial or total replacement only;

(VIII) Muscular-skeletal disorders such as complex fractures that required surgical intervention, or surgery involving the spine or extremities (e.g., arm, hand, shoulder, leg, foot, knee, or hip);

(IX) Neuromuscular disorders that are affecting function (e.g., amyotrophic lateral sclerosis (ALS), active infective polyneuritis (Guillain-Barre));

(X) Reflex sympathetic dystrophy;

(XI) Swallowing deficits due to injury or surgery to the face, head, or neck;

(XII) Spinal cord injury that occurred within the past 24 months, resulting in paraplegia or quadriplegia; or

(XIII) As part of a botulinum toxin injection protocol when botulinum toxin has been prior authorized by the agency.

(b) Physical therapy, per person, per year:

(i) Without authorization:

(A) One physical therapy evaluation;

(B) One physical therapy reevaluation at time of discharge; and

(C) Twenty-four units of physical therapy, which is approximately six hours.

(ii) With expedited prior authorization, up to 24 additional units of physical therapy may be available to continue treatment initiated under the original 24 units when the criteria below is met:

(A) To continue treatment of the original qualifying condition; and

(B) The person's diagnosis is any of the following:

(I) Acute, open, or chronic nonhealing wounds;

(II) Brain injury, which occurred within the past 24 months, with residual functional deficits;

(III) Burns - Second or third degree only;

(IV) Cerebral vascular accident, which occurred within the past 24 months, with residual functional deficits;

(V) Lymphedema;

(VI) Major joint surgery - Partial or total replacement only;

(VII) Muscular-skeletal disorders such as complex fractures that required surgical intervention, or surgery involving the spine or extremities (e.g., arm, hand, shoulder, leg, foot, knee, or hip);

(VIII) Neuromuscular disorders that are affecting function (e.g., amyotrophic lateral sclerosis (ALS), active infective polyneuritis (Guillain-Barre));

(IX) Reflex sympathetic dystrophy;

(X) Spinal cord injury, which occurred within the past 24 months, resulting in paraplegia or quadriplegia; or

(XI) As part of a botulinum toxin injection protocol when botulinum toxin has been prior authorized by the agency.

(c) Speech therapy, per person, per year:

(i) Without authorization:

(A) One speech language pathology evaluation;

(B) One speech language pathology reevaluation at the time of discharge; and

(C) Six units of speech therapy, which is approximately six hours.

(ii) With expedited prior authorization, up to six additional units of speech therapy may be available to continue treatment initiated under the original six units when the criteria below is met:

(A) To continue treatment of the original qualifying condition; and

(B) The person's diagnosis is any of the following:

(I) Brain injury, which occurred within the past 24 months, with residual cognitive or functional deficits;

(II) Burns of internal organs such as nasal oral mucosa or upper airway;

(III) Burns of the face, head, and neck - Second or third degree only;

(IV) Cerebral vascular accident, which occurred within the past 24 months, with residual functional deficits;

(V) Muscular-skeletal disorders such as complex fractures that require surgical intervention or surgery involving the vault, base of the skull, face, cervical column, larynx, or trachea;

(VI) Neuromuscular disorders that are affecting function (e.g., amyotrophic lateral sclerosis (ALS), active infection polyneuritis (Guillain-Barre));

(VII) Speech deficit due to injury or surgery to the face, head, or neck;

(VIII) Speech deficit that requires a speech generating device;

(IX) Swallowing deficit due to injury or surgery to the face, head, or neck; or

(X) As part of a botulinum toxin injection protocol when botulinum toxin has been prior authorized by the agency.

(d) Durable medical equipment (DME) needs assessments, two per person, per year.

(e) Orthotics management and training of upper or lower extremities, or both, two program units, per person, per day.

(f) Orthotic or prosthetic use, two program units, per person, per year.

(g) Muscle testing, one procedure, per person, per day. Muscle testing procedures cannot be billed in combination with each other. These procedures can be billed alone or with other physical and occupational therapy procedures.

(h) Wheelchair needs assessment, one per person, per year.

(9) For the purposes of this chapter:

(a) Each 15 minutes of timed procedure code equals one unit; and

(b) Each nontimed procedure code equals one unit, regardless of how long the procedure takes.

(10) For expedited prior authorization (EPA):

(a) A provider must establish that:

(i) The person's condition meets the clinically appropriate EPA criteria outlined in this section; and

(ii) The services are expected to result in a reasonable improvement in the person's condition and achieve the person's therapeutic individual goal within 60 calendar days of initial treatment;

(b) The appropriate EPA number must be used when the provider bills the agency;

(c) Upon request, a provider must provide documentation to the agency showing how the person's condition met the criteria for EPA; and

(d) A provider may request expedited prior authorization once per year, per person, per each therapy type.

(11) If the client does not meet the EPA clinical criteria in this section, the agency uses the process in WAC 182-501-0165 to consider prior authorization requests and approves services that are medically necessary.

(12) The agency evaluates limitation extension (LE) requests regarding scope, amount, duration, and frequency of covered health care services under WAC 182-501-0169. Providers may submit LE requests for additional units when:

(a) The criteria for an expedited prior authorization does not apply;

(b) The number of available units under the EPA have been used and services are requested beyond the limits; or

(c) A new qualifying condition arises after the initial six visits are used.

(13) Duplicate services for outpatient rehabilitation are not allowed for the same person when both providers are performing the same or similar procedure(s).

(14) The agency does not pay separately for outpatient rehabilitation that are included as part of the reimbursement for other treatment programs. This includes, but is not limited to, hospital inpatient and nursing facility services.

(15) The agency does not reimburse a health care professional for outpatient rehabilitation performed in an outpatient hospital setting when the health care professional is not employed by the hospital. The hospital must bill the agency for the services.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-24-058, s 182-545-200, filed 11/27/24, effective 1/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.385. WSR 24-14-044, § 182-545-200, filed 6/26/24, effective 7/27/24. Statutory Authority: RCW 41.05.021, 41.05.160, 18.35.040. WSR 18-09-052, § 182-545-200, filed 4/13/18, effective 5/14/18. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-03-042, § 182-545-200, filed 1/14/16, effective 2/14/16. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148). WSR 14-07-042, § 182-545-200, filed 3/12/14, effective 4/12/14. Statutory Authority: RCW 41.05.021. WSR 11-21-066, § 182-545-200, filed 10/17/11, effective 11/17/11.*

##### **Wash. Admin. Code § 182-545-400** Habilitative services. {#sec-182-545-400 omnilex-key=us-wa-regs-official--title-182--182-545-400}

(1) Habilitative services assist the client in partially or fully attaining, learning, maintaining, or improving developmental-age appropriate skills that were not fully acquired as a result of a congenital, genetic, or early acquired health condition. To the extent practical, habilitative services maximize the client's ability to function in the client's environment.

(2) Eligibility is limited to clients who are enrolled in the Washington apple health alternative benefits plan defined in WAC 182-501-0060. Clients enrolled in an agency-contracted managed care organization (MCO) must arrange for habilitative services through their MCO.

(3) The following licensed health care professionals may enroll with the agency to provide habilitative services within their scope of practice to eligible clients:

(a) Physiatrists;

(b) Occupational therapists;

(c) Occupational therapy assistants supervised by a licensed occupational therapist;

(d) Physical therapists;

(e) Physical therapy assistants supervised by a licensed physical therapist;

(f) Speech-language pathologists who have been granted a certificate of clinical competence by the American Speech-Language-Hearing Association; and

(g) Speech-language pathologists who have completed the equivalent educational and work experience necessary for such a certificate.

(4) The agency pays for habilitative services that are:

(a) Covered within the scope of the client's alternative benefits plan under WAC 182-501-0060;

(b) Medically necessary;

(c) Within currently accepted standards of evidence-based medical practice;

(d) Ordered by a physician, physician assistant, or an advanced registered nurse practitioner;

(e) Begun within thirty calendar days of the date ordered;

(f) Provided by one of the health care professionals listed in subsection (3) of this section;

(g) Authorized under this chapter, chapters 182-501 and 182-502 WAC, and the agency's published provider guides;

(h) Billed under this chapter, chapters 182-501 and 182-502 WAC, and the agency's published provider guides; and

(i) Provided as part of a habilitative treatment program:

(i) In an office or outpatient hospital setting;

(ii) In the home, by a home health agency as described in chapter 182-551 WAC; or

(iii) In a neurodevelopmental center, as described in WAC 182-545-900.

(5) For billing purposes under this section:

(a) Each fifteen minutes of timed procedure code equals one unit.

(b) Each nontimed procedure code equals one unit, regardless of how long the procedure takes.

(c) Duplicate services for habilitative services are not allowed for the same client when both providers are performing the same or similar procedure on the same day.

(d) The agency does not pay a health care professional for habilitative services performed in an outpatient hospital setting when the health care professional is not employed by the hospital. The hospital must bill the agency for the services.

(6) The limitations in subsection (7) of this section do not apply to eligible clients under age twenty-one.

(7) For eligible clients age twenty-one and older, the agency covers habilitative services that include an ongoing management plan for the client or the client's caregiver to support continued client progress. The agency limits habilitative services as follows:

(a) Occupational therapy, per client, per year:

(i) Without authorization:

(A) One occupational therapy evaluation;

(B) One occupational therapy reevaluation at time of discharge; and

(C) Twenty-four units of occupational therapy (which equals approximately six hours).

(ii) With expedited prior authorization (EPA), up to twenty-four additional units of occupational therapy may be available when the therapy is required as part of an initial botulinum toxin injection protocol for spasticity or dystonia and botulinum toxin has been authorized by the agency.

(b) Physical therapy, per client, per year:

(i) Without authorization:

(A) One physical therapy evaluation;

(B) One physical therapy reevaluation at time of discharge; and

(C) Twenty-four units of physical therapy (which equals approximately six hours).

(ii) With EPA, up to twenty-four additional units of physical therapy may be available when the therapy is required as part of an initial botulinum toxin injection protocol for spasticity or dystonia and botulinum toxin has been authorized by the agency.

(c) Speech therapy, per client, per year:

(i) Without authorization:

(A) One speech language pathology evaluation;

(B) One speech language pathology reevaluation at the time of discharge; and

(C) Six units of speech therapy (which equals approximately six hours).

(ii) With EPA, up to six additional units of speech therapy may be available when:

(A) The therapy is required as part of an initial botulinum toxin injection protocol for spasticity or dystonia and botulinum toxin has been authorized by the agency; or

(B) The client has a speech deficit which requires a speech generating device.

(d) Two durable medical equipment needs assessments, per client, per year. The agency covers devices and other durable medical equipment for habilitative purposes under chapter 182-543 WAC.

(e) Two program units of orthotics management and training of upper and lower extremities, per client, per day.

(f) Two program units for the provider to assess prosthetic or orthotic use, per client, per year.

(g) One muscle testing procedure, per client, per day.

(h) One wheelchair-needs assessment, per client, per year.

(8) The agency evaluates requests for habilitative services that exceed the limitations in this section under WAC 182-501-0169, for clients age twenty-one and older. For clients age nineteen and twenty, the agency evaluates such requests for medical necessity under chapter 182-534 WAC. The agency requires prior authorization for additional units when:

(a) The criteria for EPA do not apply;

(b) The number of available units under the EPA have been used and services are requested beyond the limits; or

(c) The provider requests it as a medically necessary service.

(9) The agency does not cover the following:

(a) Day habilitation services designed to provide training, structured activities, and specialized services to adults;

(b) Services to assist basic needs;

(c) Vocational services;

(d) Custodial services;

(e) Respite care;

(f) Recreational care;

(g) Residential treatment;

(h) Social services; and

(i) Educational services of any kind.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-08-027, § 182-545-400, filed 3/27/19, effective 4/27/19*
- *WSR 16-04-026, § 182-545-400, filed 1/25/16, effective 3/1/16.*

##### **Wash. Admin. Code § 182-545-900** Neurodevelopmental centers. {#sec-182-545-900 omnilex-key=us-wa-regs-official--title-182--182-545-900}

(1) This section describes:

(a) Neurodevelopmental centers that may be reimbursed by the agency;

(b) Clients who may receive covered services at a neurodevelopmental center; and

(c) Covered services for which a neurodevelopmental center may be reimbursed.

(2) In order to provide and be reimbursed for the services listed in subsection (4) of this section, the agency requires a neurodevelopmental center to do all of the following:

(a) Be contracted with the department of health (DOH) as a neurodevelopmental center;

(b) Provide documentation of the DOH contract to the agency; and

(c) Have an approved core provider agreement with the agency.

(3) Clients age twenty or younger may receive outpatient rehabilitation and habilitative services (occupational therapy, physical therapy, and speech therapy) in agency-approved neurodevelopmental centers.

(4) The agency reimburses neurodevelopmental centers for providing the following services to clients:

(a) Outpatient rehabilitation and habilitative services as described in chapter 182-545 WAC; and

(b) Specific pediatric evaluations and team conferences that are:

(i) Attended by the center's medical director; and

(ii) Identified as payable in the agency's provider guides.

(5) To be reimbursed, neurodevelopmental centers must meet the agency's billing requirements in WAC 182-502-0020, 182-502-0100, and 182-502-0150.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-04-026, § 182-545-900, filed 1/25/16, effective 3/1/16. Statutory Authority: RCW 41.05.021. WSR 11-21-066, § 182-545-900, filed 10/17/11, effective 11/17/11. WSR 11-14-075, recodified as § 182-545-900, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-545-900, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.09.080, 74.09.520 and 74.09.530. WSR 01-20-114, § 388-545-900, filed 10/3/01, effective 11/3/01.*

## **Chapter 182-546** Transportation services. {#struct-chapter-182-546}

##### **Wash. Admin. Code § 182-546-0050** Ambulance transportation—General. {#sec-182-546-0050 omnilex-key=us-wa-regs-official--title-182--182-546-0050}

See WAC 182-546-0100 through 182-546-4300 for ambulance transportation and WAC 182-546-5000 through 182-546-6200 for brokered/nonemergency transportation.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0050, filed 8/6/20, effective 9/6/20.*

##### **Wash. Admin. Code § 182-546-0100** Ambulance transportation—Program. {#sec-182-546-0100 omnilex-key=us-wa-regs-official--title-182--182-546-0100}

(1) The provisions of this chapter take precedence with respect to ambulance services in cases of ambiguity in, or conflict with, other agency rules governing eligibility for health care services.

(2) The medicaid agency covers emergency and nonemergency ambulance transportation to and from a covered health care service, subject to the limitations and requirements in this chapter.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0100, filed 8/6/20, effective 9/6/20. WSR 11-14-075, recodified as § 182-546-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. WSR 04-17-118, § 388-546-0100, filed 8/17/04, effective 9/17/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. WSR 01-03-084, § 388-546-0100, filed 1/16/01, effective 2/16/01.*

##### **Wash. Admin. Code § 182-546-0125** Ambulance transportation—Definitions. {#sec-182-546-0125 omnilex-key=us-wa-regs-official--title-182--182-546-0125}

The following definitions and those found in chapter 182-500 WAC apply to ambulance transportation services.

"Advanced life support (ALS)" - See RCW 18.73.030.

"Advanced life support (ALS) assessment" - Means an assessment performed by ALS trained personnel as part of an emergency response that was necessary because the client's reported conditions at the time of dispatch was such that only an ALS crew was qualified to perform the assessment. An ALS assessment does not necessarily result in an ambulance transport or determination that the client requires an ALS level of service or that the transport will be reimbursed at the ALS rate.

"Advanced life support, Level 1 (ALS1)" - Means the transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including the provision of an ALS assessment or at least one ALS intervention.

"Advanced life support, Level 1 (ALS1) emergency" - Means medically necessary ALS1 services, as previously specified, in the context of an emergency response. An emergency response is one that, at the time the ambulance provider is called, it responds immediately.

"Advanced life support, Level 2 (ALS2)" - Means transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including at least three separate administrations of one or more medications by intravenous push/bolus or by continuous infusion (excluding crystalloid fluids) or ground ambulance transport, medically necessary supplies and services, and the provision of at least one of the ALS2 procedures listed below:

(a) Endotracheal intubation;

(b) Cardiac pacing;

(c) Chest decompression;

(d) Creation of a surgical airway;

(e) Manual defibrillation/cardioversion;

(f) Placement of central venous line; or

(g) Placement of intraosseous line.

"Advanced life support (ALS) intervention" - Means a procedure that is in accordance with state and local laws, required to be done by an emergency medical technician intermediate, emergency medical technician advanced, or paramedic.

"Aggregate fee schedule amount" - See RCW 74.70.020.

"Aid vehicle" - See RCW 18.73.030.

"Air ambulance" - Means a helicopter or airplane designed and used to provide transportation for the ill and injured, and to provide personnel, facilities, and equipment to treat clients before and during transportation. Air ambulance is considered an ALS service.

"Allowable costs" - For the ground emergency medical transportation (GEMT) program only, allowable costs means an expenditure that meets the test of the appropriate Executive Office of the President of the United States, Office of Management and Budget (OMB) Circular.

"Ambulance" - Means a ground vehicle or aircraft designed and used to transport the ill and injured, provide personnel, facilities, and equipment to treat clients before and during transportation, and licensed in accordance with RCW 18.73.140.

"Ambulance transport provider" - See RCW 74.70.020.

"Bariatric patient" - Means a patient whose weight, height, or width exceeds the capacity standards of a normal ambulance gurney.

"Bariatric transport unit" - Means a specially equipped ambulance designed for the transportation of bariatric patients.

"Base rate" - Means the agency's minimum payment amount per covered trip, which includes allowances for emergency medical personnel and their services, the costs of standing orders, reusable supplies and equipment, hardware, stretchers, oxygen and oxygen administration, intravenous supplies and IV administration, disposable supplies, waiting time, and the normal overhead costs of doing business. The base rate excludes mileage.

"Basic life support (BLS)" - Means transportation by ground ambulance vehicle and the provision of medically necessary supplies and services, including BLS ambulance services as defined in chapter 18.73 RCW. The ambulance must be staffed by a person qualified as an emergency medical technician-basic (EMT basic) according to department of health (DOH) regulations. BLS does not require the ability to provide or deliver invasive medical procedures and services.

"Basic life support (BLS) emergency" - BLS services provided in an emergency response.

"Bed-confined" - Means the client is unable to perform all of the following actions:

(a) Get up from bed without assistance;

(b) Unable to bear weight or ambulate;

(c) Sit in a chair or wheelchair.

"Behavioral health disorder" - Means mental disorders and substance use disorders.

"Bordering city hospital" - Means a licensed hospital in a designated bordering city (see WAC 182-501-0175).

"Brokered transportation" - Means nonemergency transportation arranged by a broker under contract with the agency, to or from covered health care services for an eligible client (also, see "Transportation provider" in WAC 182-546-5100).

"By report" - See WAC 182-500-0015.

"Children's long-term inpatient program (CLIP)" - Means psychiatric residential treatment provided as a result of judicial commitment or review of the CLIP committee for children five through 17 years of age.

"Closest and most appropriate" - The agency-contracted facility or level of care in which the expected clinical benefits (e.g., improved symptoms) outweigh the expected negative effect (e.g., adverse reactions) to such an extent that the treatment or transportation is justified. This facility may not necessarily be the closest provider based solely on driving distance.

"Conditional release" - Means a period of time the client is released from inpatient care to outpatient care, provided that the client continues to meet certain conditions according to RCW 71.05.340.

"Cost allocation plan (CAP)" - Means a document that identifies, accumulates, and distributes allowable direct and indirect costs to cost objectives. The document also identifies the allocation methods used for distribution to cost objectives, based on relative benefits received.

"Designated crisis responder (DCR)" - Means a behavioral health professional appointed by the county or other authority authorized in rule to perform duties specified in chapter 71.05 RCW and who has received substance use disorder training as determined by the division of behavioral health and recovery.

"Detention" or "detain" - Means the lawful confinement of a person, under chapter 71.05 RCW.

"Direct costs" - Means all costs identified specifically with a particular final cost objective in order to meet emergency medical transportation requirements. This includes unallocated payroll costs for personnel work shifts, medical equipment and supplies, professional and contracted services, travel, training, and other costs directly related to delivering covered medical transportation services.

"Emergency medical service" - Means medical treatment and care that may be rendered at the scene of any medical emergency or while transporting a client in an ambulance to an appropriate medical facility, including ambulance transportation between medical facilities.

"Emergency medical transportation" - Means ambulance transportation during which a client receives necessary emergency medical services immediately prior to, or in transit to, an appropriate medical facility.

"Emergency response" - Means a BLS or ALS level of service that has been provided in immediate response to a 911 call or the equivalent.

"Evaluation and treatment facility" - See RCW 71.05.020.

"Federal financial participation (FFP)" - Means the portion of medical assistance expenditures for emergency medical services that are paid or reimbursed by the Centers for Medicare and Medicaid Services (CMS) according to the state plan for medical assistance. Clients under Title 19, U.S. Health Resources and Services Administration (HRSA) are eligible for FFP.

"Gravely disabled" - Means a condition in which a person, as a result of a mental disorder, or as the result of the use of alcohol or other psychoactive chemicals:

(a) Is in danger of serious physical harm as a result of being unable to provide for personal health or safety; or

(b) Shows repeated and escalating loss of cognitive control over personal actions and is not receiving care essential for personal health or safety.

"Ground ambulance" - Means a ground vehicle designed and used to transport the ill and injured and to provide personnel, facilities, and equipment to treat clients before and during transportation.

"Indirect costs" - Means the costs for a common or joint purpose benefiting more than one cost objective and allocated to each objective using an agency-approved indirect rate or an allocation methodology.

"Initial detention" - Means the period, up to 72 hours, in which a person is involuntarily placed in an evaluation and treatment facility under RCW 71.05.150 or 71.05.153 (see RCW 71.05.160). This period begins on the date and time the evaluation and treatment facility provisionally accepts the client for admission. See definition for "petition for initial detention."

"Interfacility" - Means transportation services between hospitals.

"Invasive procedure" - Means a medically necessary operative procedure in which skin or mucous membranes and connective tissues are cut or an instrument is introduced through a natural body orifice, e.g., an intubation tube. Invasive procedures include a range of procedures from minimally invasive (biopsy, excision) to extensive (organ transplantation). This does not include use of instruments for examinations or very minor procedures such as drawing blood.

"Involuntary Treatment Act (ITA)" - See chapters 71.05 and 71.34 RCW.

"Less restrictive alternative treatment" - Means a program of individualized treatment in a less restrictive setting than inpatient treatment and that includes the services described in RCW 71.05.585.

"Lift-off fee" - Means either of the two base rates the agency pays to air ambulance providers for transporting a client. The agency establishes separate lift-off fees for helicopters and airplanes.

"Loaded mileage" - Means the distance the client is transported in the ambulance.

"Medical attestation" - Means the medical professional is attesting to the fact that the client has a condition that justifies medical transportation and the level of care that is specified by BLS or ALS services and supplies. The condition must also be such that other means of transportation (such as taxi, bus, car, or other means) would be harmful to the client. (See WAC 182-500-0070 for additional information - Medically necessary definition.)

"Medical control" - Means the medical authority upon which an ambulance provider relies to coordinate prehospital emergency services, triage, and trauma center assignment/destination for the person being transported. The medical control is designated in the trauma care plan, by the department of health's (DOH) contracted medical program director, of the region in which the ambulance service is provided.

"Nonemergency ambulance transportation" - Means the use of a ground ambulance to carry a client who may be confined to a stretcher but typically does not require the provision of emergency medical services in transit, or the use of an air ambulance to or from an out-of-state health care service when the out-of-state health care service and air ambulance transportation are prior authorized by the agency. Nonemergency ambulance transportation is usually scheduled or prearranged. See definitions for "prone or supine transportation."

"Parent" - For the purpose of family initiated treatment under RCW 71.34.600 through 71.34.670, means a legal guardian, a person that has been given authorization to make health care decisions for the adolescent, a kinship caregiver who is involved in caring for the adolescent, or another relative who is responsible for the health care of the adolescent who may be required to provide a declaration under penalty of perjury stating that they are a relative responsible for the health care of the adolescent under RCW 9A.72.085.

"Petition for initial detention" - A document required by the superior court of Washington for admission of the client by the evaluation and treatment facility. This form is available on the Washington state superior court mental proceedings rules web page.

"Petition for revocation of a conditional release or less restrictive treatment" - Means a document completed by a designated crisis responder (DCR).

"Point of destination" - Means a health care facility generally equipped to provide the necessary medical, nursing, or behavioral health care necessary to treat the client's injury, illness, symptoms, or complaint.

"Point of pickup" - Means the location of the client at the time the client is placed on board the ambulance or transport vehicle.

"Prehospital care" - Means an assessment, stabilization, and emergency medical care of an ill or injured client by an emergency medical technician, paramedic, or other person before the client reaches the hospital.

"Prone or supine transportation" - Means transporting a client confined to a stretcher or gurney, with or without emergency medical services being provided in transit.

"Public institution" - Means a facility that is either an organizational part of a government entity or over which a governmental unit exercises final administrative control, (e.g., city/county jails and state correctional facilities).

"Publicly owned or operated" - Means an entity that is owned or operated by a unit of government. The unit of government is a state, city, county, special purpose district, or other governmental unit in the state that has taxing authority, has direct access to tax revenues, or is an Indian tribe as defined in the Indian Self-Determination and Education Assistance Act, Section 4.

"Qualifying expenditure" - Means an expenditure for covered services provided to an eligible beneficiary.

"Secure withdrawal management and stabilization facility" - Means a facility operated by either a public or private agency or by the program of an agency which provides care to voluntary individuals involuntarily detained and committed under this chapter for whom there is a likelihood of serious harm or who are gravely disabled due to the presence of a substance use disorder.

"Service period" - Means July 1st through June 30th of each Washington state fiscal year.

"Shift" - Means a standard period of time assigned for a complete cycle of work as set by each participating provider.

"Specialty care transport (SCT)" - Means interfacility (hospital-to-hospital or hospital-to-skilled nursing facility) transportation of a critically injured or ill client by a ground ambulance vehicle under the command of ALS-trained personnel with additional training above the level of a paramedic.

"Standing order" - Means an order remaining in effect indefinitely until canceled or modified by an approved medical program director (regional trauma system) or attending physician.

"Substance use disorder professional (SUDP)" - See WAC 182-500-0100.

"Transfer-down" - Means a transfer from a higher level facility to a facility of lower or equivalent level of care, or back to the original point of pickup (e.g., referring hospital or skilled nursing facility).

"Transfer-up" - Means a transfer from one hospital to a hospital of higher level care when the transfer and discharging hospital has inadequate facilities or care, or appropriate personnel to provide the necessary medical services required by the client.

"Trip" - Means a transportation one-way from the point of pickup to the point of destination by an authorized transportation provider.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-09-029, s 182-546-0125, filed 4/7/26, effective 5/8/26. Statutory Authority: Chapter 74.70 RCW, 41.05.021, 41.05.160 and 2020 c 354. WSR 21-15-010, § 182-546-0125, filed 7/8/21, effective 8/8/21. Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0125, filed 8/6/20, effective 9/6/20.*

##### **Wash. Admin. Code § 182-546-0150** Ambulance transportation—Client eligibility. {#sec-182-546-0150 omnilex-key=us-wa-regs-official--title-182--182-546-0150}

(1) Clients are eligible for ambulance transportation to covered services subject to the requirements and limitations in this chapter.

(a) Clients in the following programs are eligible for ambulance services within Washington state or bordering cities only, as designated in WAC 182-501-0175:

(i) Medical care services (MCS) as described in WAC 182-508-0005;

(ii) Alien emergency medical (AEM) services as described in WAC 182-507-0115.

(b) Clients in the categorically needy/qualified medicare beneficiary (CN/QMB) and medically needy/qualified medicare beneficiary (MN/QMB) programs are covered by medicare and medicaid, with the payment limitations described in WAC 182-546-0400(4).

(2) Clients enrolled in the agency's primary care case management (PCCM) program are eligible for ambulance services that are emergency medical services or that are approved by the PCCM in accordance with the agency's requirements. The agency pays for covered services for these clients according to the agency's published billing guides including, but not limited to, the Tribal Health Billing Guide.

(3) People under the Involuntary Treatment Act (ITA) are not eligible for ambulance transportation coverage outside the state of Washington. This exclusion from coverage applies to people who are being detained involuntarily for behavioral health treatment and being transported to or from bordering cities. See WAC 182-546-4100 through 182-546-4300.

(4) See WAC 182-546-0800 and 182-546-2500 for additional limitations on out-of-state coverage and coverage for clients with other insurance.

(5) The agency does not pay for ambulance services for persons living in public institutions, correctional facilities, and local jails, including people in work-release status with the following exceptions:

(a) If an incarcerated person is put on a legal ITA hold, the ITA eligibility supersedes the incarcerated status;

(b) If an incarcerated person is admitted to an inpatient care facility (not the emergency department), and must be transported to a second inpatient care facility to obtain the services needed. See WAC 182-503-0505(5).

(6) Clients in family planning only programs are not eligible for ambulance transportation services.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0150, filed 8/6/20, effective 9/6/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-12-091, § 182-546-0150, filed 6/5/18, effective 7/6/18. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148). WSR 14-07-042, § 182-546-0150, filed 3/12/14, effective 4/12/14. Statutory Authority: RCW 41.05.021. WSR 13-16-006, § 182-546-0150, filed 7/25/13, effective 8/25/13. WSR 11-14-075, recodified as § 182-546-0150, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. WSR 04-17-118, § 388-546-0150, filed 8/17/04, effective 9/17/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. WSR 01-03-084, § 388-546-0150, filed 1/16/01, effective 2/16/01.*

##### **Wash. Admin. Code § 182-546-0200** Ambulance transportation—Scope of coverage. {#sec-182-546-0200 omnilex-key=us-wa-regs-official--title-182--182-546-0200}

(1) The ambulance program is a medical transportation service. The medicaid agency pays for ambulance transportation to and from covered medical services when the transportation is:

(a) Within the scope of an eligible client's medical care program (see WAC 182-501-0060);

(b) Medically necessary as defined in WAC 182-500-0070 based on the client's condition at the time of the ambulance trip and as documented in the client's record;

(c) Appropriate to the client's actual medical need; and

(d) To one of the following destinations:

(i) The closest and most appropriate agency-contracted medical provider of agency-covered services; or

(ii) The designated trauma facility as identified in the emergency medical services and trauma regional patient care procedures manual.

(2) The agency limits coverage to medically necessary ambulance transportation that is required because the client cannot be safely or legally transported any other way. If a client can safely travel by car, van, taxi, or other means, the ambulance trip is not medically necessary and the agency does not cover the ambulance service. See WAC 182-546-0250 (1) and (2) for noncovered ambulance services.

(3) If medicare or another third party is the client's primary health insurer and that primary insurer denies coverage of an ambulance trip due to a lack of medical necessity, the agency requires the provider when billing the agency for that trip to:

(a) Attach the third-party determination to the claim; and

(b) Submit documentation showing that the trip meets the agency's medical necessity criteria. See WAC 182-546-1000 and 182-546-1500 for requirements for nonemergency ambulance coverage.

(4) The agency covers the following ambulance transportation:

(a) Ground ambulance when the eligible client:

(i) Has an emergency medical need for the transportation;

(ii) Needs medical attention to be available during the trip; or

(iii) Must be transported by stretcher or gurney.

(b) Air ambulance when justified under the conditions of this chapter or when the agency determines that air ambulance is less costly than ground ambulance in a particular case. In the latter case, the agency must prior authorize the air ambulance transportation. See WAC 182-546-1500 for nonemergency air ambulance coverage.

(5) See also WAC 182-531-1740 Treat and refer services.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0200, filed 8/6/20, effective 9/6/20. Statutory Authority: RCW 41.05.021, 41.05.160, and 2017 c 273. WSR 19-19-090, § 182-546-0200, filed 9/18/19, effective 10/19/19. WSR 11-14-075, recodified as § 182-546-0200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-546-0200, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. WSR 04-17-118, § 388-546-0200, filed 8/17/04, effective 9/17/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. WSR 01-03-084, § 388-546-0200, filed 1/16/01, effective 2/16/01.*

##### **Wash. Admin. Code § 182-546-0250** Ambulance transportation—Noncovered services. {#sec-182-546-0250 omnilex-key=us-wa-regs-official--title-182--182-546-0250}

(1) The medicaid agency does not cover ambulance services when the transportation is:

(a) Not medically necessary based on the client's condition at the time of service (see exception at WAC 182-546-1000);

(b) Refused by the client (see exception for ITA clients in WAC 182-546-4100 through 182-546-4300);

(c) For a client who is deceased at the time the ambulance arrives at the scene;

(d) For a client who dies after the ambulance arrives at the scene but prior to transport and the ambulance crew provided minimal to no medical interventions/supplies at the scene (see WAC 182-546-0500(2));

(e) Requested for the convenience of the client or the client's family;

(f) More expensive than bringing the necessary medical service(s) to the client's location in nonemergency situations;

(g) To transfer a client from a medical facility to the client's residence (except when the residence is a nursing facility);

(h) Requested solely because a client has no other means of transportation;

(i) Provided by other than licensed ambulance providers (e.g., wheelchair vans, cabulance, stretcher cars); or

(j) Not to the nearest appropriate medical facility.

(2) If transport does not occur, the agency does not cover the ambulance service, except as provided in WAC 182-546-0500(2) and 182-531-1740 Treat and refer services.

(3) The agency evaluates requests for services that are listed as noncovered in this chapter under the provisions of WAC 182-501-0160.

(4) For ambulance services that are otherwise covered under this chapter but are subject to one or more limitations or other restrictions, the agency evaluates, on a case-by-case basis, requests to exceed the specified limits or restrictions. The agency approves such requests when medically necessary, according to the provisions of WAC 182-501-0165 and 182-501-0169.

(5) An ambulance provider may bill a client for noncovered services as described in this section, if the requirements of WAC 182-502-0160 are met.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0250, filed 8/6/20, effective 9/6/20. Statutory Authority: RCW 41.05.021, 41.05.160, and 2017 c 273. WSR 19-19-090, § 182-546-0250, filed 9/18/19, effective 10/19/19. WSR 11-14-075, recodified as § 182-546-0250, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-546-0250, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. WSR 04-17-118, § 388-546-0250, filed 8/17/04, effective 9/17/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. WSR 01-03-084, § 388-546-0250, filed 1/16/01, effective 2/16/01.*

##### **Wash. Admin. Code § 182-546-0300** Ambulance transportation—General requirements for ambulance providers. {#sec-182-546-0300 omnilex-key=us-wa-regs-official--title-182--182-546-0300}

(1) Ambulances must be licensed, operated, and equipped according to applicable federal, state, and local statutes, ordinances and regulations. An air ambulance provider must have a current Federal Aviation Administration (FAA) air carrier operating certificate, or have a contractual relationship with an operator with a valid medical certificate.

(2) Ambulances must be staffed and operated by appropriately trained and certified personnel in accordance with chapter 18.73 RCW.

(3) Providers of ambulance services must:

(a) Meet the requirements of chapter 182-502 WAC and this chapter; and

(b) Document the medical necessity for transportation and related services billed to the medicaid agency. This documentation must be kept in the provider's file and include adequate descriptions of the severity and complexity of the client's condition at the time of the transportation and services, interventions, and supplies provided to the client prior to loading and in transit. The documentation must be made available for the agency to review upon request to ensure the agency's medical necessity criteria are met.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0300, filed 8/6/20, effective 9/6/20. WSR 11-14-075, recodified as § 182-546-0300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. WSR 04-17-118, § 388-546-0300, filed 8/17/04, effective 9/17/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. WSR 01-03-084, § 388-546-0300, filed 1/16/01, effective 2/16/01.*

##### **Wash. Admin. Code § 182-546-0400** Ambulance transportation—General limitations on payment for ambulance services. {#sec-182-546-0400 omnilex-key=us-wa-regs-official--title-182--182-546-0400}

(1) In accordance with WAC 182-502-0100(8), the agency pays providers the lesser of the provider's usual and customary charges or the maximum allowable rate established by the agency. The agency's fee schedule payment for ambulance services includes a base rate or lift-off fee plus mileage.

(2) The agency does not pay providers for mileage incurred traveling to the point of pickup or any other distances traveled when the client is not on board the ambulance. The agency pays for loaded mileage only as follows:

(a) The agency pays ground ambulance providers for the actual mileage incurred for covered trips by paying from the client's point of pickup to the point of destination.

(b) The agency pays air ambulance providers for the statute miles incurred for covered trips by paying from the client's point of pickup to the point of destination.

(3) The agency does not pay for ambulance services if:

(a) The client is not transported, unless the services are provided under WAC 182-531-1740 Treat and refer services;

(b) The client is transported but not to an appropriate treatment facility; or

(c) The client dies before the ambulance trip begins (see the single exception for ground ambulance providers at WAC 182-546-0500(2)).

(4) For clients in the categorically needy/qualified medicare beneficiary (CN/QMB) and medically needy/qualified medicare beneficiary (MN/QMB) programs, the agency's payment is as follows:

(a) If medicare covers the service, the agency pays the lesser of:

(i) The full coinsurance and deductible amounts due, based upon medicaid's allowed amount; or

(ii) The agency's maximum allowable for that service minus the amount paid by medicare.

(b) If medicare does not cover or denies ambulance services that the agency covers according to this chapter, the agency pays its maximum allowable fee; except the agency does not pay for clients on the qualified medicare beneficiaries (QMB) only program.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0400, filed 8/6/20, effective 9/6/20. Statutory Authority: RCW 41.05.021, 41.05.160, and 2017 c 273. WSR 19-19-090, § 182-546-0400, filed 9/18/19, effective 10/19/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-12-091, § 182-546-0400, filed 6/5/18, effective 7/6/18. Statutory Authority: RCW 41.05.021. WSR 13-16-006, § 182-546-0400, filed 7/25/13, effective 8/25/13. WSR 11-14-075, recodified as § 182-546-0400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. WSR 04-17-118, § 388-546-0400, filed 8/17/04, effective 9/17/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. WSR 01-03-084, § 388-546-0400, filed 1/16/01, effective 2/16/01.*

##### **Wash. Admin. Code § 182-546-0425** Ambulance transportation—During inpatient hospital stays. {#sec-182-546-0425 omnilex-key=us-wa-regs-official--title-182--182-546-0425}

(1) The medicaid agency does not pay separately for ambulance transportation when a client remains as an inpatient client at the admitting hospital and the transportation to or from another facility is for diagnostic or treatment services (e.g., MRI scanning, kidney dialysis). Transportation of an inpatient client for such services is the responsibility of the admitting hospital, regardless of the payment method the agency uses to pay the hospital.

(2) Hospital-to-hospital transfers. Except as provided in subsections (3) and (5) of this section, the agency does not pay for hospital-to-hospital transfers of a client when ambulance transportation is requested solely to:

(a) Accommodate a physician's or other health care provider's preference for facilities;

(b) Move the client closer to family or home (i.e., for personal or family convenience); or

(c) Meet insurance requirements or hospital/insurance agreements.

(3) Transfer-up services. The agency pays for transfer-up ambulance transportation services as follows:

(a) Air ambulance transportation only when transportation by ground ambulance would cause sufficient delay as to endanger the client's life or substantially impair the client's health (e.g., in major trauma cases).

(b) Air ambulance transportation for medical and surgical procedures only and not for diagnostic purposes.

(c) The reason for the transfer-up must be clearly documented in the client's hospital chart and in the ambulance trip report.

(4) Transfer-down services. The agency pays for ground ambulance transfer-down services with a signed physician certification statement (PCS) or a nonphysician certification statement (NPCS).

(5) Specialty care transport (SCT). The agency pays an ambulance provider the advanced life support (ALS) rate for an SCT-level transport, provided:

(a) The criteria for covered hospital transfers are met; and

(b) The SCT is from an acute care hospital to another acute care hospital.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0425, filed 8/6/20, effective 9/6/20. WSR 11-14-075, recodified as § 182-546-0425, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. WSR 04-17-118, § 388-546-0425, filed 8/17/04, effective 9/17/04.*

##### **Wash. Admin. Code § 182-546-0450** Ambulance transportation—Ground ambulance—Payment. {#sec-182-546-0450 omnilex-key=us-wa-regs-official--title-182--182-546-0450}

(1) The medicaid agency pays for two levels of service for ground ambulance transportation: Basic life support (BLS) and advanced life support (ALS):

(a) A BLS ambulance trip is one in which the client receives basic, noninvasive medical services at the scene, point-of-pickup, or in transit to a hospital or other appropriate treatment facility.

(b) An ALS ambulance trip is one in which the client requires more complex life-saving services at the scene, point-of-pickup, or in transit to a hospital or other appropriate treatment facility. To qualify for payment at the ALS level, certified paramedics or other ALS-qualified personnel must provide the advanced medical services on board a properly equipped vehicle as defined by chapter 18.73 RCW. Examples of complex medical services or ALS procedures include, but are not limited to, the following:

(i) Administration of medication by intravenous push/bolus or by continuous infusion;

(ii) Airway intubation;

(iii) Cardiac pacing;

(iv) Chemical restraint;

(v) Chest decompression;

(vi) Creation of surgical airway;

(vii) Initiation of intravenous therapy;

(viii) Manual defibrillation/cardioversion;

(ix) Placement of central venous line; and

(x) Placement of intraosseous line.

(2) The agency pays for ambulance services (BLS or ALS) based on the client's medical condition and the medical services provided immediately prior to or during the trip.

(a) Local ordinances or standing orders that require all ambulance vehicles be ALS-equipped do not qualify an ambulance trip for the agency's payment at the ALS level of service unless ALS services were provided on-scene or in transit to the treatment facility.

(b) A ground ambulance trip is classified and paid at a BLS level, even if certified paramedics or ALS-qualified personnel are on board the ambulance, if no ALS-type interventions were provided on-scene or in transit to the treatment facility.

(c) An ALS assessment does not qualify as an ALS transport if no ALS-type interventions were provided to the client in transit to the treatment facility.

(3) An assessment and other intervention performed on-scene with no resulting transport does not qualify for payment from the agency, except when the client dies after treatment but before transport as provided in WAC 182-546-0500(2).

(4) The agency pays ground ambulance providers for mileage as follows:

(a) Loaded mileage only.

(b) Actual mileage incurred for covered trips (i.e., from the point-of-pickup to the destination) based on trip odometer readings.

(i) The agency uses the Washington state department of transportation's (WSDOT) mileage chart. The WSDOT mileage chart indicates shortest distance between points, including the use of the ferry system.

(ii) The agency uses alternative sources to calculate distance traveling when the origin or destination points are not listed in the WSDOT's mileage chart.

(iii) If the ferry system is the normal route for travel but is not used, the reason must be documented on the claim form when billing the agency. In this case, normal means the shortest route.

(iv) Miles traveled by the ferry. To be paid, providers must report by statute miles using the Washington state department of transportation (WSDOT) ferry route mileage chart located on the WSDOT website. Providers must thoroughly document the ferry route used, including a copy of the ferry ticket.

(5) The agency's base rate includes:

(a) Necessary personnel and services;

(b) Oxygen and oxygen administration; and

(c) Intravenous supplies and intravenous administration reusable supplies, disposable supplies, required equipment, and waiting time.

(6) The agency pays ground ambulance providers the same rate for mileage, regardless of the level of service (ALS or BLS). An odometer reading showing a fraction of a mile (partial mile) at the conclusion of a transport must be rounded up to the next whole unit (one mile). The agency pays for mileage when the client is transported to and from medical services within the local community only, unless necessary medical care is not available locally. The provider must fully document in the client's record the circumstances that make medical care outside of the client's local community necessary.

(7) The agency pays for extra mileage when sufficient justification is documented in the client's record and the ambulance trip report. All records are subject to agency review. Acceptable reasons for allowable extra mileage include, but are not limited to:

(a) The initial destination hospital was on "divert" status and not accepting patients; or

(b) A road construction project or other major obstacle caused a detour, or had to be avoided to save time.

(8) When multiple ambulance providers respond to an emergency call, the agency pays only the ambulance provider who actually provides the transportation.

(9) The agency pays for an extra attendant when the ground ambulance provider documents in the client's file the justification for the extra attendant and the extra attendant is on board for the trip because of one or more of the following:

(a) The client weighs three hundred pounds or more;

(b) The client is violent or difficult to move safely;

(c) The client is being transported for ITA purposes and the client must be restrained during the trip; or

(d) More than one client is being transported, and each requires medical attention or close monitoring.

(10) The agency pays ambulance providers "by report" for ferry and bridge tolls incurred when transporting clients. Receipts must be attached to the claim submission for reimbursement. All ferry and bridge toll documentation must be kept in the client's file and made available to the agency for six years from the date of service in accordance with WAC 182-502-0020.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0450, filed 8/6/20, effective 9/6/20. WSR 11-14-075, recodified as § 182-546-0450, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. WSR 04-17-118, § 388-546-0450, filed 8/17/04, effective 9/17/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. WSR 01-03-084, § 388-546-0450, filed 1/16/01, effective 2/16/01.*

##### **Wash. Admin. Code § 182-546-0500** Ambulance transportation—Ground ambulance—Payment in special circumstances. {#sec-182-546-0500 omnilex-key=us-wa-regs-official--title-182--182-546-0500}

(1) When more than one client is transported in the same ground ambulance at the same time, the medicaid agency:

(a) Pays the ambulance providers at a reduced base rate for the second client who is being transported in the ambulance for medical treatment. This rate is set at seventy-five percent of the base rate for the applicable level of service (ALS or BLS) for the first client;

(b) Does not pay the ambulance provider a separate mileage charge for the second client being transported in the ambulance for medical treatment. The total payable mileage for the transport is from the first point of pickup.

(2) The agency pays an ambulance provider at the appropriate base rate (BLS or ALS) if no transportation takes place because the client died before transport could occur but after the ambulance crew provided medical interventions/supplies to the client at the scene prior to the client's death. The intervention(s)/supplies provided must be documented in the client's record. No mileage charge is allowed with the base rate when the client dies after medical interventions/supplies are provided but before transport takes place.

(3) In situations where a BLS entity provides the transport of the client and an ALS entity provides a service that meets the agency's fee schedule definition of an ALS intervention, the BLS provider may bill the agency the ALS rate for the transport, provided a written reimbursement agreement between the BLS and ALS entities exists. The provider must give the agency a copy of the agreement upon request. If a written agreement does not exist between the BLS and ALS entities, the agency will pay only for the BLS level of service. Only one ambulance provider may bill the agency for the transport.

(4) In ambulance service areas/jurisdictions that distinguish between residents and nonresidents, the provider must bill the agency the same rate for ambulance services provided to a client in a particular jurisdiction as would be billed for ambulance services to residents of the same jurisdiction.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0500, filed 8/6/20, effective 9/6/20. WSR 11-14-075, recodified as § 182-546-0500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. WSR 04-17-118, § 388-546-0500, filed 8/17/04, effective 9/17/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. WSR 01-03-084, § 388-546-0500, filed 1/16/01, effective 2/16/01.*

##### **Wash. Admin. Code § 182-546-0510** GEMT program overview. {#sec-182-546-0510 omnilex-key=us-wa-regs-official--title-182--182-546-0510}

(1) The ground emergency medical transportation (GEMT) program permits publicly owned or operated providers to receive cost-based payments for emergency ground ambulance transportation of clients as described in subsection (2) of this section.

(2) This program is for clients under Title XIX of the federal Social Security Act and the Affordable Care Act (ACA) only. Participating providers do not receive supplemental payments for transporting:

(a) Medicaid applicants; or

(b) Medicare/medicaid clients with dual eligibility.

(3) The cost-based payment, when combined with the amount received from all other sources of reimbursement for medicaid, must not exceed one hundred percent of allowable costs.

(4) Fire departments/districts must use the approved CAP of their local government. If the local government does not have a CAP, they must use the Centers for Medicare and Medicaid Services (CMS)-approved cost report.

(5) The state general fund cannot be used for GEMT cost-based payments.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0510, filed 8/6/20, effective 9/6/20. Statutory Authority: RCW 41.05.021, 41.05.160, and 2015 c 147. WSR 19-08-058, § 182-546-0510, filed 3/29/19, effective 5/1/19.*

##### **Wash. Admin. Code § 182-546-0515** GEMT provider participation and qualifications. {#sec-182-546-0515 omnilex-key=us-wa-regs-official--title-182--182-546-0515}

(1) Participation in the program by a GEMT provider is voluntary.

(2) To qualify under this program and receive supplemental payments, a participating provider must:

(a) Provide ground emergency transportation services to clients as described in WAC 182-546-0510(2).

(b) Be publicly owned or operated as defined in WAC 182-546-0125.

(c) Be enrolled as a medicaid provider, with an approved core provider agreement, for the service period specified in the claim.

(d) Submit a participation agreement.

(e) Renew GEMT participation annually by submitting the Centers for Medicare and Medicaid Services (CMS)-approved cost report to the agency.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0515, filed 8/6/20, effective 9/6/20. Statutory Authority: RCW 41.05.021, 41.05.160, and 2015 c 147. WSR 19-08-058, § 182-546-0515, filed 3/29/19, effective 5/1/19.*

##### **Wash. Admin. Code § 182-546-0520** GEMT supplemental payments. {#sec-182-546-0520 omnilex-key=us-wa-regs-official--title-182--182-546-0520}

(1) The agency makes supplemental payments for the uncompensated and allowable costs incurred while providing GEMT services to clients, as defined by the United States Office of Management and Budget (OMB).

(a) The amount of supplemental payments, when combined with the amount received from all other sources of reimbursement from the medicaid program, will not exceed one hundred percent of allowable costs.

(b) If the participating provider does not have any uncompensated care costs, then the participating provider will not receive payment under this program.

(2) The total payment is equal to the participating provider's allowable costs of providing the services.

(a) The participating provider must certify the uncompensated expenses using the cost reporting process described under WAC 182-546-0525. This cost reporting process allows medicaid to obtain federal matching dollars to be distributed to participating providers.

(b) The participating provider must:

(i) Include the expenditure in its budget.

(ii) Certify that the claimed expenditures for the GEMT services are eligible for FFP and that the costs were allocated to the appropriate cost objective according to the cost allocation plan.

(iii) Provide evidence, specified by the agency, supporting the certification.

(iv) Submit data, specified by the agency, determining the appropriate amounts to claim as expenditures qualifying for FFP.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0520, filed 8/6/20, effective 9/6/20. Statutory Authority: RCW 41.05.021, 41.05.160, and 2015 c 147. WSR 19-08-058, § 182-546-0520, filed 3/29/19, effective 5/1/19.*

##### **Wash. Admin. Code § 182-546-0525** GEMT claim submission and cost reporting. {#sec-182-546-0525 omnilex-key=us-wa-regs-official--title-182--182-546-0525}

(1) Each participating provider is responsible for submitting claims to the agency for services provided to eligible clients. Participating providers must submit the claims according to the rules and billing instructions in effect at the time the service is provided.

(2) On an annual basis, participating providers must certify and allocate their direct and indirect costs as qualifying expenditures eligible for FFP.

(3) The claimed costs must be necessary to carry out GEMT.

(4) Participating providers must complete cost reporting according to the Centers for Medicare and Medicaid Services (CMS)-approved cost identification principles and standards such as the most current editions of the CMS Provider Reimbursement Manual and the United States Office of Management and Budget Circular (OMB) Circular A-87.

(5) Participating providers must completely and accurately document the CMS-approved cost report as required under OMB Circular A-87 Attachment A.

(6) Participating providers must allocate direct and indirect costs to the appropriate cost objectives as indicated in the cost report instructions.

(7) Reported personnel costs including wages, salaries, and fringe benefits must be exclusively attributable to ground emergency ambulance services provided. Services do not include fire suppression.

(8) Revenues received directly, such as foundation grants and money from private fund-raising, are not eligible for certification because such revenues are not expenditures of a government entity.

(9) The sum of a participating provider's allowable direct and indirect costs are divided by the number of ground emergency medical transports to determine a participating provider's average cost per qualifying transport.

(10) Participating providers must complete an annual cost report documenting the participating provider's total CMS-approved, direct and indirect costs of delivering medicaid-covered services using a CMS-approved cost-allocation methodology. Participating providers must:

(a) Submit the cost report within five months after the close of the service period.

(b) Request an extension to the cost report deadline in writing to the agency, if needed. The agency will review requests for an extension on a case-by-case basis.

(c) Provide additional documentation justifying the information in the cost report, upon request by the agency.

(d) Assure the agency receives the cost report or additional documentation according to WAC 182-502-0020.

(i) Participating providers must comply with WAC 182-502-0020 to receive the supplemental payment under this program.

(ii) The agency pays the claims for the following service period according to the agency's current ambulance fee schedule.

(11) The costs associated with releasing a client on the scene without transportation by ambulance to a medical facility are eligible for FFP and are eligible expenditures.

(12) Other expenses associated with the prehospital care are eligible costs associated with GEMT.

(13) Expenditures are not eligible costs until the services are provided.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0525, filed 8/6/20, effective 9/6/20. Statutory Authority: RCW 41.05.021, 41.05.160, and 2015 c 147. WSR 19-08-058, § 182-546-0525, filed 3/29/19, effective 5/1/19.*

##### **Wash. Admin. Code § 182-546-0530** GEMT interim supplemental payment. {#sec-182-546-0530 omnilex-key=us-wa-regs-official--title-182--182-546-0530}

(1) The agency pays an interim supplemental payment for GEMT. These payments using the interim supplemental payment allows the agency to pay participating providers for GEMT. The payments will approximate the GEMT costs eligible for federal financial participation claimed through the certified public expenditure (CPE) process.

(2) The agency computes the interim supplemental payment for GEMT on an annual basis.

(3) To determine the interim supplemental payment for GEMT, the agency uses the most recently filed cost reports of all participating providers to determine an average cost per qualifying transport. Therefore, the cost per participating provider and the amount of interim supplemental payments will vary among the participating providers.

(4) The agency distributes the interim supplemental payments to participating providers on a weekly basis using claims data as documented in the agency's claim system.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2015 c 147. WSR 19-08-058, § 182-546-0530, filed 3/29/19, effective 5/1/19.*

##### **Wash. Admin. Code § 182-546-0535** GEMT cost reconciliation and settlement process. {#sec-182-546-0535 omnilex-key=us-wa-regs-official--title-182--182-546-0535}

(1) The agency reconciles each interim supplemental payment for GEMT to the provider's filed cost report for the service year in which interim supplemental payments are made.

(2) The agency compares the total medicaid-allowable costs to the interim supplemental payments paid to the participating providers as documented in the agency's claim system, resulting in cost reconciliation.

(3) The agency performs cost settlements based on the final Centers for Medicare and Medicaid Services (CMS)-approved cost report schedules for all participating providers.

(a) The agency:

(i) Recovers from the participating provider the federal payments that exceed the participating provider's cost per qualifying transport; or

(ii) Pays the participating provider if the cost per transport exceeds the interim supplemental payment amount.

(b) If a participating provider disputes the reimbursement rate before there is an overpayment, the provider may appeal under WAC 182-502-0220.

(c) If a participating provider disputes the agency's determination that the participating provider has been overpaid, the participating provider may request a hearing under WAC 182-502-0230.

(4) The agency reports to the CMS any difference between the payments of federal funds made to the participating providers and the federal share of the qualifying expenditures and returns excess funds to CMS.

(5) Each participating provider must agree to reimburse the agency for the costs associated with administering the GEMT program. The costs are collected during the final reconciliation and settlement process and cannot be included as an expense in the participating provider's cost report.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2015 c 147. WSR 19-08-058, § 182-546-0535, filed 3/29/19, effective 5/1/19.*

##### **Wash. Admin. Code § 182-546-0540** GEMT records maintenance. {#sec-182-546-0540 omnilex-key=us-wa-regs-official--title-182--182-546-0540}

In addition to the health care record requirements in WAC 182-502-0020, GEMT participating providers must also maintain records of accounting procedures and practices that reflect all direct and indirect costs, of any nature, spent performing GEMT services.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2015 c 147. WSR 19-08-058, § 182-546-0540, filed 3/29/19, effective 5/1/19.*

##### **Wash. Admin. Code § 182-546-0545** GEMT auditing. {#sec-182-546-0545 omnilex-key=us-wa-regs-official--title-182--182-546-0545}

(1) The agency may conduct audit or investigation activities, as described under chapters 74.09 RCW and 182-502A WAC, to determine compliance with the rules and regulations of the core provider agreement, as well as of the GEMT program.

(2) If an audit or investigation is initiated, the participating provider must retain all original records and supporting documentation until the audit or investigation is completed and all issues are resolved, even if the period of retention extends beyond the required six-year period required under WAC 182-502-0020.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0545, filed 8/6/20, effective 9/6/20. Statutory Authority: RCW 41.05.021, 41.05.160, and 2015 c 147. WSR 19-08-058, § 182-546-0545, filed 3/29/19, effective 5/1/19.*

##### **Wash. Admin. Code § 182-546-0600** Ambulance transportation—Procedure code modifiers. {#sec-182-546-0600 omnilex-key=us-wa-regs-official--title-182--182-546-0600}

When billing the medicaid agency for ambulance trips, ambulance providers must use procedure code modifiers.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0600, filed 8/6/20, effective 9/6/20. WSR 11-14-075, recodified as § 182-546-0600, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. WSR 04-17-118, § 388-546-0600, filed 8/17/04, effective 9/17/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. WSR 01-03-084, § 388-546-0600, filed 1/16/01, effective 2/16/01.*

##### **Wash. Admin. Code § 182-546-0700** Ambulance transportation—Air ambulance—Payment. {#sec-182-546-0700 omnilex-key=us-wa-regs-official--title-182--182-546-0700}

(1) The medicaid agency pays for air ambulance transportation for clients only when all of the following conditions are met:

(a) The client's medical condition requires immediate and rapid transportation beyond what ground ambulance can provide;

(b) The client's destination is an acute care hospital or appropriate trauma designated facility; and

(c) The vehicle and crew meet the requirements in WAC 182-502-0016 and this chapter.

(2) Other factors the agency may consider in payment decisions for air ambulance include:

(a) The point-of-pickup is not accessible by ground ambulance (e.g., mountain rescue);

(b) The necessary medical care is not available locally and time is of the essence; and

(c) The use of other means of air travel (e.g., commercial flight) is medically contraindicated.

(3) Lift-off fee. The agency pays a lift-off fee for each client being transported by air ambulance to an acute care facility for medical treatment.

(a) When more than one client is transported in the same ambulance at the same time, each client must meet medical necessity criteria for the provider to receive a lift-off fee for each client transported.

(b) The agency does not pay a lift-off fee:

(i) For a client onboard an air ambulance when the client is not being transported for medical treatment (e.g., a mother accompanying a child to the hospital).

(ii) When the air ambulance is dispatched in response to a call but the client is not transported by the aircraft.

(4) Statute miles. The agency pays an air ambulance provider for statute miles incurred for covered trips by paying from the client's point-of-pickup to the point of destination.

(a) When more than one client requiring medical treatment is transported in the same air ambulance at the same time, the ambulance provider must divide the statute miles traveled by the number of clients being transported for medical treatment and bill the agency the mileage portion attributable to each client.

(b) The agency does not pay for mileage for a client who is traveling in an air ambulance but is not being transported for medical treatment (e.g., a mother accompanying a child to the hospital). Only the statute miles directly associated with the client transported for treatment may be billed to the agency.

(5) Extra mileage. The agency does not pay for extra mileage incurred during an air ambulance transport, except in an unusual circumstance. The unusual circumstance must be clearly described and documented in the ambulance trip report and the client's file. The exception for an unusual circumstance does not apply to nonemergency air transports that are prior authorized by the agency. Unusual circumstances for incurring additional air miles include, but are not limited to:

(a) Having to avoid a no fly zone;

(b) Being forced to land at an alternate destination due to severe weather; and

(c) Being diverted to another designated trauma facility.

(6) Lift-off fee plus mileage. The agency's payment for an air ambulance transport (lift-off fee plus mileage) includes all necessary personnel, services, supplies, and equipment. The agency does not make separate payment to air ambulance providers for unbundled services (e.g., pediatric ventilators).

(7) More than one travel segment. When an ambulance transport requires more than one travel segment (leg) to complete, the agency limits its payment for the transport as follows:

(a) If a fixed-wing aircraft is used and the transport involves more than one lift-off for the same client on the same trip (e.g., transportation from Spokane to Portland, but the aircraft makes a stop in the Tri-Cities), the agency pays the air ambulance provider for one lift-off fee for the client and the total air miles.

(b) For nonemergency air ambulance transports that are prior authorized by the agency, the negotiated rate includes both air and ground ambulance services, unless the agency's authorization letter specifically allows for ground ambulance services to be billed separately.

(8) Nonemergency air transportation – Prior authorization and negotiated rate. Nonemergency air ambulance transportation must be prior authorized by the agency.

(a) Nonemergency air ambulance transportation includes scheduled transports to or from out-of-state treatment facilities (see WAC 182-546-1500).

(b) Nonemergency air ambulance transportation that is prior authorized by the agency are paid a negotiated rate. The negotiated rate is an all-inclusive rate and may include transportation for a legally responsible family member or legal guardian accompanying the client being transported for medical treatment.

(9) The agency does not pay:

(a) For food, lodging, and other expenses of air ambulance personnel when a scheduled transport is delayed because of changes in the medical status of the client to be transported, weather conditions, or other factors;

(b) For fuel, maintenance and other aircraft-related expenses resulting from transportation delays because of changes in the medical status of the client to be transported, weather conditions, or other factors;

(c) Separately for ground ambulance services to and from airports and treatment facilities when these transportation services are specifically included in the negotiated air ambulance rate; and

(d) For canceled air ambulance transports, for any reason.

(10) The agency does not pay private organizations for volunteer medical air ambulance transportation services unless no other air ambulance option is available. The use of private, volunteer air transportation must be prior authorized by the agency to be payable. If authorized by the agency, the agency's payment for the transport is the lesser of:

(a) The provider's actual incurred and documented cost (e.g., fuel); or

(b) The agency's established rate (fee schedule).

(11) If the agency determines, upon review, that an air ambulance transport was not:

(a) Medically necessary, the agency may deny, recoup, or limit its payment to the amount the agency would have paid to a ground ambulance provider for the same distance traveled; or

(b) To the closest, most appropriate agency-contracted hospital, the agency may deny, recoup, or limit its payment to the maximum amount it would have paid an air ambulance provider for a transport to the nearest, most appropriate agency-contracted facility.

(12) The agency uses commercial airline companies whenever the client's medical condition permits the client to be transported safely by nonmedical or scheduled carriers.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0700, filed 8/6/20, effective 9/6/20. WSR 11-14-075, recodified as § 182-546-0700, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. WSR 04-17-118, § 388-546-0700, filed 8/17/04, effective 9/17/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. WSR 01-03-084, § 388-546-0700, filed 1/16/01, effective 2/16/01.*

##### **Wash. Admin. Code § 182-546-0800** Ambulance transportation—Provided in another state or U.S. territory—Payment. {#sec-182-546-0800 omnilex-key=us-wa-regs-official--title-182--182-546-0800}

(1) The medicaid agency pays for emergency ambulance transportation provided to clients who are in another state or U.S. territory according to the provisions of WAC 182-501-0180, 182-501-0182, and 182-502-0120.

(2) To receive payment from the agency, an out-of-state ambulance provider must:

(a) Meet the licensing requirements for Washington state and of the ambulance provider's home state or province;

(b) Have an approved core provider agreement with the agency.

(3) The agency pays for emergency ambulance transportation provided out-of-state for eligible clients when the transport is:

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

(b) Medically necessary as defined in WAC 182-500-0070; and

(c) To the closest, most appropriate treatment facility.

(4) The agency does not pay for an ambulance transport provided in another state for a client when:

(a) The client's medical eligibility program covers health care services within Washington state or designated bordering cities only. See WAC 182-546-0150 and 182-546-0200(5);

(b) The transport was nonemergency and was not prior authorized by the agency.

(5) The agency pays for emergency ambulance transportation at the lower of:

(a) The provider's billed amount; or

(b) The rate established by the agency.

(6) The agency does not pay for nonemergency (ground or air ambulance) transportation outside the state of Washington (i.e., both origin and destination points are outside the state's borders).

(7) An ambulance provider who transports a client to a facility outside the state (excluding designated bordering cities) or brings a client into the state from a location outside the state (excluding designated border cities) must obtain prior authorization from the agency for a nonemergency transport in order to be paid. See WAC 182-546-4000 for transports under the ITA.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0800, filed 8/6/20, effective 9/6/20. WSR 11-14-075, recodified as § 182-546-0800, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035. WSR 08-08-064, § 388-546-0800, filed 3/31/08, effective 5/1/08. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. WSR 04-17-118, § 388-546-0800, filed 8/17/04, effective 9/17/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. WSR 01-03-084, § 388-546-0800, filed 1/16/01, effective 2/16/01.*

##### **Wash. Admin. Code § 182-546-0900** Ambulance transportation—Provided outside the United States and U.S. territories—Payment. {#sec-182-546-0900 omnilex-key=us-wa-regs-official--title-182--182-546-0900}

The medicaid agency does not pay for ambulance transportation for eligible clients traveling outside of the United States and U.S. territories. See WAC 182-501-0184 for ambulance coverage in British Columbia, Canada.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0900, filed 8/6/20, effective 9/6/20. WSR 11-14-075, recodified as § 182-546-0900, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035. WSR 08-08-064, § 388-546-0900, filed 3/31/08, effective 5/1/08. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. WSR 04-17-118, § 388-546-0900, filed 8/17/04, effective 9/17/04.*

##### **Wash. Admin. Code § 182-546-1000** Ambulance transportation—Nonemergency ground—Payment. {#sec-182-546-1000 omnilex-key=us-wa-regs-official--title-182--182-546-1000}

(1) The medicaid agency pays for nonemergency ground ambulance transportation when a client is transferred to a higher level facility, or when all of the following requirements are met:

(a) The ambulance transportation is medically necessary. See subsection (3) of this section for documentation requirements.

(b) The agency pays for nonemergency ground ambulance transportation with a completed PCS or NPCS form.

(i) All requests for nonemergency transports must be directed to the client's primary or attending physician or health care team who will complete the physician certification statement (PCS) form or nonphysician certification statement (NPCS) form. See subsection (3) of this section. The PCS/NPCS form or medical documentation must be maintained in the client's file.

(ii) In the event that the provider is unable to obtain the PCS or NPCS, the provider must maintain evidence of the attempts to obtain the PCS or NPCS in the client's file.

(2) The agency pays for nonemergency ground ambulance transportation at the BLS ambulance level of service under the following conditions:

(a) The client is bed-confined and must be transported by stretcher or gurney (in the prone or supine position) for medical or safety reasons. Justification for stretcher or gurney must be documented in the client's record; or

(b) The client's medical condition requires that they have basic ambulance level medical attention available during transportation, regardless of bed confinement.

(3) For nonemergency ambulance services from a psychiatric unit within a hospital to a behavioral health facility, the ambulance provider must obtain a licensed mental health professional (LMHP) (e.g., psychiatrist, MSW) signed PCS or NPCS within forty-eight hours after the transport.

(4) The agency covers medically necessary nonemergency ambulance services that are either unscheduled or that are scheduled on a nonrepetitive basis under the following circumstances:

(a) From any point of origin to the nearest hospital with the ability to provide the type and level of care necessary for the client's illness or injury.

(b) From a hospital to the client's home when the place of residence is a residential care facility, the client must be transported by stretcher in a prone or supine position, the client is morbidly obese, or medical attention/monitoring is required in transit.

(c) For a bed-confined client who is receiving renal dialysis for treatment of end stage renal disease (ESRD), from the place of origin to the nearest facility with the ability to provide renal dialysis, including the return trip.

(5) The agency requires ambulance providers to thoroughly document the medical necessity for use of nonemergency ground ambulance transportation as follows:

(a) For scheduled, nonemergency ambulance services that are repetitive in nature, the ambulance provider must obtain a signed PCS from the client's attending physician or other designated medical professional certifying that the ambulance services are medically necessary. The PCS must specify the place of origin, destination, and the expected duration of treatment or span of dates during which the client requires repetitive nonemergency ambulance services.

(b) A PCS for repetitive, nonemergency ambulance services (e.g., wound treatment center) is valid for sixty calendar days as long as the agency's medical necessity requirement for use of ambulance transportation is met. A new PCS is required every thirty calendar days after the initial sixty-day period for a client using repetitive, nonemergency ambulance services. Kidney dialysis clients may receive nonemergency ground ambulance transportation to and from outpatient kidney dialysis services for up to three months per authorization span.

(c) For unscheduled, nonrepetitive, nonemergency ambulance services, the ambulance provider must obtain a signed PCS or NPCS within forty-eight hours after the transport. The PCS or NPCS must specify the place of origin and destination and certify that the ambulance services are medically necessary. If the provider is unable to obtain the signed PCS or NPCS within twenty-one calendar days following the date of transport from the attending physician or alternate provider, the provider must submit a claim to the agency. The provider must be able to show acceptable documentation of the attempts to obtain the PCS or NPCS.

(d) For an unscheduled, nonrepetitive, nonemergency ambulance service, if the ambulance provider is not able to obtain a signed PCS from the attending physician, a signed nonphysician certification statement (NPCS) form must be obtained from a qualified provider who is employed by the client's attending physician or by the hospital or facility where the client is being treated and who has knowledge of the client's medical condition at the time the ambulance service was furnished. One of the following members of the client's health care team may sign the certification form:

(i) A physician assistant;

(ii) A nurse practitioner;

(iii) A registered nurse;

(iv) A clinical nurse specialist;

(v) A hospital discharge planner;

(vi) A licensed practical nurse;

(vii) A social worker; or

(viii) A case manager.

(e) A copy of the signed PCS or NPCS must accompany the claim submitted to the agency.

(f) In addition to the signed PCS or NPCS, all other program criteria must be met in order for the agency to pay for the service.

(g) A signed PCS or NPCS must be attached to the claim submission for the following conditions:

(i) Altered mental status (i.e., alzheimer, dementia, acute psychosis, and suicide ideation – Not services that fall under the Involuntary Treatment Act;

(ii) Bariatric;

(iii) Bedbound (not able to stand or bear weight unassisted);

(iv) Continuous cardiac monitoring;

(v) Quadriplegic;

(vi) Requires a ventilator;

(vii) Requires continuous oxygen usage in transit; and

(viii) Tracheostomy (needed for prolonged respiratory support).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-1000, filed 8/6/20, effective 9/6/20. WSR 11-14-075, recodified as § 182-546-1000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. WSR 04-17-118, § 388-546-1000, filed 8/17/04, effective 9/17/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. WSR 01-03-084, § 388-546-1000, filed 1/16/01, effective 2/16/01.*

##### **Wash. Admin. Code § 182-546-1500** Ambulance transportation—Nonemergency air—Payment. {#sec-182-546-1500 omnilex-key=us-wa-regs-official--title-182--182-546-1500}

(1) The medicaid agency pays for a nonemergency air ambulance transport only when the transport is prior authorized by the agency.

(2) The agency authorizes a nonemergency air ambulance transport only when the following conditions are met:

(a) The client's destination is an acute care hospital or approved rehabilitation facility; and

(b) The client's physical or medical condition is such that travel by any other means endangers the client's health; or

(c) Air ambulance is less costly than ground ambulance under the circumstances.

(3) The agency requires providers to thoroughly document the circumstances requiring a nonemergency air ambulance transport. The medical necessity justification and all supporting documentation must be received, evaluated, and approved by the agency before the air ambulance transport takes place.

(4) The agency pays a negotiated rate for a medically necessary nonemergency interstate air ambulance transportation that the agency has prior authorized. The air ambulance provider is responsible for ensuring that all medical services necessary for the client's health and safety during the transport are available on board the vehicle or aircraft.

(5) Unless otherwise specified in the agency's authorization letter, the contractual amount for a nonemergency air ambulance transport includes:

(a) The cost of medically necessary ground transportation from the discharge facility to the point-of-pickup (airstrip); and

(b) The cost of medically necessary ground ambulance transportation from the landing point (airstrip) to the receiving facility.

(6) Payment for nonemergency air ambulance transportation clients may not exceed published fee schedule amounts, except when the agency expressly allows payment of a negotiated rate for a prior authorized nonemergency transport.

(7) Billing documentation must include a copy of the agency's authorization letter, adequate descriptions of the severity and complexity of the transport, and the medical interventions provided in transit.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-1500, filed 8/6/20, effective 9/6/20. WSR 11-14-075, recodified as § 182-546-1500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. WSR 04-17-118, § 388-546-1500, filed 8/17/04, effective 9/17/04.*

##### **Wash. Admin. Code § 182-546-2500** Ambulance transportation to out-of-state treatment facilities—Coordination of benefits. {#sec-182-546-2500 omnilex-key=us-wa-regs-official--title-182--182-546-2500}

(1) The medicaid agency does not pay for a client's ambulance transportation to an out-of-state treatment facility when the medical service, treatment, or procedure sought by the client is available from an in-state facility or in a designated bordering city, whether or not the client has other insurance coverage.

(2) For clients who are otherwise eligible for out-of-state coverage under WAC 182-546-0150, but have other third-party insurance, the agency may not pay for transportation to or from out-of-state treatment facilities when the client's primary insurance:

(a) Denies the client's request for medical services out-of-state as not medically necessary;

(b) Denies the client's request for transportation as not medically necessary; or

(c) Denies the client's requested mode of transportation as not medically necessary.

(3) For clients who are otherwise eligible for out-of-state coverage under WAC 182-546-0150, but have other third-party insurance, the agency does not consider requests for transportation to or from out-of-state treatment facilities unless the client has requested coverage of the benefit from their primary insurer and been denied.

(4) If the agency authorizes transportation to or from an out-of-state treatment facility for a client with other third-party insurance, the agency's liability is limited to the cost of the least costly means of transportation that does not jeopardize the client's health, as determined by the agency in consultation with the client's referring physician.

(5) For clients eligible for out-of-state coverage but have other third-party insurance, the agency considers requests for transportation to or from out-of-state treatment facilities under the provisions of WAC 182-501-0165.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-2500, filed 8/6/20, effective 9/6/20. WSR 11-14-075, recodified as § 182-546-2500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. WSR 04-17-118, § 388-546-2500, filed 8/17/04, effective 9/17/04.*

##### **Wash. Admin. Code § 182-546-3000** Ambulance transportation—Transporting qualified trauma cases. {#sec-182-546-3000 omnilex-key=us-wa-regs-official--title-182--182-546-3000}

The medicaid agency does not pay ambulance providers who meet department of health (DOH) criteria for participation in the statewide trauma network an additional amount for transports involving qualified trauma cases described in WAC 182-550-5450. Subject to the availability of trauma care fund (TCF) monies allocated for such purpose, the agency may make supplemental payments to these ambulance providers, also known as verified prehospital providers.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-3000, filed 8/6/20, effective 9/6/20. WSR 11-14-075, recodified as § 182-546-3000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 70.168.040, 74.08.090, and 74.09.500. WSR 10-12-013, § 388-546-3000, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. WSR 04-17-118, § 388-546-3000, filed 8/17/04, effective 9/17/04.*

##### **Wash. Admin. Code § 182-546-4100** Ambulance transportation—Behavioral health treatment—General. {#sec-182-546-4100 omnilex-key=us-wa-regs-official--title-182--182-546-4100}

The medicaid agency pays for medically necessary ambulance transportation to and from a covered behavioral health service (see WAC 182-546-4300) subject to the conditions and limitations within this chapter. For purposes of Involuntary Treatment Act (ITA) and voluntary behavioral health services:

(1) The agency pays for transportation services for people involuntarily detained for behavioral health services when they have been assessed by a DCR and found to be one of the following:

(a) A danger to self;

(b) A danger to others;

(c) At substantial risk of inflicting physical harm upon the property of others; or

(d) Gravely disabled as a result of their behavioral health condition.

(2) The agency pays for ambulance transportation to take a client to and from an inpatient facility for behavioral health admission under the ITA.

(3) The agency pays for ambulance transportation services to take a client to the hospital for a voluntary inpatient behavioral health stay when medically necessary.

(4) The DCR authorizes the treatment destination based on the client's legal status.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-4100, filed 8/6/20, effective 9/6/20.*

##### **Wash. Admin. Code § 182-546-4200** Ambulance transportation—Behavioral health treatment—Coverage. {#sec-182-546-4200 omnilex-key=us-wa-regs-official--title-182--182-546-4200}

(1) To be considered an Involuntary Treatment Act (ITA) transport, a client's involuntary status must have resulted from:

(a) A petition for initial detention filed by a DCR (seventy-two hour hold); and

(b) Continued hospitalization (fourteen-day, ninety-day, or one hundred eighty-day holds) under order of the superior court in a community hospital (not for clients residing in western or eastern state hospitals); or

(c) A petition for revocation of a conditional release or less restrictive treatment agreement.

(2) ITA transportation for a client is covered:

(a) From:

(i) The site of initial detention;

(ii) A court competency hearing;

(iii) A local emergency room department;

(iv) An evaluation and treatment facility;

(v) A state hospital; and

(vi) A secured detoxification facility or crisis response center.

(b) To:

(i) A state hospital;

(ii) A less restrictive alternative setting (except home);

(iii) A court competency hearing;

(iv) A local emergency room department;

(v) An evaluation and treatment facility; and

(vi) A secured detoxification facility or crisis response center.

(c) When provided by an ambulance transportation provider or law enforcement.

(d) When transported to the closest and most appropriate destination or a place designated by the DCR and/or courts. The reason for a diversion to a more distant facility must be clearly documented in the client's file.

(3) Children's long-term inpatient program (CLIP) - Transportation provided to a children's long-term inpatient program (CLIP) facility is considered a form of nonemergency medical transportation and requires a physician certification statement (PCS) or nonphysician certification statement (NPCS).

(4) Parent initiated treatment (PIT) - Use of nonemergency ambulance transportation to an inpatient psychiatric facility for voluntary inpatient admission must be medically necessary at the time of transport. The agency requires a PCS or NPCS signed by a psychiatric registered nurse, psychiatric advanced registered nurse practitioner (ARNP), or psychiatric physician's assistant (PA). The PCS or NPCS form documents the client's medical condition at the time of the transport.

(5) Persons without apple health or other coverage - If the person does not have apple health or any third-party health insurance, and the person or the person's family cannot pay for transportation related to services in RCW 71.05.150 through 71.05.310 and 71.05.340:

(a) The ambulance provider may submit a claim to the agency for that person; and

(b) The claim must be accompanied by back-up documentation consistent with Washington superior court mental proceeding Rule 2.2 and show that the transport occurred within three days of the person's detention.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-4200, filed 8/6/20, effective 9/6/20.*

##### **Wash. Admin. Code § 182-546-4300** Ambulance transportation—Behavioral health treatment—Reimbursement. {#sec-182-546-4300 omnilex-key=us-wa-regs-official--title-182--182-546-4300}

(1) The agency, as payer of last resort, pays the transportation costs for clients that a Washington designated crisis responder (DCR) detains under the ITA on a seventy-two hour initial detention or five-day revocation hold until the client is discharged from the evaluation and treatment facility or admitted to a state-managed inpatient facility.

(2) The agency pays only when it determines that the involuntarily detained client:

(a) Does not have any other third-party liability (TPL) payment source; and

(b) When requiring the client to pay would result in a substantial hardship upon the client or the client's family. Refer to WAC 182-502-0160.

(3) The DCR must complete and sign a copy of the agency's authorization of Secure Ambulance Transportation Services to/from Behavioral Health Services form (HCA 42-0003) and must keep it in the client's file.

(4) The agency establishes payment for behavioral health related transportation services when the transportation provider complies with the agency's requirements for drivers, driver training, vehicle and equipment standards and maintenance. Providers must clearly identify ITA transportation on the claim when billing the agency.

(5) The agency does not pay for transportation costs to or from out-of-state or bordering cities for clients under the ITA program under any circumstance.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-4300, filed 8/6/20, effective 9/6/20.*

##### **Wash. Admin. Code § 182-546-4700** Ambulance transportation—Ambulance transport fund—Purpose. {#sec-182-546-4700 omnilex-key=us-wa-regs-official--title-182--182-546-4700}

Chapter 74.70 RCW establishes the quality assurance fee for specified providers of emergency ambulance services through July 1, 2028. The fee is added to base funding from all other sources to support additional medicaid payments. The fee applies to nonpublic and nonfederal providers of emergency ambulance services. This is a dedicated fund established within the state treasury, known as the ambulance transport fund. The ambulance transport fund is used to receive and distribute funds.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 74.70.901, and 2023 c 11. WSR 24-18-059, § 182-546-4700, filed 8/28/24, effective 9/28/24. Statutory Authority: Chapter 74.70 RCW, 41.05.021, 41.05.160 and 2020 c 354. WSR 21-15-010, § 182-546-4700, filed 7/8/21, effective 8/8/21.*

##### **Wash. Admin. Code § 182-546-4725** Ambulance transportation—Ambulance transport fund—Notices, payment, and interest. {#sec-182-546-4725 omnilex-key=us-wa-regs-official--title-182--182-546-4725}

(1) The agency assesses each ambulance transport provider a quality assurance fee to be paid on a quarterly basis.

(2) The agency sends each ambulance transport provider an assessment notice or invoice specified due dates.

(3) The agency assesses interest and penalties on quality assurance fees not paid on the due date according to RCW 43.20B.695.

(a) Fee payments more than sixty days overdue include an assessed penalty equal to the interest charge and payment due for each month for which payment is not received after sixty days.

(b) Any interest or penalties is deposited in the ambulance transport fund.

(c) The agency may waive a portion or all of the interest or penalties, or both.

(4) If a payment is sixty days past due, the agency sends written notice of delinquent fees. After written notice, the agency will deduct the past due payment, along with interest and penalties, from any reimbursement.

**History**
- *Statutory Authority: Chapter 74.70 RCW, 41.05.021, 41.05.160 and 2020 c 354. WSR 21-15-010, § 182-546-4725, filed 7/8/21, effective 8/8/21.*

##### **Wash. Admin. Code § 182-546-5000** Nonemergency transportation—General. {#sec-182-546-5000 omnilex-key=us-wa-regs-official--title-182--182-546-5000}

(1) The agency covers nonemergency nonambulance transportation to and from covered health care services, as required by 42 C.F.R. 431.53, subject to the limitations and requirements under WAC 182-546-5000 through 182-546-6200. See WAC 182-546-1000 for nonemergency ground ambulance transportation.

(2) The agency pays for nonemergency transportation for clients covered under state-funded medical programs subject to funding appropriated by the legislature.

(3) Clients may not select the transportation provider or the mode of transportation.

(4) A client's right to freedom of choice does not require the agency to cover transportation at unusual or exceptional cost in order to meet a client's personal choice of health care provider.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 42 C.F.R. §§ 431.53 and 440.170. WSR 23-17-118, § 182-546-5000, filed 8/18/23, effective 9/18/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-12-022, § 182-546-5000, filed 5/20/16, effective 6/20/16*
- *WSR 15-03-050, § 182-546-5000, filed 1/14/15, effective 2/14/15. WSR 11-17-032, recodified as § 182-546-5000, filed 8/9/11, effective 8/9/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.500. WSR 11-15-029, § 388-546-5000, filed 7/12/11, effective 8/12/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. WSR 01-06-029, § 388-546-5000, filed 3/2/01, effective 4/2/01.*

##### **Wash. Admin. Code § 182-546-5100** Nonemergency transportation—Definitions. {#sec-182-546-5100 omnilex-key=us-wa-regs-official--title-182--182-546-5100}

The following definitions and those found in chapter 182-500 WAC apply to nonemergency medical brokered transportation. Unless otherwise defined in WAC 182-546-5200 through 182-546-6000, medical terms are used as commonly defined within the scope of professional medical practice in the state of Washington.

"Against medical advice (AMA)" - When a client elects to discharge from a health care facility against the advice of medical professionals.

"Ambulance" - See WAC 182-546-0125.

"Broker" - An organization or entity contracted with the agency to arrange nonemergency transportation and related services for clients.

"Drop off point" - The location authorized by the transportation broker for the client's trip to end.

"Early periodic screening, diagnosis, and treatment (EPSDT)" - See WAC 182-534-0050.

"Escort" - A person authorized by the transportation broker to accompany and be transported with a client to a health care service. An escort's transportation may be authorized depending on the client's age, mental state or capacity, safety requirements, mobility skills, communication skills, or cultural issues.

"Guardian" - A person who is legally responsible for a client and who may be required to be present when a client is receiving health care services.

"Local community" - The client's city or town of residence or nearest location to residence.

"Local provider" - A provider, as defined in WAC 182-500-0085, who delivers covered health care service within the client's local community, and the treatment facility where the services are delivered within the client's local community.

"Lodging and meals" - Temporary housing and meals provided during a client's out-of-area medical stay.

"Mode" - A method of transportation assistance used by the general public that an individual client can use in a specific situation. Methods that may be considered include, but are not limited to:

• Air transport;

• Public bus;

• Commercial bus;

• Ferries/water taxis;

• Gas vouchers/gas cards;

• Grouped or shared-ride vehicles;

• Mileage reimbursement;

• Parking;

• Stretcher vans or cars;

• Taxi;

• Tickets;

• Tolls;

• Train;

• Volunteer drivers;

• Walking or other personal conveyance; and

• Wheelchair vans.

"Noncompliance or noncompliant" - When a client:

• Fails to appear at the pickup point of the trip at the scheduled pickup time;

• Misuses or abuses agency-paid medical, transportation, or other services;

• Fails to comply with the rules, procedures, or policies of the agency or those of the agency's transportation brokers, the brokers' subcontracted transportation providers, or health care service providers;

• Poses a direct threat to the health or safety of self or others; or

• Engages in violent, seriously disruptive, or illegal conduct.

"Pickup point" - The location authorized by the agency's transportation broker for the client's trip to begin.

"Return trip" - The return of the client to the client's residence, or another authorized drop-off point, from the location where a covered health care service has occurred.

"Service animal" - An animal individually trained to work or perform tasks for an individual with a disability. The work or task an animal has been trained to provide must be directly related to the individual's disability. Animals whose sole function is to provide comfort or emotional support do not qualify as service animals under the American with Disabilities Act.

"Stretcher car or van" - A vehicle that can legally transport a client in a prone or supine position when the client does not require medical attention en route.

"Stretcher trip" - A transportation service that requires a client to be transported in a prone or supine position without medical attention during the trip. This may be by stretcher, board, gurney, or other appropriate device. Medical or safety requirements must be the basis for transporting a client in the prone or supine position.

"Transportation provider" - A person or company under contract with a broker to provide trips to eligible clients.

"Trip" - Transportation one-way from the pickup point to the drop off point by an authorized transportation provider.

"Urgent care" - An unplanned appointment for a covered medical service with verification from an attending physician or facility that the client must be seen that day or the following day.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-07-031, s 182-546-5100, filed 3/11/26, effective 4/11/26. Statutory Authority: RCW 41.05.021, 41.05.160, 42 C.F.R. §§ 431.53 and 440.170. WSR 23-17-118, § 182-546-5100, filed 8/18/23, effective 9/18/23*
- *WSR 20-05-066, § 182-546-5100, filed 2/14/20, effective 3/16/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-12-022, § 182-546-5100, filed 5/20/16, effective 6/20/16*
- *WSR 15-03-050, § 182-546-5100, filed 1/14/15, effective 2/14/15. WSR 11-17-032, recodified as § 182-546-5100, filed 8/9/11, effective 8/9/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.500. WSR 11-15-029, § 388-546-5100, filed 7/12/11, effective 8/12/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035. WSR 08-08-064, § 388-546-5100, filed 3/31/08, effective 5/1/08. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. WSR 01-06-029, § 388-546-5100, filed 3/2/01, effective 4/2/01.*

##### **Wash. Admin. Code § 182-546-5200** Nonemergency transportation broker and provider requirements. {#sec-182-546-5200 omnilex-key=us-wa-regs-official--title-182--182-546-5200}

(1) The medicaid agency requires:

(a) Brokers and subcontracted transportation providers to be licensed, equipped, and operated in accordance with applicable federal, state, and local laws, and the terms specified in their contracts;

(b) Brokers to:

(i) Screen their employees and subcontracted transportation providers and employees prior to hiring or contracting, and on an ongoing basis thereafter, to assure that employees and contractors are not excluded from receiving federal funds as required by 42 U.S.C. 1320a-7 and 42 U.S.C. 1320c-5; and

(ii) Report immediately to the agency any information discovered regarding an employee's or contractor's exclusion from receiving federal funds in accordance with 42 U.S.C. 1320a-7 and 42 U.S.C. 1320c-5.

(c) Drivers and passengers to comply with all applicable federal, state, and local laws and regulations during transport.

(2) Brokers:

(a) Must determine the level of assistance needed by the client (e.g., curb-to-curb, door-to-door, door-through-door, hand-to-hand) and the mode of transportation to be used for each authorized trip;

(b) Must select the lowest cost available mode or alternative that is both accessible to the client and appropriate to the client's medical condition and personal capabilities;

(c) Must have subcontracts with transportation providers in order for the providers to be paid by the broker;

(d) Must provide transportation services comparable to those available to the general public in the local community;

(e) May subcontract with licensed ambulance providers for nonemergency trips in licensed ground ambulance vehicles; and

(f) Must negotiate in good faith a contract with a federally recognized tribe that has all or part of its contract health service delivery area, as established by 42 C.F.R. Sec. 136.22, within the broker's service region, to provide transportation services when requested by that tribe. The contract must comply with federal and state requirements for contracts with tribes. When the agency approves the request of a tribe or a tribal agency to administer or provide transportation services under WAC 182-546-5100 through 182-546-6200, tribal members may obtain their transportation services from the tribe or tribal agency with coordination from and payment through the transportation broker.

(3) If the broker is not open for business and is unavailable to give advance approval for transportation to an urgent care appointment or after a hospital discharge, the subcontracted transportation provider must either:

(a) Provide the transportation in accordance with the broker's after-hours instructions and request a retroactive authorization from the broker within two business days of the transport; or

(b) Deny the transportation, if the requirements of this section cannot be met.

(4) If the subcontracted transportation provider provides transportation as described in subsection (3)(a) of this section, the broker may grant retroactive authorization and must document the reason in the client's trip record.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-12-022, § 182-546-5200, filed 5/20/16, effective 6/20/16*
- *WSR 15-03-050, § 182-546-5200, filed 1/14/15, effective 2/14/15. WSR 11-17-032, recodified as § 182-546-5200, filed 8/9/11, effective 8/9/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.500. WSR 11-15-029, § 388-546-5200, filed 7/12/11, effective 8/12/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. WSR 01-06-029, § 388-546-5200, filed 3/2/01, effective 4/2/01.*

##### **Wash. Admin. Code § 182-546-5300** Nonemergency transportation—Client eligibility. {#sec-182-546-5300 omnilex-key=us-wa-regs-official--title-182--182-546-5300}

(1) The agency pays for nonemergency transportation for Washington apple health (WAH) clients, including persons enrolled in an agency-contracted managed care organization (MCO), to and from health care services when the health care service(s) meets the requirements in WAC 182-546-5500.

(2) Persons assigned to the patient review and coordination (PRC) program according to WAC 182-501-0135 may be restricted to certain providers.

(a) Brokers may authorize transportation of a PRC client to only those providers to whom the person is assigned or referred by their primary care provider (PCP), or for covered services which do not require referrals.

(b) If a person assigned to PRC chooses to receive service from a provider, pharmacy, or hospital that is not in the person's local community, the person's transportation is limited per WAC 182-546-5700.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-12-022, § 182-546-5300, filed 5/20/16, effective 6/20/16. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148). WSR 14-07-042, § 182-546-5300, filed 3/12/14, effective 4/12/14. WSR 11-17-032, recodified as § 182-546-5300, filed 8/9/11, effective 8/9/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.500. WSR 11-15-029, § 388-546-5300, filed 7/12/11, effective 8/12/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. WSR 01-06-029, § 388-546-5300, filed 3/2/01, effective 4/2/01.*

##### **Wash. Admin. Code § 182-546-5400** Nonemergency transportation—Client responsibility. {#sec-182-546-5400 omnilex-key=us-wa-regs-official--title-182--182-546-5400}

(1) Clients must comply with applicable state, local, and federal laws during transport.

(2) Clients must comply with the rules, procedures and policies of the medicaid agency, brokers, the brokers' subcontracted transportation providers, and health care service providers.

(3) A client who is noncompliant may have limited transportation mode options available.

(4) Clients must request, arrange, and obtain authorization for transportation at least two business days before a health care appointment, except when the request is for an urgent care appointment or a hospital discharge. Requests for trips to urgent care appointments must not be to an emergency department (also known as an emergency room).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-12-022, § 182-546-5400, filed 5/20/16, effective 6/20/16*
- *WSR 15-03-050, § 182-546-5400, filed 1/14/15, effective 2/14/15. WSR 11-17-032, recodified as § 182-546-5400, filed 8/9/11, effective 8/9/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.500. WSR 11-15-029, § 388-546-5400, filed 7/12/11, effective 8/12/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. WSR 01-06-029, § 388-546-5400, filed 3/2/01, effective 4/2/01.*

##### **Wash. Admin. Code § 182-546-5500** Nonemergency transportation—Covered trips. {#sec-182-546-5500 omnilex-key=us-wa-regs-official--title-182--182-546-5500}

(1) The medicaid agency covers nonemergency transportation for a Washington apple health client to and from health care services if all of the following apply:

(a) The health care services are:

(i) Within the scope of coverage of the eligible client's benefit services package;

(ii) Covered as defined in WAC 182-501-0050 through 182-501-0065 and the specific program rules; and

(iii) Authorized, as required under specific program rules.

(b) The health care service is medically necessary as defined in WAC 182-500-0070;

(c) The health care service is being provided:

(i) Under fee-for-service, by an agency-contracted provider;

(ii) Through an agency-contracted managed care organization (MCO), by an MCO provider;

(iii) Through a behavioral health organization (BHO), by a BHO contractor; or

(iv) Through one of the following providers, as long as the provider is eligible for enrollment as a medicaid provider (see WAC 182-502-0012):

(A) A medicare enrolled provider;

(B) A provider in the network covered by the client's primary insurance where there is third-party insurance;

(C) A provider performing services paid for by the Veteran's Administration, charitable program, or other voluntary program (Shriners, etc.).

(d) The trip is to a local provider as defined in WAC 182-546-5100 (see WAC 182-546-5700(3) for local provider exceptions);

(e) The transportation is the lowest cost available mode or alternative that is both accessible to the client and appropriate to the client's medical condition and personal capabilities;

(f) The trip is authorized by the broker before a client's travel; and

(g) The trip is a minimum of three-quarters of a mile from pick-up point to the drop-off point (see WAC 182-546-6200(7) for exceptions to the minimum distance requirement).

(2) Coverage for nonemergency medical transportation is limited to one roundtrip per day, with the exception of multiple medical appointments which cannot be accessed in one roundtrip.

(3) For clients age 20 and younger, see the early periodic screening, diagnosis, and treatment (EPSDT) program described in chapter 182-534 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-07-031, s 182-546-5500, filed 3/11/26, effective 4/11/26. Statutory Authority: RCW 41.05.021, 41.05.160, 2014 c 225. WSR 16-06-053, § 182-546-5500, filed 2/24/16, effective 4/1/16. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-03-050, § 182-546-5500, filed 1/14/15, effective 2/14/15. WSR 11-17-032, recodified as § 182-546-5500, filed 8/9/11, effective 8/9/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.500. WSR 11-15-029, § 388-546-5500, filed 7/12/11, effective 8/12/11. Statutory Authority: RCW 74.08.090 and 42 C.F.R. Part 440. WSR 10-05-079, § 388-546-5500, filed 2/15/10, effective 3/18/10. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. WSR 01-06-029, § 388-546-5500, filed 3/2/01, effective 4/2/01.*

##### **Wash. Admin. Code § 182-546-5550** Nonemergency transportation—Exclusions and limitations. {#sec-182-546-5550 omnilex-key=us-wa-regs-official--title-182--182-546-5550}

(1) The following service categories listed in WAC 182-501-0060 are subject to the following exclusions and limitations:

(a) Adult day health (ADH) - Nonemergency transportation for ADH services is not provided through the brokers. ADH providers are responsible for arranging or providing transportation to ADH services.

(b) Against medical advice (AMA) discharges - Nonemergency transportation is not provided through the brokers for clients that elect to discharge from a facility or hospital AMA.

(c) Ambulance - Nonemergency ambulance transportation is not provided through the brokers except as specified in WAC 182-546-5200 (2)(e).

(d) Emergency department (ED) - When a client is discharged from the ED, brokers may provide transportation only to another medicaid-covered service or to the client's residence.

(e) Hospice services - Nonemergency transportation is not provided through the brokers when the health care service is related to a client's hospice diagnosis. See WAC 182-551-1210.

(f) Medical equipment, durable (DME) - Nonemergency transportation is not provided through the brokers for DME services, except for complex rehabilitation technology (CRT) and DME equipment that needs to be fitted to the client (such as braces/crutches, wheelchairs).

(g) Medical nutrition services - Nonemergency transportation is not provided through the brokers to pick up medical nutrition products.

(h) Medical supplies/equipment, nondurable (MSE) - Nonemergency transportation is not provided through the brokers for MSE services.

(i) The following mental health and substance use disorder services:

(i) Nonemergency transportation brokers generally provide one round trip per day. The broker must request agency approval for additional trips for off-site activities.

(ii) Nonemergency transportation of an involuntarily detained person under the Involuntary Treatment Act (ITA) is not a service provided or authorized by transportation brokers. Involuntary transportation is a service provided by an ambulance or a designated ITA transportation provider.

(iii) Nonemergency transportation is not provided through the brokers to or from information and assistance services which include:

(A) Alcohol and drug information school;

(B) Information and crisis services; and

(C) Emergency service patrol.

(j) Program of all-inclusive care for the elderly (PACE)-nonemergency transportation for clients in the PACE program is not provided through the brokers. The PACE contractor is responsible for transportation to PACE services.

(k) Standalone pharmacy trips - Transportation that occurs solely for the purpose of picking up a medication prescribed by a health care provider from a pharmacy.

(i) The broker may provide mileage reimbursement to the client or coordinate a standalone pharmacy trip only when:

(A) The client cannot receive the medication through the mail and such transportation assistance has been requested two business days in advance; or

(B) Documentation from a medical professional has been provided to the broker that indicates medication was prescribed for a condition that requires urgent treatment.

(ii) A standalone pharmacy trip that meets the conditions of (k) of this subsection is restricted to one trip per week per household, unless documentation from a medical professional indicates the medication must be picked up urgently.

(iii) Documentation of medical necessity from the client's health care provider, pharmacy, or other medical professional is required before the broker can authorize a standalone pharmacy trip more frequently than once a week per household.

(iv) If the client has a scheduled trip to an eligible medical appointment in the same week as a pharmacy pick up, the prescription must be picked up when in route to or from the medical appointment. See WAC 182-546-5600 (3)(b).

(2) Service animals as defined in WAC 182-546-5100 may be transported with clients.

(3) The following programs do not have a benefit for brokered nonemergency transportation through the agency:

(a) Federal medicare savings and state-funded medicare buy-in programs (see chapter 182-517 WAC);

(b) Family planning services - Nonemergency transportation is not provided for clients that are enrolled only in family planning only services; and

(c) Alien emergency medical (AEM) - See WAC 182-507-0115.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 42 C.F.R. §§ 431.53 and 440.170. WSR 23-17-118, § 182-546-5550, filed 8/18/23, effective 9/18/23*
- *WSR 20-05-066, § 182-546-5550, filed 2/14/20, effective 3/16/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-12-022, § 182-546-5550, filed 5/20/16, effective 6/20/16*
- *WSR 15-03-050, § 182-546-5550, filed 1/14/15, effective 2/14/15. WSR 11-17-059, recodified as § 182-546-5550, filed 8/15/11, effective 8/15/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.500. WSR 11-15-029, § 388-546-5550, filed 7/12/11, effective 8/12/11.*

##### **Wash. Admin. Code § 182-546-5600** Nonemergency transportation—Intermediate stops or delays. {#sec-182-546-5600 omnilex-key=us-wa-regs-official--title-182--182-546-5600}

(1) The agency does not pay for any costs related to intermediate stops or delays that are not directly related to the original approved trip, including trips that would, or did, result in additional transportation costs due to client convenience.

(2) Brokers may authorize intermediate stops or delays for clients if the broker determines that the intermediate stop is:

(a) Directly related to the original approved trip; or

(b) Likely to limit or eliminate the need for supplemental covered trips.

(3) The agency considers the following reasons to be related to the original trip:

(a) Transportation of the client to and from an immediate subsequent medical referral/appointment; or

(b) Transportation of the client to a pharmacy to obtain one or more prescriptions when in route to or from the covered service and the pharmacy is within a reasonable distance of the usual route to the medical appointment. The agency does not pay for transportation of the client to a pharmacy to obtain medicare Part D prescriptions unless the prescription is billable to medicaid and not paid by medicare Part D.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 42 C.F.R. §§ 431.53 and 440.170. WSR 23-17-118, § 182-546-5600, filed 8/18/23, effective 9/18/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-03-050, § 182-546-5600, filed 1/14/15, effective 2/14/15. WSR 11-17-032, recodified as § 182-546-5600, filed 8/9/11, effective 8/9/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.500. WSR 11-15-029, § 388-546-5600, filed 7/12/11, effective 8/12/11.*

##### **Wash. Admin. Code § 182-546-5700** Nonemergency transportation—Local provider and trips outside client's local community. {#sec-182-546-5700 omnilex-key=us-wa-regs-official--title-182--182-546-5700}

(1) A client receiving services provided under fee-for-service or through a medicaid agency-contracted managed care organization (MCO) may be transported to a local provider only.

(a) A local provider's medical specialty may vary as long as the provider is capable of providing medically necessary care that is the subject of the appointment or treatment;

(b) A provider may be considered an available local provider if:

(i) Providers in the client's local community are not accepting medicaid clients; or

(ii) Providers in the client's local community are not contracted with the client's MCO, primary care case management group, or third-party coverage.

(2) Brokers are responsible for considering and authorizing exceptions. See subsection (3) of this section for exceptions.

(3) A broker may transport a client to a provider outside the client's local community for covered health care services when any of the following apply:

(a) The health care service is not available within the client's local community.

(i) If requested by the broker, the client or the client's provider must provide documentation from the client's primary care provider (PCP), specialist, or other appropriate provider verifying the medical necessity for the client to be served by a health care provider outside of the client's local community.

(ii) If the service is not available in the client's local community, the broker may authorize transportation to the nearest provider where the service may be obtained;

(b) The transportation to a provider outside the client's local community is required for continuity of care.

(i) If requested by the broker, the client or the client's provider must submit documentation from the client's PCP, specialist, or other appropriate provider verifying the existence of ongoing treatment for medically necessary care by the provider and the medical necessity for the client to continue to be served by the health care provider.

(ii) If the broker authorizes transportation to a provider outside the client's local community based on continuity of care, this authorization is for a limited period of time for completion of ongoing care for a specific medical condition. Each transport must be related to the ongoing treatment of the specific condition that requires continuity of care.

(iii) Ongoing treatment of medical conditions that may qualify for transportation based on continuity of care include, but are not limited to:

(A) Active cancer treatment;

(B) Recent transplant (within the last twelve months);

(C) Scheduled surgery (within the next sixty days);

(D) Major surgery (within the previous ninety days); or

(E) Third trimester of pregnancy;

(c) The health care service is paid by a third-party payer who requires or refers the client to a specific provider within their network;

(d) The total cost to the agency, including transportation costs, is lower when the health care service is obtained outside of the client's local community; and

(e) A provider outside the client's local community has been issued a global payment by the agency for services the client will receive, and the broker determines it to be cost effective to provide transportation for the client to complete treatment with this provider.

(4) Brokers determine whether an exception should be granted based on documentation from the client's health care providers and program rules.

(5) When a client or a provider moves to a new community, the existence of a provider-client relationship, independent of other factors, does not constitute a medical need for the broker to authorize and pay for transportation to the previous provider.

(6) The health care service must be provided in the state of Washington or a designated border city, unless the agency specifically authorizes transportation to an out-of-state provider in accordance with WAC 182-546-5800.

(7) If local Washington apple health providers refuse to see a client due to the client's noncompliance, the agency does not authorize or pay more for nonemergency transportation to a provider outside the client's local community.

(a) In this circumstance, the agency pays for the least costly, most appropriate, mode of transportation from one of the following options:

(i) Transit bus fare;

(ii) Commercial bus or train fare;

(iii) Gas voucher/gas card; or

(iv) Mileage reimbursement.

(b) The agency's payment, whether fare, tickets, voucher, or mileage reimbursement, is determined using the number of miles from the client's authorized pickup point (e.g., client residence) to the location of the local health care provider who otherwise would have been available if not for the client's noncompliance.

(8) The agency may grant an exception to subsection (7) of this section for a life-sustaining service or as reviewed and authorized by the agency's medical director or designee in accordance with WAC 182-502-0050 and 182-502-0270.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-12-022, § 182-546-5700, filed 5/20/16, effective 6/20/16*
- *WSR 15-03-050, § 182-546-5700, filed 1/14/15, effective 2/14/15. WSR 11-17-032, recodified as § 182-546-5700, filed 8/9/11, effective 8/9/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.500. WSR 11-15-029, § 388-546-5700, filed 7/12/11, effective 8/12/11.*

##### **Wash. Admin. Code § 182-546-5800** Nonemergency transportation—Trips out-of-state/out-of-country. {#sec-182-546-5800 omnilex-key=us-wa-regs-official--title-182--182-546-5800}

(1) The agency reviews requests for out-of-state nonemergency transportation in accordance with regulations for covered health care services including, but not limited to, WAC 182-501-0180, 182-501-0182 and 182-501-0184. Out-of-state requests must be submitted to the agency no less than seven business days prior to the client's anticipated travel date.

(2) The agency does not pay for nonemergency transportation to or from locations outside of the United States and U.S. territories, except as allowed under WAC 182-501-0184 for British Columbia, Canada.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 42 C.F.R. §§ 431.53 and 440.170. WSR 23-17-118, § 182-546-5800, filed 8/18/23, effective 9/18/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-03-050, § 182-546-5800, filed 1/14/15, effective 2/14/15. WSR 11-17-032, recodified as § 182-546-5800, filed 8/9/11, effective 8/9/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.500. WSR 11-15-029, § 388-546-5800, filed 7/12/11, effective 8/12/11.*

##### **Wash. Admin. Code § 182-546-5900** Nonemergency transportation—Meals, lodging, escort/guardian. {#sec-182-546-5900 omnilex-key=us-wa-regs-official--title-182--182-546-5900}

(1) The agency may pay for meals and lodging for clients who must be transported to health care services outside of the client's local community. The agency's transportation brokers determine when meals and lodging are necessary based on a client's individual need.

(2) Brokers may authorize payment for meals and lodging for up to one calendar month. Extensions beyond the initial calendar month must be prior authorized by the broker on a month-to-month, week-to-week, or as-needed basis.

(3) Brokers may not authorize payment for alcohol, cannabis, or other nonfood items.

(4) Brokers follow the agency's guidelines in determining the reasonable costs of meals and lodging. The reasonable cost of lodging and meals is measured against the state per diem for the location where the client is receiving covered health care services.

(5) The agency pays for the transportation of an authorized escort, including meals and lodging, when all of the following apply:

(a) The client is present, except as stated in subsection (5) of this section; and

(b) The broker determines the transportation costs of an escort are necessary based upon the client's age, mental state or capacity, safety requirements, mobility requirements, communication or translation requirements, or cultural issues.

(6) The agency may authorize and pay for the transportation of an authorized escort or guardian, with or without the presence of the client, if the broker determines, and documents, that the presence of the authorized escort or guardian is necessary to ensure that the client has access to medically necessary care.

(7) Lodging and meals for all out-of-state nonemergency transportation must be prior authorized by the agency. Border areas as defined by WAC 182-501-0175 are considered in-state under this section and subsequent sections.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 42 C.F.R. §§ 431.53 and 440.170. WSR 23-17-118, § 182-546-5900, filed 8/18/23, effective 9/18/23*
- *WSR 20-05-066, § 182-546-5900, filed 2/14/20, effective 3/16/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-03-050, § 182-546-5900, filed 1/14/15, effective 2/14/15. WSR 11-17-032, recodified as § 182-546-5900, filed 8/9/11, effective 8/9/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.500. WSR 11-15-029, § 388-546-5900, filed 7/12/11, effective 8/12/11.*

##### **Wash. Admin. Code § 182-546-6000** Nonemergency transportation—Authorization. {#sec-182-546-6000 omnilex-key=us-wa-regs-official--title-182--182-546-6000}

(1) The medicaid agency contracts with brokers to authorize or deny requests for transportation services.

(2) Exceptional requests to transport a client may be referred to the agency's medical director or designee for review.

(3) Nonemergency medical transportation, other than ambulance, must be prior authorized by the broker. See WAC 182-546-5200 (3) and (4) and 182-546-6200(4) for granting retroactive authorization.

(4) The broker mails a written notice of denial to each client who is denied authorization of transportation.

(5) A client who is denied nonemergency transportation under this chapter may request an administrative hearing, if one is available under state and federal law.

(6) If the agency approves a medical service under exception to rule (ETR), the authorization requirements of this section apply to transportation services related to the ETR service.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-12-022, § 182-546-6000, filed 5/20/16, effective 6/20/16*
- *WSR 15-03-050, § 182-546-6000, filed 1/14/15, effective 2/14/15. WSR 11-17-032, recodified as § 182-546-6000, filed 8/9/11, effective 8/9/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.500. WSR 11-15-029, § 388-546-6000, filed 7/12/11, effective 8/12/11.*

##### **Wash. Admin. Code § 182-546-6100** Nonemergency transportation—Noncovered. {#sec-182-546-6100 omnilex-key=us-wa-regs-official--title-182--182-546-6100}

(1) The medicaid agency does not cover nonemergency transportation that is not specifically addressed in WAC 182-546-5000 through 182-546-6200.

(2) Brokers do not provide nonemergency transportation for admissions under the Involuntary Treatment Act (ITA), as defined in WAC 182-546-4000.

(3) The agency does not provide escorts or cover the cost of wages of escorts.

(4) The agency does not cover the purchase or repair of equipment for privately owned vehicles or modifications of privately owned vehicles under the nonemergency transportation program. The purchase or repair of equipment for a privately owned vehicle or modification of a privately owned vehicle is not a health care service. Exception to rule (ETR) as described in WAC 182-501-0160 is not available for equipment that is not a health care service.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-03-050, § 182-546-6100, filed 1/14/15, effective 2/14/15. WSR 11-17-032, recodified as § 182-546-6100, filed 8/9/11, effective 8/9/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.500. WSR 11-15-029, § 388-546-6100, filed 7/12/11, effective 8/12/11.*

##### **Wash. Admin. Code § 182-546-6200** Nonemergency transportation—Reimbursement. {#sec-182-546-6200 omnilex-key=us-wa-regs-official--title-182--182-546-6200}

(1) To be reimbursed for trips, meals, or lodging, the requestor must receive prior authorization from the broker at least two business days in advance of the client's travel.

(2) A client must request reimbursement of preauthorized expenditures for trips, meals, or lodging within 30 calendar days after their medical appointment. The broker may consider reimbursement requests beyond 30 calendar days if a client shows good cause as defined in WAC 388-02-0020 for having not requested reimbursement within 30 calendar days.

(3) To be reimbursed for transportation-related services, the requestor must provide the broker with legible copies of:

(a) Itemized receipt(s);

(b) The operator's valid driver's license;

(c) Valid vehicle registration; and

(d) Proof of insurance for the vehicle/operator at the time of the trip.

(4) The agency or the broker may retroactively authorize and reimburse for transportation costs, including meals and lodging when:

(a) A client is approved for a delayed certification period as defined in WAC 182-500-0025, or for a retroactive eligibility period as defined in WAC 182-500-0095, or is retroactively eligible for a medically needy program which requires a spenddown as defined in WAC 182-500-0100;

(b) The transportation costs were not used to meet a client spenddown liability in accordance with WAC 182-519-0110;

(c) The transportation costs for which retroactive reimbursement is requested falls within the period of retroactive eligibility or delayed certification;

(d) The client received medically necessary services that were covered by the client's medical program for the date(s) of service for which retroactive reimbursement is requested; and

(e) The request for retroactive reimbursement is made within 60 calendar days from the date of eligibility notification (award letter), not to exceed eight months from the date(s) of service for which reimbursement is requested.

(5) When transportation cost(s) are retroactively authorized, the reimbursement amount must not exceed the reimbursement amount that would have been authorized prior to the date(s) of service.

(6) To be paid by the broker for nonemergency transportation services:

(a) Ambulance providers must be subcontracted with the broker in accordance with WAC 182-546-5200.

(b) Nonambulance providers must be subcontracted with the broker in accordance with WAC 182-546-5200.

(7) The agency, through its contracted brokers, does not pay for nonemergency transportation when:

(a) The health care service the client is requesting transportation to or from is not a service covered by the client's medical program;

(b) The covered health care service is within three-quarters of a mile from the pick-up point, except when:

(i) The client's documented and verifiable medical condition and personal capabilities demonstrates that the client is not able to walk three-quarters mile distance;

(ii) The trip involves an area that the broker determines is not physically accessible to the client; or

(iii) The trip involves an area that the agency's broker considers to be unsafe for the client, other riders, or the driver.

(c) The client has personal or informal transportation resources that are available and appropriate to the clients' needs;

(d) Fixed-route public transportation service is available to the client within three-quarters of a mile walking distance. Exceptions to this rule may be granted by the transportation broker when the need for more specialized transportation is documented. Examples of such a need may be the client's use of a portable ventilator, a walker, or a quad cane; or

(e) The mode of transport that the client requests is not necessary, suitable, or appropriate to the client's medical condition.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 42 C.F.R. §§ 431.53 and 440.170. WSR 23-17-118, § 182-546-6200, filed 8/18/23, effective 9/18/23*
- *WSR 20-05-066, § 182-546-6200, filed 2/14/20, effective 3/16/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-03-050, § 182-546-6200, filed 1/14/15, effective 2/14/15. WSR 11-17-032, recodified as § 182-546-6200, filed 8/9/11, effective 8/9/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.500. WSR 11-15-029, § 388-546-6200, filed 7/12/11, effective 8/12/11.*

## **Chapter 182-547** Hearing aids. {#struct-chapter-182-547}

##### **Wash. Admin. Code § 182-547-0100** General. {#sec-182-547-0100 omnilex-key=us-wa-regs-official--title-182--182-547-0100}

(1) The medicaid agency covers the hearing aids listed in this chapter, according to agency rules and subject to the limitations and requirements in this chapter. See also WAC 182-531-0375 audiology services.

(2) The agency pays for hearing aids when:

(a) Covered;

(b) Within the scope of an eligible client's medical care program;

(c) Medically necessary as defined under WAC 182-500-0070;

(d) Authorized, as required within this chapter, chapters 182-501 and 182-502 WAC, and the agency's published billing instructions and provider notices;

(e) Billed according to this chapter, chapters 182-501 and 182-502 WAC, and the agency's published billing instructions and provider notices;

(f) The client completes a hearing evaluation, including an audiogram or developmentally appropriate diagnostic physiologic test, that is administered by and the results interpreted by a hearing health care professional; and

(g) The licensed audiologist, hearing aid specialist, otolaryngologist, or otologist concludes that the client may benefit from a hearing aid.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2018 c 159. WSR 19-20-043, § 182-547-0100, filed 9/25/19, effective 11/1/19. Statutory Authority: RCW 41.05.021. WSR 13-20-013, § 182-547-0100, filed 9/20/13, effective 10/21/13. WSR 11-14-075, recodified as § 182-547-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-015, § 388-547-0100, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090 and 74.09.530. WSR 09-12-034, § 388-547-0100, filed 5/27/09, effective 7/1/09.*

##### **Wash. Admin. Code § 182-547-0200** Definitions. {#sec-182-547-0200 omnilex-key=us-wa-regs-official--title-182--182-547-0200}

The following definitions, the definitions found in RCW 18.35.010, and those found in chapter 182-500 WAC apply to this chapter.

"Bone-anchored hearing aid" or "bone conduction hearing device" means a type of hearing aid that transmits sound vibrations through bones in the head. The inner ear translates the vibrations the same way a normal ear translates sound waves. These devices can be surgically implanted or worn on headbands.

"Cochlear implant device" means an electrical device that receives sound and transmits the resulting signal to electrodes implanted in the cochlea. That signal stimulates the cochlea so that hearing impaired persons can perceive sound.

"Digital hearing aids" means wearable sound-amplifying devices that use a digital circuit to analyze and process sound.

"Hearing aids" means wearable sound-amplifying devices that are intended to compensate for hearing loss. These devices use a digital circuit to analyze and process sound. Hearing aids are described by where they are worn in the ear as in-the-ear (ITE), behind-the-ear (BTE), etc.

"Hearing health care professional" means an audiologist or hearing aid specialist licensed under chapter 18.35 RCW, or a physician specializing in diseases and disorders of the ear licensed under chapter 18.71 RCW.

"Maximum allowable fee" means the maximum dollar amount that the medicaid agency will pay a provider for specific services, supplies and equipment.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2018 c 159. WSR 19-20-043, § 182-547-0200, filed 9/25/19, effective 11/1/19. Statutory Authority: RCW 41.05.021. WSR 13-20-013, § 182-547-0200, filed 9/20/13, effective 10/21/13. WSR 11-14-075, recodified as § 182-547-0200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.530. WSR 09-12-034, § 388-547-0200, filed 5/27/09, effective 7/1/09.*

##### **Wash. Admin. Code § 182-547-0700** Eligibility. {#sec-182-547-0700 omnilex-key=us-wa-regs-official--title-182--182-547-0700}

(1) Clients covered by one of the Washington apple health programs as listed in the table in WAC 182-501-0060 are eligible for hearing aids and related services.

(2) Clients enrolled in a medicaid agency-contracted managed care organization (MCO) must arrange for hearing aid and related services directly through the client's MCO. Additionally, clients enrolled in an agency-contracted MCO must obtain replacement parts for cochlear implant devices and bone-anchored hearing aids, including batteries, through their MCO.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2018 c 159. WSR 19-20-043, § 182-547-0700, filed 9/25/19, effective 11/1/19. Statutory Authority: RCW 41.05.021. WSR 13-20-013, § 182-547-0700, filed 9/20/13, effective 10/21/13. WSR 11-14-075, recodified as § 182-547-0700, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-015, § 388-547-0700, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090 and 74.09.530. WSR 09-12-034, § 388-547-0700, filed 5/27/09, effective 7/1/09.*

##### **Wash. Admin. Code § 182-547-0800** Coverage—Clients age twenty years and younger. {#sec-182-547-0800 omnilex-key=us-wa-regs-official--title-182--182-547-0800}

(1) The medicaid agency covers new, nonrefurbished, monaural or binaural hearing aid(s), which includes the ear molds, for eligible clients age twenty and younger. In order for the provider to receive payment, the hearing aid must meet the client's specific hearing needs and carry a manufacturer's warranty for a minimum of one year.

(2) The agency pays for the following replacements as long as the need for replacement is not due to the client's carelessness, negligence, recklessness, deliberate intent, or misuse in accordance with WAC 182-501-0050:

(a) Hearing aid(s), which includes the ear molds, when:

(i) The client's hearing aid(s) are:

(A) Lost;

(B) Beyond repair; or

(C) Not sufficient for the client's hearing loss; and

(ii) All warranties are expired.

(b) Ear mold(s) when the client's existing ear mold is damaged or no longer fits the client's ear.

(3) The agency pays for repairs of hearing aids that are less than five years old as follows:

(a) A maximum of two repairs, per hearing aid, per year, when the repair is less than fifty percent of the cost of a new hearing aid. To receive payment, all of the following must be met:

(i) All warranties are expired; and

(ii) The repair warranty is for a minimum of six months.

(b) A rental hearing aid(s) for up to thirty days while the client's own hearing aid is being repaired. In the case of a rental hearing aid(s), the agency pays separately for an ear mold(s).

(4) The agency pays for cochlear implant device and bone-anchored hearing aid replacement parts when:

(a) The manufacturer's warranty has expired;

(b) The part is for immediate use, not a back-up part; and

(c) The part needs to be replaced due to normal wear and tear and is not related to misuse or abuse of the item (see WAC 182-501-0050).

(5) The agency covers external sound processors for cochlear implant devices, including maintenance and repair.

(6) The agency covers bone-anchored hearing aid speech processors, including maintenance and repair.

(7) The agency covers batteries for hearing aids, external sound processors for cochlear implant devices, and bone-anchored hearing aid sound processors.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2018 c 159. WSR 19-20-043, § 182-547-0800, filed 9/25/19, effective 11/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-03-042, § 182-547-0800, filed 1/12/15, effective 2/12/15. Statutory Authority: RCW 41.05.021. WSR 13-20-013, § 182-547-0800, filed 9/20/13, effective 10/21/13. WSR 11-14-075, recodified as § 182-547-0800, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-015, § 388-547-0800, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090 and 74.09.530. WSR 09-12-034, § 388-547-0800, filed 5/27/09, effective 7/1/09.*

##### **Wash. Admin. Code § 182-547-0850** Coverage—Clients age twenty-one and older. {#sec-182-547-0850 omnilex-key=us-wa-regs-official--title-182--182-547-0850}

(1) Nonrefurbished, monaural hearing aids. The medicaid agency covers one new nonrefurbished monaural hearing aid, which includes the ear mold, every five years for clients age twenty-one and older.

(a) The client must have an average decibel loss of forty-five or greater in the better ear, based on a pure-tone audiometric evaluation by a licensed audiologist or a licensed hearing aid specialist at 1000, 2000, 3000, and 4000 hertz (Hz) with effective masking as indicated.

(b) The hearing aid must meet the client's specific hearing needs and carry a manufacturer's warranty for a minimum of one year.

(2) Binaural hearing aids. The agency covers binaural hearing aids. Prior authorization (PA) is required.

(3) Replacement. The agency covers the following replacements if the need for replacement is not due to the client's carelessness, negligence, recklessness, deliberate intent, or misuse under WAC 182-501-0050(7):

(a) One replacement hearing aid, including the ear mold, in a five-year period when the warranty is expired and the client's hearing aid(s) is:

(i) Lost; or

(ii) Broken and cannot be repaired.

(b) One replacement ear mold, per year, when the client's existing ear mold is damaged or no longer fits the client's ear.

(4) Repair of hearing aids. The agency covers two repairs, per hearing aid, per year, when the cost of the repair is less than fifty percent of the cost of a new hearing aid. To receive payment, all of the following must be met:

(a) All warranties are expired; and

(b) The repair is under warranty for a minimum of ninety days.

(5) Repair or replacement of external components of cochlear implant devices and bone-anchored hearing aids. The agency covers the following repair or replacement of external components of cochlear implant devices and bone-anchored hearing aids. PA is required.

(a) Repair or replacement of external components of cochlear implant devices. If the client has bilateral cochlear implant devices, both devices are eligible for repair and replacement of external components; and

(b) Repair or replacement of external components of bone-anchored hearing aids, whether implanted or worn with a headband. If the client has bilateral bone-anchored hearing aids, both devices are eligible for repair and replacement of external components.

(6) Rental of hearing aids. The agency covers rental hearing aid(s) for up to two months while the client's own hearing aid(s) is being repaired. For rental hearing aid(s) only, the agency pays separately for an ear mold(s).

(7) Second hearing aid. The agency pays for a second hearing aid when the client either meets the following clinical criteria or a limitation extension is requested and approved:

(a) The client tries one hearing aid for a ninety-day period, but the hearing aid does not adequately meet the client's hearing need; and

(b) One of the following reasons is documented in the client's record. The client is:

(i) Unable to or has difficulty with conducting job duties with only one hearing aid;

(ii) Unable to or has difficulty with functioning in the school environment with only one hearing aid;

(iii) Unable to live safely in the community with only one hearing aid; or

(iv) Legally blind.

(8) Batteries. The agency covers batteries for hearing aids, external sound processors for cochlear implant devices, and bone-anchored hearing aid sound processors.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2018 c 159. WSR 19-20-043, § 182-547-0850, filed 9/25/19, effective 11/1/19.*

##### **Wash. Admin. Code § 182-547-0900** Noncovered services—Clients age twenty-one and older. {#sec-182-547-0900 omnilex-key=us-wa-regs-official--title-182--182-547-0900}

(1) The medicaid agency does not cover the following items:

(a) Tinnitus maskers;

(b) Frequency modulation (FM) systems, including the computer-aided hearing devices for FM systems; and

(c) Nonprescription hearing aids or similar devices including, but not limited to:

(i) Personal sound amplification products (PSAPs);

(ii) Hearables; and

(iii) Pocket talkers or similar devices.

(2) The agency evaluates requests for noncovered hearing aids and related services according to WAC 182-501-0160.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2018 c 159. WSR 19-20-043, § 182-547-0900, filed 9/25/19, effective 11/1/19. Statutory Authority: RCW 41.05.021. WSR 13-20-013, § 182-547-0900, filed 9/20/13, effective 10/21/13. WSR 11-14-075, recodified as § 182-547-0900, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.530. WSR 09-12-034, § 388-547-0900, filed 5/27/09, effective 7/1/09.*

##### **Wash. Admin. Code § 182-547-1000** Prior authorization—Clients age twenty and younger. {#sec-182-547-1000 omnilex-key=us-wa-regs-official--title-182--182-547-1000}

(1) Prior authorization is not required for clients age twenty and younger for hearing aid(s) and services.

(2) The agency pays for services according to the early and periodic screening, diagnostic, and treatment (EPSDT) provisions, as described in chapter 182-534 WAC. The standard for coverage for EPSDT is that services, treatment, or other measures are medically necessary, safe and effective, and not experimental.

(3) When billing, providers must send claims for clients age twenty and younger directly to the medicaid agency. Providers do not have to obtain authorization from the local children with special health care needs (CSHCN) coordinator.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2018 c 159. WSR 19-20-043, § 182-547-1000, filed 9/25/19, effective 11/1/19. Statutory Authority: RCW 41.05.021. WSR 13-20-013, § 182-547-1000, filed 9/20/13, effective 10/21/13. WSR 11-14-075, recodified as § 182-547-1000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.530. WSR 09-12-034, § 388-547-1000, filed 5/27/09, effective 7/1/09.*

##### **Wash. Admin. Code § 182-547-1050** Prior authorization—Clients age twenty-one and older. {#sec-182-547-1050 omnilex-key=us-wa-regs-official--title-182--182-547-1050}

(1) The agency requires prior authorization for covered hearing aids when the clinical criteria set forth in this chapter are not met. The agency evaluates these requests on a case-by-case basis to determine whether they are medically necessary, according to the process found in WAC 182-501-0165.

(2) For covered services that require prior authorization (PA), the provider must properly request authorization in accordance with the medicaid agency's rules and billing instructions.

(3) The agency evaluates requests for covered services that are subject to limitations or other restrictions and considers such services beyond those limitations or restrictions as described in WAC 182-501-0169.

(4) When the agency authorizes hearing aids or hearing aid-related services, the PA indicates only that the specific service is medically necessary; it is not a guarantee of payment. The client must be eligible for covered services at the time those services are provided.

(5) To receive payment, providers must order and dispense hearing aids and hearing aid-related services within the authorized time frame.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2018 c 159. WSR 19-20-043, § 182-547-1050, filed 9/25/19, effective 11/1/19.*

##### **Wash. Admin. Code § 182-547-1100** Reimbursement. {#sec-182-547-1100 omnilex-key=us-wa-regs-official--title-182--182-547-1100}

(1) The medicaid agency's payment for purchased hearing aids includes all of the following:

(a) The audiometric evaluation;

(b) An impression for an ear mold;

(c) The ear mold;

(d) The dispensing fee;

(e) A conformity evaluation, if done;

(f) Three batteries; and

(g) Up to three follow-up visits for the fitting, orientation, and checking of the hearing aid.

(2) The agency denies payment for hearing aids and services when claims are submitted without the prior authorization number, when required, or the appropriate diagnosis or procedure code(s).

(3) The agency does not pay for hearing aid charges paid by insurance or other payer source.

(4) To receive payment, the provider must keep documentation in the client's medical file to support the medical necessity for the specific make and model of the hearing aid ordered for the client. This documentation must include the record of the audiology testing providing evidence that the client's hearing loss meets the eligibility criteria for a hearing aid.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 2018 c 159. WSR 19-20-043, § 182-547-1100, filed 9/25/19, effective 11/1/19. Statutory Authority: RCW 41.05.021. WSR 13-20-013, § 182-547-1100, filed 9/20/13, effective 10/21/13. WSR 11-14-075, recodified as § 182-547-1100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.530. WSR 09-12-034, § 388-547-1100, filed 5/27/09, effective 7/1/09.*

## **Chapter 182-548** Federally qualified health centers. {#struct-chapter-182-548}

##### **Wash. Admin. Code § 182-548-1000** Federally qualified health centers—Purpose. {#sec-182-548-1000 omnilex-key=us-wa-regs-official--title-182--182-548-1000}

This chapter establishes the medicaid agency's:

(1) Requirements for enrollment as a federally qualified health center (FQHC) provider; and

(2) Reimbursement methodology for services provided by an FQHC to a Washington apple health client.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-11-008, § 182-548-1000, filed 5/7/15, effective 6/7/15. WSR 11-14-075, recodified as § 182-548-1000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, BIPA of 2000 Section 702, sections 201 and 209 of 2009-2011 budget bill, and 42 U.S.C. 1396a(bb). WSR 10-09-002, § 388-548-1000, filed 4/7/10, effective 5/8/10.*

##### **Wash. Admin. Code § 182-548-1100** Federally qualified health centers—Definitions. {#sec-182-548-1100 omnilex-key=us-wa-regs-official--title-182--182-548-1100}

This section contains definitions of words or phrases that apply to this chapter. Unless defined in this chapter, the definitions found in chapter 182-500 WAC apply.

"APM index" - The agency uses the alternative payment methodology (APM) to update APM encounter payment rates on an annual basis. The APM index is a measure of input price changes experienced by Washington's federally qualified health center (FQHC) and rural health clinic (RHC) providers. The index is derived from the federal medicare economic index (MEI) and Washington-specific variable measures.

"Base year" - The year that is used as the benchmark in measuring an FQHC's total reasonable costs for establishing base encounter rates.

"Cost center" - A category of service approved to be provided by the FQHC under WAC 182-548-1200 and reported in the medicaid cost report. The categories of services provided by the FQHC may include medical, mental health, dental, maternity support services, and substance use disorder.

"Cost report" - A statement of costs and provider utilization that occurred during the time period covered by the cost report. FQHCs complete a cost report when there is a request for a change in scope rate adjustment, there is a rebasing of the encounter rate, or the agency sets a base rate.

"Encounter" - A face-to-face or telemedicine (including audio-only telemedicine) visit between an encounter-eligible client and an FQHC provider who exercises independent judgment when providing services that qualify for encounter rate reimbursement.

"Encounter-eligible client" - A client who receives benefits under Title XIX (medicaid) or Title XXI (CHIP).

"Encounter rate" - A cost-based, facility-specific rate for covered FQHC services.

"Enhancements (also called managed care enhancements)" - A monthly amount the agency pays to FQHCs for each client enrolled with a managed care organization (MCO). FQHCs may contract with MCOs to provide services under managed care programs. FQHCs receive enhancements from the agency in addition to the negotiated payments they receive from the MCOs for services provided to enrollees.

"Federally qualified health center (FQHC)" - An entity that has entered into an agreement with the Centers for Medicare and Medicaid Services (CMS) to meet medicare program requirements under 42 C.F.R. 405.2434 and:

(a) Is receiving a grant under section 329, 330, or 340 of the federal Public Health Service (PHS) Act, or is receiving funding from such a grant under a contract with the recipient of such a grant and meets the requirements to receive a grant under section 330 of the PHS Act;

(b) Based on the recommendation of the PHS, is determined by CMS to meet the requirements for receiving such a grant;

(c) Was treated by CMS, for purposes of medicare part B, as a comprehensive federally funded health center (FFHC) as of January 1, 1990; or

(d) Is an outpatient health program or facility operated by a tribe or tribal organization under the federal Indian Self-Determination and Education Assistance Act of 1975 or an Urban Indian organization receiving funding under Title V of the federal Indian Health Care Improvement Act of 1976.

"Fee-for-service" - A payment method the agency uses to pay providers for covered medical services provided to Washington apple health clients, which excludes services provided by the agency's contracted managed care organizations and services that qualify for an encounter rate.

"Interim rate" - The rate the agency establishes to pay an FQHC for covered FQHC services prior to the establishment of a permanent rate for that FQHC.

"Medicare economic index (MEI)" - An index published in the Federal Register used in the calculation of changes to determine allowed charges for physician services. The agency adjusts FQHC encounter rates and enhancement rates by the MEI each year on January 1st.

"Rebasing" - The process of recalculating encounter rates using actual cost report data.

**History**
- *Statutory Authority: 42 U.S.C. 1396a(bb), 42 U.S.C. 1396d (2)(A), RCW 41.05.021, and 41.05.160. WSR 22-22-049, § 182-548-1100, filed 10/27/22, effective 1/1/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-11-008, § 182-548-1100, filed 5/7/15, effective 6/7/15. WSR 11-14-075, recodified as § 182-548-1100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, BIPA of 2000 Section 702, sections 201 and 209 of 2009-2011 budget bill, and 42 U.S.C. 1396a(bb). WSR 10-09-002, § 388-548-1100, filed 4/7/10, effective 5/8/10.*

##### **Wash. Admin. Code § 182-548-1200** Federally qualified health centers—Enrollment. {#sec-182-548-1200 omnilex-key=us-wa-regs-official--title-182--182-548-1200}

(1) To enroll as a Washington apple health provider and receive payment for services, a federally qualified health center (FQHC) must:

(a) Receive FQHC certification for participation in the Title XVIII (medicare) program according to 42 C.F.R. 491;

(b) Sign a core provider agreement with the medicaid agency; and

(c) Operate in accordance with applicable federal, state, and local laws.

(2) The medicaid agency uses one of two timeliness standards for determining the effective date of a medicaid-certified FQHC.

(a) The agency uses medicare's effective date if the FQHC returns a properly completed core provider agreement and a properly completed FQHC enrollment packet within 60 calendar days from the date of CMS's written notification to the FQHC of the medicare certification.

(b) The agency uses the date when both the properly completed FQHC enrollment packet and properly completed core provider agreement have been received if either of the required documentation is submitted 61 or more calendar days after the date of medicare's letter notifying the clinic of the medicare certification.

**History**
- *Statutory Authority: 42 U.S.C. 1396a(bb), 42 U.S.C. 1396d (2)(A), RCW 41.05.021, and 41.05.160. WSR 22-22-049, § 182-548-1200, filed 10/27/22, effective 1/1/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-11-008, § 182-548-1200, filed 5/7/15, effective 6/7/15. WSR 11-14-075, recodified as § 182-548-1200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, BIPA of 2000 Section 702, sections 201 and 209 of 2009-2011 budget bill, and 42 U.S.C. 1396a(bb). WSR 10-09-002, § 388-548-1200, filed 4/7/10, effective 5/8/10.*

##### **Wash. Admin. Code § 182-548-1300** Federally qualified health centers—Services. {#sec-182-548-1300 omnilex-key=us-wa-regs-official--title-182--182-548-1300}

(1) The following outpatient services qualify for FQHC encounter rate reimbursement:

(a) Physician services specified in 42 C.F.R. 405.2412.

(b) Nurse practitioner or physician assistant services specified in 42 C.F.R. 405.2414.

(c) Clinical psychologist and clinical social worker services specified in 42 C.F.R. 405.2450.

(d) Visiting nurse services specified in 42 C.F.R. 405.2416.

(e) Nurse-midwife services specified in 42 C.F.R. 405.2401.

(f) Preventive primary services specified in 42 C.F.R. 405.2448.

(2) The medicaid agency pays for FQHC services when they are:

(a) Within the scope of an encounter-eligible client's Washington apple health program. Refer to WAC 182-501-0060 scope of services; and

(b) Medically necessary as defined in WAC 182-500-0070.

(3) FQHC services may be provided by any of the following individuals in accordance with 42 C.F.R. 405.2446:

(a) Physicians;

(b) Physician assistants (PA);

(c) Nurse practitioners (NP);

(d) Nurse midwives or other specialized nurse practitioners;

(e) Certified nurse midwives;

(f) Registered nurses or licensed practical nurses; and

(g) Psychologists or clinical social workers.

**History**
- *Statutory Authority: 42 U.S.C. 1396a(bb), 42 U.S.C. 1396d (2)(A), RCW 41.05.021, and 41.05.160. WSR 22-22-049, § 182-548-1300, filed 10/27/22, effective 1/1/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-11-008, § 182-548-1300, filed 5/7/15, effective 6/7/15. WSR 11-14-075, recodified as § 182-548-1300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, BIPA of 2000 Section 702, sections 201 and 209 of 2009-2011 budget bill, and 42 U.S.C. 1396a(bb). WSR 10-09-002, § 388-548-1300, filed 4/7/10, effective 5/8/10.*

##### **Wash. Admin. Code § 182-548-1400** Federally qualified health centers—Payment methodologies. {#sec-182-548-1400 omnilex-key=us-wa-regs-official--title-182--182-548-1400}

(1) For services provided during the period beginning January 1, 2001, and ending December 31, 2008, the medicaid agency's payment methodology for federally qualified health centers (FQHC) was a prospective payment system (PPS) as authorized by 42 U.S.C. 1396a (bb)(2) and (3).

(2) For services provided beginning January 1, 2009, FQHCs have the choice to be reimbursed under the PPS or to be reimbursed under an alternative payment methodology (APM), as authorized by 42 U.S.C. 1396a (bb)(6). As required by 42 U.S.C. 1396a (bb)(6), payments made under the APM are at least as much as payments that would have been made under the PPS.

(3) The agency calculates FQHC PPS encounter rates as follows:

(a) Until an FQHC's first audited medicaid cost report is available, the agency pays an average encounter rate of other similar FQHCs within the state, otherwise known as an interim rate.

(b) Upon availability of the FQHC's first audited medicaid cost report, the agency sets FQHC encounter rates at 100 percent of its total reasonable costs as defined in the cost report. FQHCs receive this rate for the remainder of the calendar year during which the audited cost report became available. The encounter rate is then adjusted each January 1st by the percent change in the medicare economic index (MEI).

(4) For FQHCs in existence during calendar years 1999 and 2000, the agency sets encounter rates prospectively using a weighted average of 100 percent of the FQHC's total reasonable costs for calendar years 1999 and 2000 and adjusted for any increase or decrease in the scope of services furnished during the calendar year 2001 to establish a base encounter rate.

(a) The agency adjusts PPS base encounter rates to account for an increase or decrease in the scope of services provided during calendar year 2001 in accordance with WAC 182-548-1500.

(b) The agency determines PPS base encounter rates using audited cost reports, and each year's rate is weighted by the total reported encounters. The agency does not apply a capped amount to these base encounter rates. The formula used to calculate base encounter rates is as follows:

| Specific FQHC Base Encounter Rate | = | (Year 1999 Rate x Year 1999 Encounters) + (Year 2000 Rate x Year 2000 Encounters) |
| --- | --- | --- |
| (Year 1999 Encounters + Year 2000 Encounters) for each FQHC | | |

(c) Beginning in calendar year 2002 and any year thereafter, encounter rates are adjusted by the MEI for primary care services, and adjusted for any increase or decrease in the FQHC's scope of services.

(5) The agency calculates the FQHC's APM encounter rate for services provided during the period beginning January 1, 2009, and ending April 6, 2011, as follows:

(a) The APM utilizes the FQHC base encounter rates, as described in subsection (4)(b) of this section.

(b) Base rates are adjusted to reflect any approved changes in scope of service in calendar years 2002 through 2009.

(c) The adjusted base rates are then increased by each annual percentage, from calendar years 2002 through 2009, of the IHS Global Insight index, also called the APM index. The result is the year 2009 APM rate for each FQHC that chooses to be reimbursed under the APM.

(6) This subsection describes the encounter rates that the agency pays FQHCs for services provided during the period beginning April 7, 2011, and ending June 30, 2011. On January 12, 2012, the federal Centers for Medicare and Medicaid Services (CMS) approved a state plan amendment (SPA) containing the methodology outlined in this section.

(a) During the period that CMS approval of the SPA was pending, the agency continued to pay FQHCs at the encounter rates described in subsection (5) of this section.

(b) Each FQHC has the choice of receiving either its PPS rate, as determined under the method described in subsection (3) of this section, or a rate determined under a revised APM, as described in (c) of this subsection.

(c) The revised APM uses each FQHC's PPS rate for the current calendar year, increased by five percent.

(d) For all payments made for services provided during the period beginning April 7, 2011, and ending June 30, 2011, the agency recoups from FQHCs any amount in excess of the encounter rate established in this section. This process is specified in emergency rules that took effect on October 29, 2011, (WSR 11-22-047) and February 25, 2012 (WSR 12-06-002).

(7) This subsection describes the encounter rates that the agency pays FQHCs for services provided on and after July 1, 2011. On January 12, 2012, CMS approved a SPA containing the methodology outlined in this section.

(a) Each FQHC has the choice of receiving either its PPS rate as determined under the method described in subsection (3) of this section, or a rate determined under a revised APM, as described in (b) of this subsection.

(b) The revised APM, known as APM-3, is as follows:

(i) For FQHCs that rebased their rate effective January 1, 2010, the revised APM is their allowed cost per visit during the cost report year increased by the cumulative percentage increase in the MEI between the cost report year and January 1, 2011.

(ii) For FQHCs that did not rebase their rate effective January 1, 2010, the revised APM is based on their PPS base rate from 2001 (or subsequent year for FQHCs receiving their initial FQHC designation after 2002) increased by the cumulative percentage increase in the IHS Global Insight index from the base year through calendar year 2008 and by the cumulative percentage increase in the MEI from calendar years 2009 through 2011. The rates were increased by the MEI effective January 1, 2012, and are increased by the MEI each January 1st thereafter.

(c) For all payments made for services provided during the period beginning July 1, 2011, and ending January 11, 2012, the agency recoups from FQHCs any amount paid in excess of the encounter rate established in this section. This process is specified in emergency rules that took effect on October 29, 2011, (WSR 11-22-047) and February 25, 2012 (WSR 12-06-022).

(d) For FQHCs that choose to be paid under the revised APM, the agency periodically rebases the encounter rates using the FQHC cost reports and other relevant data. Rebasing is done only for FQHCs that are reimbursed under the APM.

(e) The agency ensures that the payments made under the APM are at least equal to the payments that would be made under the PPS.

(8) This subsection describes the payment methodology that the agency uses to pay participating FQHCs for services provided beginning July 1, 2017, and ending December 31, 2022.

(a) Each FQHC may receive payments under the APM described in subsection (7) of this section, or receive payments under the revised APM described in this subsection.

(b) The revised APM, known as APM-4, is as follows:

(i) The revised APM establishes a budget-neutral, baseline per member per month (PMPM) rate for each FQHC. The PMPM rate accounts for enhancement payments in accordance with the definition of enhancements in WAC 182-548-1100. For the purposes of this section, "budget-neutral" means the cost of the revised APM to the agency will not exceed what would have otherwise been spent not including the revised APM on a per member per year basis.

(ii) The agency pays the FQHC a PMPM payment each month for each managed care client assigned to them by an MCO.

(iii) The agency pays the FQHC a PMPM rate in addition to the amounts the MCO pays the FQHC. The agency may prospectively adjust the FQHC's PMPM rate for any of the following reasons:

(A) Quality and access metrics performance.

(B) FQHC encounter rate changes.

(iv) In accordance with 42 U.S.C. 1396a (bb)(5)(A), the agency performs an annual reconciliation.

(A) If the FQHC was underpaid, the agency pays the difference, and the PMPM rate may be subject to prospective adjustment under (b)(iii) of this subsection.

(B) If the FQHC was overpaid, the PMPM rate may be subject to prospective adjustment under (b)(iii) of this subsection.

**History**
- *Statutory Authority: 42 U.S.C. 1396a(bb), 42 U.S.C. 1396d (2)(A), RCW 41.05.021, and 41.05.160. WSR 22-22-049, § 182-548-1400, filed 10/27/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. 1396a (bb)(5)(A). WSR 20-24-083, § 182-548-1400, filed 11/25/20, effective 1/1/21. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-12-016, § 182-548-1400, filed 5/30/17, effective 7/1/17*
- *WSR 15-11-008, § 182-548-1400, filed 5/7/15, effective 6/7/15*
- *WSR 14-14-056, § 182-548-1400, filed 6/26/14, effective 8/1/14. Statutory Authority: RCW 41.05.021. WSR 12-16-060, § 182-548-1400, filed 7/30/12, effective 8/30/12. WSR 11-14-075, recodified as § 182-548-1400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, BIPA of 2000 Section 702, sections 201 and 209 of 2009-2011 budget bill, and 42 U.S.C. 1396a(bb). WSR 10-09-002, § 388-548-1400, filed 4/7/10, effective 5/8/10.*

##### **Wash. Admin. Code § 182-548-1450** Federally qualified health centers—General payment information. {#sec-182-548-1450 omnilex-key=us-wa-regs-official--title-182--182-548-1450}

(1) The agency limits FQHC encounter rate reimbursement to one per client, per day except in the following circumstances:

(a) There is a subsequent visit in the same cost center that requires separate evaluation and treatment on the same day for unrelated diagnoses; or

(b) There are separate visits in different types of cost centers that occur with different health care professionals. (For example, a client with a separate medical and dental visit on the same day.)

(2) All services provided within the same cost center performed on the same day must be included in the same encounter, except for in the circumstance outlined in subsection (1)(a) of this section.

(3) Services and supplies incidental to an encounter are included in the encounter rate payment and must be billed on the same claim.

(4) FQHCs must provide services in a single encounter that are typically rendered in a single visit based on clinical guidance and standards of care.

(a) FQHCs must not split services into multiple encounters unless there is clinical justification. (For example, fluoride treatment must be provided on the same day as an encounter-eligible service.)

(b) Clinical justification must be based on medical necessity and documented in the client's record.

(5) Services provided in an FQHC that are not encounter-eligible are paid on a fee-for-service basis according to agency rules, billing guides and fee schedules.

(6) Managed care organization (MCO) contracted services provided in an FQHC for clients enrolled in an MCO are paid for by the MCO.

(7) For clients enrolled with an MCO, the agency pays each FQHC a supplemental payment in addition to the amounts paid by the MCO. The supplemental payments, called enhancements, are paid in amounts necessary to ensure compliance with 42 U.S.C. 1396a (bb)(5)(A).

(a) The FQHCs receive an enhancement payment each month for each managed care client assigned to them by an MCO.

(b) To ensure that the appropriate amounts are paid to each FQHC, the agency performs an annual reconciliation of the enhancement payments.

(i) For each FQHC, the agency compares the amount paid in enhancement payments to the amount determined by the following formula:

(Managed care encounters x encounter rate) - MCO payments for FQHC services

(ii) If the agency determines that the FQHC was overpaid, the agency recoups the appropriate amount. If the agency determines that the FQHC was underpaid, the agency pays the difference.

(iii) The agency may prospectively adjust the FQHC's monthly enhancement payments if the agency determines the FQHC has been overpaid or underpaid in the annual reconciliation.

(A) The agency uses the FQHC's most current reconciliation data, and any supplemental information provided by the FQHC to determine if any adjustment to the enhancement rate is necessary.

(B) If the agency determines a prospective adjustment to enhancement payments is necessary, the agency notifies the FQHC in writing at least 30 calendar days prior to the enhancement payment adjustment.

(8) The agency pays the encounter rate and the enhancement payments with respect to services provided to encounter-eligible clients. Services provided to clients who are enrolled in medical programs that are paid only in state funds are not encounter-eligible; these claims are paid on a fee-for-service basis regardless of the type of service performed.

**History**
- *Statutory Authority: 42 U.S.C. 1396a(bb), 42 U.S.C. 1396d (2)(A), RCW 41.05.021, and 41.05.160. WSR 22-22-049, § 182-548-1450, filed 10/27/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. 1396a (bb)(5)(A). WSR 20-24-083, § 182-548-1450, filed 11/25/20, effective 1/1/21. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-12-016, § 182-548-1450, filed 5/30/17, effective 7/1/17.*

##### **Wash. Admin. Code § 182-548-1500** Federally qualified health centers—Change in scope of service rate adjustment. {#sec-182-548-1500 omnilex-key=us-wa-regs-official--title-182--182-548-1500}

In accordance with 42 U.S.C. 1396a (bb)(3)(B), the agency adjusts its payment rate to a federally qualified health center (FQHC) to take into account any increase or decrease in the scope of the FQHC's services. The procedures and requirements for any such rate adjustment are described below.

(1) Triggering events.

(a) An FQHC may file a change in scope of services rate adjustment application with the agency on its own initiative only when the FQHC satisfies the criteria described in (a)(i), (ii), and (iii) of this subsection.

(i) When the cost to the FQHC of providing covered health care services to eligible clients has increased or decreased due to one or more of the following triggering events:

(A) A change in the type of health care services the FQHC provides;

(B) A change in the intensity of health care services the FQHC provides. Intensity means the total quantity of labor and materials consumed by an individual client during an average encounter has increased;

(C) A change in the duration of health care services the FQHC provides. Duration means the length of an average encounter has increased;

(D) A change in the amount of health care services the FQHC provides in an average encounter;

(E) Any change comparable to (a)(i)(A) through (D) of this subsection in which the type, intensity, duration or amount of services has decreased and the cost of an average encounter has decreased.

(ii) The cost change equals or exceeds:

(A) An increase of one and three-quarters percent in the prospective payment system (PPS) rate per encounter over one year as measured by comparing the cost per encounter to the then current PPS rate;

(B) A decrease of two and one-half percent in the PPS rate per encounter over one year as measured by comparing the cost per encounter to the then current PPS rate; or

(C) A cumulative increase or decrease of five percent in the PPS rate per encounter as compared to the current year's cost per encounter.

(iii) The costs reported to the agency to support the proposed change in scope rate adjustment are reasonable under OMB Circular A-122 or successor (the Uniform Grants Guidance) and other applicable state and federal law.

(b) At any time, the agency may instruct the FQHC to file a medicaid cost report with a position statement indicating whether the FQHC asserts that its PPS rate should be increased or decreased due to a change in the scope of services.

(i) The FQHC files a completed cost report and position statement no later than 90 calendar days after receiving the instruction from the agency. If the FQHC has not received the annual audit report at the time of the agency's request, the FQHC informs the agency, in writing, that it will submit one of the following alternatives:

(A) The cost report and position statement within 90 calendar days of receiving its annual audit report; or

(B) The cost report and position statement based on the prior year's audit.

(ii) The agency reviews the FQHC's cost report and position statement under the same criteria listed above for an application for a change in scope adjustment.

(iii) The agency will not request more than one change in scope in a calendar year.

(2) Filing requirements.

(a) The FQHC may apply for a prospective change in scope of service rate adjustment, a retrospective change in scope of service rate adjustment, or both, in a single application.

(b) Unless instructed to file an application by the agency, the FQHC may file no more than one change in scope of service application per calendar year; however, more than one type of change in scope may be included in a single application.

(c) The FQHC files for a change in scope of service rate adjustment based on the following deadlines, whichever is later:

(i) Ninety calendar days after the end of the FQHC's fiscal year, demonstrating that the change in scope occurred as documented in the medicaid cost report.

(ii) Ninety calendar days after the FQHC learned, based on its annual audit, that the cost threshold in subsection (1)(a)(ii) of this section was met during the fiscal year.

(d) Prospective change in scope.

(i) A prospective change in scope of service rate adjustment application must state each triggering event listed in subsection (1)(a)(i) of this section that supports the FQHC's application.

(ii) A prospective change in scope of service rate adjustment application must be based on one of the following:

(A) A change the FQHC plans to implement in the future. The FQHC submits 12 months of projected data and costs sufficient to establish an interim rate; or

(B) A change which occurred in the FQHC's most recent fiscal year with less than 12 months of experience to support the change reflected in the medicaid cost report. The FQHC submits a combination of historical data and projected costs sufficient to establish an interim rate.

(iii) The interim rate adjustment goes into effect after the change takes effect.

(iv) The interim rate is subject to the post change in scope review and rate adjustment process defined in subsection (5) of this section.

(v) If the change in scope occurs less than 90 calendar days after the FQHC submitted a complete application to the agency, the interim rate takes effect no later than 90 calendar days after the complete application was submitted to the agency.

(vi) If the change in scope occurs more than 90 calendar days but less than 180 calendar days after the FQHC submitted a complete application to the agency, the interim rate takes effect when the change in scope occurs.

(vii) If the FQHC fails to implement a change in service identified in its prospective change in scope of service rate adjustment application within 180 calendar days, the application is void and the FQHC may resubmit the application to the agency, in such a circumstance, (b) of this subsection does not apply.

(viii) If the change in scope is based on a triggering event that already occurred but is supported by less than 12 months of data in the filed cost report, the interim rate takes effect on the date the FQHC submitted the completed application to the agency.

(e) Retrospective change in scope.

(i) A retrospective change in scope of service rate adjustment application must state each triggering event listed in subsection (1)(a)(i) of this section that supports its application and include 12 months of data documenting the cost change caused by the triggering event. A retrospective change in scope is a change that took place in the past and the FQHC is seeking to adjust its rate based on that change.

(ii) If approved, a retrospective rate adjustment takes effect on the date the FQHC submitted a complete application to the agency, as determined by the agency.

(3) Supporting documentation.

(a) To apply for a change in scope of service rate adjustment, the FQHC submits the following supporting documentation to the agency in electronic format by email to fqhcrhc@hca.wa.gov:

(i) A narrative description of the proposed change in scope;

(ii) A description of each cost center on the cost report that was or will be affected by the change in scope;

(iii) The FQHC's most recent audited financial statements, if audit is required by federal law;

(iv) The implementation date for the proposed change in scope; and

(v) Any additional documentation requested by the agency.

(b) A prospective change in scope of service rate adjustment application must also include the projected medicaid cost report and the projected medicare cost report with supplemental schedules necessary to identify the medicaid cost per visit for the 12-month period following implementation of the change in scope.

(c) A retrospective change in scope of service rate adjustment application must also include the medicaid cost report and the medicare cost report with supplemental schedules necessary to identify the medicaid cost per visit and encounter data for one of the following:

(i) The 12-month period following the implementation of the triggering event; or

(ii) The fiscal year following implementation of the proposed change in scope.

(4) Review of the application.

(a) Application processing.

(i) The agency reviews the application for completeness, accuracy, and compliance with program rules.

(ii) Within 60 calendar days of receiving the application, the agency notifies the FQHC of any deficient documentation or request any additional information that is necessary to process the application. If the FQHC does not provide the agency with the documentation or information within 30 calendar days of the request, the agency may deny the application.

(iii) Within 90 calendar days of receiving a complete application, including any additional documentation or information that the agency might request, the agency sends the FQHC:

(A) A decision stating whether it will implement a PPS rate change; and

(B) A rate-setting statement if the rate change is implemented.

(iv) The FQHC may appeal the decision on the application as provided for in WAC 182-548-1650.

(b) Determining rate for change in scope.

(i) The agency sets an interim rate for prospective changes in scope by adjusting the FQHC's existing rate by the projected average cost per encounter of any approved change. The agency reviews the costs to determine if they are reasonable, and set a new interim rate based on the determined cost per encounter.

(ii) The agency sets an adjusted encounter rate for retrospective changes in scope by adjusting the FQHC's existing rate by the documented average cost per encounter of the approved change. The agency reviews the costs to determine whether they are reasonable, and set a new rate based on the determined cost per encounter.

(c) If the FQHC is paid under an alternative payment methodology (APM), any change in scope of service rate adjustment approved by the agency modifies the PPS rate in addition to the APM.

(d) The agency may delegate the duties related to application processing and rate setting to a third party. The agency retains final responsibility and authority for making decisions related to changes in scope.

(5) Post change in scope of services rate adjustment review.

(a) If the approved change in scope rate adjustment was based on a retrospective change in scope application (i.e., based on a year or more of actual encounter data), the agency may conduct a post change in scope rate adjustment review.

(b) If the approved change in scope rate adjustment was based on a prospective change in scope application (i.e., based on less than a full year of actual encounter data), the FQHC submits the following information to the agency within 18 months of the effective date of the rate adjustment:

(i) Medicaid cost report and medicare cost report with supplemental schedules necessary to identify the medicaid cost per visit and encounter data for 12 consecutive months of experience following implementation of the change in scope;

(ii) A narrative description of the request;

(iii) A description of each cost center on the cost report that was affected by the change in scope;

(iv) The FQHC's most recent audited financial statements, if audit is required by applicable law; and

(v) Any additional documentation requested by the agency.

(c) The agency conducts the post change in scope review within 90 calendar days of receiving the cost report and encounter data from the FQHC.

(d) If necessary, the agency adjusts the encounter rate within 90 calendar days to ensure that the rate reflects the reasonable cost of the change in scope of services.

(e) A rate adjustment based on a post change in scope review takes effect on the date the agency issues its adjustment. The new rate is prospective.

(f) If the FQHC fails to submit the post change in scope cost report or related encounter data, the agency provides written notice to the center or clinic within 30 calendar days.

(g) If the FQHC fails to submit required documentation within five months of the notice identified in (f) of this subsection, the agency may reinstate the prechange in scope encounter rate going forward from the date the interim rate was established. The agency may recoup any overpayment to the FQHC.

**History**
- *Statutory Authority: 42 U.S.C. 1396a(bb), 42 U.S.C. 1396d (2)(A), RCW 41.05.021, and 41.05.160. WSR 22-22-049, § 182-548-1500, filed 10/27/22, effective 1/1/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-05-023, § 182-548-1500, filed 2/9/15, effective 3/12/15. WSR 11-14-075, recodified as § 182-548-1500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, BIPA of 2000 Section 702, sections 201 and 209 of 2009-2011 budget bill, and 42 U.S.C. 1396a(bb). WSR 10-09-002, § 388-548-1500, filed 4/7/10, effective 5/8/10.*

##### **Wash. Admin. Code § 182-548-1600** Federally qualified health centers—Appeals related to overpayments. {#sec-182-548-1600 omnilex-key=us-wa-regs-official--title-182--182-548-1600}

An overpayment assessment by the agency against an FQHC identified in the annual managed care reconciliation (see WAC 182-548-1450) may be appealed based on WAC 182-502-0230 and RCW 41.05A.170. Administrative hearing appeals are governed by chapter 34.05 RCW (Administrative Procedure Act) and chapter 182-526 WAC (HCA administrative hearing rules).

**History**
- *Statutory Authority: 42 U.S.C. 1396a(bb), 42 U.S.C. 1396d (2)(A), RCW 41.05.021, and 41.05.160. WSR 22-22-049, § 182-548-1600, filed 10/27/22, effective 1/1/23.*

##### **Wash. Admin. Code § 182-548-1650** Federally qualified health centers—Appeals related to rate setting. {#sec-182-548-1650 omnilex-key=us-wa-regs-official--title-182--182-548-1650}

(1) An FQHC provider has a right to an administrative appeal of agency action related to rate setting under this chapter based on the rules in this section.

(a) The rules in WAC 182-502-0220 do not apply to appeals of agency action related to rate setting under this chapter.

(b) Appeals related to rate setting under this section are not governed by the Administrative Procedure Act, chapter 34.05 RCW.

(c) Any rate change that the agency grants that is the result of fraudulent practices on the part of the FQHC, including as described under RCW 74.09.210, is exempt from the appeal provisions in this chapter.

(d) An FQHC who fails to submit requested information as outlined in this chapter will be determined to have abandoned their appeal.

(2) The first level of appeal.

(a) An FQHC provider who wants to contest an agency action concerning the reimbursement rate must file a written appeal with the agency. Written appeals must be sent to the address provided in the rate notification letter.

(b) The FQHC must file the appeal within 60 calendar days of the date of the rate notification letter from the agency, unless an extension has been granted.

(i) The agency may grant a time extension for the appeal period if the FQHC makes such a request before the expiration of the 60-day period.

(ii) The agency does not consider an appeal filed after the 60-day period unless an extension is granted by the agency.

(c) The appeal must include the following:

(i) A statement of the specific issue being appealed;

(ii) Supporting documentation; and

(iii) A request for the agency to recalculate the rate.

(d) When an FQHC appeals a portion of a rate, the agency may review all components of the reimbursement rate.

(e) To complete a review of the appeal, the agency may do one or both of the following:

(i) Request additional information;

(ii) Conduct an audit of the documentation provided.

(f) The agency issues a decision or requests additional information within 60 calendar days of receiving the rate appeal request. When the agency requests additional information:

(i) The FQHC has 45 calendar days from the date of the request to submit the additional information to the agency; and

(ii) The agency issues a decision within 30 calendar days of receipt of the additional information.

(g) Any rate increase or decrease resulting from an appeal is effective retroactively to the rate effective date in the notification letter. The exception is identified in (h) of this subsection.

(h) If an appeal is related to the denial of a change in scope rate adjustment application, any rate adjustment effective date is established by the following rules:

(i) For prospective change in scope, the effective date of the rate adjustment is established by WAC 182-548-1500 (2)(d);

(ii) For retrospective change in scope, the effective date of the rate adjustment is established by WAC 182-548-1500 (2)(e);

(iii) For a post change in scope of services, the effective date of the rate adjustment is established by WAC 182-548-1500 (5)(e).

(3) The second level of appeal.

(a) When an FQHC disagrees with a rate review decision from the first level of appeal, it may file a request along with supporting documentation for a dispute conference with the agency. For this section, "dispute conference" means an informal administrative appeal to resolve FQHC disagreements with an agency action not resolved at the first level of appeal.

(b) If an FQHC files a request for a dispute conference, it must submit the request to the agency within 30 calendar days after the date of the rate review decision.

(i) Any request for a dispute conference must be sent to the address indicated in the rate review decision.

(ii) The agency does not consider dispute conference requests submitted after the 30-day period for the first level decision.

(c) The agency conducts the dispute conference within 90 calendar days of receiving the request.

(d) The agency-director designee issues the final decision within 30 calendar days of the conference. Extensions of time for extenuating circumstances may be granted by the agency-director designee.

(e) Any rate increase or decrease resulting from a dispute conference decision is effective on the date specified in the dispute conference decision.

(f) The dispute conference is the final level of administrative appeal within the agency and precedes judicial action.

(4) The agency considers an FQHC who fails to attempt to resolve disputed rates as provided in this section has abandoned the dispute.

**History**
- *Statutory Authority: 42 U.S.C. 1396a(bb), 42 U.S.C. 1396d (2)(A), RCW 41.05.021, and 41.05.160. WSR 22-22-049, § 182-548-1650, filed 10/27/22, effective 1/1/23.*

## **Chapter 182-549** Rural health clinics. {#struct-chapter-182-549}

##### **Wash. Admin. Code § 182-549-1000** Rural health clinics—Purpose. {#sec-182-549-1000 omnilex-key=us-wa-regs-official--title-182--182-549-1000}

This chapter establishes the medicaid agency's reimbursement methodology for rural health clinic (RHC) services. RHC conditions for certification are found in 42 C.F.R. Part 491.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-11-008, § 182-549-1000, filed 5/7/15, effective 6/7/15. WSR 11-14-075, recodified as § 182-549-1000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 42 C.F.R. 405.2472, 42 C.F.R. 491. WSR 08-05-011, § 388-549-1000, filed 2/7/08, effective 3/9/08.*

##### **Wash. Admin. Code § 182-549-1100** Rural health clinics—Definitions. {#sec-182-549-1100 omnilex-key=us-wa-regs-official--title-182--182-549-1100}

This section contains definitions of words and phrases that apply to this chapter. Unless defined in this chapter, the definitions found in chapter 182-500 WAC apply.

"APM index" - The agency uses the alternative payment methodology (APM) to update APM encounter payment rates on an annual basis. The APM index is a measure of input price changes experienced by Washington's federally qualified health center (FQHC) and rural health clinic (RHC) providers. The index is derived from the federal medicare economic index (MEI).

"Base year" - The year that is used as the benchmark in measuring an RHC's total reasonable costs for establishing base encounter rates.

"Change in scope" - The process by which an RHC's rate(s) can be adjusted due to changes in type, intensity, duration, or amount of services outlined under WAC 182-549-1500.

"Cost center" - A category of service approved to be provided by the RHC under WAC 182-549-1200 and reported in the medicare cost report and supplemental documentation. The categories of services to be provided by the RHC may include medical and dental.

"Encounter" - A face-to-face or telemedicine (including audio-only telemedicine) visit between an encounter-eligible client and an RHC provider who exercises independent judgment when providing services that qualify for encounter rate reimbursement.

"Encounter-eligible client" - A client who receives benefits under Title XIX (medicaid) or Title XXI (CHIP).

"Encounter rate" - A cost-based, facility-specific rate for covered RHC services.

"Enhancements (also called managed care enhancements or supplemental payments)" - A monthly amount the agency pays to RHCs through a managed care organization (MCO) that has contracted with the RHC to provide services to clients enrolled with the MCO. The enhancement is in addition to the negotiated payment that RHCs receive from the MCO. RHCs participating in the payment method described in WAC 182-549-1450 (7)(b) do not receive enhancements.

"Fee-for-service" - A payment method the agency uses to pay providers for covered medical services provided to Washington apple health clients, which excludes services provided by the agency's contracted managed care organizations and services that qualify for an encounter payment.

"Interim rate" - The rate the agency establishes to pay an RHC for covered RHC services prior to the establishment of a permanent rate for that RHC.

"Medicare cost report" - The cost report is a statement of costs and provider utilization. RHCs must complete and submit a report annually to medicare.

"Medicare economic index (MEI)" - An index published in the Federal Register used in the calculation of changes to determine allowed charges for physician services. The agency adjusts RHC encounter rates and enhancement rates by the MEI each year on January 1st.

"Mobile unit" - The objects, equipment, and supplies necessary for provision of the services furnished directly by the RHC are housed in a mobile structure.

"Permanent unit" - The objects, equipment, and supplies necessary for the provision of the services furnished directly by the RHC are housed in a permanent structure.

"Rebasing" - The process of recalculating encounter rates using actual cost report data for all rural health clinics listed in the medicare cost report.

"Rural area" - An area that is not delineated as an urbanized area by the U.S. Census Bureau.

"Rural health clinic (RHC)" - A clinic, as defined in 42 C.F.R. 405.2401(b), that is primarily engaged in providing RHC services and is:

• Located in a rural area designated as a shortage area as defined under 42 C.F.R. 491.2;

• Certified by medicare as an RHC in accordance with applicable federal requirements; and

• Not a rehabilitation agency or a facility primarily for the care and treatment of mental diseases.

"Rural health clinic (RHC) services" - Outpatient or ambulatory care of the nature typically provided in a physician's office or outpatient clinic or similar setting, including specified types of diagnostic examination, laboratory services, and emergency treatments. The specific list of services which must be made available by the clinic can be found under 42 C.F.R. Part 491.9.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-01-208, s 182-549-1100, filed 12/24/25, effective 1/24/26. Statutory Authority: 42 U.S.C. 1396a(bb), 42 U.S.C. 1396d (2)(A), RCW 41.05.021, and 41.05.160. WSR 22-22-049, § 182-549-1100, filed 10/27/22, effective 1/1/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-02-070, § 182-549-1100, filed 12/26/19, effective 1/26/20*
- *WSR 18-10-058, § 182-549-1100, filed 4/27/18, effective 5/28/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 1 § 213(1)(ll). WSR 17-22-070, § 182-549-1100, filed 10/27/17, effective 1/1/18. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-11-008, § 182-549-1100, filed 5/7/15, effective 6/7/15. WSR 11-14-075, recodified as § 182-549-1100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 42 U.S.C. 1396a(bb), 42 C.F.R. 405.2472, and 42 C.F.R. 491. WSR 10-09-030, § 388-549-1100, filed 4/13/10, effective 5/14/10. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 42 C.F.R. 405.2472, 42 C.F.R. 491. WSR 08-05-011, § 388-549-1100, filed 2/7/08, effective 3/9/08.*

##### **Wash. Admin. Code § 182-549-1200** Rural health clinics—Enrollment. {#sec-182-549-1200 omnilex-key=us-wa-regs-official--title-182--182-549-1200}

(1) To participate in the Title XIX (medicaid) program or the Title XXI (CHIP) program and receive payment for services, a rural health clinic (RHC) must:

(a) Receive RHC certification for participation in the Title XVIII (medicare) program according to 42 C.F.R. 491;

(b) Sign a core provider agreement with the medicaid agency;

(c) Comply with the clinical laboratory improvement amendments (CLIA) of 1988 testing for all laboratory sites per 42 C.F.R. Part 493; and

(d) Operate in accordance with applicable federal, state, and local laws.

(2) An RHC may be a permanent or mobile unit. If an entity owns clinics in multiple locations, each individual site must be certified by the agency in order to receive reimbursement from the agency as an RHC.

(3) The agency uses one of two timeliness standards for determining the effective date of a medicaid-certified RHC.

(a) The agency uses medicare's effective date if the RHC returns a properly completed core provider agreement and a properly completed RHC enrollment packet within 60 calendar days from the date of CMS's written notification to the RHC of the medicare certification.

(b) The agency uses the date the medicare certification letter is received by the agency if the RHC returns either the properly completed core provider agreement or properly completed RHC enrollment packet after 60 calendar days of the date of medicare's letter notifying the clinic of the medicare certification.

**History**
- *Statutory Authority: 42 U.S.C. 1396a(bb), 42 U.S.C. 1396d (2)(A), RCW 41.05.021, and 41.05.160. WSR 22-22-049, § 182-549-1200, filed 10/27/22, effective 1/1/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-02-070, § 182-549-1200, filed 12/26/19, effective 1/26/20*
- *WSR 15-11-008, § 182-549-1200, filed 5/7/15, effective 6/7/15. WSR 11-14-075, recodified as § 182-549-1200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 42 C.F.R. 405.2472, 42 C.F.R. 491. WSR 08-05-011, § 388-549-1200, filed 2/7/08, effective 3/9/08.*

##### **Wash. Admin. Code § 182-549-1300** Rural health clinics—Services. {#sec-182-549-1300 omnilex-key=us-wa-regs-official--title-182--182-549-1300}

(1) Rural health clinic (RHC) services are defined under 42 C.F.R. 440.20(b).

(2) The medicaid agency pays for RHC services when they are:

(a) Within the scope of an encounter-eligible client's benefit package. See WAC 182-501-0060; and

(b) Medically necessary as defined in WAC 182-500-0070.

(3) RHC services may be provided by any of the following individuals in accordance with 42 C.F.R. 405.2401, 491.7, and 491.8:

(a) Physicians;

(b) Physician assistants (PA);

(c) Nurse practitioners (NP);

(d) Nurse midwives or other specialized nurse practitioners;

(e) Certified nurse midwives;

(f) Registered nurses (RN) or licensed practical nurses (LPN);

(g) Psychologists or clinical social workers; and

(h) Dental services specified in 42 C.F.R. Sec. 440.100.

**History**
- *Statutory Authority: 42 U.S.C. 1396a(bb), 42 U.S.C. 1396d (2)(A), RCW 41.05.021, and 41.05.160. WSR 22-22-049, § 182-549-1300, filed 10/27/22, effective 1/1/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-02-070, § 182-549-1300, filed 12/26/19, effective 1/26/20*
- *WSR 15-11-008, § 182-549-1300, filed 5/7/15, effective 6/7/15. WSR 11-14-075, recodified as § 182-549-1300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 42 C.F.R. 405.2472, 42 C.F.R. 491. WSR 08-05-011, § 388-549-1300, filed 2/7/08, effective 3/9/08.*

##### **Wash. Admin. Code § 182-549-1400** Rural health clinics—Reimbursement and limitations. {#sec-182-549-1400 omnilex-key=us-wa-regs-official--title-182--182-549-1400}

(1) For services provided during the period beginning January 1, 2001, and ending December 31, 2008, the medicaid agency's payment methodology for rural health clinics (RHC) was a prospective payment system (PPS) as authorized by 42 U.S.C. 1396a (bb)(2) and (3).

(2) For services provided beginning January 1, 2009, RHCs have the choice to be reimbursed under the PPS or be reimbursed under an alternative payment methodology (APM), as authorized by 42 U.S.C. 1396a (bb)(6). As required by 42 U.S.C. 1396a (bb)(6), payments made under the APM are at least as much as payments that would have been made under the PPS.

(3) The agency calculates RHC PPS encounter rates for RHC core services as follows:

(a) Until an RHC submits its first audited or as filed medicare cost report to the agency, the agency pays the RHC an average encounter rate of other similar RHCs within the state, otherwise known as an interim rate. Similar RHCs are defined as either all hospital based or all free-standing RHCs.

(b) Upon the RHC's request to the agency, which must include the submission of their first as filed or audited medicare cost report, the agency calculates the PPS rates for core services for all RHCs in the medicare cost report.

(i) The agency rebases each RHC's encounter rate(s) by dividing 100 percent of the RHC's costs by the total number of RHC encounters reported in the submitted cost report.

(ii) If the medicare cost report contains less than 12 months of data for the RHC(s), the agency sets an interim rate. Within 18 months of the effective date of the interim rate adjustment, the RHC must submit a medicare cost report to the agency, containing 12 months of data for the RHC(s).

(iii) The agency follows the rate structure calculated in the medicare cost report when setting medicaid RHC encounter rates. If RHC encounter rates are combined on the medicare cost report, medicaid encounter rates will be combined. If the medicare cost report has separate rates for each RHC on the cost report, medicaid encounter rates will be separate for each clinic.

(c) The agency uses the medicare cost report data and applies medicaid-specific adjustments, such as adding medicaid services not covered by medicare and allocating overhead to services not reported in the medicare cost report (e.g., dental services).

(d) The encounter rate is effective for all RHCs on the date the agency receives the submitted medicare cost report from the RHC.

(e) RHCs receive this rate for the remainder of the calendar year during which the submitted medicare cost report became available to the agency. The agency then adjusts the encounter rate each January 1st by the percentage change of the medicare economic index (MEI) as reported in the Federal Register.

(4) For RHCs in existence during calendar years 1999 and 2000, the agency set the encounter rates prospectively using a weighted average of 100 percent of the RHC's total reasonable costs for calendar years 1999 and 2000 and adjusted for any increase or decrease in the scope of services furnished during the calendar year 2001 to establish a base encounter rate.

(a) The agency adjusted PPS base encounter rates to account for an increase or decrease in the scope of services provided during calendar year 2001 in accordance with WAC 182-549-1500.

(b) The agency determined PPS base encounter rates using medicare's audited cost reports, and each year's rate was weighted by the total reported encounters. The agency did not apply a capped amount to these base encounter rates. The formula used to calculate base encounter rates was as follows:

| Specific RHC Base Encounter Rate | = | (Year 1999 Rate x Year 1999 Encounters) + (Year 2000 Rate x Year 2000 Encounters) |
| --- | --- | --- |
| (Year 1999 Encounters + Year 2000 Encounters) for each RHC | | |

(c) Beginning in calendar year 2002 and any year thereafter, encounter rates are adjusted by the MEI and adjusted for any increase or decrease in the RHC's scope of services.

(5) The agency calculated RHC's APM encounter rates for services provided during the period beginning January 1, 2009, and ending April 6, 2011, as follows:

(a) The APM used the RHC base encounter rates as described in subsection (4)(b) of this section.

(b) Base rates were increased by each annual percentage, from calendar years 2002 through 2009, of the IHS Global Insight index, also called the APM index.

(c) The result was the year 2009 APM rates for each RHC that chose to be reimbursed under the APM.

(6) This subsection describes the encounter rates that the agency paid RHCs for services provided during the period beginning April 7, 2011, and ending June 30, 2011. On January 12, 2012, the federal Centers for Medicare and Medicaid Services (CMS) approved a state plan amendment (SPA) containing the methodology outlined in this section.

(a) During the period that CMS approval of the SPA was pending, the agency continued to pay RHCs at the encounter rate described in subsection (5) of this section.

(b) Each RHC had the choice of receiving either its PPS rate, as determined under the method described in subsection (3) of this section, or a rate determined under a revised APM, as described in (c) of this subsection.

(c) The revised APM used each RHC's PPS rate for the current calendar year, increased by five percent.

(d) For all payments made for services provided during the period beginning April 7, 2011, and ending June 30, 2011, the agency recouped from RHCs any amount paid in excess of the encounter rate established in this section. This process was specified in emergency rules that took effect on October 29, 2011, (WSR 11-22-047) and February 25, 2012 (WSR 12-06-002).

(7) This subsection describes the encounter rate that the agency pays RHCs for services provided on and after July 1, 2011. On January 12, 2012, CMS approved a SPA containing the methodology outlined in this section.

(a) Each RHC has the choice of receiving either its PPS rate, as determined under the method described in subsection (3) of this section, or a rate determined under a revised APM, as described in (b) of this subsection.

(b) The revised APM, known as APM-3, is as follows:

(i) For RHCs that rebased their rate effective January 1, 2010, the revised APM is their allowed cost per visit during the cost report year increased by the cumulative percentage increase in the MEI between the cost report year and January 1, 2011.

(ii) For RHCs that did not rebase their rate effective January 1, 2010, the revised APM is based on their PPS base rate from 2001 (or subsequent year for RHCs receiving their initial RHC designation after 2002) increased by the cumulative percentage increase in the IHS Global Insight index from the base year through calendar year 2008 and the cumulative increase in the MEI from calendar years 2009 through 2011. The rates are increased by the MEI effective January 1, 2012, and each January 1st thereafter.

(c) For all payments made for services provided during the period beginning July 1, 2011, and ending January 11, 2012, the agency recouped from RHCs any amount paid in excess of the encounter rate established in this section. This process was specified in emergency rules that took effect on October 29, 2011, (WSR 11-22-047) and February 25, 2012 (WSR 12-06-002).

(d) For RHCs that choose to be paid under the revised APM, the agency periodically rebases the encounter rates using the RHC cost reports and other relevant data. Rebasing is done only for RHCs that are reimbursed under the APM.

(e) The agency makes sure that the payments made under the APM are at least equal to the payments that would be made under the PPS.

(8) This subsection describes the payment methodology that the agency uses to pay participating RHCs for services provided beginning July 1, 2017, and ending December 31, 2022.

(a) Each RHC may receive payments under the APM described in subsection (7) of this section, or receive payments under the revised APM described in this subsection.

(b) The revised APM, known as APM-4, is as follows:

(i) The revised APM establishes a budget-neutral, baseline per member per month (PMPM) rate for each RHC. The PMPM rate accounts for enhancement payments in accordance with the definition of enhancements in WAC 182-548-1100. For the purposes of this section, "budget-neutral" means the cost of the revised APM to the agency will not exceed what would have otherwise been spent not including the revised APM on a per member per year basis.

(ii) The agency pays the RHC a PMPM payment each month for each managed care client assigned to them by an MCO.

(iii) The agency pays the RHC a PMPM payment each month in addition to the amounts the MCO pays the RHC.

(iv) The agency may prospectively adjust the RHC's PMPM rate for any of the following reasons:

(A) Quality and access metrics performance.

(B) RHC encounter rate changes.

(v) In accordance with 42 U.S.C. 1396a (bb)(5)(A), the agency performs an annual reconciliation.

(A) If the RHC was underpaid, the agency pays the difference, and the PMPM rate may be subject to prospective adjustment under (b)(iv) of this subsection.

(B) If the RHC was overpaid, the PMPM rate may be subject to prospective adjustment under (b)(iv) of this subsection.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-01-208, s 182-549-1400, filed 12/24/25, effective 1/24/26. Statutory Authority: 42 U.S.C. 1396a(bb), 42 U.S.C. 1396d (2)(A), RCW 41.05.021, and 41.05.160. WSR 22-22-049, § 182-549-1400, filed 10/27/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. 1396a (bb)(5)(A). WSR 20-24-083, § 182-549-1400, filed 11/25/20, effective 1/1/21. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-02-070, § 182-549-1400, filed 12/26/19, effective 1/26/20*
- *WSR 17-12-016, § 182-549-1400, filed 5/30/17, effective 7/1/17*
- *WSR 15-11-008, § 182-549-1400, filed 5/7/15, effective 6/7/15. Statutory Authority: RCW 41.05.021. WSR 12-16-060, § 182-549-1400, filed 7/30/12, effective 8/30/12. WSR 11-14-075, recodified as § 182-549-1400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 42 U.S.C. 1396a(bb), 42 C.F.R. 405.2472, and 42 C.F.R. 491. WSR 10-09-030, § 388-549-1400, filed 4/13/10, effective 5/14/10. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 42 C.F.R. 405.2472, 42 C.F.R. 491. WSR 08-05-011, § 388-549-1400, filed 2/7/08, effective 3/9/08.*

##### **Wash. Admin. Code § 182-549-1450** Rural health clinics—General payment information. {#sec-182-549-1450 omnilex-key=us-wa-regs-official--title-182--182-549-1450}

(1) The medicaid agency limits RHC encounter rate reimbursement to one per client, per day except in the following circumstances:

(a) There is a subsequent visit in the same cost center that requires separate evaluation and treatment on the same day for unrelated diagnoses; or

(b) There are separate visits in different types of cost centers that occur with different health care professionals. (For example, a client with a separate medical and dental visit on the same day.)

(2) All services provided within the same cost center performed on the same day must be included in the same encounter, except for in the circumstances outlined in subsection (1)(a) of this section.

(3) Services and supplies incidental to an encounter are included in the encounter rate payment and must be billed on the same claim.

(4) RHCs must provide services in a single encounter that are typically rendered in a single visit based on clinical guidance and standards of care.

(a) RHCs must not split services into multiple encounters unless there is clinical justification. (For example, fluoride treatment must be provided on the same day as an encounter-eligible service.)

(b) Clinical justification must be based on medical necessity and documented in the client's record.

(5) Services provided in an RHC that are not encounter-eligible are paid on a fee-for-service basis. These services are paid according to agency rules, billing guides and fee schedules.

(6) Managed care organization (MCO) contracted services provided in an RHC for clients enrolled in an MCO are paid for by the MCO.

(7) For clients enrolled with MCOs, the RHC receives encounter rate reimbursement using either the method described in (a) or (b) of this subsection.

(a) RHCs receive an enhancement payment in addition to the MCO's negotiated payment. The agency makes enhancement payments in amounts necessary to ensure that the RHC receives the full encounter rate to comply with 42 U.S.C. 1396a (bb)(5)(A).

(i) The RHCs receive a monthly enhancement payment for each managed care client assigned to them by an MCO.

(ii) To ensure that the appropriate amounts are paid to each RHC, the agency performs an annual reconciliation of the enhancement payments.

(A) For each RHC, the agency compares the amount paid in enhancement payments to the amount determined by the following formula:

(Managed care encounters x encounter rate) - MCO payments for RHC services.

(B) If the agency determines that the RHC was overpaid, the agency recoups the appropriate amount. If the agency determines that the RHC was underpaid, the agency pays the difference.

(C) The agency may prospectively adjust the RHC's monthly enhancement payments if the agency determines the RHC has been overpaid or underpaid in the annual reconciliation.

(D) The agency uses the RHC's most current reconciliation data, and any supplemental information provided by the RHC to determine if any adjustment to the enhancement rate is necessary.

(E) If the agency determines a prospective adjustment to enhancement payments is necessary, the agency notifies the RHC in writing at least 30 calendar days prior to the enhancement payment adjustment.

(F) For dates of service on and after January 1, 2018, reconciliations are conducted in the calendar year following the calendar year for which the enhancements were paid. Reconciliations are conducted by the agency or the clinic with final review and approval by the agency. The process of settling over or under payments may extend beyond the calendar year in which the reconciliations were conducted.

(b) Effective January 1, 2018, instead of distributing monthly enhancement payments to the RHCs, MCOs pay the full encounter rate directly to participating clinics for encounter-eligible services.

(i) RHC participation is voluntary. The RHC notifies the agency in writing whether it will participate or not by no later than November 1st prior to the year of participation.

(ii) The agency performs a reconciliation or claim review with the MCO as outlined in the MCO contract. Reconciliations or claim reviews make sure appropriate amounts are paid to each RHC and that MCOs are not put at risk for, or have any right to, the enhancement portion of the claim. If an MCO has been overpaid, the agency recoups the appropriate amount. If an MCO has been underpaid, the agency pays the difference.

(iii) RHCs participating in the revised alternative payment method (APM) as described in WAC 182-549-1400(8) are not eligible to receive encounter payments directly from MCOs under this section.

(8) The agency pays the encounter rate and the enhancement payments with respect to services provided to encounter-eligible clients. Services provided to clients who are enrolled in medical programs that are paid only in state funds are not encounter-eligible; these claims are paid on a fee-for-service basis, regardless of the type of service performed.

**History**
- *Statutory Authority: 42 U.S.C. 1396a(bb), 42 U.S.C. 1396d (2)(A), RCW 41.05.021, and 41.05.160. WSR 22-22-049, § 182-549-1450, filed 10/27/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160*
- *42 U.S.C. 1396a (bb)(5)(A). WSR 20-24-083, § 182-549-1450, filed 11/25/20, effective 1/1/21. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-02-070, § 182-549-1450, filed 12/26/19, effective 1/26/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 1 § 213(1)(ll). WSR 17-22-070, § 182-549-1450, filed 10/27/17, effective 1/1/18. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-12-016, § 182-549-1450, filed 5/30/17, effective 7/1/17.*

##### **Wash. Admin. Code § 182-549-1500** Rural health clinics—Change in scope of service rate adjustment. {#sec-182-549-1500 omnilex-key=us-wa-regs-official--title-182--182-549-1500}

In accordance with 42 U.S.C. 1396a (bb)(3)(B), the agency adjusts its payment rate to a rural health clinic (RHC) to take into account any increase or decrease in the scope of the RHC's services. The procedures and requirements for any such rate adjustments are described below.

(1) Triggering events.

(a) An RHC may file a change in scope of services rate adjustment application with the agency on its own initiative only when the RHC satisfies the criteria described in (a)(i), (ii), (iii), and (iv) of this subsection.

(i) When the cost to the RHC of providing covered health care services to eligible clients has increased or decreased due to one or more of the following triggering events:

(A) A change in the type of health care services the RHC provides;

(B) A change in the intensity of health care services the RHC provides. Intensity means the total quantity of labor and materials consumed by an individual client during an average encounter has increased;

(C) A change in the duration of health care services the RHC provides. Duration means the length of an average encounter has increased;

(D) A change in the amount of health care services the RHC provides in an average encounter;

(E) Any change comparable to (a)(i)(A) through (D) of this subsection in which the type, intensity, duration or amount of services has decreased and the cost of an average encounter has decreased.

(ii) The cost change equals or exceeds:

(A) An increase of one and three-quarters percent in the prospective payment system (PPS) rate per encounter over one year as measured by comparing the cost per encounter to the then current PPS rate;

(B) A decrease of two and one-half percent in the PPS rate per encounter over one year as measured by comparing the cost per encounter to the then current PPS rate; or

(C) A cumulative increase or decrease of five percent in the PPS rate per encounter as compared to the current year's cost per encounter.

(iii) The costs reported to the agency to support the proposed change in scope rate adjustment are reasonable and accurate under state and federal law.

(iv) An approved change in scope includes rate adjustments using the overhead and visit allocation methodology as reported for all RHCs listed in the medicare cost report. The medicaid rate may also include the allocation of overhead to medicaid eligible services not reported in the medicare cost report (e.g., dental services), as directed by the agency.

(b) At any time, the agency may instruct the RHC to file a medicare cost report with a position statement indicating whether the RHC asserts that its PPS rate should be increased or decreased due to a change in the scope of services.

(i) The RHC files a completed medicare cost report and position statement no later than 90 calendar days after receiving the instruction from the agency to file an application;

(ii) The agency reviews the RHC(s) cost report and position statement under the same criteria listed above for an application for a change in scope adjustment;

(iii) The agency will not request more than one change in scope in a calendar year.

(2) Filing requirements.

(a) The RHC may apply for a prospective change in scope of service rate adjustment, a retrospective change in scope of service rate adjustment, or both, in a single application.

(b) Unless instructed to file an application by the agency, the RHC may file no more than one change in scope of service application per calendar year; however, more than one type of change in scope may be included in a single application.

(c) The RHC files for a change in scope of service rate adjustment based on the following deadlines, whichever is later:

(i) Ninety calendar days after the end of the RHC's fiscal year, demonstrating that the change in scope occurred.

(ii) Ninety calendar days after the RHC learned the cost threshold in subsection (1)(a)(ii) of this section was met.

(d) Prospective change in scope.

(i) A prospective change in scope of service rate adjustment application states each triggering event listed in subsection (1)(a)(i) of this section that supports the RHC's application.

(ii) A prospective change in scope of service rate adjustment application must be based on one of the following:

(A) A change the RHC plans to implement in the future. The RHC submits 12 months of projected data and costs sufficient to establish an interim rate; or

(B) A change with less than 12 months of experience to support the change reflected in the medicare cost report. The RHC submits a combination of historical data and projected costs sufficient to establish an interim rate.

(iii) The interim rate adjustment goes into effect after the change takes effect.

(iv) The interim rate is subject to the post change in scope review and rate adjustment process defined in subsection (5) of this section.

(v) If the change in scope occurs less than 90 calendar days after the RHC submitted a complete application to the agency, the interim rate takes effect no later than 90 calendar days after the complete application was submitted to the agency.

(vi) If the change in scope occurs more than 90 calendar days but less than 180 calendar days after the RHC submitted a complete application to the agency, the interim rate takes effect when the change in scope occurs.

(vii) If the RHC fails to implement a change in service identified in its prospective change in scope of service rate adjustment application within 180 calendar days, the application is void and the RHC may resubmit the application to the agency, in such a circumstance, (b) of this subsection does not apply.

(viii) If the change in scope is based on a triggering event that already occurred but is supported by less than 12 months of data in the filed cost report, the interim rate takes effect on the date the RHC submitted the completed application to the agency.

(e) Retrospective change in scope.

(i) A retrospective change in scope of service rate adjustment application states each triggering event listed in subsection (1)(a)(i) of this section that supports its application and includes 12 months of data documenting the cost change caused by the triggering event. A retrospective change in scope is a change that took place in the past and the RHC is seeking to adjust its rate(s) based on that change.

(ii) If approved, a retrospective rate adjustment takes effect on the date the RHC submitted a complete application to the agency, as determined by the agency.

(3) Supporting documentation.

(a) To apply for a change in scope of service rate adjustment, the RHC submits the following supporting documentation for all RHCs in the medicare cost report to the agency in electronic format by email to fqhcrhc@hca.wa.gov:

(i) Medicare cost report;

(ii) A narrative description of the proposed change in scope;

(iii) A description of each cost center on the cost report that was or will be affected by the change in scope;

(iv) The RHC's most recent audited financial statements, if audit is required by federal law;

(v) The implementation date for the proposed change in scope; and

(vi) Any additional documentation requested by the agency.

(b) A prospective change in scope of service rate adjustment application must also include the projected medicare cost report with supplemental schedules necessary to identify the medicaid cost per visit for the 12-month period following implementation of the change in scope.

(c) A retrospective change in scope of service rate adjustment application must also include the medicare cost report with supplemental schedules necessary to identify the medicaid cost per visit and encounter data for one of the following:

(i) The 12-month period following the implementation of the triggering event; or

(ii) The fiscal year following implementation of the proposed change in scope.

(4) Review of the application.

(a) Application processing.

(i) The agency reviews the application for completeness, accuracy, and compliance with program rules.

(ii) Within 60 days of receiving the application, the agency notifies the RHC of any deficient documentation or requests any additional information that is necessary to process the application. If the RHC does not provide the agency with the documentation or information requested within 30 calendar days of the request, the agency may deny the application.

(iii) Within 90 calendar days of receiving a complete application, including any additional documentation or information that the agency might request, the agency sends the RHC:

(A) A decision stating whether it will implement a PPS rate change; and

(B) A rate-setting statement if the rate change is implemented.

(iv) The RHC may appeal the decision on the application as provided for in WAC 182-549-1650.

(b) Determining rate for change in scope.

(i) The agency sets an interim rate for prospective changes in scope by adjusting the RHC's existing rate by the projected average cost per encounter of any approved change. The agency reviews the costs to determine if they are reasonable, and sets a new interim rate based on the determined cost per encounter.

(ii) The agency sets an adjusted encounter rate for retrospective changes in scope by adjusting the RHC's existing rate by the documented average cost per encounter of the approved change. The agency reviews the costs to determine whether they are reasonable, and sets a new rate based on the determined cost per encounter.

(iii) The agency follows the rate structure calculated in the medicare cost report when setting medicaid RHC encounter rates. If RHC encounter rates are combined on the medicare cost report, medicaid encounter rates will be combined. If the medicare cost report has separate rates for each RHC on the cost report, medicaid encounter rates will be separate for each clinic.

(c) If the RHC is paid under an alternative payment methodology (APM), any change in scope of service rate adjustment approved by the agency modifies the PPS rate in addition to the APM.

(d) The agency may delegate the duties related to application processing and rate setting to a third party. The agency retains final responsibility and authority for making decisions related to changes in scope.

(5) Post change in scope of services rate adjustment review.

(a) If the approved change in scope rate adjustment was based on a retrospective change in scope application (i.e., based on a year or more of actual encounter data), the agency may conduct a post change in scope rate adjustment review for all RHCs listed in the medicare cost report.

(b) If the approved change in scope rate adjustment was based on a prospective change in scope application (i.e., less than a full year of actual encounter data), the following information is submitted to the agency for each RHC listed in the medicare cost report within 18 months of the effective date of the rate adjustment:

(i) The most recent audited or as filed medicare cost report with supplemental schedules necessary to identify the medicaid cost per visit and encounter data for 12 consecutive months of experience following implementation of the change in scope;

(ii) A narrative description of the request;

(iii) A description of each cost center on the cost report that was affected by the change in scope;

(iv) The RHC's most recent audited financial statements, if audit is required by applicable law; and

(v) Any additional documentation requested by the agency.

(c) The agency conducts the post change in scope review within 90 calendar days of receiving the cost report and encounter data from the RHC.

(d) If necessary, the agency adjusts the encounter rate(s) within 90 calendar days to make sure that the rate reflects the reasonable cost of the change in scope of services.

(e) A rate adjustment based on a post change in scope review takes effect on the date the agency issues its adjustment. The new rate is prospective.

(f) If the RHC fails to submit the post change in scope cost report or related encounter data, the agency provides written notice to the clinic within 30 calendar days.

(g) If the RHC fails to submit required documentation within five months of the notice identified in (f) of this subsection, the agency may reinstate the prechange in scope encounter rate going forward from the date the interim rate was established. The agency may recoup any overpayment to the RHC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-01-208, s 182-549-1500, filed 12/24/25, effective 1/24/26. Statutory Authority: 42 U.S.C. 1396a(bb), 42 U.S.C. 1396d (2)(A), RCW 41.05.021, and 41.05.160. WSR 22-22-049, § 182-549-1500, filed 10/27/22, effective 1/1/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-02-070, § 182-549-1500, filed 12/26/19, effective 1/26/20*
- *WSR 15-05-020, § 182-549-1500, filed 2/9/15, effective 3/12/15. WSR 11-14-075, recodified as § 182-549-1500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 42 U.S.C. 1396a(bb), 42 C.F.R. 405.2472, and 42 C.F.R. 491. WSR 10-09-030, § 388-549-1500, filed 4/13/10, effective 5/14/10. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.522, 42 C.F.R. 405.2472, 42 C.F.R. 491. WSR 08-05-011, § 388-549-1500, filed 2/7/08, effective 3/9/08.*

##### **Wash. Admin. Code § 182-549-1600** Rural health clinics—Appeals related to overpayments. {#sec-182-549-1600 omnilex-key=us-wa-regs-official--title-182--182-549-1600}

An overpayment assessment by the agency against an RHC that was identified in the annual managed care reconciliation (see WAC 182-549-1450) may be appealed based on WAC 182-502-0230 and RCW 41.05A.170. Administrative hearing appeals are governed by chapter 34.05 RCW (Administrative Procedure Act) and chapter 182-526 WAC (HCA administrative hearing rules).

**History**
- *Statutory Authority: 42 U.S.C. 1396a(bb), 42 U.S.C. 1396d (2)(A), RCW 41.05.021, and 41.05.160. WSR 22-22-049, § 182-549-1600, filed 10/27/22, effective 1/1/23.*

##### **Wash. Admin. Code § 182-549-1650** Rural health clinics—Appeals related to rate setting. {#sec-182-549-1650 omnilex-key=us-wa-regs-official--title-182--182-549-1650}

(1) An RHC provider has a right to an administrative appeal of agency action related to rate setting under this chapter based on the rules in this section.

(a) The rules in WAC 182-502-0220 do not apply to appeals of agency action related to rate setting under this chapter.

(b) Appeals related to rate setting under this section are not governed by the Administrative Procedure Act, chapter 34.05 RCW.

(c) Any rate change that the agency grants that is the result of fraudulent practices on the part of the RHC, including as described under RCW 74.09.210, is exempt from the appeal provisions in this chapter.

(d) An RHC who fails to submit requested information as outlined in this chapter will be determined to have abandoned their appeal.

(2) The first level of appeal.

(a) An RHC provider who wants to contest an agency action concerning the reimbursement rate must file a written appeal with the agency. Written appeals must be sent to the address provided in the rate notification letter.

(b) The RHC must file the appeal within 60 calendar days of the date of the rate notification letter from the agency, unless an extension has been granted.

(i) The agency may grant a time extension for the appeal period if the RHC makes such a request before the expiration of the 60-day period.

(ii) The agency does not consider an appeal filed after the 60-day period unless an extension is granted by the agency.

(c) The appeal must include the following:

(i) A statement of the specific issue being appealed;

(ii) Supporting documentation; and

(iii) A request for the agency to recalculate the rate.

(d) When an RHC appeals a portion of a rate, the agency may review all components of the reimbursement rate.

(e) To complete a review of the appeal, the agency may do one or both of the following:

(i) Request additional information;

(ii) Conduct an audit of the documentation provided.

(f) The agency issues a decision or requests additional information within 60 calendar days of receiving the rate appeal request. When the agency requests additional information:

(i) The RHC has 45 calendar days from the date of the request to submit the additional information to the agency; and

(ii) The agency issues a decision within 30 calendar days of receipt of the additional information.

(g) Any rate increase or decrease resulting from an appeal is effective retroactively to the rate effective date in the notification letter. The exception is identified in (h) of this subsection.

(h) If an appeal is related to the denial of a change in scope rate adjustment application, any rate adjustment effective date is established by the following rules:

(i) For prospective change in scope, the effective date of the rate adjustment is established by WAC 182-549-1500 (2)(d);

(ii) For retrospective change in scope, the effective date of the rate adjustment is established by WAC 182-549-1500 (2)(e);

(iii) For a post change in scope of services, the effective date of the rate adjustment is established by 182-549-1500 (5)(e).

(3) The second level of appeal.

(a) When an RHC disagrees with a rate review decision from the first level of appeal, it may file a request along with supporting documentation for a dispute conference with the agency. For this section "dispute conference" means an informal administrative appeal to resolve RHC disagreements with an agency action not resolved at the first level of appeal.

(b) If an RHC files a request for a dispute conference, it must submit the request to the agency within 30 calendar days after the date of the rate review decision.

(i) Any request for a dispute conference must be sent to the address indicated in the rate review decision.

(ii) The agency does not consider dispute conference requests submitted after the 30-day period for the first level decision.

(c) The agency conducts the dispute conference within 90 calendar days of receiving the request.

(d) The agency-director designee issues the final decision within 30 calendar days of the conference. Extensions of time for extenuating circumstances may be granted by the agency-director designee.

(e) Any rate increase or decrease resulting from a dispute conference decision is effective on the date specified in the dispute conference decision.

(f) The dispute conference is the final level of administrative appeal within the agency and precedes judicial action.

(4) The agency considers an RHC who fails to attempt to resolve disputed rates as provided in this section has abandoned the dispute.

**History**
- *Statutory Authority: 42 U.S.C. 1396a(bb), 42 U.S.C. 1396d (2)(A), RCW 41.05.021, and 41.05.160. WSR 22-22-049, § 182-549-1650, filed 10/27/22, effective 1/1/23.*

## **Chapter 182-550** Hospital services. {#struct-chapter-182-550}

##### **Wash. Admin. Code § 182-550-1000** Applicability. {#sec-182-550-1000 omnilex-key=us-wa-regs-official--title-182--182-550-1000}

The medicaid agency pays for hospital services provided to eligible clients when:

(1) The eligible client is a patient in an acute care hospital and the hospital meets the definition of hospital or psychiatric hospital in RCW 70.41.020, chapter 182-500 or WAC 182-550-1050;

(2) The services are medically necessary as defined under WAC 182-500-0070; and

(3) The conditions, exceptions and limitations in this chapter are met.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-1000, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-1000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-11-129, § 388-550-1000, filed 5/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-1000, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-1050** Hospital services definitions. {#sec-182-550-1050 omnilex-key=us-wa-regs-official--title-182--182-550-1050}

The following definitions and abbreviations, those found in chapter 182-500 WAC, Medical definitions, and definitions and abbreviations found in other sections of this chapter apply to this chapter. When a term is not defined in this chapter, other agency or agency's designee WAC, or state or federal law, the medical definitions found in Taber's Cyclopedic Medical Dictionary apply.

"Accommodation costs" - The expenses incurred by a hospital to provide its patients services for which a separate charge is not customarily made. These expenses include, but are not limited to, room and board, medical social services, psychiatric social services, and the use of certain hospital equipment and facilities.

"Accredited" or "accreditation" - A term used by nationally recognized health organizations, such as the commission on accreditation of rehabilitation facilities (CARF), to indicate a facility meets both professional and community standards of medical care.

"Acute" - A medical condition of severe intensity with sudden onset. For the purposes of the acute physical medicine and rehabilitation (Acute PM&R) program, acute means an intense medical episode, not longer than three months.

"Acute care" - Care provided for patients who are not medically stable or have not attained a satisfactory level of rehabilitation. These patients require frequent monitoring by a health care professional to maintain their health status.

"Acute physical medicine and rehabilitation (acute PM&R)" - A comprehensive inpatient rehabilitative program coordinated by an interdisciplinary team at an agency-approved rehabilitation facility. The program provides 24-hour specialized nursing services and an intense level of therapy for specific medical conditions for which the client shows significant potential for functional improvement. Acute PM&R is a 24 hour inpatient comprehensive program of integrated medical and rehabilitative services provided during the acute phase of a client's rehabilitation.

"Administrative day" or "administrative days" - One or more days of a hospital stay in which an acute inpatient or observation level of care is not medically necessary, and a lower level of care is appropriate.

"Administrative day rate" - The agency's statewide medicaid average daily nursing facility rate.

"Aggregate cost" - The total cost or the sum of all constituent costs.

"Aggregate operating cost" - The total cost or the sum of all operating costs.

"All-patient DRG grouper (AP-DRG)" - A computer software program that determines the medical and surgical diagnosis-related group (DRG) assignments used by the agency for inpatient admissions between August 1, 2007, and June 30, 2014.

"All-patient refined DRG grouper (APR-DRG)" - A computer software program that determines the medical and surgical diagnosis-related group (DRG) assignments used by the agency for inpatient admissions on and after July 1, 2014.

"Allowable" - The calculated amount for payment, after exclusion of any "nonallowed service or charge," based on the applicable payment method before final adjustments, deductions, and add-ons.

"Allowed amount" - The initial calculated amount for any procedure or service, after exclusion of any "nonallowed service or charge," that the agency allows as the basis for payment computation before final adjustments, deductions, and add-ons.

"Allowed charges" - The total billed charges for allowable services.

"Allowed covered charges" - The total billed charges for services minus the billed charges for noncovered services, denied services, or both.

"Ambulatory payment classification (APC)" - A grouping that categorizes outpatient visits according to the clinical characteristics, the typical resource use, and the costs associated with the diagnoses and the procedures performed.

"Ambulatory surgery" - A surgical procedure that is not expected to require an inpatient hospital admission.

"Ancillary services" - Additional or supporting services provided by a hospital to a client during the client's hospital stay. These services include, but are not limited to: Laboratory, radiology, drugs, delivery room, operating room, postoperative recovery rooms, and other special items and services.

"Appropriate level of care" - The level of care required to best manage a client's illness or injury based on:

(1) The severity of illness and the intensity of services required to treat the illness or injury; or

(2) A condition-specific episode of care.

"Audit" - An assessment, evaluation, examination, or investigation of a health care provider's accounts, books, and records, including:

(1) Health, financial, and billing records pertaining to billed services paid by the agency through Washington apple health, by a person not employed or affiliated with the provider, to verify the service was provided as billed and was allowable under program regulations; and

(2) Financial, statistical, and health records, including mathematical computations and special studies conducted supporting the medicare cost report (Form 2552-96 and 2552-10 or successor form), submitted to the agency to establish program rates for payment to hospital providers.

"Authorization" - See "prior authorization" and "expedited prior authorization (EPA)."

"Bad debt" - An operating expense or loss incurred by a hospital because of uncollectible accounts receivables.

"Bedside nursing services" - Services included under the room and board services paid to the facility and provided by nursing service personnel. These services include, but are not limited to: Medication administration, IV hydration and IV medication administration, vaccine administration, dressing applications, therapies, glucometry testing and other point of care testing, catheterizations, tube feedings and irrigations, and equipment monitoring services.

"Billed charge" - The charge submitted to the agency by the provider.

"Bordering city hospital" - A hospital located in one of the cities listed in WAC 182-501-0175.

"Budget neutral" - A condition in which a claims model produces aggregate payments to hospitals that are the same under two separate payment systems. See also "budget neutrality factor."

"Budget neutrality factor" - A multiplier used by the agency to ensure that modifications to the payment method and rates are budget neutral. See also "budget neutral."

"Budget target" - Funds appropriated by the legislature or through the agency's budget process to pay for a specific group of services, including anticipated caseload changes or vendor rate increases.

"Budget target adjuster" - A multiplier applied to the outpatient prospective payment system (OPPS) payment to ensure aggregate payments do not exceed the established budget target.

"Bundled services" - Interventions integral to or related to the major procedure. The agency does not pay separately for these services.

"Case mix" - A relative value assigned to a DRG or classification of patients in a medical care environment representing the resource intensity demands placed on an institution.

"Case mix index (CMI)" - The average relative weight of all cases treated in a hospital during a defined period.

"Centers for Medicare and Medicaid Services (CMS)" - See WAC 182-500-0020.

"Charity care" - See chapter 70.170 RCW.

"Children's health insurance program (CHIP)" - The federal Title XXI program under which medical care is provided to uninsured children younger than age 19. Part of Washington apple health.

"Children's hospital" - A hospital primarily serving children.

"Client" - A person who receives or is eligible to receive services through agency programs.

"CMS PPS input price index" - A measure, expressed as a percentage, of the annual inflationary costs for hospital services.

"Commission on accreditation of rehabilitation facilities (CARF)" - See http://www.carf.org/home/.

"Comprehensive hospital abstract reporting system (CHARS)" - The department of health's (DOH's) inpatient hospital data collection, tracking, and reporting system.

"Condition-specific episode of care" - Care provided to a client based on the client's primary condition, complications, comorbidities, standard treatments, and response to treatments.

"Contract hospital" - A hospital contracted by the agency to provide specific services.

"Conversion factor" - A hospital-specific dollar amount that is used in calculating inpatient payments.

"Core provider agreement (CPA)" - The basic contract the agency holds with providers serving Washington apple health clients.

"Cost report" - See "medicare cost report."

"Costs" - Agency-approved operating, medical education, and capital-related costs (capital costs) as reported and identified on the "cost report."

"Covered charges" - Billed charges submitted to the agency on a claim by the provider, less the noncovered charges indicated on the claim.

"Covered services" - See "hospital covered service" and WAC 182-501-0050.

"Critical border hospital" - An acute care hospital located in a bordering city (see WAC 182-501-0175 for list) that the agency has, through analysis of admissions and hospital days, designated as critical to provide health care for Washington apple health clients.

"Current procedural terminology (CPT)" - A systematic listing of descriptive terms and identifying codes for reporting medical services, procedures, and interventions performed by physicians. CPT is copyrighted and published annually by the American Medical Association (AMA).

"Deductible" - The dollar amount a client is responsible for before an insurer, such as medicare, starts paying or the initial specific dollar amount for which the client is responsible.

"Department of social and health services (DSHS)" - The Washington state agency that provides food assistance, financial aid, medical and behavioral health care, and other services to eligible children, families, and vulnerable adults and seniors of Washington state.

"Diagnosis code" - A set of numeric or alphanumeric characters assigned by the current published ICD-CM coding guidelines used by the agency as a shorthand symbol to represent the nature of a disease or condition.

"Diagnosis-related group (DRG)" - A classification system that categorizes hospital patients into clinically coherent and homogenous groups with respect to resource use. Classification of patients is based on the current published ICD-CM coding guidelines used by the agency, the presence of a surgical procedure, patient age, presence or absence of significant comorbidities or complications, and other relevant criteria.

"Direct medical education costs" - The direct costs of providing an approved medical residency program as recognized by medicare.

"Discharging hospital" - The institution releasing a client from the acute care hospital setting.

"Discount factor" - The percentage applied to additional significant procedures when a claim has multiple significant procedures or when the same procedure is performed multiple times on the same day. Not all significant procedures are subject to a discount factor.

"Disproportionate share hospital (DSH) payment" - A supplemental payment made by the agency to a hospital that qualifies for one or more of the disproportionate share hospital programs identified in the state plan. See WAC 182-550-4900.

"Disproportionate share hospital (DSH) program" - A program through which the agency makes payment adjustments to eligible hospitals that serve a disproportionate number of low-income clients in accordance with legislative direction and established payment methods. See 1902 (a)(13)(A)(iv) of the Social Security Act. See also WAC 182-550-4900 through 182-550-5400.

"Dispute conference" - See "hospital dispute conference."

"Distinct unit" - A distinct area for psychiatric, rehabilitation, or withdrawal management services which has been certified by medicare within an acute care hospital or approved by the agency within a children's hospital.

"Division of behavioral health and recovery services (DBHR)" - The division within HCA that administers mental health, problem gambling, and substance abuse programs authorized by chapters 43.20A, 71.05, 71.24, 71.34, and 70.96A RCW.

"DRG" - See "diagnosis-related group."

"DRG allowed amount" - The DRG relative weight multiplied by the conversion factor.

"DRG average length-of-stay" - The agency's average length-of-stay for a DRG classification established during an agency DRG rebasing and recalibration project.

"DRG-exempt services" - Services paid through methods other than DRG, such as per diem rate, per case rate, or ratio of costs-to-charges (RCC).

"DRG payment" - The total payment made by the agency for a client's inpatient hospital stay. The DRG payment is the DRG allowed amount plus the high outlier minus any third-party liability, client participation, medicare payment, and any other adjustments applied by the agency.

"DRG relative weight" - A factor used in the calculation of DRG payments. As of July 1, 2014, the medicaid agency uses the 3MTM Corporation's national weights developed for the all-patient refined-diagnosis-related group (APR-DRG) software.

"Emergency medical condition" - See WAC 182-500-0030.

"Emergency room" or "emergency facility" or "emergency department" - A distinct hospital-based facility which provides unscheduled services to clients who require immediate medical attention. An emergency department must be capable of providing emergency medical, surgical, and trauma care services 24 hours a day, seven days a week. A physically separate extension of an existing hospital emergency department may be considered a freestanding emergency department as long as the extension provides comprehensive emergency medical, surgical, and trauma care services 24 hours a day, seven days a week.

"Emergency services" - Health care services required by and provided to a client after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in placing the client's health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. Inpatient maternity services are considered emergency services by the agency.

"Enhanced ambulatory patient groupings (EAPG)" - The payment system used by the agency to calculate reimbursement to hospitals for the facility component of outpatient services on and after July 1, 2014. This system uses 3M's EAPGs as the primary basis for payment.

"Equivalency factor (EF)" - A factor that may be used by the agency in conjunction with other factors to determine the level of a state-administered program payment. See WAC 182-550-4800.

"Exempt hospital - DRG payment method" - A hospital that for a certain client category is reimbursed for services to Washington apple health clients through methodologies other than those using DRG conversion factors.

"Expedited prior authorization (EPA)" - See WAC 182-500-0030.

"Experimental service" - A procedure, course of treatment, drug, or piece of medical equipment, which lacks scientific evidence of safety and effectiveness. See WAC 182-531-0050. A service is not "experimental" if the service:

(1) Is generally accepted by the medical profession as effective and appropriate; and

(2) Has been approved by the federal Food and Drug Administration (FDA) or other requisite government body if approval is required.

"Fee-for-service" - See WAC 182-500-0035.

"Fiscal intermediary" - Medicare's designated fiscal intermediary for a region or category of service, or both.

"Fixed per diem rate" - A daily amount used to determine payment for specific services provided in long-term acute care (LTAC) hospitals.

"Formal release" - When a client:

(1) Discharges from a hospital or distinct unit;

(2) Dies in a hospital or distinct unit;

(3) Transfers from a hospital or distinct unit as an acute care transfer; or

(4) Transfers from the hospital or distinct unit to a designated psychiatric unit or facility, or a designated acute rehabilitation unit or facility.

"Global surgery days" - The number of preoperative and follow-up days that are included in the payment to the physician for the major surgical procedure.

"Graduate medical education costs" - The direct and indirect costs of providing medical education in teaching hospitals. See "direct medical education costs" and "indirect medical education costs."

"Grouper" - See "all-patient DRG grouper (AP-DRG)" and "all-patient refined DRG grouper (APR-DRG)."

"Health care authority (medicaid agency)" - The Washington state agency that administers Washington apple health.

"High outlier" - A DRG claim classified by the agency as being allowed a high outlier payment that is paid under the DRG payment method, does not meet the definition of "administrative day," and has extraordinarily high costs as determined by the agency. See WAC 182-550-3700.

"Hospice" - A medically directed, interdisciplinary program of palliative services for terminally ill clients and the clients' families. Hospice is provided under arrangement with a Washington state-licensed and Title XVIII-certified Washington state hospice.

"Hospital" - An entity that is licensed as an acute care hospital in accordance with applicable state laws and regulations, or the applicable state laws and regulations of the state in which the entity is located when the entity is out-of-state, and is certified under Title XVIII of the federal Social Security Act. The term "hospital" includes a medicare or state-certified distinct rehabilitation unit, a "psychiatric hospital" as defined in this section, or any other distinct unit of the hospital.

"Hospital cost report" - See "cost report."

"Hospital covered service" - Any service, treatment, equipment, procedure, or supply provided by a hospital, covered under a Washington apple health program, and within the scope of an eligible client's Washington apple health program.

"Hospital readmission" - A situation in which a client who was admitted as an inpatient and discharged from the hospital has returned to inpatient status to the same or a different hospital.

"Indirect medical education costs" - The indirect costs of providing an approved medical residency program as recognized by medicare.

"Inflation adjustment" - For cost inflation, this is the hospital inflation adjustment. This adjustment is determined by using the inflation factor method approved by the legislature. For charge inflation, this is the inflation factor determined by comparing average discharge charges for the industry from one year to the next, as found in the comprehensive hospital abstract reporting system (CHARS) Hospital Census and Charges by Payer report.

"Inpatient hospital admission" - A formal admission to a hospital based on an evaluation of the client using objective clinical indicators to provide medically necessary, acute inpatient care. These indicators include assessment, monitoring, and therapeutic services as required to best manage the client's illness or injury. All applicable indicators must be documented in the client's health record. The decision to admit a client to inpatient status should be based on the condition-specific episode of care, severity of illness presented, and the intensity of services rendered. The agency does not deem inpatient hospital admissions as covered or noncovered solely on the basis of the length of time the client actually spends in the hospital. Generally, a client remains overnight and occupies a bed. Inpatient status can apply even if the client is discharged or transferred to another acute hospital and does not actually use a hospital bed overnight. For the agency to recognize a stay as inpatient there must be a physician admission order in the client's medical record indicating the status as inpatient.

"Inpatient medicaid DRG conversion factor" - A dollar amount that represents selected hospitals' average costs of treating medicaid and CHIP clients. The conversion factor is a rate that is multiplied by a DRG relative weight to pay medicaid and CHIP claims under the DRG payment method. See WAC 182-550-3800 for how this conversion factor is calculated.

"Inpatient services" - Health care services provided to a client during hospitalization whose condition warrants formal admission and treatment in a hospital.

"Inpatient state-administered program conversion factor" - A DRG conversion factor reduced from the inpatient medicaid DRG conversion factor to pay a hospital for inpatient services provided to a client eligible under a state-administered program. The conversion factor is multiplied by a DRG relative weight to pay claims under the DRG payment method.

"Intermediary" - See "fiscal intermediary."

"International Classification of Diseases (ICD-9-CM and ICD-10-CM)" - The systematic listing of diseases, injuries, conditions, and procedures as numerical or alpha numerical designations (coding).

"Length of stay (LOS)" - The number of days of inpatient hospitalization, calculated by adding the total number of days from the admission date to the discharge date, and subtracting one day.

"Long-term acute care (LTAC) services" - Inpatient intensive long-term care services provided in agency-approved LTAC hospitals to eligible Washington apple health clients who meet criteria for level 1 or level 2 services. See WAC 182-550-2565 through 182-550-2596.

"LTAC level 1 services" - LTAC services provided to a client who requires eight or more hours of direct skilled nursing care per day and the client's medical needs cannot be met at a lower level of care due to clinical complexity. Level 1 services include one of the following:

(1) Ventilator weaning care; or

(2) Care for a client who has:

(a) Chronic open wounds that require on-site wound care specialty services and daily assessments and/or interventions; and

(b) At least one comorbid condition (such as chronic renal failure requiring hemodialysis).

"LTAC level 2 services" - LTAC services provided to a client who requires four or more hours of direct skilled nursing care per day, and the clients' medical needs cannot be met at a lower level of care due to clinical complexity. Level 2 services include at least one of the following:

(1) Ventilator care for a client who is ventilator-dependent and is not weanable and has complex medical needs; or

(2) Care for a client who:

(a) Has a tracheostomy;

(b) Requires frequent respiratory therapy services for complex airway management and has the potential for decannulation; and

(c) Has at least one comorbid condition (such as quadriplegia).

"Major diagnostic category (MDC)" - One of the mutually exclusive groupings of principal diagnosis areas in the AP-DRG and APR-DRG classification systems.

"Medical care services (MCS)" - See WAC 182-500-0070.

"Medical education costs" - The expenses incurred by a hospital to operate and maintain a formally organized graduate medical education program.

"Medical visit" - Diagnostic, therapeutic, or consultative services provided to a client by a health care professional in an outpatient setting.

"Medicare cost report" - The medicare cost report (Form 2552-96 or Form 2552-10), or successor document, completed and submitted annually by a hospital provider.

"Medicare crossover" - A claim involving a client who is eligible for both medicare benefits and medicaid.

"Medicare physician fee schedule (MPFS)" - The official CMS publication of relative value units and medicare payment policy indicators for the resource-based relative value scale (RBRVS) payment program.

"Medicare Part A" - See WAC 182-500-0070.

"Medicare Part B" - See WAC 182-500-0070.

"Medicare payment principles" - The rules published in the federal register regarding payment for services provided to medicare clients.

"Military hospital" - A hospital reserved for the use of military personnel, their dependents, and other authorized users.

"Modifier" - A two-digit alphabetic and/or numeric identifier added to the procedure code to indicate the type of service performed. The modifier provides the means by which the reporting hospital can describe or indicate that a performed service or procedure has been altered by some specific circumstance but not changed in its definition or code. The modifier can affect payment or be used for information only. Modifiers are listed in fee schedules.

"National Correct Coding Initiative (NCCI)" - A national standard for the accurate and consistent description of medical goods and services using procedural codes. The standard is based on coding conventions defined in the American Medical Associations' Current Procedural Terminology (CPT®) manual, current standards of medical and surgical coding practice, input from specialty societies, and analysis of current coding practices. The Centers for Medicare and Medicaid Services (CMS) maintain NCCI policy. Information can be found at http://www.cms.hhs.gov/NationalCorrectCodInitEd/.

"National Drug Code (NDC)" - The 11-digit number the manufacturer or labeler assigns to a pharmaceutical product and attaches to the product container at the time of packaging. The 11-digit NDC is composed of a five-four-two grouping. The first five digits comprise the labeler code assigned to the manufacturer by the FDA. The second grouping of four digits is assigned by the manufacturer to describe the ingredients, dose form, and strength. The last grouping of two digits describes the package size.

"National payment rate (NPR)" - A rate for a given procedure code, published by CMS, that does not include a state- or location-specific adjustment.

"National Provider Identifier (NPI)" - A standard, unique identifier for health care providers assigned by CMS. The agency's ProviderOne system pays for inpatient and outpatient services using only one NPI per provider. The agency may make an exception for inpatient claims billed with medicare-certified, distinct unit NPIs.

"Nationwide rate" - See "national payment rate (NPR)."

"NCCI edit" - A software step used to determine if a claim is billing for a service that is not in accordance with federal and state statutes, federal and state regulations, agency fee schedules, billing instructions, and other publications. The agency has the final decision whether the NCCI edits allow automated payment for services that were not billed in accordance with governing law, NCCI standards, or agency policy.

"Newborn" or "neonate" or "neonatal" - A person younger than 29 days old.

"Nonallowed service or charge" - A service or charge billed by the provider as noncovered or denied by the agency. This service or charge cannot be billed to the client except under the conditions identified in WAC 182-502-0160.

"Noncovered charges" - Billed charges a provider submits to the agency on a claim and indicates them on the claim as noncovered.

"Noncovered service or charge" - A service or charge the agency does not consider or pay for as a "hospital covered service." This service or charge may not be billed to the client, except under the conditions identified in WAC 182-502-0160.

"Nursing service personnel" - A group of health care professionals that includes, but is not limited to: Registered nurse (RN), licensed practical nurse (LPN), certified nursing assistant/nursing assistant certified (CNA/NAC).

"Observation services" - A well-defined set of clinically appropriate services furnished while determining whether a client will require formal inpatient admission or be discharged from the hospital. Services include ongoing short-term treatment, monitoring, assessment, and reassessment. Rarely do reasonable and necessary observation services exceed 48 hours. The agency or the agency's designee may determine through the retrospective utilization review process that an inpatient hospital service should have been billed as an observation service.

"Operating costs" - All expenses incurred providing accommodation and ancillary services, excluding capital and medical education costs.

"Orthotic device" or "orthotic" - A corrective or supportive device that:

(1) Prevents or corrects physical deformity or malfunction; or

(2) Supports a weak or deformed portion of the body.

"Outliers" - Cases with extraordinarily high costs when compared to other cases in the same DRG.

"Out-of-state hospital" - Any hospital located outside the state of Washington and the bordering cities designated in WAC 182-501-0175. For Washington apple health clients requiring psychiatric services, an "out-of-state hospital" is any hospital located outside the state of Washington.

"Outpatient" - A client who is receiving health care services, other than inpatient services, in a hospital setting.

"Outpatient care" - See "outpatient hospital services."

"Outpatient enhanced ambulatory payment grouper (EAPG)" - A software program the agency uses for classifying and editing in enhanced ambulatory payment grouping-based OPPS.

"Outpatient hospital" - A hospital authorized by DOH to provide outpatient services.

"Outpatient hospital services" - Those health care services that are within a hospital's licensure and provided to a client who is designated as an outpatient.

"Outpatient observation" - See "observation services."

"Outpatient prospective payment system (OPPS)" - The payment system used by the agency to calculate reimbursement to hospitals for the facility component of outpatient services.

"Outpatient prospective payment system (OPPS) conversion factor" - See "outpatient prospective payment system (OPPS) rate."

"Outpatient prospective payment system (OPPS) rate" - A hospital-specific multiplier assigned by the agency that is one of the components of the APC payment calculation.

"Outpatient surgery" - A surgical procedure that is not expected to require an inpatient hospital admission.

"Pass-throughs" - Certain drugs, devices, and biologicals, as identified by CMS, for which providers are entitled to additional separate payment until the drugs, devices, or biologicals are assigned their own APC.

"Per diem" - A method which uses a daily rate to calculate payment for services provided as a "hospital covered service."

"PM&R" - See "Acute PM&R."

"Point of care testing (POCT)" - A test designed to be used at or near the site where the patient is located, that does not require permanent dedicated space, and that is performed outside the physical facilities of the clinical laboratory.

"Primary care case management (PCCM)" - The coordination of health care services under the agency's Indian health center or tribal clinic managed care program. See WAC 182-538-068.

"Principal diagnosis" - The condition chiefly responsible for the admission of the patient to the hospital.

"Prior authorization" - See WAC 182-500-0085.

"Private room rate" - The rate customarily charged by a hospital for a one-bed room.

"Prospective payment system (PPS)" - A payment system in which what is needed to calculate payments (methods, types of variables, and other factors) is set in advance and is knowable by all parties before care is provided. In a retrospective payment system, what is needed (actual costs or charges) is not available until after care is provided.

"Prosthetic device" or "prosthetic" - A replacement, corrective, or supportive device prescribed by a physician or other licensed practitioner, within the scope of his or her practice as defined by state law, to:

(1) Artificially replace a missing portion of the body;

(2) Prevent or correct physical deformity or malfunction; or

(3) Support a weak or deformed portion of the body.

"Psychiatric hospital" - A medicare-certified distinct psychiatric unit, a medicare-certified psychiatric hospital, or a state-designated pediatric distinct psychiatric unit in a medicare-certified acute care hospital. Eastern state hospital and western state hospital are excluded from this definition.

"Public hospital district" - A hospital district established under chapter 70.44 RCW.

"Ratable" - A factor used to calculate inpatient payments for state-administered programs.

"Ratio of costs-to-charges (RCC)" - A method used to pay hospitals for some services exempt from the DRG payment method. It also refers to the percentage applied to a hospital's allowed covered charges for medically necessary services to determine estimated costs, as determined by the agency, and payment to the hospital for some DRG-exempt services.

"Rebasing" - The process used by the agency to update hospital payment policies, related variables (rates, factors, thresholds, multipliers, and caps), and system processes (edits, adjudication, grouping, etc.).

"Recalibration" - The process of recalculating DRG relative weights using historical data.

"Rehabilitation units" - Specifically identified rehabilitation hospitals and designated rehabilitation units of hospitals that meet agency and medicare criteria for distinct rehabilitation units.

"Relative weights" - See "DRG relative weights."

"Reserve days" - The days beyond the ninetieth day of hospitalization of a medicare patient for a benefit period or incidence of illness. See also "lifetime hospitalization reserve."

"Revenue code" - A nationally assigned coding system for billing inpatient and outpatient hospital services, home health services, and hospice services.

"Room and board" - Routine supplies and services provided to a client during the client's hospital stay. This includes, but is not limited to, a regular or special care hospital room and related furnishings, room supplies, dietary and bedside nursing services, and the use of certain hospital equipment and facilities.

"Rural health clinic" - See WAC 182-549-1100.

"Rural hospital" - An acute care health care facility capable of providing or assuring availability of inpatient and outpatient hospital health services in a rural area.

"Semi-private room rate" - A rate customarily charged for a hospital room with two to four beds; this charge is generally lower than a private room rate and higher than a ward room. See also "multiple occupancy rate."

"Significant procedure" - A procedure, therapy, or service provided to a client that constitutes one of the primary reasons for the visit to the health care professional, and represents a substantial portion of the resources associated with the visit.

"Specialty hospitals" - Children's hospitals, psychiatric hospitals, cancer research centers or other hospitals which specialize in treating a particular group of patients or diseases.

"Spenddown" - See chapter 182-519 WAC.

"State plan" - The plan filed by the agency with CMS, Department of Health and Human Services (DHHS), outlining how the state will administer medicaid and CHIP services, including the hospital program.

"Status indicator (SI)" - A code assigned to each medical procedure or service by the agency that contributes to the selection of a payment method.

"Subacute care" - Care provided to a client which is less intensive than that given at an acute care hospital. Skilled nursing, nursing care facilities and other facilities provide subacute care services.

"Substance use disorder (SUD)" - See RCW 71.05.020.

"Survey" - An inspection or review conducted by a federal, state, or private agency to evaluate and monitor a facility's compliance with program requirements.

"Swing bed" - An inpatient hospital bed certified by CMS for either acute inpatient hospital or skilled nursing services.

"Swing-bed day" - A day in which a client is receiving skilled nursing services in a hospital-designated swing bed at the hospital's census hour.

"Total patient days" - All patient days in a hospital for a given reporting period, excluding days for skilled nursing, nursing care, and observation days.

"Transfer" - To move a client from one acute care setting to a higher level acute care setting for emergency care or to a post-acute, lower level care setting for ongoing care.

"Transferring hospital" - The hospital or distinct unit that transfers a client to another acute care or subacute facility or distinct unit, or to a nonhospital setting.

"UB-04" - The uniform billing document required for use nationally by hospitals, nursing facilities, hospital-based skilled nursing facilities, home health agencies, and hospice agencies in billing for services provided to patients. This document includes the current national uniform billing data element specifications developed by the National Uniform Billing Committee and approved and modified by the Washington state payer group or the agency.

"Vendor rate increase" - An adjustment determined by the legislature, that may be used to periodically increase rates for payment to vendors, including health care providers, that do business with the state.

"Washington apple health program" - Any health care program administered through the medicaid agency.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-06-040, s 182-550-1050, filed 2/27/25, effective 4/1/25*
- *WSR 21-15-128, § 182-550-1050, filed 7/21/21, effective 8/21/21. Statutory Authority: RCW 41.05.021, 41.05.160, 2014 c 225. WSR 16-06-053, § 182-550-1050, filed 2/24/16, effective 4/1/16. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-12-047, § 182-550-1050, filed 5/29/14, effective 7/1/14. WSR 11-14-075, recodified as § 182-550-1050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-052, § 388-550-1050, filed 6/28/07, effective 8/1/07*
- *WSR 04-20-057, § 388-550-1050, filed 10/1/04, effective 11/1/04. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and Public Law 104-191. WSR 03-19-043, § 388-550-1050, filed 9/10/03, effective 10/11/03. Statutory Authority: RCW 74.08.090 and 42 U.S.C. 1395 x(v), 42 C.F.R. 447.271, .11303, and .2652. WSR 01-16-142, § 388-550-1050, filed 7/31/01, effective 8/31/01. Statutory Authority: RCW 74.08.090, 74.09.730, 42 U.S.C. 1395 x(v), 42 C.F.R. 447.271, .11303 and .2652. WSR 99-14-039, § 388-550-1050, filed 6/30/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 42 U.S.C. 1395 x(v), 42 C.F.R. 447.271, 447.11303, and 447.2652. WSR 99-06-046, § 388-550-1050, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-1050, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-1100** Hospital care—General. {#sec-182-550-1100 omnilex-key=us-wa-regs-official--title-182--182-550-1100}

(1) The medicaid agency:

(a) Pays for an eligible Washington apple health client's admission to a hospital only when the client's attending physician orders admission and when the admission and treatment provided:

(i) Are covered under WAC 182-501-0050, 182-501-0060 and 182-501-0065;

(ii) Are medically necessary as defined in WAC 182-500-0070;

(iii) Are determined according to WAC 182-501-0165 when prior authorization is required;

(iv) Are authorized when required under this chapter; and

(v) Meet applicable state and federal requirements.

(b) For hospital admissions, defines "attending physician" as the client's primary care provider, or the primary provider of care to the client at the time of admission.

(2) Medical record documentation of hospital services must meet the requirements in WAC 182-502-0020.

(3) The agency pays for a hospital covered service provided to an eligible apple health client enrolled in an agency-contracted managed care organization (MCO) plan, under the fee-for-service program if the service is excluded from the MCO's capitation contract with the agency and meets prior authorization requirements. (See WAC 182-550-2600 for inpatient psychiatric services.)

(4) The agency pays up to 26 days of inpatient hospital care for hospital-based withdrawal management, medical stabilization, and drug treatment for chemical dependent pregnant clients eligible under the substance-using pregnant people (SUPP) program.

See WAC 182-533-0701 through 182-533-0730.

(5) The agency pays for inpatient hospital withdrawal management of acute alcohol or other drug intoxication when the services are provided to an eligible client:

(a) In a withdrawal management unit in a hospital that has a withdrawal management provider agreement with the agency to perform these services and the services are approved by the division of behavioral health and recovery (DBHR) within the health care authority (HCA); or

(b) In an acute hospital and all the following criteria are met:

(i) The hospital does not have a withdrawal management specific provider agreement with DBHR;

(ii) The hospital provides the care in a medical unit;

(iii) Nonhospital-based withdrawal management is not medically appropriate for the client;

(iv) The client does not require medically necessary inpatient psychiatric care and it is determined that an approval from the agency or the agency's designee as an inpatient stay is not indicated;

(v) The client's stay qualifies as an inpatient stay;

(vi) The client is not participating in the agency's substance-using pregnant people (SUPP) program; and

(vii) The client's principal diagnosis meets the agency's medical inpatient withdrawal management criteria listed in the agency's published billing instructions.

(6) The agency covers medically necessary dental-related services provided to an eligible client in a hospital-based dental clinic when the services:

(a) Are provided under chapter 182-535 WAC; and

(b) Are billed on the American Dental Association (ADA) or health care financing administration (HCFA) claim form.

(7) The agency pays a hospital for covered dental-related services, including oral and maxillofacial surgeries, that are provided in the hospital's operating room, when:

(a) The covered dental-related services are medically necessary and provided under chapter 182-535 WAC;

(b) The covered dental-related services are billed on a UB claim form; and

(c) At least one of the following is true:

(i) The dental-related service(s) is provided to an eligible apple health client on an emergency basis;

(ii) The client is eligible under the division of developmental disability program;

(iii) The client is age eight or younger; or

(iv) The dental service is prior authorized by the agency.

(8) For inpatient voluntary or involuntary psychiatric admissions, see WAC 182-550-2600.

(9) For clients age 20 and younger, see the early periodic screening, diagnosis, and treatment (EPSDT) program described in chapter 182-534 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-07-031, s 182-550-1100, filed 3/11/26, effective 4/11/26*
- *WSR 23-19-018, § 182-550-1100, filed 9/8/23, effective 10/9/23*
- *WSR 23-04-049, § 182-550-1100, filed 1/26/23, effective 2/26/23*
- *WSR 21-15-128, § 182-550-1100, filed 7/21/21, effective 8/21/21. Statutory Authority: RCW 41.05.021, 41.05.160, 2014 c 225. WSR 16-06-053, § 182-550-1100, filed 2/24/16, effective 4/1/16. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-1100, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-1100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-053, § 388-550-1100, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.08.090 and 42 U.S.C. 1395x(v), 42 C.F.R. 447.271, .11303, and .2652. WSR 01-16-142, § 388-550-1100, filed 7/31/01, effective 8/31/01. Statutory Authority: RCW 74.08.090. WSR 01-02-075, § 388-550-1100, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-1100, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-1200** Restrictions on hospital coverage. {#sec-182-550-1200 omnilex-key=us-wa-regs-official--title-182--182-550-1200}

A hospital covered service provided to a person eligible under a Washington apple health (WAH) program that is paid by the agency's fee-for-services payment system must be within the scope of the person's WAH program. Coverage restriction includes, but is not limited to the following:

(1) Persons enrolled with the agency's managed care organization (MCO) plans are subject to the respective plan's policies and procedures for coverage of hospital services;

(2) Persons covered by primary care case management are subject to the persons' primary care physicians' approval for hospital services;

(3) For emergency care exemptions for persons described in subsections (1) and (2) of this section, see WAC 182-538-100;

(4) Health care services provided by a hospital located out-of-state are:

(a) Not covered for persons eligible under the medical care services (MCS) program. However, persons eligible for MCS are covered for that program's scope of care in bordering city and critical border hospitals.

(b) Covered for:

(i) Emergency care for eligible medicaid and CHIP persons without prior authorization, based on the medical necessity and utilization review standards and limits established by the agency.

(ii) Nonemergency out-of-state care for medicaid and CHIP persons when prior authorized by the agency based on the medical necessity and utilization review standards and limits.

(iii) Hospitals in bordering cities and critical border hospitals, based on the same client eligibility criteria and authorization policies as for instate hospitals. See WAC 182-501-0175 for a list of bordering cities.

(c) Covered for out-of-state voluntary inpatient psychiatric hospital services for eligible medicaid and CHIP clients based on authorization by a division of behavioral health and recovery (DBHR) designee.

(5) See WAC 182-550-1100 for hospital services for substance-using pregnant people (SUPP) program clients;

(6) All psychiatric inpatient hospital admissions, length of stay extensions, and transfers must be prior authorized by a DBHR designee. See WAC 182-550-2600;

(7) For persons eligible for both medicare and medicaid (dual eligibles), the agency pays deductibles and coinsurance, unless the person has exhausted his or her medicare Part A benefits. If medicare benefits are exhausted, the agency pays for hospitalization for such persons subject to agency rules. See also chapter 182-502 WAC;

(8) The agency does not pay for covered inpatient hospital services for a WAH client:

(a) Who is discharged from a hospital by a physician because the person no longer meets medical necessity for acute inpatient level of care; and

(b) Who chooses to stay in the hospital beyond the period of medical necessity.

(9) If the hospital's utilization review committee determines the person's stay is beyond the period of medical necessity, as described in subsection (8) of this section, the hospital must:

(a) Inform the person in a written notice that the agency is not responsible for payment (42 C.F.R. 456);

(b) Comply with the requirements in WAC 182-502-0160 in order to bill the person for the service(s); and

(c) Send a copy of the written notice in (a) of this subsection to the agency.

(10) Other coverage restrictions, as determined by the agency.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-04-049, § 182-550-1200, filed 1/26/23, effective 2/26/23. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-019, § 182-550-1200, filed 7/24/14, effective 8/24/14. WSR 11-14-075, recodified as § 182-550-1200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-018, § 388-550-1200, filed 6/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 42 U.S.C. 1395 x(v), 42 C.F.R. 447.271, 447.11303, and 447.2652. WSR 99-06-046, § 388-550-1200, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-1200, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-1300** Revenue code categories and subcategories. {#sec-182-550-1300 omnilex-key=us-wa-regs-official--title-182--182-550-1300}

(1) Revenue code categories and subcategories listed in this chapter are published in the UB-92 or UB-04 National Uniform Billing Data Element Specifications Manual.

(2) The medicaid agency requires a hospital provider to report and bill all hospital services provided to Washington apple health clients using the appropriate revenue codes published in the manual referenced in subsection (1) of this section.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-1300, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-1300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-018, § 388-550-1300, filed 6/22/07, effective 8/1/07. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and Public Law 104-191. WSR 03-19-044, § 388-550-1300, filed 9/10/03, effective 10/11/03. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-1300, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-1350** Revenue code categories and subcategories—CPT and HCPCS reporting requirements for outpatient hospitals. {#sec-182-550-1350 omnilex-key=us-wa-regs-official--title-182--182-550-1350}

(1) The medicaid agency requires an outpatient hospital provider to report the appropriate current procedural terminology (CPT) or health care common procedure coding system (HCPCS) codes in addition to the required revenue codes on an outpatient claim line when using any of the following revenue code categories and subcategories:

(a) "IV therapy," only subcategories "general classification" and "infusion pump";

(b) "Medical/surgical supplies and devices," only subcategory "other supplies/devices";

(c) "Oncology";

(d) "Laboratory";

(e) "Laboratory pathological";

(f) "Radiology - Diagnostic";

(g) "Radiology - Therapeutic and/or chemotherapy administration";

(h) "Nuclear medicine";

(i) "CT scan";

(j) "Operating room services," only subcategories "general classification" and "minor surgery";

(k) "Blood and blood components";

(l) "Administration, processing, and storage for blood components";

(m) "Other imaging services";

(n) "Respiratory services";

(o) "Physical therapy";

(p) "Occupational therapy";

(q) "Speech therapy - Language pathology";

(r) "Emergency room," only subcategories "general classification" and "urgent care";

(s) "Pulmonary function";

(t) "Audiology";

(u) "Cardiology";

(v) "Ambulatory surgical care";

(w) "Clinic," only subcategories "general classification" and "other clinic";

(x) "Magnetic resonance technology (MRT)";

(y) "Medical/surgical supplies - Extension," only subcategory "surgical dressings";

(z) "Pharmacy - Extension" subcategories "Erythropoietin (EPO) less than ten thousand units," "Erythropoietin (EPO) ten thousand or more units," "drugs requiring detailed coding," and "self-administrable drugs";

(aa) "Labor room/delivery," only subcategories "general classification," "labor," "delivery," and "birthing center";

(bb) "EKG/ECG (electrocardiogram)";

(cc) "EEG (electroencephalogram)";

(dd) "Gastro-intestinal services";

(ee) "Specialty room - Treatment/observation room," subcategory "treatment room and observation room";

(ff) "Telemedicine," only subcategory "other telemedicine";

(gg) "Extra-corporeal shock wave therapy (formerly lithotripsy)";

(hh) "Acquisition of body components," only subcategories "general classification" and "cadaver donor";

(ii) "Hemodialysis - Outpatient or home," only subcategory "general classification";

(jj) "Peritoneal dialysis - Outpatient or home," only subcategory "general classification";

(kk) "Continuous ambulatory peritoneal dialysis (CAPD) - Outpatient or home," only subcategory "general classification";

(ll) "Continuous cycling peritoneal dialysis (CCPD) - Outpatient or home," only subcategory "general classification";

(mm) "Miscellaneous dialysis," only subcategories "general classification" and "ultrafiltration";

(nn) "Behavioral health treatments/services," only subcategory "electroshock therapy";

(oo) "Other diagnostic services";

(pp) "Other therapeutic services," only subcategories "general classification," "cardiac rehabilitation," and "other therapeutic service"; and

(qq) Other revenue code categories and subcategories identified and published by the agency.

(2) For an outpatient claim line requiring a CPT or HCPCS code, the agency denies payment if the required code is not reported on the line.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-1350, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-1350, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-018, § 388-550-1350, filed 6/22/07, effective 8/1/07. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and Public Law 104-191. WSR 03-19-044, § 388-550-1350, filed 9/10/03, effective 10/11/03.*

##### **Wash. Admin. Code § 182-550-1400** Covered and noncovered revenue code categories and subcategories for inpatient hospital services. {#sec-182-550-1400 omnilex-key=us-wa-regs-official--title-182--182-550-1400}

Subject to the limitations and restrictions listed, this section identifies covered and noncovered revenue code categories and subcategories for inpatient hospital services.

(1) The medicaid agency pays for an inpatient hospital covered service in the following revenue code categories and subcategories when the hospital provider accurately bills:

(a) "Room & board - Private (one bed)," only subcategories "general classification," "medical/surgical/gyn," "OB," "pediatric," and "oncology";

(b) "Room & board - Semi-private (two bed)," only subcategories "general classification," "medical/surgical/gyn," "OB," "pediatric," and "oncology";

(c) "Room & board - Semi-private - (three and four beds)," only subcategories "general classification," "medical/surgical/gyn," "OB," "pediatric," and "oncology";

(d) "Room & board - Deluxe private," only subcategories "general classification," "medical/surgical/gyn," "OB," "pediatric," and "oncology";

(e) "Nursery," only subcategories "general classification," "newborn - level I," "newborn - level II," "newborn - level III," "newborn - level IV," and "nursery other";

(f) "Subacute care," only subcategories "subacute care - level I";

(g) "Intensive care unit," only subcategories "general classification," "surgical," "medical," "pediatric," "intermediate ICU," "burn care," and "trauma";

(h) "Coronary care unit," only subcategories "general classification," "myocardial infarction," "pulmonary care," and "intermediate CCU";

(i) "Special charges," only subcategories "general classification";

(j) "Pharmacy," only subcategories "general classification," "generic drugs," "nongeneric drugs," "drugs incident to other diagnostic services," "drugs incident to radiology," "nonprescription," and "IV solutions";

(k) "IV therapy," only subcategories "general classification," "infusion pump," "IV therapy/pharmacy services," "IV therapy/drug/supply delivery" and "IV therapy/supplies";

(l) "Medical/surgical supplies and devices," only subcategories "general classification," "nonsterile supply," "sterile supply," "pacemaker," "intraocular lens," and "other implant";

(m) "Oncology," only subcategory "general classification";

(n) "Laboratory," only subcategories "general classification," "chemistry," "immunology," "nonroutine dialysis," "hematology," "bacteriology & microbiology," and "urology";

(o) "Laboratory pathology," only subcategories "general classification," "cytology," "histology," and "biopsy";

(p) "Radiology - Diagnostic," only subcategories "general classification," "angiocardiography," "arthrography," "arteriography," and "chest X-ray";

(q) "Radiology - Therapeutic and/or chemotherapy administration," only subcategories "general classification," "chemotherapy administration - injected," "chemotherapy administration - oral," "radiation therapy," and "chemotherapy administration - IV";

(r) "Nuclear medicine," only subcategories "general classification," "diagnostic," "therapeutic," "diagnostic radiopharmaceuticals," and "therapeutic radiopharmaceuticals";

(s) "CT scan," only subcategories "general classification," "head scan," and "body scan";

(t) "Operating room services," only subcategories "general classification" and "minor surgery";

(u) "Anesthesia," only subcategories "general classification," "anesthesia incident to radiology," and "anesthesia incident to other diagnostic services";

(v) "Administration, processing and storage for blood and blood component," only subcategories "general classification" and "administration";

(w) "Other imaging services," only subcategories "general classification," "diagnostic mammography," "ultrasound," and "positron emission tomography";

(x) "Respiratory services," only subcategories "general classification," "inhalation services" and "hyperbaric oxygen therapy";

(y) "Physical therapy," only subcategories "general classification," "visit charge," "hourly charge," "group rate," and "evaluation or reevaluation";

(z) "Speech therapy - Language pathology," only subcategories "general classification," "visit charge," "hourly charge," "group rate," and "evaluation or reevaluation";

(aa) "Emergency room," only subcategories "general, urgent care classification" and "urgent care";

(bb) "Pulmonary function," only subcategory "general classification";

(cc) "Cardiology," only subcategories "general classification," "cardiac cath lab," "stress test," and "echocardiology";

(dd) "Ambulatory surgical care," only subcategory "general classification";

(ee) "Outpatient services," only subcategory "general classification";

(ff) "Magnetic resonance technology (MRT)," only subcategories "general classification," "MRI - Brain (including brainstem)," "MRI - Spinal cord (including spine)," "MRI-other," "MRA - Head and neck," "MRA - Lower extremities," and "MRA-other";

(gg) "Medical/surgical supplies - Extension," only subcategories "supplies incident to radiology," "supplies incident to other diagnostic services," and "surgical dressings";

(hh) "Pharmacy-extension," only subcategories "single source drug," "multiple source drug," "restrictive prescription," "erythropoietin (EPO) less than 10,000 units," "erythropoietin (EPO) 10,000 or more units," "drugs requiring detailed coding," and "self-administrable drugs";

(ii) "Cast room," only subcategory "general classification";

(jj) "Recovery room," only subcategory "general classification";

(kk) "Labor room/delivery," only subcategory "general

classification," "labor," "delivery," and "birthing center";

(ll) "EKG/ECG (Electrocardiogram)," only subcategories "general classification," "holter monitor," and "telemetry";

(mm) "EEG (Electroencephalogram)," only subcategory "general classification";

(nn) "Gastro-intestinal services," only subcategory "general classification";

(oo) "Treatment/observation room," only subcategories "general classification," "treatment room," and "observation room";

(pp) "Extra-corporeal shock wave therapy (formerly lithotripsy)," only subcategory "general classification";

(qq) "Inpatient renal dialysis," only subcategories "general classification," "inpatient hemodialysis," "inpatient peritoneal (non-CAPD)," "inpatient continuous ambulatory peritoneal dialysis (CAPD)," and "inpatient continuous cycling peritoneal dialysis (CCPD)";

(rr) "Acquisition of body components," only subcategories "general classification," "living donor," and "cadaver donor";

(ss) "Miscellaneous dialysis," only subcategory "ultra filtration";

(tt) "Other diagnostic services," only subcategories "general classification," "peripheral vascular lab," "electromyelogram," and "pregnancy test"; and

(uu) "Other therapeutic services," only subcategory "general classification."

(2) The agency pays for an inpatient hospital covered service in the following revenue code subcategories only when the hospital provider is approved by the agency to provide the specific service:

(a) "All-inclusive rate," only subcategory "all-inclusive room & board plus ancillary";

(b) "Room & board - Private (one bed)," only subcategory "psychiatric";

(c) "Room & board - Semi-private (two beds)," only subcategories "psychiatric," " withdrawal management," "rehabilitation," and "other";

(d) "Room & board - Semi-private three and four beds," only subcategories "psychiatric" and " withdrawal management";

(e) "Room & board - Deluxe private," only subcategory "psychiatric";

(f) "Room & board - Ward," only subcategories "general classification" and " withdrawal management";

(g) "Room & board - Other," only subcategories "general classification" and "other";

(h) "Leave of absence," only subcategories "general classification";

(i) "Intensive care unit," only subcategory "psychiatric";

(j) "Coronary care unit," only subcategory "heart transplant";

(k) "Operating room services," only subcategories "organ transplant-other than kidney" and "kidney transplant";

(l) "Occupational therapy," only subcategories "general classification," "visit charge," "hourly charge," "group rate" and "evaluation or reevaluation";

(m) "Clinic," only subcategory "chronic pain clinic";

(n) "Ambulance," only subcategory "neonatal ambulance services";

(o) "Behavioral health treatment/services," only subcategory "electroshock treatment"; and

(p) "Behavioral health treatment/services - Extension," only subcategory "rehabilitation."

(3) The agency pays revenue code category "occupational therapy," subcategories "general classification," "visit charge," "hourly charge," "group rate," and "evaluation or reevaluation" when:

(a) A client is in an acute PM&R facility;

(b) A client is age 20 or younger; or

(c) The diagnosis code is listed in the agency's published billing instructions.

(4) The agency does not pay for inpatient hospital services in the following revenue code categories and subcategories:

(a) "All-inclusive rate," subcategory "all-inclusive room and board";

(b) "Room & board - Private (one bed)" subcategories "hospice," " withdrawal management," "rehabilitation," and "other";

(c) "Room & board - Semi-private (two bed)," subcategory "hospice";

(d) "Room & board - Semi-private - (three and four beds)," subcategories "hospice," "rehabilitation," and "other";

(e) "Room & board - Deluxe private," subcategories "hospice," " withdrawal management," "rehabilitation," and "other";

(f) "Room & board - Ward," subcategories "medical/surgical/gyn," "OB," "pediatric," "psychiatric," "hospice," "oncology," "rehabilitation," and "other";

(g) "Room & board - Other," subcategories "sterile environment," and "self care";

(h) "Intensive care unit," subcategory "other intensive care";

(i) "Coronary care unit," subcategory "other coronary care";

(j) "Incremental nursing charge";

(k) "All-inclusive ancillary";

(l) "Pharmacy," subcategories "take home drugs," "experimental drugs," and "other pharmacy";

(m) "IV therapy," subcategory "other IV therapy";

(n) "Medical/surgical supplies and devices," subcategories "take home supplies," "prosthetic/orthotics devices," "oxygen - take home," and "other supplies/devices";

(o) "Oncology," subcategory "other oncology";

(p) "Durable medical equipment (other than renal)";

(q) "Laboratory," subcategories "renal patient (home)," and "other laboratory";

(r) "Laboratory pathology," subcategory "other laboratory - pathological";

(s) "Radiology - Diagnostic," subcategory "other radiology - diagnostic";

(t) "Radiology - Therapeutic," subcategory "other radiology - therapeutic";

(u) "Nuclear medicine," subcategory "other nuclear medicine";

(v) "CT scan," subcategory "other CT scan";

(w) "Operating room services," subcategory "other operating room services";

(x) "Anesthesia," subcategories "acupuncture," and "other anesthesia";

(y) "Blood and blood components";

(z) "Administration, processing and storage for blood and blood components," subcategory "other processing and storage";

(aa) "Other imaging services," subcategories "screening mammography," and "other imaging services";

(bb) "Respiratory services," subcategory "other respiratory services";

(cc) "Physical therapy," subcategory "other physical therapy";

(dd) "Occupational therapy," subcategory "other occupational therapy";

(ee) "Speech therapy - Language pathology," subcategory "other speech-language pathology";

(ff) "Emergency room," subcategories "EMTALA emergency medical screening services," "ER beyond EMTALA screening," and "other emergency room";

(gg) "Pulmonary function," subcategory "other pulmonary function";

(hh) "Audiology";

(ii) "Cardiology," subcategory "other cardiology";

(jj) "Ambulatory surgical care," subcategory "other ambulatory surgical care";

(kk) "Outpatient services," subcategory "other outpatient service";

(ll) "Clinic," subcategories "general classification," "dental clinic," "psychiatric clinic," "OB-gyn clinic," "pediatric clinic," "urgent care clinic," "family practice clinic," and "other clinic";

(mm) "Free-standing clinic";

(nn) "Osteopathic services";

(oo) "Ambulance," subcategories "general classification," "supplies," "medical transport," "heart mobile," "oxygen," "air ambulance," "pharmacy," "telephone transmission EKG," and "other ambulance";

(pp) "Home health (HH) skilled nursing";

(qq) "Home health (HH) medical social services";

(rr) "Home health (HH) - Aide";

(ss) "Home health (HH) - Other visits";

(tt) "Home health (HH) - Units of service";

(uu) "Home health (HH) - Oxygen";

(vv) "Magnetic resonance technology (MRT)," subcategory "other MRT";

(ww) "Medical" "medical/surgical supplies - extension," subcategory "FDA investigational devices";

(xx) "Home IV therapy services";

(yy) "Hospice services";

(zz) "Respite care";

(aaa) "Outpatient special residence charges";

(bbb) "Trauma response";

(ccc) "Cast room," subcategory "other cast room";

(ddd) "Recovery room," subcategory "other recovery room";

(eee) "Labor room/delivery," subcategories "circumcision" and "other labor room/delivery";

(fff) "EKG/ECG (Electrocardiogram)," subcategory "other EKG/ECG";

(ggg) "EEG (Electroencephalogram)," subcategory "other EEG";

(hhh) "Gastro-intestinal services," subcategory "other gastro-intestinal";

(iii) "Specialty room - Treatment/observation room," subcategory "other specialty rooms";

(jjj) "Preventive care services";

(kkk) "Telemedicine";

(lll) "Extra-corporeal shock wave therapy (formerly lithotripsy)," subcategory "other ESWT";

(mmm) "Inpatient renal dialysis," subcategory "other inpatient dialysis";

(nnn) "Acquisition of body components," subcategories "unknown donor," "unsuccessful organ search - donor bank charges," and "other donor";

(ooo) "Hemodialysis - Outpatient or home";

(ppp) "Peritoneal dialysis - Outpatient or home";

(qqq) "Continuous ambulatory peritoneal dialysis (CAPD) - Outpatient or home";

(rrr) "Continuous cycling peritoneal dialysis (CCPD) - Outpatient or home";

(sss) "Miscellaneous dialysis," subcategories "general

classification," "home dialysis aid visit," and "other miscellaneous dialysis";

(ttt) "Behavioral health treatments/services," subcategories "general classification," "milieu therapy," "play therapy," "activity therapy," "intensive outpatient services - psychiatric," "intensive outpatient services - substance use disorder (SUD)," "community behavioral health program (day treatment)";

(uuu) "Behavioral health treatment/services" - (extension), subcategories "rehabilitation," "partial hospitalization - less intensive," "partial hospitalization - intensive," "individual therapy," "group therapy," "family therapy," "bio feedback," "testing," and "other behavioral health treatment/services";

(vvv) "Other diagnostic services," subcategories "general classification," "pap smear," "allergy test," and "other diagnostic service";

(www) "Medical rehabilitation day program";

(xxx) "Other therapeutic services," subcategories "recreational therapy," "cardiac rehabilitation," "drug rehabilitation," "alcohol rehabilitation," "complex medical equipment - routine," "complex medical equipment - ancillary," and "other therapeutic services";

(yyy) "Other therapeutic services - extension," subcategories "athletic training" and "kinesiotherapy";

(zzz) "Professional fees";

(aaaa) "Patient convenience items"; and

(bbbb) Revenue code categories and subcategories that are not identified in this section.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 48.43.815. WSR 25-08-038, s 182-550-1400, filed 3/27/25, effective 4/27/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-15-128, § 182-550-1400, filed 7/21/21, effective 8/21/21*
- *WSR 15-18-065, § 182-550-1400, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-1400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-018, § 388-550-1400, filed 6/22/07, effective 8/1/07. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and Public Law 104-191. WSR 03-19-045, § 388-550-1400, filed 9/10/03, effective 10/11/03. Statutory Authority: RCW 74.08.090. WSR 01-02-075, § 388-550-1400, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-1400, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-1500** Covered and noncovered revenue code categories and subcategories for outpatient hospital services. {#sec-182-550-1500 omnilex-key=us-wa-regs-official--title-182--182-550-1500}

(1) The medicaid agency pays for an outpatient hospital covered service in the following revenue code categories and subcategories when the hospital provider accurately bills:

(a) "Pharmacy," only subcategories "general classification," "generic drugs," "nongeneric drugs," "drugs incident to other diagnostic services," "drugs incident to radiology," "nonprescription," and "IV solutions";

(b) "IV therapy," only subcategories "general classification," "infusion pump," "IV therapy/pharmacy services," "IV therapy/drug/supply delivery," and "IV therapy/supplies";

(c) "Medical/surgical supplies and devices," only subcategories "general classification," "nonsterile supply," "sterile supply," "prosthetic/orthotic devices," "pacemaker," "intraocular lens," and "other implant," and "other supplies/devices";

(d) "Oncology," only subcategory "general classification";

(e) "Durable medical equipment (other than renal)," only subcategory "general classification";

(f) "Laboratory," only subcategories "general classification," "chemistry," "immunology," "renal patient (home)," "nonroutine dialysis," "hematology," "bacteriology and microbiology," and "urology";

(g) "Laboratory pathology," only subcategories "general classification," "cytology," "histology," and "biopsy";

(h) "Radiology - Diagnostic," only subcategories "general classification," "angiocardiography," "arthrography," "arteriography," and "chest X-ray";

(i) "Radiology - Therapeutic and/or chemotherapy administration," only subcategories "general classification," "chemotherapy - injected," "chemotherapy - oral," "radiation therapy," and "chemotherapy - IV";

(j) "Nuclear medicine," only subcategories "general classification," "diagnostic," and "therapeutic," "diagnostic radiopharmaceuticals," and "therapeutic radiopharmaceuticals";

(k) "CT scan," only subcategories "general classification," "CT-head scan," and "CT-body scan";

(l) "Operating room services," only subcategories "general classification" and "minor surgery";

(m) "Anesthesia," only subcategories "general classification," "anesthesia incident to radiology," and "anesthesia incident to other diagnostic services";

(n) "Administration, processing and storage for blood and blood components," only subcategories "general classification" and "administration";

(o) "Other imaging," only subcategories "general classification," "diagnostic mammography," "ultrasound," "screening mammography," and "positron emission tomography";

(p) "Respiratory services," only subcategories "general classification," "inhalation services," and "hyperbaric oxygen therapy";

(q) "Physical therapy," only subcategories "general classification," "visit charge," "hourly charge," "group rate," and "evaluation or reevaluation";

(r) "Occupational therapy," only subcategories "general classification," "visit charge," "hourly charge," "group rate," and "evaluation or reevaluation";

(s) "Speech therapy - Language pathology," only subcategories "general classification," "visit charge," "hourly charge," "group rate," and "evaluation or reevaluation";

(t) "Emergency room," only subcategories "general classification" and "urgent care";

(u) "Pulmonary function," only subcategory "general classification";

(v) "Audiology," only subcategories "general classification," "diagnostic," and "treatment";

(w) "Cardiology," only subcategories "general classification," "cardiac cath lab," "stress test," and "echocardiology";

(x) "Ambulatory surgical care," only subcategory "general classification";

(y) "Clinic," only subcategories "general classification," and "dental";

(z) "Magnetic resonance technology (MRT)," only subcategories "general classification," "MRI - Brain (including brainstem)," "MRI - Spinal cord (including spine)," "MRI-other," "MRA - Head and neck," "MRA - Lower extremities" and "MRA-other";

(aa) "Medical/surgical supplies - Extension," only subcategories "supplies incident to radiology," "supplies incident to other diagnostic services," and "surgical dressings";

(bb) "Pharmacy - Extension," only subcategories "single source drug," "multiple source drug," "restrictive prescription," "erythropoietin (EPO) less than 10,000 units," "erythropoietin (EPO) 10,000 or more units," "drugs requiring detailed coding," and "self-administrable drugs";

(cc) "Cast room," only subcategory "general classification";

(dd) "Recovery room," only subcategory "general classification";

(ee) "Labor room/delivery," only subcategories "general classification," "labor," "delivery," and "birthing center";

(ff) "EKG/ECG (Electrocardiogram)," only subcategories "general classification," "holter monitor," and "telemetry";

(gg) "EEG (Electroencephalogram)," only subcategory "general classification";

(hh) "Gastro-intestinal services," only subcategory "general classification";

(ii) "Specialty room - Treatment/observation room," only subcategories "treatment room," and "observation room";

(jj) "Preventative care services," only subcategory "vaccine administration";

(kk) "Telemedicine," only subcategory "general classification";

(ll) "Extra-corporeal shock wave therapy (formerly lithotripsy)," subcategory "general classification";

(mm) "Acquisition of body components," only subcategories "general classification," "living donor," "cadaver donor," and "stem cells-allogeneic";

(nn) "Hemodialysis - Outpatient or home," only subcategory "general classification";

(oo) "Peritoneal dialysis - Outpatient or home," only subcategory "general classification";

(pp) "Continuous ambulatory peritoneal dialysis (CAPD) - Outpatient or home," only subcategory "general classification";

(qq) "Continuous cycling peritoneal dialysis (CCPD) - Outpatient or home," only subcategory "general classification";

(rr) "Miscellaneous dialysis," only subcategories "general classification," and "ultra filtration";

(ss) "Behavioral health treatments/services," only subcategories "electroshock treatment" and "intensive outpatient services - psychiatric";

(tt) "Behavioral health treatment/services," only subcategory "partial hospitalization - intensive";

(uu) "Other diagnostic services," only subcategories "general classification," "peripheral vascular lab," "electromyelogram," "pap smear," and "pregnancy test"; and

(vv) "Other therapeutic service," only subcategories "general classification" and "cardiac rehabilitation."

(2) The agency pays for an outpatient hospital covered service in the following revenue code subcategories only when the outpatient hospital provider is approved by the agency to provide the specific service:

(a) "Clinic," only subcategory "other clinic";

(b) "Outpatient services," subcategory "other outpatient services"; and

(c) "Other therapeutic services," only subcategory "other therapeutic services."

(3) The agency does not pay for outpatient hospital services in the following revenue code categories and subcategories:

(a) "All-inclusive rate";

(b) "Room & board - Private (one bed)";

(c) "Room & board - Semi-private (two beds)";

(d) "Room & board - Semi-private (three and four beds)";

(e) "Room & board - Deluxe private";

(f) "Room & board - Ward";

(g) "Room & board - Other";

(h) "Nursery";

(i) "Leave of absence";

(j) "Subacute care";

(k) "Intensive care unit";

(l) "Coronary care unit";

(m) "Special charges";

(n) "Incremental nursing charge rate";

(o) "All-inclusive ancillary";

(p) "Pharmacy," subcategories "take home drugs," "experimental drugs," and "other pharmacy";

(q) "IV therapy," subcategory "other IV therapy";

(r) "Medical/surgical supplies and devices," subcategories "take home supplies" and "oxygen - take home";

(s) "Oncology," subcategory "other oncology";

(t) "Durable medical equipment (other than renal)," subcategories "rental," "purchase of new DME," "purchase of used DME," "supplies/drugs for DME effectiveness (home health agency only)," and "other equipment";

(u) "Laboratory," subcategory "other laboratory";

(v) "Laboratory pathology," subcategory "other laboratory pathological";

(w) "Radiology - Diagnostic," subcategory "other radiology - diagnostic";

(x) "Radiology - Therapeutic and/or chemotherapy administration," subcategory "other radiology - therapeutic";

(y) "Nuclear medicine," subcategory "other nuclear medicine";

(z) "CT scan," subcategory "other CT scan";

(aa) "Operating room services," subcategories "organ transplant - other than kidney," "kidney transplant," and "other operating room services";

(bb) "Anesthesia," subcategories "acupuncture" and "other anesthesia";

(cc) "Blood and blood components";

(dd) "Administration, processing and storage for blood and blood component," subcategories "processing and storage" and "other blood handling";

(ee) "Other imaging," subcategory "other imaging service";

(ff) "Respiratory services," subcategory "other respiratory services";

(gg) "Physical therapy services," subcategory "other physical therapy";

(hh) "Occupational therapy services," subcategory "other occupational therapy";

(ii) "Speech therapy - Language pathology," subcategory "other speech-language pathology";

(jj) "Emergency room," subcategories "EMTALA emergency medical screening services," "ER beyond EMTALA screening" and "other emergency room";

(kk) "Pulmonary function," subcategory "other pulmonary function";

(ll) "Audiology," subcategory "other audiology";

(mm) "Cardiology," subcategory "other cardiology";

(nn) "Ambulatory surgical care," subcategory "other ambulatory surgical care";

(oo) "Outpatient services," "general classification";

(pp) "Clinic," subcategories "chronic pain center," "psychiatric clinic," "OB-GYN clinic," "pediatric clinic," "urgent care clinic," and "family practice clinic";

(qq) "Free-standing clinic";

(rr) "Osteopathic services";

(ss) "Ambulance";

(tt) "Home health (HH) - Skilled nursing";

(uu) "Home health (HH) - Medical social services";

(vv) "Home health (HH) - Aide";

(ww) "Home health (HH) - Other visits";

(xx) "Home health (HH) - Units of service";

(yy) "Home health (HH) - Oxygen";

(zz) "Magnetic resonance technology (MRT)," subcategory "other MRT";

(aaa) "Medical/surgical supplies - Extension," only subcategory "FDA investigational devices";

(bbb) "Home IV therapy services";

(ccc) "Hospice services";

(ddd) "Respite care";

(eee) "Outpatient special residence charges";

(fff) "Trauma response";

(ggg) "Pre-hospice/palliative care services";

(hhh) "Labor room/delivery," subcategories "circumcision" and "other labor room/delivery";

(iii) "EKG/ECG (Electrocardiogram)," subcategory "other EKG/ECG";

(jjj) "Speciality room - Treatment/observation room," subcategories "general classification" and "other speciality rooms";

(kkk) "Preventive care services," "general classification";

(lll) "Inpatient renal dialysis";

(mmm) "Acquisition of body components," subcategories "unknown donor," "unsuccessful organ search - donor bank charges," and "other donor";

(nnn) "Hemodialysis - Outpatient or home," subcategories "hemodialysis/composite or other rate," "home supplies," "home equipment," "maintenance 100 percent (home)," "support services (home)," and "other outpatient hemodialysis (home)";

(ooo) "Peritoneal dialysis - Outpatient or home," subcategories "peritoneal/composite or other rate," "home supplies," "home equipment," "maintenance 100 percent (home)," "support services (home)," and "other outpatient peritoneal dialysis (home)";

(ppp) "Continuous ambulatory peritoneal dialysis (CAPD) - Outpatient or home," subcategories "CAPD/composite or other rate," "home supplies," "home equipment," "maintenance 100 percent (home)," "support services (home)," and "other outpatient CAPD (home)";

(qqq) "Continuous cycling peritoneal dialysis (CCPD) - Outpatient or home," subcategories "CCPD/composite or other rate," "home supplies," "home equipment," "maintenance 100 percent (home)," "support services (home)," and "other outpatient CCPD (home)";

(rrr) "Miscellaneous dialysis," subcategories "home dialysis aid visit" and "other miscellaneous dialysis";

(sss) "Behavioral health treatments/services," subcategories "general classification," "milieu therapy," "play therapy," "activity therapy," "intensive outpatient services - chemical," and "community behavioral health program (day treatment)";

(ttt) "Behavioral health treatment/services (extension)," subcategories "rehabilitation," "partial hospitalization - less intensive," "individual therapy," "group therapy," "family therapy," "bio feedback," "testing," and "other behavioral health treatment/services";

(uuu) "Other diagnostic services," subcategories "allergy test" and "other diagnostic services";

(vvv) "Medical rehabilitation day program";

(www) "Other therapeutic services - extension," subcategories "recreational therapy," "education/training," "drug rehabilitation," "alcohol rehabilitation," "complex medical equipment - routine," "complex medical equipment - ancillary," "athletic training," and "kinesiotherapy";

(xxx) "Professional fees";

(yyy) "Patient convenience items";

(zzz) "Behavioral health accommodations"; and

(aaaa) Revenue code categories and subcategories that are not identified in this section.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 48.43.815. WSR 25-08-038, s 182-550-1500, filed 3/27/25, effective 4/27/25. Statutory Authority: RCW 41.05.021, 41.05.160, 71.24.385, and 2022 c 94 § 1 (1)(a)(ix). WSR 24-14-040, § 182-550-1500, filed 6/26/24, effective 7/27/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-1500, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-1500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-018, § 388-550-1500, filed 6/22/07, effective 8/1/07. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and Public Law 104-191. WSR 03-19-046, § 388-550-1500, filed 9/10/03, effective 10/11/03. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-1500, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-1600** Specific items/services not covered. {#sec-182-550-1600 omnilex-key=us-wa-regs-official--title-182--182-550-1600}

The medicaid agency does not pay for an inpatient or outpatient hospital service, treatment, equipment, drug, or supply that is not listed or referred to as a covered service in this chapter. The following list of noncovered items and services is not intended to be all-inclusive. Noncovered items and services include, but are not limited to:

(1) Personal care items such as, but not limited to, slippers, toothbrush, comb, hair dryer, and make-up;

(2) Telephone/telegraph services or television/radio rentals;

(3) Medical photographic or audio/videotape records;

(4) Crisis counseling;

(5) Psychiatric day care;

(6) Ancillary services, such as respiratory and physical therapy, performed by regular nursing staff assigned to the floor or unit;

(7) Standby personnel and travel time;

(8) Routine hospital medical supplies and equipment such as bed scales;

(9) Handling fees and portable X-ray charges;

(10) Room and equipment charges ("rental charges") for use periods concurrent with another room or similar equipment for the same client;

(11) Cafeteria charges; and

(12) Services and supplies provided to nonpatients, such as meals and "father packs."

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-1600, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-1600, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-018, § 388-550-1600, filed 6/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-1600, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-1650** Adverse events, hospital-acquired conditions, and present on admission indicators. {#sec-182-550-1650 omnilex-key=us-wa-regs-official--title-182--182-550-1650}

Refer to WAC 182-502-0022 for the payment policy for provider preventable conditions.

**History**
- *Statutory Authority: 42 C.F.R. § 447.26. WSR 13-11-051, § 182-550-1650, filed 5/14/13, effective 7/1/13. WSR 11-14-075, recodified as § 182-550-1650, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and Centers for Medicare and Medicaid Services (CMS). WSR 09-24-061, § 388-550-1650, filed 11/25/09, effective 1/1/10.*

##### **Wash. Admin. Code § 182-550-1700** Authorization and utilization review (UR) of inpatient and outpatient hospital services. {#sec-182-550-1700 omnilex-key=us-wa-regs-official--title-182--182-550-1700}

(1) This section applies to the agency's authorization and utilization review (UR) of inpatient and outpatient hospital services provided to Washington apple health (medicaid) clients receiving services through the fee-for-service program. For clients enrolled in an agency-contracted managed care organization (MCO), see chapters 182-538 and 182-538D WAC. See chapter 182-546 WAC for transportation services.

(2) All hospital services paid for by the agency are subject to UR for medical necessity, appropriate level of care, and program compliance.

(3) Authorization for inpatient and outpatient hospital services is valid only if a client is eligible for covered services on the date of service. Authorization does not guarantee payment.

(4) The agency will deny, recover, or adjust hospital payments if the agency or its designee determines, as a result of UR, that a hospital service does not meet the requirements in federal regulations and WAC.

(5) The agency may perform one or more types of UR described in subsection (6) of this section.

(6) The agency's UR:

(a) Is a concurrent, prospective, and/or retrospective (including postpay and prepay) formal evaluation of a client's documented medical care to assure that the services provided are proper and necessary and of good quality. The review considers the appropriateness of the place of care, level of care, and the duration, frequency or quantity of services provided in relation to the conditions(s) being treated; and

(b) Includes one or more of the following:

(i) "Concurrent utilization review"—An evaluation performed by the agency or its designee during a client's course of care. A continued stay review performed during the client's hospitalization is a form of concurrent UR;

(ii) "Prospective utilization review"—An evaluation performed by the agency or its designee prior to the provision of health care services. Preadmission authorization is a form of prospective UR; and

(iii) "Retrospective utilization review"—An evaluation performed by the agency or its designee following the provision of health care services that includes both a post-payment retrospective UR (performed after health care services are provided and paid), and a prepayment retrospective UR (performed after health care services are provided but prior to payment). Retrospective UR is routinely performed as an audit function.

(7) During the UR process, the agency or its designee notifies the appropriate oversight entity if either of the following is identified:

(a) A quality of care concern; or

(b) Fraudulent conduct.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-18-059, § 182-550-1700, filed 8/26/21, effective 9/26/21. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-019, § 182-550-1700, filed 7/24/14, effective 8/24/14. WSR 11-14-075, recodified as § 182-550-1700, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-018, § 388-550-1700, filed 6/22/07, effective 8/1/07*
- *WSR 04-20-058, § 388-550-1700, filed 10/1/04, effective 11/1/04. Statutory Authority: RCW 74.08.090. WSR 01-02-075, § 388-550-1700, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-1700, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-1800** Hospital specialty services not requiring prior authorization. {#sec-182-550-1800 omnilex-key=us-wa-regs-official--title-182--182-550-1800}

The medicaid agency pays for certain specialty services without requiring prior authorization when such services are provided consistent with agency medical necessity and utilization review standards. These services include, but are not limited to, the following:

(1) All transplant procedures specified in WAC 182-550-1900(2) under the conditions established in WAC 182-550-1900;

(2) Chronic pain management services, including outpatient evaluation and inpatient treatment, as described under WAC 182-550-2400;

(3) Polysomnograms and multiple sleep latency tests, as described under WAC 182-531-1500; and

(4) Weight loss program (allowed only in outpatient hospital setting), as described under WAC 182-550-6450.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-06-040, s 182-550-1800, filed 2/27/25, effective 4/1/25. Statutory Authority: RCW 41.05.021. WSR 13-07-029, § 182-550-1800, filed 3/13/13, effective 4/13/13. WSR 11-14-075, recodified as § 182-550-1800, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-018, § 388-550-1800, filed 6/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-1800, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-1900** Transplant coverage. {#sec-182-550-1900 omnilex-key=us-wa-regs-official--title-182--182-550-1900}

(1) The medicaid agency pays for medically necessary transplant procedures only for eligible Washington apple health clients. Clients eligible under the alien emergency medical (AEM) program are not eligible for transplant coverage.

(2) The agency covers the following transplant procedures when the transplant procedures are performed in a health care facility, as defined in WAC 247-04-020, that has a transplant certificate of need from the department of health:

(a) Bone marrow;

(b) Cornea;

(c) Skin grafts;

(d) Stem cell, autologous and allogeneic;

(e) Intestine;

(f) Kidney;

(g) Liver or combination liver-kidney;

(h) Heart or combination heart-lung;

(i) Lung, single or bilateral;

(j) Pancreas or combination pancreas-kidney; and

(k) Other transplant services determined to be medically necessary. See WAC 182-501-0165 and 182-500-0070.

(3) The agency pays for procedures covered under subsection (2)(a) through (d) of this section, performed at qualified facilities, subject to the limitations in this chapter.

(4) For procedures covered under subsection (2)(e) through (k) of this section, the agency pays facility charges only to those facilities that meet the standards and conditions:

(a) Established by the agency; and

(b) Specified in WAC 182-550-2100.

(5) The agency considers organ procurement fees as being included in the payment to the transplant facility. The agency may make an exception to this policy and pay these fees separately to a transplant facility when an eligible apple health client is covered by a third-party payer that will pay for the organ transplant procedure itself but not for the organ procurement.

(6) The agency, without requiring prior authorization, pays for up to 15 matched donor searches per client approved for a bone marrow transplant. The agency requires prior authorization for matched donor searches in excess of 15 per bone marrow transplant client.

(7) The agency does not pay for experimental transplant procedures.

(8) The agency pays for identical organ transplant procedures as determined medically necessary (see WAC 182-501-0165).

(9) The agency may conduct a postpayment retrospective utilization review as described in WAC 182-550-1700, and may adjust the payment if the agency determines the criteria in this section are not met.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-01-096, s 182-550-1900, filed 12/13/24, effective 1/13/25*
- *WSR 15-18-065, § 182-550-1900, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-1900, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-018, § 388-550-1900, filed 6/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-1900, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-2100** Requirements—Transplant facilities. {#sec-182-550-2100 omnilex-key=us-wa-regs-official--title-182--182-550-2100}

This section applies to requirements for facilities that perform the medicaid agency-approved transplants described in WAC 182-550-1900(2).

(1) The agency requires instate transplant facilities to meet the following requirements to be paid for transplant services provided to Washington apple health clients. A facility must have:

(a) An approved certificate of need (CON) from the state department of health (DOH) for the type of transplant procedure to be performed; and

(b) Approval as a medicare-certified transplant facility.

(c) The agency does not require medicare or department of health approval as a transplant facility for a facility that provides stem cell, skin graft, or corneal transplant services.

(2) The agency requires an out-of-state transplant facility, including bordering city and critical border facilities, to be a medicare-certified transplant facility and participating in that state's medicaid program. All out-of-state transplant services must be prior authorized.

(3) The agency applies the following specific requirements to a stem cell transplant facility:

(a) A stem cell transplant facility must be in compliance with 21 C.F.R. § 1271 to perform any of the following stem cell services:

(i) Harvesting, if it has its own apheresis equipment which meets federal or American Association of Blood Banks (AABB) requirements;

(ii) Processing, if it meets AABB quality of care requirements for human tissue/tissue banking; and

(iii) Reinfusion, if it meets the criteria established by the Foundation for the Accreditation of Cellular Therapy.

(b) A stem cell transplant facility may purchase stem cell processing and harvesting services from other agency-approved processing providers.

(4) The agency does not pay a stem cell transplant facility for AABB inspection and certification fees related to stem cell transplant services.

(5) The agency does not pay for any service that requires consent under RCW 18.130.420.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-01-096, s 182-550-2100, filed 12/13/24, effective 1/13/25*
- *WSR 15-18-065, § 182-550-2100, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-2100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-018, § 388-550-2100, filed 6/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-2100, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-2301** Hospital and medical criteria requirements for bariatric surgery. {#sec-182-550-2301 omnilex-key=us-wa-regs-official--title-182--182-550-2301}

(1) The medicaid agency pays a hospital for bariatric surgery and bariatric surgery-related services only when the surgery is provided in an inpatient hospital setting and only when:

(a) The client:

(i) Qualifies for bariatric surgery by successfully completing all requirements under WAC 182-531-1600; and

(ii) Continues to meet the criteria to qualify for bariatric surgery under WAC 182-531-1600 up to the actual surgery date.

(b) The hospital:

(i) Is accredited by the metabolic and bariatric surgery accreditation and quality improvement program (MBSAQIP); and

(ii) Receives prior authorization from the agency before performing a bariatric surgery for a Washington apple health client.

(2) See WAC 182-531-1600(13) for requirements for surgeons who perform bariatric surgery.

(3) Authorization does not guarantee payment. Authorization for bariatric surgery and bariatric surgery-related services is valid only if:

(a) The client is eligible on the date of admission and date of service; and

(b) The hospital and professional providers meet the criteria in this section and other applicable WAC to perform bariatric surgery or to provide bariatric surgery-related services.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-24-107, § 182-550-2301, filed 12/6/17, effective 1/6/18*
- *WSR 15-18-065, § 182-550-2301, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-2301, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-018, § 388-550-2301, filed 6/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-12-022, § 388-550-2301, filed 5/20/05, effective 6/20/05.*

##### **Wash. Admin. Code § 182-550-2400** Inpatient chronic pain management services. {#sec-182-550-2400 omnilex-key=us-wa-regs-official--title-182--182-550-2400}

(1) The medicaid agency pays a hospital that is specifically approved by the agency to provide inpatient chronic pain management services, an all-inclusive per diem facility fee. The agency pays professional fees for chronic pain management services to performing providers under the agency's fee schedule.

(2) A client qualifies for inpatient chronic pain management services when all the following apply:

(a) The client has had pain for at least three months and has not improved with conservative treatment, including tests and therapies;

(b) At least six months have passed since a previous surgical procedure was done concerning the pain problem; and

(c) A client with active substance abuse must have completed a withdrawal management program, if appropriate, and must be free from drugs and/or alcohol for at least six months.

(3) The agency:

(a) Covers inpatient chronic pain management training to assist eligible clients to manage chronic pain.

(b) Pays for only one inpatient hospital stay, up to a maximum of twenty-one consecutive days, for chronic pain management training per a client's lifetime.

(c) Does not require prior authorization for chronic pain management services.

(d) Does not pay for services unrelated to the chronic pain management services that are provided during the client's inpatient stay, unless the hospital requests and receives prior authorization from the agency.

(4) All applicable claim payment adjustments for client responsibility, third party liability, medicare crossover, etc., apply to the agency.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-15-128, § 182-550-2400, filed 7/21/21, effective 8/21/21*
- *WSR 15-18-065, § 182-550-2400, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-2400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-018, § 388-550-2400, filed 6/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-2400, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-2431** Hospice services—Inpatient payments. {#sec-182-550-2431 omnilex-key=us-wa-regs-official--title-182--182-550-2431}

See chapter 182-551 WAC Alternatives to hospital services, subchapter I—Hospice services.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-2431, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-2431, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 42 U.S.C. 1395 x(v), 42 C.F.R. 447.271, 447.11303, and 447.2652. WSR 99-06-046, § 388-550-2431, filed 2/26/99, effective 3/29/99.*

##### **Wash. Admin. Code § 182-550-2500** Inpatient hospice services. {#sec-182-550-2500 omnilex-key=us-wa-regs-official--title-182--182-550-2500}

(1) The medicaid agency pays hospice agencies participating in the Washington apple health program for general inpatient and inpatient respite services provided to clients in hospice care, when:

(a) The hospice agency coordinates the provision of the inpatient services; and

(b) The services are related to the medical condition for which the client sought hospice care.

(2) Hospice agencies must bill the agency for their services using revenue codes. The agency pays hospice providers a set per diem fee according to the type of care provided to the client on a daily basis.

(3) The agency pays hospital providers directly according to this chapter for inpatient care provided to clients in the hospice program for medical conditions not related to their terminal illness.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-2500, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-2500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-018, § 388-550-2500, filed 6/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-2500, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-2501** Acute physical medicine and rehabilitation (acute PM&R) program—General. {#sec-182-550-2501 omnilex-key=us-wa-regs-official--title-182--182-550-2501}

Acute physical medicine and rehabilitation (acute PM&R) is a twenty-four-hour inpatient comprehensive program of integrated medical and rehabilitative services provided during the acute phase of a client's rehabilitation. The medicaid agency requires prior authorization for acute PM&R services. (See WAC 182-550-2561 for prior authorization requirements.)

(1) An interdisciplinary team coordinates individualized acute PM&R services at an agency-approved rehabilitation hospital to achieve the following for a client:

(a) Improved health and welfare; and

(b) Maximum physical, social, psychological, and educational or vocational potential.

(2) The agency determines and authorizes a length of stay based on:

(a) The client's acute PM&R needs; and

(b) Community standards of care for acute PM&R services.

(3) When the agency's authorized acute period of rehabilitation ends, the hospital provider discharges the client to the client's residence, or to an appropriate level of care. Therapies may continue to help the client achieve maximum potential through other agency programs such as:

(a) Home health services;

(b) Nursing facilities;

(c) Outpatient physical, occupational, and speech therapies; or

(d) Neurodevelopmental centers.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-2501, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-2501, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 07-12-039, § 388-550-2501, filed 5/30/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.520 and 42 C.F.R. 482.56. WSR 03-06-047, § 388-550-2501, filed 2/28/03, effective 3/31/03. Statutory Authority: RCW 74.08.090 and 74.09.520. WSR 99-17-111, § 388-550-2501, filed 8/18/99, effective 9/18/99.*

##### **Wash. Admin. Code § 182-550-2521** Client eligibility requirements for acute PM&R services. {#sec-182-550-2521 omnilex-key=us-wa-regs-official--title-182--182-550-2521}

(1) Only a client who is eligible for one of the Washington apple health programs may receive acute PM&R services, subject to the restrictions and limitations in this section and WAC 182-550-2501, 182-550-2511, 182-550-2531, 182-550-2541, 182-550-2551, 182-550-2561, 182-550-3381, and other rules:

(a) Categorically needy program (CNP);

(b) Children's health insurance program (CHIP);

(c) Medically needy program (LCP-MNP);

(d) Alien emergency medical (AEM)(CNP);

(e) Alien emergency medical (AEM)(LCP-MNP);

(f) Medical care services.

(2) If a client is enrolled in an agency managed care organization (MCO) plan at the time of acute care admission, that plan pays for and coordinates acute PM&R services as appropriate.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-019, § 182-550-2521, filed 7/24/14, effective 8/24/14. WSR 11-14-075, recodified as § 182-550-2521, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 07-12-039, § 388-550-2521, filed 5/30/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.520 and 42 C.F.R. 482.56. WSR 03-06-047, § 388-550-2521, filed 2/28/03, effective 3/31/03. Statutory Authority: RCW 74.08.090 and 74.09.520. WSR 99-17-111, § 388-550-2521, filed 8/18/99, effective 9/18/99.*

##### **Wash. Admin. Code § 182-550-2531** Requirements for becoming an acute PM&R provider. {#sec-182-550-2531 omnilex-key=us-wa-regs-official--title-182--182-550-2531}

(1) Before August 1, 2007, only an in-state or bordering city hospital may apply to become a medicaid agency-approved acute PM&R hospital. After July 31, 2007, an in-state, bordering city or critical border hospital may apply to become an agency-approved acute PM&R hospital. To apply, the agency requires the hospital provider to submit a letter of request to:

Acute PM&R Program Manager

Clinical Quality and Care Transformation (CQCT)

Medical and Dental Services

P.O. Box 45506

Olympia, WA 98504-5506

(2) A hospital that applies to become an agency-approved acute PM&R facility must provide the agency with documentation that confirms the facility is all the following:

(a) A medicare-certified hospital;

(b) Accredited by the joint commission on accreditation of health care organizations (JCAHO);

(c) Licensed by the department of health (DOH) as an acute care hospital as defined under WAC 246-310-010;

(d) Commission on accreditation of rehabilitation facilities (CARF) accredited as a comprehensive integrated inpatient rehabilitation program or as a pediatric family centered rehabilitation program, unless subsection (3) of this section applies;

(e) For dates of admission before July 1, 2007, contracted under the agency's selective contracting program, if in a selective contracting area, unless exempted from the requirements by the agency; and

(f) Operating per the standards set by DOH (excluding the certified rehabilitation registered nurse (CRRN) requirement) in either:

(i) WAC 246-976-800 Level I trauma rehabilitation designation; or

(ii) WAC 246-976-800 Level II trauma rehabilitation designation.

(3) A hospital not yet accredited by CARF:

(a) May apply for or be awarded a twelve-month conditional written approval by the agency if the facility:

(i) Provides the agency with documentation that it has started the process of obtaining full CARF accreditation; and

(ii) Is actively operating under CARF standards.

(b) Must obtain full CARF accreditation within twelve months of the agency's conditional approval date. If this requirement is not met, the agency sends a letter of notification to revoke the conditional approval.

(4) A hospital qualifies as an agency-approved acute PM&R hospital when:

(a) The hospital meets all the applicable requirements in this section; and

(b) The agency provides written notification that the hospital qualifies to be paid for providing acute PM&R services to eligible Washington apple health clients.

(5) The agency-approved acute PM&R hospitals must meet the general requirements in chapter 182-502 WAC Administration of medical programs—Providers.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-10-058, § 182-550-2531, filed 5/2/17, effective 6/2/17*
- *WSR 15-18-065, § 182-550-2531, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-2531, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 07-12-039, § 388-550-2531, filed 5/30/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.520 and 42 C.F.R. 482.56. WSR 03-06-047, § 388-550-2531, filed 2/28/03, effective 3/31/03. Statutory Authority: RCW 74.08.090 and 74.09.520. WSR 99-17-111, § 388-550-2531, filed 8/18/99, effective 9/18/99.*

##### **Wash. Admin. Code § 182-550-2541** Quality of care—Agency-approved acute PM&R hospital. {#sec-182-550-2541 omnilex-key=us-wa-regs-official--title-182--182-550-2541}

(1) To ensure quality of care, the medicaid agency may conduct reviews (e.g., post-pay, on-site) of any agency-approved acute PM&R hospital.

(2) A provider of acute PM&R services must act on any report of substandard care or violation of the hospital's medical staff bylaws and CARF standards. The provider must have and follow written procedures that:

(a) Provide a resolution to either a complaint or grievance or both; and

(b) Comply with applicable CARF standards for adults or pediatrics as appropriate.

(3) A complaint or grievance regarding substandard conditions or care may be investigated by any one or more of the following:

(a) The department of health (DOH);

(b) The joint commission on accreditation of health care organizations (JCAHO);

(c) CARF;

(d) The agency; or

(e) Other agencies with review authority for the medicaid agency's programs.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-2541, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-2541, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 07-12-039, § 388-550-2541, filed 5/30/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.520 and 42 C.F.R. 482.56. WSR 03-06-047, § 388-550-2541, filed 2/28/03, effective 3/31/03. Statutory Authority: RCW 74.08.090 and 74.09.520. WSR 99-17-111, § 388-550-2541, filed 8/18/99, effective 9/18/99.*

##### **Wash. Admin. Code § 182-550-2551** When the medicaid agency authorizes acute PM&R services. {#sec-182-550-2551 omnilex-key=us-wa-regs-official--title-182--182-550-2551}

(1) Acute PM&R services may be authorized when all of the following are met:

(a) The client has all of the following:

(i) Extensive or complex medical needs;

(ii) Nursing needs; and

(iii) Therapy needs.

(b) The client has a new or recent significant impairment in two or more of the following areas:

(i) Mobility and strength;

(ii) Self-care/ADLs (activities of daily living);

(iii) Communication; or

(iv) Cognitive/perceptual functioning.

(c) The client has a new or recent onset of one of the following conditions:

(i) Brain injury caused by trauma or disease.

(ii) Spinal cord injury resulting in:

(A) Quadriplegia; or

(B) Paraplegia.

(iii) Extensive burns.

(iv) Bilateral limb loss.

(v) Stroke or aneurysm with resulting hemiplegia or cognitive deficits, including speech and swallowing deficits.

(vi) Multiple trauma (after the client is cleared to bear weight) with complicated orthopedic conditions and neurological deficits.

(vii) Skin flap surgery after severe pressure ulcer for a client who:

(A) Requires close observation by a surgeon; and

(B) Is ready to mobilize or be upright in a chair.

(viii) Acute inflammatory demyelinating polyneuropathy (AIDP).

(2) If the client does not meet the clinical criteria set forth in this section, the agency will evaluate the request for medical necessity according to the process in WAC 182-501-0165.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-10-058, § 182-550-2551, filed 5/2/17, effective 6/2/17. WSR 11-14-075, recodified as § 182-550-2551, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520 and 42 C.F.R. 482.56. WSR 03-06-047, § 388-550-2551, filed 2/28/03, effective 3/31/03. Statutory Authority: RCW 74.08.090 and 74.09.520. WSR 99-17-111, § 388-550-2551, filed 8/18/99, effective 9/18/99.*

##### **Wash. Admin. Code § 182-550-2561** The agency's prior authorization requirements for acute PM&R services. {#sec-182-550-2561 omnilex-key=us-wa-regs-official--title-182--182-550-2561}

(1) The medicaid agency requires prior authorization for acute PM&R services. The acute PM&R provider of services must obtain prior authorization:

(a) Before admitting a client to the rehabilitation unit; and

(b) For an extension of stay before the client's current authorized period of stay expires.

(2) For an initial admit:

(a) A client must:

(i) Be eligible under one of the programs listed in WAC 182-550-2521, subject to the restrictions and limitations listed in that section;

(ii) Require acute PM&R services as determined in WAC 182-550-2551;

(iii) Be medically stable and show evidence of physical and cognitive readiness to participate in the rehabilitation program; and

(iv) Be willing and capable to participate at least three hours per day, seven days per week, in acute PM&R activities.

(b) The acute PM&R provider of services must:

(i) Submit a request for prior authorization to the agency's clinical consultation team as published in the agency's acute PM&R billing instructions; and

(ii) Include sufficient medical information to justify that:

(A) Acute PM&R treatment would effectively enable the client to obtain a greater degree of self-care or independence;

(B) The client's medical condition requires that intensive 24-hour inpatient comprehensive acute PM&R services be provided in an agency-approved acute PM&R facility; and

(C) The client suffers from severe disabilities including, but not limited to, neurological or cognitive deficits.

(3) For an extension of stay:

(a) A client must meet the conditions listed in subsection (2)(a) of this section and have observable and significant improvement; and

(b) The acute PM&R provider of services must:

(i) Submit a request for the extension of stay to the agency clinical consultation team as published in the agency's acute PM&R billing instructions; and

(ii) Include sufficient medical information to justify the extension and include documentation that the client's condition has observably and significantly improved.

(4) If the agency denies the request for an extension of stay, the client must be transferred to an appropriate lower level of care as described in WAC 182-550-2501(3).

(5) The agency's clinical consultation team approves or denies authorization for acute PM&R services for initial stays or extensions of stay based on individual circumstances and the medical information received. The agency notifies the client and the acute PM&R provider of a decision.

(a) If the agency approves the request for authorization, the notification letter includes:

(i) The number of days requested;

(ii) The allowed dates of service;

(iii) An agency-assigned authorization number;

(iv) Applicable limitations to the authorized services; and

(v) The agency's process to request additional services.

(b) If the agency denies the request for authorization, the notification letter includes:

(i) The number of days requested;

(ii) The reason for the denial;

(iii) Alternative services available for the client; and

(iv) The client's right to request an administrative hearing. (See subsection (7) of this section.)

(6) A hospital or other facility intending to transfer a client to an agency-approved acute PM&R hospital or an agency-approved acute PM&R hospital requesting an extension of stay for a client must:

(a) Discuss the agency's authorization decision with the client or the client's legal representative; and

(b) Document in the client's medical record that the agency's decision was discussed with the client or the client's legal representative.

(7) A client who does not agree with a decision regarding acute PM&R services has a right to an administrative hearing under chapter 182-526 WAC. After receiving a request for an administrative hearing, the agency may request additional information from the client and the facility, or both. After the agency reviews the available information, the result may be:

(a) A reversal of the initial agency decision;

(b) Resolution of the client's issue(s); or

(c) An administrative hearing conducted per chapter 182-526 WAC.

(8) The agency may authorize administrative days for a client who:

(a) Does not meet requirements described in subsection (3) of this section; or

(b) Is waiting for a discharge destination or a discharge plan.

(9) The agency does not authorize acute PM&R services for a client who:

(a) Is deconditioned by a medical illness or by surgery; or

(b) Has loss of function primarily as a result of a psychiatric condition; or

(c) Has had a recent surgery and has no complicating neurological deficits. Examples of surgeries that do not qualify a client for inpatient acute PM&R services without extenuating circumstances are:

(i) Single amputation;

(ii) Single extremity surgery; and

(iii) Spine surgery.

**History**
- *Statutory Authority: RCW 35.05.353 (1)(c), 41.05.021, and 41.05.160. WSR 25-10-099, s 182-550-2561, filed 5/7/25, effective 6/7/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-2561, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-2561, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 07-12-039, § 388-550-2561, filed 5/30/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.520 and 42 C.F.R. 482.56. WSR 03-06-047, § 388-550-2561, filed 2/28/03, effective 3/31/03. Statutory Authority: RCW 74.08.090 and 74.09.520. WSR 99-17-111, § 388-550-2561, filed 8/18/99, effective 9/18/99.*

##### **Wash. Admin. Code § 182-550-2565** The long-term acute care (LTAC) program—General. {#sec-182-550-2565 omnilex-key=us-wa-regs-official--title-182--182-550-2565}

The long-term acute care (LTAC) program is a twenty-four-hour inpatient comprehensive program of integrated medical and rehabilitative services provided in a medicaid agency-approved LTAC hospital during the acute phase of a client's care. The agency requires prior authorization for LTAC stays. See WAC 182-550-2590 for prior authorization requirements.

(1) A facility's multidisciplinary team coordinates individualized LTAC services at an agency-approved LTAC hospital.

(2) The agency determines the authorized length of stay for LTAC services based on the client's need as documented in the client's medical records and the criteria described in WAC 182-550-2590.

(3) When the agency-authorized length of stay ends, the provider transfers the client to a more appropriate level of care or, if appropriate, discharges the client to the client's residence.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-2565, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-2565, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-11-129, § 388-550-2565, filed 5/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090. WSR 02-14-162, § 388-550-2565, filed 7/3/02, effective 8/3/02.*

##### **Wash. Admin. Code § 182-550-2575** Client eligibility requirements for LTAC services. {#sec-182-550-2575 omnilex-key=us-wa-regs-official--title-182--182-550-2575}

Only a client who is eligible for one of the following programs may receive LTAC services, subject to the restrictions and limitations in WAC 182-550-1050, 182-550-2565, 182-550-2580, 182-550-2585, 182-550-2590, 182-550-2595, 182-550-2596, and other rules:

(1) Categorically needy program (CNP);

(2) State children's health insurance program (SCHIP);

(3) Limited casualty program - Medically needy program (LCP-MNP);

(4) Alien emergency medical (AEM)(CNP); or

(5) Alien emergency medical (AEM)(LCP-MNP).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-2575, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-2575, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-11-129, § 388-550-2575, filed 5/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090. WSR 02-14-162, § 388-550-2575, filed 7/3/02, effective 8/3/02.*

##### **Wash. Admin. Code § 182-550-2580** Requirements for becoming an LTAC hospital. {#sec-182-550-2580 omnilex-key=us-wa-regs-official--title-182--182-550-2580}

(1) To apply to become a medicaid agency-approved long-term acute care (LTAC) hospital, the agency requires a hospital to:

(a) Submit a letter of request to:

LTAC Program Manager

Division of Health Care Services

Health and Recovery Services Administration

P.O. Box 45506

Olympia WA 98504-5506; and

(b) Include in the letter required under (a) of this subsection, documentation that confirms the hospital is:

(i) Medicare-certified for LTAC;

(ii) Accredited by the joint commission on accreditation of health care organizations (JCAHO);

(iii) Licensed as an acute care hospital by the department of health (DOH) under chapter 246-320 WAC (if an in-state hospital), or by the state in which the hospital is located (if an out-of-state hospital); and

(iv) Enrolled with the agency as a medicaid participating provider.

(2) A hospital qualifies as an agency-approved LTAC hospital when:

(a) The hospital meets all the requirements in this section;

(b) The agency's clinical staff has conducted an on-site visit and recommended approval of the hospital's request for LTAC designation; and

(c) The agency provides written notification to the hospital that it qualifies for payment when providing LTAC services to eligible Washington apple health clients.

(3) Agency-approved LTAC hospitals must meet the general requirements in chapter 182-502 WAC.

(4) The agency may, in its sole discretion, approve a hospital located in Idaho or Oregon that is not in a designated bordering city as an LTAC hospital if:

(a) The hospital meets the requirements of this section; and

(b) The hospital provider signs a contract with the agency agreeing to the payment rates established for LTAC services in accordance with WAC 182-550-2595.

(5) The agency does not have any legal obligation to approve any hospital or other entity as an LTAC hospital.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-2580, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-2580, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 08-21-039, § 388-550-2580, filed 10/8/08, effective 11/8/08*
- *WSR 07-11-129, § 388-550-2580, filed 5/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090. WSR 02-14-162, § 388-550-2580, filed 7/3/02, effective 8/3/02.*

##### **Wash. Admin. Code § 182-550-2585** LTAC hospitals—Quality of care. {#sec-182-550-2585 omnilex-key=us-wa-regs-official--title-182--182-550-2585}

(1) To ensure quality of care, the medicaid agency may conduct post-pay or on-site reviews of any agency-approved LTAC hospital. See chapter 182-502A WAC for additional information on audits conducted by agency staff.

(2) A provider of LTAC services must act on any reports of substandard care or violations of the hospital's medical staff bylaws. The provider must have and follow written procedures that provide a resolution to either a complaint or grievance or both.

(3) A complaint or grievance regarding substandard conditions or care may be investigated by any one or more of the following:

(a) The department of health (DOH);

(b) The joint commission on accreditation of health care organizations (JCAHO);

(c) The agency; or

(d) Other agencies with review authority for the agency's programs.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-2585, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-2585, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-11-129, § 388-550-2585, filed 5/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090. WSR 02-14-162, § 388-550-2585, filed 7/3/02, effective 8/3/02.*

##### **Wash. Admin. Code § 182-550-2590** Agency prior authorization requirements for Level 1 and Level 2 LTAC services. {#sec-182-550-2590 omnilex-key=us-wa-regs-official--title-182--182-550-2590}

(1) The medicaid agency requires prior authorization for Level 1 and Level 2 long term acute care (LTAC) inpatient stays. The prior authorization process includes all the following:

(a) For an initial 30-day stay:

(i) The client must:

(A) Be eligible under one of the programs listed in WAC 182-550-2575; and

(B) Require Level 1 or Level 2 LTAC services as defined in WAC 182-550-1050.

(ii) The LTAC provider of services must:

(A) Before admitting the client to the LTAC hospital, submit a request for prior authorization to the agency as published in the agency's LTAC billing instructions;

(B) Include sufficient medical information to justify the requested initial stay;

(C) Obtain prior authorization from the agency's medical director or designee, when accepting the client from the transferring hospital; and

(D) Meet all the requirements in WAC 182-550-2580.

(b) For any extension of stay, the criteria in (a) of this subsection must be met, and the LTAC provider of services must submit a request for the extension of stay to the agency with sufficient medical justification.

(2) The agency authorizes Level 1 or Level 2 LTAC services for initial stays or extensions of stay based on the client's circumstances and the medical justification received.

(3) A client who does not agree with a decision regarding a length of stay has a right to an administrative hearing under chapter 182-526 WAC. After receiving a request for an administrative hearing, the agency may request additional information from the client and the facility, or both. After the agency reviews the available information, the result may be:

(a) A reversal of the initial agency decision;

(b) Resolution of the client's issue(s); or

(c) An administrative hearing conducted according to chapter 182-526 WAC.

(4) The agency may authorize an administrative day rate payment, and pharmaceuticals, for a client who meets one or more of the following. The client:

(a) Does not meet the requirements for Level 1 or Level 2 LTAC services;

(b) Is waiting for placement in another hospital or other facility; or

(c) If appropriate, is waiting to be discharged to the client's residence.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 74.09.520, and 2025 c 367. WSR 26-01-069, s 182-550-2590, filed 12/12/25, effective 1/12/26. Statutory Authority: RCW 35.05.353 (1)(c), 41.05.021, and 41.05.160. WSR 25-10-099, s 182-550-2590, filed 5/7/25, effective 6/7/25. Statutory Authority: RCW 41.05.021, 41.05.160, and 74.09.520(13). WSR 23-21-063, § 182-550-2590, filed 10/12/23, effective 1/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-18-026, § 182-550-2590, filed 8/28/19, effective 9/28/19*
- *WSR 15-18-065, § 182-550-2590, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-2590, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 08-21-039, § 388-550-2590, filed 10/8/08, effective 11/8/08*
- *WSR 07-11-129, § 388-550-2590, filed 5/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090. WSR 02-14-162, § 388-550-2590, filed 7/3/02, effective 8/3/02.*

##### **Wash. Admin. Code § 182-550-2595** Identification of and payment methodology for services and equipment included in the LTAC fixed per diem rate. {#sec-182-550-2595 omnilex-key=us-wa-regs-official--title-182--182-550-2595}

(1) In addition to room and board, the LTAC fixed per diem rate includes, but is not limited to, the following (see the medicaid agency's LTAC billing instructions for applicable revenue codes):

(a) Room and board - Rehabilitation;

(b) Room and board - Intensive care;

(c) Pharmacy - Up to and including two hundred dollars per day in total allowed covered charges for any combination of pharmacy services that includes prescription drugs, total parenteral nutrition (TPN) therapy, IV infusion therapy, and epogen or neupogen therapy;

(d) Medical/surgical supplies and devices;

(e) Laboratory - General;

(f) Laboratory - Chemistry;

(g) Laboratory - Immunology;

(h) Laboratory - Hematology;

(i) Laboratory - Bacteriology and microbiology;

(j) Laboratory - Urology;

(k) Laboratory - Other laboratory services;

(l) Respiratory services;

(m) Physical therapy;

(n) Occupational therapy; and

(o) Speech-language therapy.

(2) The agency pays the LTAC hospital for services covered by the LTAC fixed per diem rate by the rate in effect at the date of admission, minus the sum of:

(a) Client liability, whether or not collected by the provider; and

(b) Any amount of coverage from third parties, whether or not collected by the provider, including, but not limited to, coverage from:

(i) Insurers and indemnitors;

(ii) Other federal or state health care programs;

(iii) Payments made to the provider on behalf of the client by individuals or organizations not liable for the client's financial obligations; and

(iv) Any other contractual or legal entitlement of the client, including, but not limited to:

(A) Crime victims' compensation;

(B) Workers' compensation;

(C) Individual or group insurance;

(D) Court-ordered dependent support arrangements; and

(E) The tort liability of any third party.

(3) The agency may make annual rate increases to the LTAC fixed per diem rate by using a vendor rate increase. The agency may rebase the LTAC fixed per diem rate periodically.

(4) When the agency establishes a special client service contract to complement the core provider agreement with an out-of-state LTAC hospital for services, the contract terms take precedence over any conflicting payment program policies set in WAC by the agency.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-2595, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-2595, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-11-129, § 388-550-2595, filed 5/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090. WSR 03-02-056, § 388-550-2595, filed 12/26/02, effective 1/26/03*
- *WSR 02-14-162, § 388-550-2595, filed 7/3/02, effective 8/3/02.*

##### **Wash. Admin. Code § 182-550-2596** Services and equipment covered by the agency but not included in the LTAC fixed per diem rate. {#sec-182-550-2596 omnilex-key=us-wa-regs-official--title-182--182-550-2596}

(1) The medicaid agency uses the ratio of costs-to-charges (RCC) payment method to pay an LTAC hospital for the following that are not included in the LTAC fixed per diem rate:

(a) Pharmacy - After the first two hundred dollars per day in total allowed covered charges for any combination of pharmacy services that includes prescription drugs, total parenteral nutrition (TPN) therapy, IV infusion therapy, and epogen or neupogen therapy;

(b) Radiology services;

(c) Nuclear medicine services;

(d) Computerized tomographic (CT) scan;

(e) Operating room services;

(f) Anesthesia services;

(g) Blood storage and processing;

(h) Blood administration;

(i) Other imaging services - Ultrasound;

(j) Pulmonary function services;

(k) Cardiology services;

(l) Recovery room services;

(m) EKG/ECG services;

(n) Gastro-intestinal services;

(o) Inpatient hemodialysis; and

(p) Peripheral vascular laboratory services.

(2) The agency uses the appropriate inpatient or outpatient payment method described in other published WAC to pay providers other than LTAC hospitals for services and equipment that are covered by the agency but not included in the LTAC fixed per diem rate. The provider must bill the agency directly and the agency pays the provider directly.

(3) Transportation services that are related to transporting a client to and from another facility for the provision of outpatient medical services while the client is still an inpatient at the LTAC hospital, or related to transporting a client to another facility after discharge from the LTAC hospital:

(a) Are not covered or reimbursed through the LTAC fixed per diem rate;

(b) Are not payable directly to the LTAC hospital;

(c) Are subject to the provisions in chapter 182-546 WAC; and

(d) Must be billed directly to the:

(i) Agency by the transportation company to be reimbursed if the client required ambulance transportation; or

(ii) Agency's contracted transportation broker, subject to the prior authorization requirements and provisions described in chapter 182-546 WAC, if the client:

(A) Required nonemergency transportation; or

(B) Did not have a medical condition that required transportation in a prone or supine position.

(4) The agency evaluates requests for covered transportation services that are subject to limitations or other restrictions, and approves the services beyond those limitations or restrictions under WAC 182-501-0165 and 182-501-0169.

(5) When the agency established a special client service contract to complement the core provider agreement with an out-of-state LTAC hospital for services, the contract terms take precedence over any conflicting payment program policies set in WAC by the agency.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-2596, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-2596, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-11-129, § 388-550-2596, filed 5/22/07, effective 8/1/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-550-2596, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090. WSR 03-02-056, § 388-550-2596, filed 12/26/02, effective 1/26/03*
- *WSR 02-14-162, § 388-550-2596, filed 7/3/02, effective 8/3/02.*

##### **Wash. Admin. Code § 182-550-2598** Critical access hospitals (CAHs). {#sec-182-550-2598 omnilex-key=us-wa-regs-official--title-182--182-550-2598}

(1) The following definitions and abbreviations and those found in chapter 182-500 WAC and WAC 182-182-1050 apply to this section:

(a) "CAH" see "critical access hospital."

(b) "Cost settlement" means a reconciliation of the fee-for-service interim CAH payments with a CAH's actual costs determined in conjunction with the use of the CAH's final settled medicare cost report (Form 2552-96) after the end of the CAH's HFY.

(c) "Critical access hospital (CAH)" means a hospital that is approved by the department of health (DOH) for inclusion in DOH's critical access hospital program.

(d) "HFY" see "hospital fiscal year."

(e) "Hospital fiscal year" means each individual hospital's medicare cost report fiscal year.

(f) "Interim CAH payment" means the actual payment the medicaid agency makes for claims submitted by a CAH for service provided during its current HFY, using the appropriate weighted costs-to-charges (WCC) rate, as determined by the agency.

(g) "Revenue codes and procedure codes to cost centers crosswalk" means a document that indicates the revenue codes and procedure codes that are assigned by each hospital to a specific cost center in each hospital's medicare cost report.

(h) "Weighted costs-to-charges (WCC) rate" means a rate the agency uses to determine a CAH payment. See subsection (5) of this section for how the agency calculates a WCC rate.

(i) "WCC rate" see "weighted costs-to-charges rate."

(2) To be paid as a CAH by the agency, a hospital must be approved by the department of health (DOH) for inclusion in DOH's critical access hospital program. The hospital must provide proof of CAH status to the agency upon request. A CAH paid under the CAH program must meet the general applicable requirements in chapter 182-502 WAC. For information on audits and the audit appeal process, see chapter 182-502A WAC.

(3) The agency pays an eligible CAH for inpatient and outpatient hospital services provided to fee-for-service Washington apple health clients on a cost basis (except when services are provided in a distinct psychiatric unit, a distinct rehabilitation unit, or detoxification unit), using weighted costs-to-charges WCC rates and a retrospective cost settlement process. The agency pays CAH fee-for-service claims subject to retrospective cost settlement, adjustments such as a third party payment amount, any client responsibility amount, etc.

(4) For inpatient and outpatient hospital services provided to clients enrolled in a managed care organization (MCO) plan, WCC rates for each CAH are incorporated into the calculations for the managed care capitated premiums. The agency considers managed care health options and MHD designee WCC payment rates to be cost. Cost settlements are not performed by the agency for managed care claims.

(5) The agency prospectively calculates fee-for-service and managed care inpatient and outpatient WCC rates separately for each CAH.

(a) Before the agency's calculation of the prospective interim inpatient WCC and outpatient WCC rates for each hospital participating in the CAH program, the CAH must timely submit the following to the agency:

(i) Within twenty working days of receiving the request from the agency, the CAH's estimated aggregate charge master change for its next HFY;

(ii) At the time that the "as filed" version of the medicare cost report the CAH initially submits to the medicare fiscal intermediary for the cost settlement of its most recently completed HFY, a copy of that same medicare cost report;

(iii) At the same time that the "as filed" version of the medicare cost report the CAH has submitted to the medicare fiscal intermediary for cost settlement of its most recently completed HFY, the CAH's corresponding revenue codes and procedure codes to cost centers crosswalk that indicates the revenue codes and procedure codes that are assigned by each hospital to a specific cost center in the hospital's medicare cost report;

(iv) At the same time that the "as filed" version of the medicare cost report the CAH has submitted to the medicare fiscal intermediary for cost settlement of its most recently completed HFY, a document indicating any differences between the CAH's revenue codes and procedure codes to cost centers crosswalk and the standard revenue codes and procedure codes to cost centers crosswalk that the agency provides to the CAH from the agency's CAH WCC rate calculation model. (For example, a CAH hospital might indicate when it submits its crosswalk to the agency that a difference exists in the CAH's placement of statistics for the anesthesia revenue code normally identified to the anesthesia cost center in the agency's CAH WCC rate calculation model, but identified to the surgery cost center in the CAH's submitted medicare cost report.)

(b) The agency:

(i) Determines if differences between the CAH's crosswalk and the crosswalk in the CAH WCC rate calculation model will be allowed when the CAH timely submits the document identified in (a)(iii) and (a)(iv) of this subsection. If the CAH does not timely submit the document, the agency may use the CAH WCC rate calculation model without considering the differences.

(ii) Does not allow unbundling or merging of the standard cost centers identified in the CAH WCC rate calculation model when the agency calculates the WCC rates. This is a standard the agency follows during the rate calculation process even though the CAH hospital may have in contrast to the CAH WCC rate calculation model indicated multiple cost centers, or merged into fewer costs centers, when reporting in the medicare cost report. (For example, a CAH reports to the agency that in the agency's standard radiology cost center grouping in the CAH WCC rate calculation model, the hospital has established three costs centers in the medicare cost report, which are radioisotopes, radiology therapeutic, and radiology diagnostic. During the rate calculation process, the agency combines these three cost centers under the standard radiology cost center grouping. No unbundling of the standard cost center grouping is allowed.)

(c) The agency:

(i) Obtains from its medicaid management information system (MMIS), the following fee-for-service summary claims data submitted by each CAH for services provided during the same HFY identified in (a)(ii) of this subsection:

(A) Washington apple health program codes;

(B) Inpatient and outpatient hospital claim types;

(C) Procedure codes (for outpatient hospital claims only), revenue codes, and diagnosis related group (DRG) codes (for inpatient claims only);

(D) Claim allowed charges, third party liability, client paid amounts, and agency paid amounts; and

(E) Units of service.

(ii) Obtains Level III trauma payment data from the department of health (DOH).

(iii) Obtains the costs-to-charges ration (CCR) of each respective cost center from the "as filed" version of the medicare cost report identified in (a)(ii) of this subsection, supplemented by any crosswalk information as described in (a)(iii) and (a)(iv) of this subsection.

(iv) Obtains from the managed care encounter data the following data submitted by each CAH for services provided during the same HFY identified:

(A) Washington apple health program codes;

(B) Inpatient and outpatient hospital claim types;

(C) Procedure codes (for outpatient hospital claims only), revenue codes, and diagnosis related group (DGR) codes (for inpatient claims only); and

(D) Claim allowed charges.

(v) Separates the inpatient claims data and outpatient hospital claims data;

(vi) Obtains the cost center claim allowed charges by classifying inpatient and outpatient hospital claim allowed charges from (c)(i) and (c)(iv) of this subsection billed by a CAH (using any one of, or a combination of, procedure codes, revenue codes, or DRG codes) into the related cost center in the CAH's "as filed" medicare cost report the CAH initially submits to the agency.

(vii) Uses the claims classifications and cost center combinations as defined in the agency's CAH WCC rate calculation model;

(viii) Assigns a CAH that does not have a cost center ratio that CAH's cost center average;

(ix) Allows changes only if a revenue codes and procedure codes to cost centers crosswalk has been timely submitted (see (a)(iii), (a)(iv), and (b)(i) of this subsection) and a cost center average is being used;

(x) Does not allow an unbundling of cost centers (see (b)(ii) of this subsection);

(xi) Determines the agency-weighted costs for each cost center by multiplying the cost center's claim allowed charges from (c)(i) and (c)(iv) of this subsection for the appropriate inpatient or outpatient claim type by the related service costs center ratio;

(xii) Sums all:

(A) Claim allowed charges from (c)(i) and (c)(iv) of this subsection separately for inpatient hospital claims.

(B) Claim allowed charges from (c)(i) and (c)(iv) of this subsection separately for outpatient hospital claims.

(xiii) Sums all:

(A) Agency-weighted costs from (c)(xi) of this subsection separately for inpatient hospital claims.

(B) Agency-weighted costs from (c)(xi) of this subsection separately for outpatient hospital claims.

(xiv) Multiplies each hospital's total agency-weighted costs from (c)(xiii) of this subsection by the centers for medicare and medicaid services (CMS) medicare market basket inflation rate to update costs from the HFY to the rate setting period. The medicare market basket inflation rate is published and updated by CMS periodically;

(xv) Multiplies each hospital's total claim allowed charges from (c)(xii) of this subsection by the CAH estimated charge master change from (a)(i) of this subsection. If the charge master change factor is not submitted timely by the hospital (see (a)(i) of this subsection), the agency will apply a reasonable alternative factor; and

(xvi) Determines:

(A) The inpatient WCC rates by dividing the calculation result from (c)(xiv) of this subsection by the calculation result from (c)(xv) of this subsection.

(B) The outpatient WCC rates by dividing the calculation result from (c)(xiv) of this subsection by the calculation result from (c)(xv) of this subsection.

(6) For a currently enrolled hospital provider that is new to the CAH program, the basis for calculating initial prospective WCC rates for inpatient and outpatient hospital claims for:

(a) Fee-for-service clients is:

(i) The hospital's most recent "as filed" medicare cost report; and

(ii) The appropriate MMIS summary claims data for that HFY.

(b) MCO clients is:

(i) The hospital's most recent "as filed" medicare cost report; and

(ii) The appropriate managed care encounter data for that HFY.

(7) For a newly licensed hospital that is also a CAH, the agency uses the current statewide average WCC rates for the initial prospective WCC rates.

(8) For a CAH that comes under new ownership, the agency uses the prior owner's WCC rates until:

(a) The new owner submits its first "as filed" medicare cost report to the medicare fiscal intermediary, and at the same time to the agency, the documents identified in (5)(a)(i) through (a)(iv) of this section; and

(b) The agency has calculated new WCC rates based on the new owner's "as filed" medicare cost report and other timely submitted documents.

(9) In addition to the prospective managed care inpatient and outpatient WCC rates, the agency:

(a) Incorporates the WCC rates into the calculations for the agency's MCO capitated premium that will be paid to the MCO plan; and

(b) Requires all MCO plans having contract relationships with CAHs to pay inpatient and outpatient WCC rates applicable to managed care claims. For purposes of this section, the agency considers the WCC rates used to pay CAHs for care given to clients enrolled in an MCO plan to be cost. Cost settlements are not performed for claims that are submitted to the MCO plans.

(10) For fee-for-service claims only, the agency uses the same methodology as outlined in subsection (5) of this section to perform an interim retrospective cost settlement for each CAH after the end of the CAH's HFY, using "as filed" medicare cost report data from that HFY that is being cost settled, the other documents identified in subsection (5)(a)(i), (a)(iii) and (a)(iv) of this section, when data from the MMIS related to fee-for-service claims. Specifically, the agency:

(a) Compares actual agency total interim CAH payments to the agency-weighted CAH fee-for-service costs for the period being cost settled. (Interim payments are the sum of third party liability/client payments, agency claim payments, and Level III trauma payments); and

(b) Pays the hospital the difference between CAH costs and interim CAH payments if actual CAH costs are determined to exceed the total interim CAH payments for that period. The agency recoups from the hospital the difference between CAH costs and interim CAH payments if actual CAH costs are determined to be less than total interim CAH payments.

(11) The agency performs finalized cost settlements using the same methodology as outlined in subsection (10) of this section, except that the agency uses the hospital's "final settled" medicare cost report instead of the initial "as filed" medicare cost report for the HFY being cost settled. The "final settled" medicare cost report received from the medicare fiscal intermediary must be submitted by the CAH to the agency by the sixtieth day of the hospital's receipt of that medicare cost report.

(12) A CAH must have and follow written procedures that provide a resolution to complaints and grievances.

(13) To ensure quality of care:

(a) A CAH is responsible to investigate any reports of substandard care or violations of the hospital's medical staff bylaws; and

(b) A complaint or grievance regarding substandard conditions or care may be investigated by any one or more of the following:

(i) Department of health (DOH); or

(ii) Other agencies with review authority for agency programs.

(14) The agency pays detoxification units, distinct psychiatric units, and distinct rehabilitation units operated by CAH hospitals using inpatient payment methods other than WCC rates and cost settlement.

(a) For dates of admission before August 1, 2007, the agency uses the RCW payment method to pay for services provided in detoxification units, distinct psychiatric units, and distinct rehabilitation units. The exception is for state-administered programs' psychiatric claims, which are paid using:

(i) The DRG payment method for claims grouped to stable DRG relative weights (unless the claim has an HIV-related diagnosis), and in conjunction with the base community psychiatric hospitalization payment method; or

(ii) The RCW payment method for other psychiatric claims (except for DRGs 469 and 470), in conjunction with the base community psychiatric hospitalization payment method.

(b) For dates of admission after July 31, 2007, the agency uses the per diem payment method to pay for services provided in detoxification units, distinct psychiatric units, and distinct rehabilitation units.

(15) The agency may conduct a post pay or on-site review of any CAH.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-2598, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-2598, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-054, § 388-550-2598, filed 6/28/07, effective 8/1/07*
- *WSR 07-03-077, § 388-550-2598, filed 1/17/07, effective 2/17/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.5225. WSR 06-04-089, § 388-550-2598, filed 1/31/06, effective 3/3/06*
- *WSR 05-01-026, § 388-550-2598, filed 12/3/04, effective 1/3/05. Statutory Authority: RCW 74.08.090, 74.04.050, 74.09.5225, and HB 1162, 2001 2nd sp.s. c 2. WSR 02-13-099, § 388-550-2598, filed 6/18/02, effective 7/19/02.*

##### **Wash. Admin. Code § 182-550-2600** Inpatient psychiatric services. {#sec-182-550-2600 omnilex-key=us-wa-regs-official--title-182--182-550-2600}

(1) The medicaid agency or the agency's designee pays for covered inpatient psychiatric services for eligible Washington apple health clients.

(2) The definitions found in chapter 182-500 WAC and WAC 182-550-1050 apply to this section.

(3) To be paid for an inpatient psychiatric admission, the hospital provider or hospital unit provider must meet the requirements for payment including the applicable general conditions of payment criteria in WAC 182-502-0100.

(4) When billing the agency directly for Washington apple health clients not enrolled in an agency-contracted managed care organization (MCO) plan, hospitals may use the expedited prior authorization (EPA) process for inpatient psychiatric services that require authorization when the EPA criteria is met.

(a) To meet the EPA criteria, the inpatient admission must:

(i) Be medically necessary;

(ii) Have psychiatric needs as the focus of treatment and not have an acute medical condition;

(iii) Not have a less-restrictive placement available; and

(iv) Be approved or ordered by the professional in charge of the facility.

(b) If the EPA criteria is not met, a hospital may request prior authorization from the agency or the agency's designee.

(5) Authorization of elective, nonemergency, or emergency-related poststabilization services by an agency-contracted MCO plan are subject to federal rules, including 42 C.F.R. 438.114 and 438.210.

(6) When clients enrolled in an agency-contracted MCO plan are involuntarily detained or committed under chapter 71.05 or 71.34 RCW, the stay must be treated as either an emergency or poststabilization service, and authorization must follow the rules found in 42 C.F.R. 438.114.

(7) When a hospital or hospital unit bills the agency directly, the agency pays the administrative day rate and pays for pharmaceuticals for any authorized days that meet the administrative day definition in WAC 182-550-1050 when less restrictive alternative treatments are not available, posing a barrier to the client's safe discharge.

(8) The agency may review paid claims and recoup any improperly paid claims, including determining whether the client did not meet EPA criteria or other conditions of payment. See WAC 182-502-0230 and chapter 182-502A WAC.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 74.09.520, and 2025 c 367. WSR 26-01-069, s 182-550-2600, filed 12/12/25, effective 1/12/26. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-09-027, § 182-550-2600, filed 4/10/24, effective 5/11/24*
- *WSR 19-18-026, § 182-550-2600, filed 8/28/19, effective 9/28/19*
- *WSR 15-18-065, § 182-550-2600, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-2600, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-053, § 388-550-2600, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-2600, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-2650** Base community psychiatric hospitalization payment method for medicaid and CHIP clients and nonmedicaid and non-CHIP clients. {#sec-182-550-2650 omnilex-key=us-wa-regs-official--title-182--182-550-2650}

(1) Effective for dates of admission from July 1, 2005, through June 30, 2007, and in accordance with legislative directive, the agency implemented two separate base community psychiatric hospitalization payment rates, one for medicaid and children's health insurance program (CHIP) clients and one for nonmedicaid and non-CHIP clients. Effective for dates of admission on and after July 1, 2007, the base community psychiatric hospitalization payment method for medicaid and CHIP clients and nonmedicaid and non-CHIP clients is no longer used. (For the purpose of this section, a "nonmedicaid or non-CHIP client" is defined as a client eligible under the medical care services (MCS) program, as determined by the agency.)

(a) The medicaid base community psychiatric hospital payment rate is a minimum per diem for claims for psychiatric services provided to medicaid and CHIP covered patients, paid to hospitals that accept commitments under the Involuntary Treatment Act (ITA).

(b) The nonmedicaid base community psychiatric hospital payment rate is a minimum allowable per diem for claims for psychiatric services provided to indigent patients paid to hospitals that accept commitments under the ITA.

(2) For the purposes of this section, "allowable" means the calculated allowed amount for payment based on the payment method before adjustments, deductions, or add-ons.

(3) To be eligible for payment under the base community psychiatric hospitalization payment method:

(a) A client's inpatient psychiatric voluntary hospitalization must:

(i) Be medically necessary as defined in WAC 182-500-0070. In addition, the agency considers medical necessity to be met when:

(A) Ambulatory care resources available in the community do not meet the treatment needs of the client;

(B) Proper treatment of the client's psychiatric condition requires services on an inpatient basis under the direction of a physician;

(C) The inpatient services can be reasonably expected to improve the client's condition or prevent further regression so that the services will no longer be needed; and

(D) The client, at the time of admission, is diagnosed as having an emotional/behavioral disturbance as a result of a mental disorder as defined in the current published Diagnostic and Statistical Manual of the American Psychiatric Association. The agency does not consider withdrawal management to be psychiatric in nature.

(ii) Be approved by the professional in charge of the hospital or hospital unit.

(iii) Be authorized by the appropriate division of behavioral health and recovery (DBHR) designee prior to admission for covered diagnoses.

(iv) Meet the criteria in WAC 182-550-2600.

(b) A client's inpatient psychiatric involuntary hospitalization must:

(i) Be in accordance with the admission criteria in chapters 71.05 and 71.34 RCW.

(ii) Be certified by a DBHR designee.

(iii) Be approved by the professional in charge of the hospital or hospital unit.

(iv) Be prior authorized by the agency or the agency's designee.

(v) Meet the criteria in WAC 182-550-2600.

(4) Payment for all claims is based on covered days within a client's approved length of stay (LOS), subject to client eligibility and agency-covered services.

(5) The medicaid base community psychiatric hospitalization payment rate applies only to a medicaid or CHIP client admitted to a nonstate-owned free-standing psychiatric hospital located in Washington state.

(6) The nonmedicaid base community psychiatric hospitalization payment rate applies only to a nonmedicaid or CHIP client admitted to a hospital:

(a) Designated by the agency as an ITA-certified hospital; or

(b) That has an agency-certified ITA bed that was used to provide ITA services at the time of the nonmedicaid or non-CHIP admission.

(7) For inpatient hospital psychiatric services provided to eligible clients for dates of admission on and after July 1, 2005, through June 30, 2007, the agency pays:

(a) A hospital's department of health (DOH)-certified distinct psychiatric unit as follows:

(i) For medicaid and CHIP clients, inpatient hospital psychiatric services are paid using the agency-specific nondiagnosis related group (DRG) payment method.

(ii) For nonmedicaid and non-CHIP clients, the allowable for inpatient hospital psychiatric services is the greater of:

(A) The state-administered program DRG allowable (including the high cost outlier allowable, if applicable), or the agency-specified non-DRG payment method if no relative weight exists for the DRG in the agency's payment system; or

(B) The nonmedicaid base community psychiatric hospitalization payment rate multiplied by the covered days.

(b) A hospital without a DOH-certified distinct psychiatric unit as follows:

(i) For medicaid and CHIP clients, inpatient hospital psychiatric services are paid using:

(A) The DRG payment method; or

(B) The agency-specified non-DRG payment method if no relative weight exists for the DRG in the agency's payment system.

(ii) For nonmedicaid and CHIP clients, the allowable for inpatient hospital psychiatric services is the greater of:

(A) The state-administered program DRG allowable (including the high cost outlier allowable, if applicable), or the agency-specified non-DRG payment method if no relative weight exists for the DRG in the agency's payment system; or

(B) The nonmedicaid base community psychiatric hospitalization payment rate multiplied by the covered days.

(c) A nonstate-owned free-standing psychiatric hospital as follows:

(i) For medicaid and CHIP clients, inpatient hospital psychiatric services are paid using as the allowable, the greater of:

(A) The ratio of costs-to-charges (RCC) allowable; or

(B) The medicaid base community psychiatric hospitalization payment rate multiplied by covered days.

(ii) For nonmedicaid and non-CHIP clients, inpatient hospital psychiatric services are paid the same as for medicaid and CHIP clients, except the base community inpatient psychiatric hospital payment rate is the nonmedicaid rate, and the RCC allowable is the state-administered program RCC allowable.

(d) A hospital, or a distinct psychiatric unit of a hospital, that is participating in the certified public expenditure (CPE) payment program, as follows:

(i) For medicaid and CHIP clients, inpatient hospital psychiatric services are paid using the methods identified in WAC 182-550-4650.

(ii) For nonmedicaid and non-CHIP clients, inpatient hospital psychiatric services are paid using the methods identified in WAC 182-550-4650 in conjunction with the nonmedicaid base community psychiatric hospitalization payment rate multiplied by covered days.

(e) A hospital, or a distinct psychiatric unit of a hospital, that is participating in the critical access hospital (CAH) program, as follows:

(i) For medicaid and CHIP clients, inpatient hospital psychiatric services are paid using the agency-specified non-DRG payment method.

(ii) For nonmedicaid and non-CHIP clients, inpatient hospital psychiatric services are paid using the agency-specified non-DRG payment method.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-15-128, § 182-550-2650, filed 7/21/21, effective 8/21/21. Statutory Authority: RCW 41.05.021, 41.05.160, 2014 c 225. WSR 16-06-053, § 182-550-2650, filed 2/24/16, effective 4/1/16. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-019, § 182-550-2650, filed 7/24/14, effective 8/24/14. WSR 11-14-075, recodified as § 182-550-2650, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-053, § 388-550-2650, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.500, and 2005 c 518, § 204, Part II. WSR 07-06-043, § 388-550-2650, filed 3/1/07, effective 4/1/07.*

##### **Wash. Admin. Code § 182-550-2750** Hospital discharge planning services. {#sec-182-550-2750 omnilex-key=us-wa-regs-official--title-182--182-550-2750}

For discharge planning service requirements, see chapter 246-320 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-19-018, § 182-550-2750, filed 9/8/23, effective 10/9/23. WSR 11-14-075, recodified as § 182-550-2750, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-2750, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-2900** Payment limits—Inpatient hospital services. {#sec-182-550-2900 omnilex-key=us-wa-regs-official--title-182--182-550-2900}

(1) Eligibility for payment. To be eligible for payment for covered inpatient hospital services, a hospital must:

(a) Have a core-provider agreement with the medicaid agency; and

(b) Be an in-state hospital, a bordering city hospital, a critical border hospital, or a distinct unit of that hospital, as defined in WAC 182-550-1050; or

(c) Be an out-of-state hospital that meets the conditions in WAC 182-550-6700.

(2) Exclusions. The agency does not pay for any of the following:

(a) Inpatient care or services, or both, provided in a hospital or distinct unit to a client when a managed care organization (MCO) plan is contracted to cover those services.

(b) Care or services, or both, provided in a hospital or distinct unit provided to a client enrolled in the hospice program, unless the care or services are completely unrelated to the terminal illness that qualifies the client for the hospice benefit.

(c) Ancillary services provided in a hospital or distinct unit unless explicitly spelled out in this chapter.

(d) Additional days of hospitalization on a non-DRG claim when:

(i) Those days exceed the number of days established by the agency or the agency's designee under WAC 182-550-2600, as the approved length of stay (LOS); and

(ii) The hospital or distinct unit has not received prior authorization for an extended LOS from the agency or the agency's designee as specified in WAC 182-550-4300(4). The agency may perform a prospective, concurrent, or retrospective utilization review as described in WAC 182-550-1700, to evaluate an extended LOS. An agency designee may also perform those utilization reviews to evaluate an extended LOS.

(e) Inpatient hospital services when the agency determines that the client's medical record fails to support the medical necessity and inpatient level of care for the inpatient admission. The agency may perform a retrospective utilization review as described in WAC 182-550-1700, to evaluate if the services are medically necessary and are provided at the appropriate level of care.

(f) Two separate inpatient hospitalizations if a client is readmitted to the same or affiliated hospital or distinct unit within 14 calendar days of discharge and the agency determines that one inpatient hospitalization does not qualify for a separate payment. See WAC 182-550-3000 (7)(f) for the agency's review of 14-day readmissions.

(g) Inpatient claims for 14-day readmissions considered to be provider preventable as described in WAC 182-550-2950.

(h) A client's day(s) of absence from the hospital or distinct unit.

(i) A nonemergency transfer of a client. See WAC 182-550-3600 for hospital transfers.

(j) Charges related to a provider preventable condition (PPC), hospital acquired condition (HAC), serious reportable event (SRE), or a condition not present on admission (POA). See WAC 182-502-0022.

(k) An early elective delivery as defined in WAC 182-500-0030. The agency may pay for a delivery before 39 weeks gestation, including induction and cesarean section, if medically necessary under WAC 182-533-0400(20).

(3) Interim billed inpatient hospital claims. This section defines when the agency considers payment for an interim billed inpatient hospital claim.

(a) When the agency is the primary payer, each interim billed nonpsychiatric claim must:

(i) Be submitted in 60-calendar-day intervals, unless the client is discharged before the next 60-calendar-day interval.

(ii) Document the entire date span between the client's date of admission and the current date of services billed, and include the following for that date span:

(A) All inpatient hospital services provided; and

(B) All applicable diagnosis codes and procedure codes.

(iii) Be submitted as an adjustment to the previous interim billed hospital claim.

(b) When the agency is not the primary payer:

(i) The agency pays an interim billed nonpsychiatric claim when the criteria in (a) of this subsection are met; and

(ii) Either of the following:

(A) Sixty calendar days have passed from the date the agency became the primary payer; or

(B) A client is eligible for both medicare and medicaid and has exhausted the medicare lifetime reserve days for inpatient hospital care.

(c) For psychiatric claims, (a)(i) and (b)(i) of this subsection do not apply.

(i) When the agency is the primary payer, each billed psychiatric claim may be submitted in 60-calendar-day intervals unless the client is discharged before the next 60-calendar-day interval.

(ii) If a claim is submitted under (c)(i) of this subsection, the claim must document the current dates of services billed and include the following for that date span:

(A) All inpatient hospital services provided; and

(B) All applicable diagnosis codes and procedure codes.

(d) When the agency is not the primary payer, the agency pays a billed psychiatric claim when:

(i) The criteria in (c)(i) of this subsection are met; and

(ii) Either of the following occur:

(A) Sixty calendar days have passed from the date the agency became the primary payer; or

(B) A client is eligible for both medicare and medicaid and has exhausted the medicare lifetime reserve days for inpatient hospital care.

(4) Admission period for claims. The agency considers for payment a hospital claim submitted for a client's continuous inpatient hospital admission of 60 calendar days or less upon the client's formal release from the hospital or distinct unit.

(5) Billing for hospital claims. To be eligible for payment, a hospital or distinct unit must bill the agency using an inpatient hospital claim:

(a) Under the current national uniform billing data element specifications:

(i) Developed by the National Uniform Billing Committee (NUBC);

(ii) Approved or modified, or both, by the Washington state payer group or the agency; and

(iii) In effect on the date of the client's admission.

(b) Under the current published international classification of diseases clinical modification coding guidelines;

(c) Subject to the rules in this section and other applicable rules;

(d) Under the agency's published billing instructions and other documents; and

(e) With the date span that covers the client's entire hospitalization. See subsection (3) of this section for when the agency considers and pays an initial interim billed hospital claim and any subsequent interim billed hospital claims;

(f) That requires an adjustment due to, but not limited to, charges that were not billed on the original paid claim (e.g., late charges), through submission of an adjusted hospital claim. Each adjustment to a paid hospital claim must provide complete documentation for the entire date span between the client's admission date and discharge date, and include the following for that date span:

(i) All inpatient hospital services provided; and

(ii) All applicable diagnosis codes and procedure codes; and

(g) With the appropriate NUBC revenue code specific to the service or treatment provided to the client.

(6) Multiple hospital rates. When a hospital charges multiple rates for an accommodation room and board revenue code, the agency pays the hospital's lowest room and board rate for that revenue code. The agency may request the hospital's charge master. Room charges must not exceed the hospital's usual and customary charges to the general public, as required by 42 C.F.R. Sec. 447.271.

(7) Administrative day rate. The agency allows hospitals an administrative day rate for those days of a hospital stay in which a client no longer meets criteria for the acute inpatient level of care, as provided in WAC 182-550-4550.

(8) Payment for observation services. The agency pays for observation services according to WAC 182-550-6000, 182-550-7200, and other applicable rules.

(9) Required adjustments. The agency determines its actual payment for an inpatient hospital admission by making any required adjustments from the calculations of the allowed covered charges. Adjustments include:

(a) Client participation (e.g., spenddown);

(b) Any third-party liability amount, including medicare part A and part B; and

(c) Any other adjustments as determined by the agency.

(10) Clients under state-administered programs. The agency pays hospitals less for services provided to clients eligible under state-administered programs, as provided in WAC 182-550-4800.

(11) Final charges. All hospital providers must present final charges to the agency according to WAC 182-502-0150.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-20-048, § 182-550-2900, filed 9/28/23, effective 10/29/23*
- *WSR 21-18-059, § 182-550-2900, filed 8/26/21, effective 9/26/21*
- *WSR 19-18-026, § 182-550-2900, filed 8/28/19, effective 9/28/19*
- *WSR 19-13-006, § 182-550-2900, filed 6/6/19, effective 7/7/19*
- *WSR 18-11-074, § 182-550-2900, filed 5/16/18, effective 7/1/18*
- *WSR 15-24-021, § 182-550-2900, filed 11/19/15, effective 1/1/16. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-12-047, § 182-550-2900, filed 5/29/14, effective 7/1/14. WSR 11-14-075, recodified as § 182-550-2900, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 07-14-055, § 388-550-2900, filed 6/28/07, effective 8/1/07*
- *WSR 04-20-058, § 388-550-2900, filed 10/1/04, effective 11/1/04. Statutory Authority: RCW 74.08.090 and 42 U.S.C. 1395x(v), 42 C.F.R. 447.271, .11303, and .2652. WSR 01-16-142, § 388-550-2900, filed 7/31/01, effective 8/31/01. Statutory Authority: RCW 74.09.090, 42 U.S.C. 1395x(v) and 1396r-4, 42 C.F.R. 447.271, 11303 and 2652. WSR 99-14-027, § 388-550-2900, filed 6/28/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 42 U.S.C. 1395 x(v), 42 C.F.R. 447.271, 447.11303, and 447.2652. WSR 99-06-046, § 388-550-2900, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-2900, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-2950** Payment limits—Provider preventable fourteen-day readmissions. {#sec-182-550-2950 omnilex-key=us-wa-regs-official--title-182--182-550-2950}

(1) Introduction. The rules in this section establish the medicaid agency's payment policy for inpatient claims for provider preventable fourteen-day readmissions and do not apply to any other rules regarding payment for hospital admissions.

(2) Applicability. The rules in this section apply to inpatient hospital claims made for clients enrolled in the fee-for-service program and to clients enrolled in an agency-contracted managed care organization (MCO).

(a) The rules in this section do not apply to:

(i) Professional claims submitted for services rendered in the inpatient setting during a readmission; or

(ii) Claims submitted by critical access hospitals.

(b) The rules in this section apply only to provider preventable readmissions and not to other types of fourteen-day hospital inpatient readmissions that do not qualify for payment for other reasons.

(3) Provider preventable readmission.

(a) For the purpose of this section, readmission means an inpatient hospital admission to the same or an affiliated hospital within fourteen calendar days of a discharge from a prior admission and clinically related to the prior admission.

(b) Inpatient claims from hospitals for fourteen-day readmissions that the agency or the agency's designee considers to be provider preventable do not qualify for payment.

(c) A readmission is provider preventable if the agency or the agency's designee determines there is a reasonable expectation the hospital could have prevented the readmission by one or more of the following:

(i) Quality of care provided during the index (initial) hospitalization. The quality of care provided during the index hospitalization must follow current, evidence-based standards of care for the health care specialty at issue and must be:

(A) Safely administered without physically harming the client;

(B) Free from medical error that subsequently results in readmission due to that error;

(C) Evidence based, producing outcomes that are supported by evidence and effective in treating the client. The quality of care must follow the hospital's current standards for care of the client's diagnosis during that treatment period;

(D) Client-centered, focusing on the client's individual needs. The quality of care must be appropriate for the diagnosis and involve the patient in the planning of their care;

(E) Timely, with treatment that did not result in a delay of care, and the client was not prematurely discharged;

(F) Medically necessary for treatment of a diagnosis recognized by the current International Statistical Classification of Diseases and Related Health Problems (ICD); and

(G) Equitable in quality for all clients, regardless of differences in personal characteristics or beliefs.

(ii) Discharge planning. Discharge planning must occur as directed in the Centers for Medicare and Medicaid Services' (CMS) interpretive guidelines for 42 C.F.R. Sec. 482.43, in Publication #100-07 State Operations Manual (Rev. 183, October 12, 2018), Appendix A, Section 482.43, Conditions of Participation: Discharge planning (CMS Manual). Discharge planning must include, but is not limited to:

(A) A clearly written discharge plan that actively involves the client or client's representative in the discharge process; and

(B) An assessment of the client's capability for postdischarge care and follow up including, but not limited to:

(I) The client's functional status and cognitive ability;

(II) The type of posthospital care the client requires, and whether such care requires the services of health care professionals or facilities;

(III) The availability of the required posthospital health care services to the client; and

(IV) The availability and capability of family, or friends, or both to provide follow-up care in the home.

(iii) Discharge process. Upon discharge, the provider must meet the following discharge components:

(A) Provide the client with all required prescriptions and provide education regarding the appropriate use of these medications; and

(B) Provide the client with written instructions in the client's primary language.

(I) If written instructions cannot be provided, the hospital must provide verbal instructions through an interpreter and document that the client's questions were answered.

(II) Written instructions must include home care instructions including, but not limited to:

• Contact numbers for discharge-related questions;

• Information describing when the client should call the provider with concerns and when to call 911;

• Dietary restrictions;

• Wound care, when applicable; and

• Activity limitations.

(iv) Postdischarge follow-up. Postdischarge follow-up documents must include:

(A) A complete discharge summary, including case management discharge summaries and a risk assessment score that is accessible by outpatient clinics for ease in care coordination.

(B) Dates and contact numbers for follow-up appointments arranged with the primary care provider for all intensive and high-risk clients before the client leaves the hospital.

(C) Arrangements for medical supplies, equipment, and home care services, as needed, before the client leaves the hospital.

(4) Exclusions. The following types of inpatient readmission claims are exempt or do not qualify as provider preventable readmissions:

(a) Inpatient psychiatric care;

(b) Readmissions not clinically related to the index (initial) admission;

(c) Readmissions that are planned or scheduled including, but not limited to:

(i) Admissions for repetitive treatments such as cancer chemotherapy or other required treatments for cancer, transfusions for chronic anemia, burn therapy, dialysis, or other planned treatments for renal failure;

(ii) Planned therapeutic or procedural admissions following diagnostic admissions, when the therapeutic treatment clinically could not occur during the same case; or

(iii) Planned admissions on the same day to a different hospital unit for continuing care (including transfers for mental health, chemical dependency, rehabilitation, and similar transfers that may be technically coded as discharge/admission for billing purposes).

(d) Admissions for required cancer treatments, including treatment-related toxicities or care for advanced-stage cancer;

(e) End of life and hospice care;

(f) Claims for clients who left against medical advice from index admission;

(g) Obstetrical claim admissions after an antepartum admission;

(h) Claims for readmission with a primary diagnosis of mental health or substance use disorder;

(i) Neonatal inpatient services;

(j) Transplant services, when the admission occurs within one hundred eighty days of transplant;

(k) Claims from a different hospital system other than where the index admission occurred;

(l) Claims to resume care for a client because the client did not comply with the discharge plan; or

(m) Readmissions resulting from the client's refusal of the recommended discharge plan and the index hospital making a less appropriate alternative plan to accommodate client preferences.

(5) Postpayment utilization review. The agency or the agency's designee performs a postpayment utilization review of the index hospital admission and all fourteen-day readmissions to determine what claims may qualify for recovery.

(6) Client financial responsibility. Clients are not financially liable for claims denied based on provider preventable fourteen-day readmissions that would have otherwise been paid by the agency or the agency's designee.

(7) Dispute resolution.

(a) Fee-for-service readmissions. If a hospital disputes a determination regarding fee-for-service readmissions, the agency follows the process in chapter 182-502A WAC and the administrative hearing procedure described in chapter 182-526 WAC.

(b) Managed care organization readmissions. MCOs must have an internal dispute resolution process for disputes arising out of a readmission. A hospital must access the MCO's internal dispute resolution process to dispute a provider preventable readmission determination by the MCO, as described in the hospital's individual contract with the MCO.

(c) Final determination review process. If the hospital has exhausted the MCO's internal dispute resolution process and the hospital continues to dispute the determination, the MCO and agency will follow the process regarding the fourteen-day readmission review program as described in the apple health managed care contract.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-13-006, § 182-550-2950, filed 6/6/19, effective 7/7/19.*

##### **Wash. Admin. Code § 182-550-3000** Payment method. {#sec-182-550-3000 omnilex-key=us-wa-regs-official--title-182--182-550-3000}

(1) The medicaid agency uses the diagnosis-related group (DRG) payment method to pay for covered inpatient hospital services, except as specified in WAC 182-550-4300 and 182-550-4400.

(2) The agency assigns a DRG code to each claim for an inpatient hospital stay using Solventum™ software (AP-DRG or APR-DRG) or other software currently in use by the agency. That DRG code determines the method used to pay claims for prospective payment system (PPS) hospitals. For the purpose of this section, PPS hospitals include all in-state and border area hospitals, except both of the following:

(a) Critical access hospitals (CAH), which the agency pays per WAC 182-550-2598; and

(b) Military hospitals, which the agency pays using the following payment methods depending on the revenue code billed by the hospital:

(i) Ratio of costs-to-charges (RCC); and

(ii) Military subsistence per diem.

(3) For each DRG code, the agency establishes an average length of stay (ALOS). The agency may use the DRG ALOS as part of its authorization process and payment methods as specified in this chapter.

(4) An inpatient claim payment includes all hospital covered services provided to a client during days the client is eligible. This includes, but is not limited to:

(a) The inpatient hospital stay;

(b) Outpatient hospital services, including preadmission, emergency department, and observation services related to an inpatient hospital stay and provided within one calendar day of a client's inpatient hospital stay. These outpatient services must be billed on the inpatient hospital claim;

(c) Any hospital covered service for which the admitting hospital sends the client to another facility or provider during the client's inpatient hospital stay, and the client returns as an inpatient to the admitting hospital.

(5) The agency's claim payment for an inpatient stay is determined by the payment method. The agency pays hospitals for inpatient hospital covered services provided to clients using the following methods:

| Payment Method | General Description of Payment Formula | WAC Reference |
| --- | --- | --- |
| DRG (Diagnostic Related Group) | DRG specific relative weight times hospital specific DRG rate times maximum service adjustor | 182-550-3000 |
| Per Diem | Hospital-specific daily rate for the service (psych, rehab, withdrawal management, or SUPP) times covered allowable days | 182-550-2600 and 182-550-3381 |
| Fixed Per Diem for Long Term Acute Care (LTAC) | Fixed LTAC rate per day times allowed days plus ratio of cost to charges times allowable covered ancillaries not included in the daily rate | 182-550-2595 and 182-550-2596 |
| Ratio of Costs-to-Charges (RCC) | RCC times billed covered allowable charges | 182-550-4500 |
| Cost Settlement with Ratio of Costs-to-Charges | RCC times billed covered allowable charges (subject to hold harmless and other settlement provisions of the Certified Public Expenditure program) | 182-550-4650 and 182-550-4670 |
| Cost Settlement with Weighted Costs-to-Charges (WCC) | WCC times billed covered allowable charges subject to Critical Access Hospital settlement provisions | 182-550-2598 |
| Military | Depending on the revenue code billed by the hospital: • RCC times billed covered allowable charges; and • Military subsistence per diem | 182-550-4300 |
| Administrative Day | Standard administrative day rate times days authorized by the agency combined with RCC times pharmaceutical charges that are allowable and covered for administrative days | 182-550-3381 |

(6) For claims paid using the DRG method, the payment may not exceed the billed amount.

(7) The agency may adjust the initial allowable calculated for a claim when one or more of the following occur:

(a) A claim qualifies as a high outlier (see WAC 182-550-3700);

(b) A claim is paid by the DRG method and a client transfers from one acute care hospital or distinct unit per WAC 182-550-3600;

(c) A client is not eligible for a Washington apple health program on one or more days of the hospital stay;

(d) A client has third-party liability coverage at the time of admission to the hospital or distinct unit;

(e) A client is eligible for Part B medicare, the hospital submitted a timely claim to medicare for payment, and medicare has made a payment for the Part B hospital charges;

(f) A client is discharged from an inpatient hospital stay and, within 14 calendar days, is readmitted as an inpatient to the same hospital or an affiliated hospital. The agency or the agency's designee performs a retrospective utilization review (see WAC 182-550-1700) on the initial admission and all readmissions to determine which inpatient hospital stays qualify for payment. The review may determine:

(i) If both admissions qualify for separate reimbursement;

(ii) If both admissions must be combined to be reimbursed as one payment; or

(iii) Which inpatient hospital stay qualifies for individual payment.

(g) A readmission is due to a complication arising from a previous admission (e.g., provider preventable condition described in WAC 182-502-0022). The agency or the agency's designee performs a retrospective utilization review to determine if both admissions are appropriate and qualify for individual payments; or

(h) The agency identifies an enhanced payment due to a provider preventable condition, hospital-acquired condition, serious reportable event, or a condition not present on admission.

(8) In response to direction from the legislature, the agency may change any one or more payment methods outlined in chapter 182-550 WAC for the purpose of achieving the legislature's targeted expenditure levels. The legislative direction may take the form of express language in the Biennial Appropriations Act or may be reflected in the level of funding appropriated to the agency in the Biennial Appropriations Act. In response to this legislative direction, the agency may calculate an adjustment factor (known as an "inpatient adjustment factor") to apply to inpatient hospital rates.

(a) The inpatient adjustment factor is a specific multiplier calculated by the agency and applied to existing inpatient hospital rates to meet targeted expenditure levels as directed by the legislature.

(b) The agency will apply the inpatient adjustment factor when the agency determines that its expenditures on inpatient hospital rates will exceed the legislature's targeted expenditure levels.

(c) The agency will apply any such inpatient adjustment factor to each affected rate.

(9) The agency does not pay for a client's day of absence from the hospital.

(10) The agency pays an interim billed hospital claim for covered inpatient hospital services provided to an eligible client only when the interim billed claim meets the criteria in WAC 182-550-2900.

(11) The agency applies to the allowable for each claim all applicable adjustments for client responsibility, any third-party liability, medicare payments, and any other adjustments as determined by the agency.

(12) The agency pays hospitals in designated bordering cities for allowed covered services as described under WAC 182-550-3900.

(13) The agency pays out-of-state hospitals for allowed covered services as described under WAC 182-550-4000.

(14) The agency's annual aggregate payments for inpatient hospital services, including payments to state-operated hospitals, will not exceed the estimated amounts that the agency would have paid using medicare payment principles.

(15) When hospital ownership changes, the agency's payment to the hospital will not exceed the amount allowed under 42 U.S.C. Section 1395x (v)(1)(O).

(16) Hospitals participating in the apple health program must annually submit to the agency:

(a) A copy of the hospital's CMS medicare cost report (Form 2552 version currently in use by the agency) that is the official "as filed" cost report submitted to the medicare fiscal intermediary; and

(b) A disproportionate share hospital (DSH) application if the hospital wants to be considered for DSH payments. See WAC 182-550-4900 for the requirements for a hospital to qualify for a DSH payment.

(17) Reports referred to in subsection (16) of this section must be completed according to:

(a) Medicare's cost reporting requirements;

(b) The provisions of this chapter; and

(c) Instructions issued by the agency.

(18) The agency requires hospitals to follow generally accepted accounting principles.

(19) Participating hospitals must permit the agency to conduct periodic audits of their financial records, statistical records, and any other records as determined by the agency.

(20) The agency limits payment for private room accommodations to the semiprivate room rate. Room charges must not exceed the hospital's usual and customary charges to the general public as required by 42 C.F.R. Sec. 447.271.

(21) For psychiatric hospitals and psychiatric hospital units, when a claim groups to a DRG code that pays by the DRG method, the agency may manually price the claim at the hospital's psychiatric per diem rate.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 74.09.520, and 2025 c 367. WSR 26-01-069, s 182-550-3000, filed 12/12/25, effective 1/12/26. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-04-049, § 182-550-3000, filed 1/26/23, effective 2/26/23*
- *WSR 21-15-128, § 182-550-3000, filed 7/21/21, effective 8/21/21*
- *WSR 19-04-004, § 182-550-3000, filed 1/23/19, effective 3/1/19*
- *WSR 18-11-074, § 182-550-3000, filed 5/16/18, effective 7/1/18*
- *WSR 15-24-096, § 182-550-3000, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-12-047, § 182-550-3000, filed 5/29/14, effective 7/1/14. WSR 11-14-075, recodified as § 182-550-3000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-063, § 388-550-3000, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 07-14-055, § 388-550-3000, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 05-11-077, § 388-550-3000, filed 5/17/05, effective 6/17/05. Statutory Authority: RCW 74.08.090, 42 U.S.C. 1395 x(v), 42 C.F.R. 447.271, 447.11303, and 447.2652. WSR 99-06-046, § 388-550-3000, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-3000, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-3381** Payment method for acute PM&R services and administrative day services. {#sec-182-550-3381 omnilex-key=us-wa-regs-official--title-182--182-550-3381}

This section describes the agency's payment method for acute physical medicine and rehabilitation (PM&R) services provided by acute PM&R hospitals.

(1) The agency pays an acute PM&R hospital for acute PM&R services based on a rehabilitation per diem rate. See chapter 182-550 WAC and WAC 182-550-3000.

(2) Acute PM&R room and board includes, but is not limited to:

(a) Facility use;

(b) Social services (e.g., discharge planning);

(c) Bed and standard room furnishings; and

(d) Dietary and nursing services.

(3) When the agency authorizes administrative day(s) for a client as described in WAC 182-550-2561(8), the agency pays the facility:

(a) The administrative day rate; and

(b) For pharmaceuticals prescribed for the client's use during the administrative portion of the client's stay.

(4) The agency pays for transportation services provided to a client receiving acute PM&R services in an acute PM&R hospital according to chapter 182-546 WAC.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 74.09.520, and 2025 c 367. WSR 26-01-069, s 182-550-3381, filed 12/12/25, effective 1/12/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 74.09.520(13). WSR 23-21-063, § 182-550-3381, filed 10/12/23, effective 1/1/24. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-12-047, § 182-550-3381, filed 5/29/14, effective 7/1/14. WSR 11-14-075, recodified as § 182-550-3381, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 07-14-055, § 388-550-3381, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.520 and 42 C.F.R. 482.56. WSR 03-06-047, § 388-550-3381, filed 2/28/03, effective 3/31/03. Statutory Authority: RCW 74.08.090 and 74.09.520. WSR 99-17-111, § 388-550-3381, filed 8/18/99, effective 9/18/99.*

##### **Wash. Admin. Code § 182-550-3400** Case-mix index. {#sec-182-550-3400 omnilex-key=us-wa-regs-official--title-182--182-550-3400}

(1) The medicaid agency calculates the case-mix index (CMI) for each individual hospital to measure the relative cost for treating medicaid and CHIP cases in a given hospital. The CMI represents the relative acuity of the claims.

(2) Using medicaid and children's health insurance program (CHIP) admissions data from the individual hospital and the hospital's base period cost report, the agency calculates the CMI by:

(a) Multiplying the number of medicaid and CHIP admissions to the hospital for a specific diagnosis-related group (DRG) classification by the relative weight for that DRG classification. The agency repeats this process for each DRG billed by the hospital;

(b) Adding together the products in (a) of this subsection for all of the medicaid and CHIP admissions to the hospital in the base year; and

(c) Dividing the sum obtained in (b) of this subsection by the corresponding number of medicaid and CHIP hospital admissions.

(3) The agency recalculates each hospital's CMI during inpatient hospital rebasing, or as needed.

**History**
- *Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-12-047, § 182-550-3400, filed 5/29/14, effective 7/1/14. WSR 11-14-075, recodified as § 182-550-3400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 07-14-055, § 388-550-3400, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-3400, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-3470** Payment method—Bariatric surgery—Per case rate. {#sec-182-550-3470 omnilex-key=us-wa-regs-official--title-182--182-550-3470}

(1) Effective through June 30, 2019, the medicaid agency:

(a) Pays for bariatric surgery provided in designated agency-approved hospitals when all criteria established in WAC 182-550-2301 are met;

(b) Requires qualification and prior authorization of the provider before bariatric surgery related services are provided (see WAC 182-550-2301); and

(c) Uses a per case rate to pay for bariatric surgery.

(2) For dates of admission before August 1, 2007, the agency determines the per case rate by using a hospital-specific medicare fee schedule rate the agency used to pay for bariatric surgery.

(3) For dates of admission after July 31, 2007, the agency determines the per case rate by using the bariatric per case rate calculation method described in this subsection and established by the agency's new inpatient payment system implemented on August 1, 2007.

(a) To adjust hospital-specific operating, capital, and direct medical education costs, the agency:

(i) Inflates the hospital-specific operating, capital, and direct medical education routine costs from the hospital's medicare cost report fiscal year to the mid-point of the state fiscal year.

(ii) Divides the labor portion of the hospital-specific operating costs by the hospital-specific medicare wage index in effect for the medicare inpatient prospective payment system federal fiscal year that most closely matches the time period covered by the medicare cost report used for these calculations.

(b) To determine the statewide standardized weighted average cost per case by using the adjusted hospital-specific operating and capital costs derived in (a) of this subsection, the agency:

(i) Adjusts the hospital-specific operating and capital costs to remove the indirect costs associated with approved medical education programs; then

(ii) Calculates the operating standardized amount by dividing statewide aggregate adjusted operating costs by the statewide aggregate number cases in the base year claims data; then

(iii) Calculates the capital standardized amount by dividing statewide aggregate adjusted capital costs by the statewide aggregate number of cases in the base year claims data.

(c) To make hospital-specific adjustments to the statewide operating and capital standardized amounts, the agency:

(i) Defines the adjusted operating standardized amount for bariatric services as the average of all instate hospitals operating standardized amount after making adjustments for the wage index and the indirect medical education. The agency:

(A) To determine the labor portion, uses the factor established by medicare multiplied by the statewide operating standardized amount, then multiplies the labor portion of the operating standardized amount by (1.0 plus the most currently available hospital-specific medicare wage index); then

(B) Adds the nonlabor portion of the operating standardized amount to the labor portion derived in (c)(i)(A) of this subsection; then

(C) Multiplies the amount derived in (c)(i)(B) of this subsection by 1.0 plus the most currently available hospital-specific medicare operating indirect medical education factor to derive the operating standardized amount for bariatric services; then

(D) Adjusts the hospital-specific operating standardized amount for bariatric services for inflation based on the CMS PPS input price index. The adjustment is to reflect the increases in price index levels between the base year data and the payment system implementation year.

(E) Calculates the statewide bariatric operating payment per case amount by:

(I) Totaling the hospital-specific amounts derived in (c)(i)(D) of this subsection for each hospital approved by the agency to provide bariatric services; and

(II) Dividing the results in (E)(I) of this subsection by the number of instate hospitals approved by the agency to provide bariatric services.

(ii) Defines the adjusted capital standardized amount for bariatric services as the average of all instate hospitals capital standardized amount after adjusting for the indirect medical education. The agency:

(A) Multiplies the amount derived in (b)(iii) of this subsection by (1.0 plus the most currently available hospital-specific medicare capital indirect medical education factor) to derive the adjusted indirect medical education capital standardized amount for bariatric services.

(B) Adjusts the hospital-specific capital standardized amount for bariatric services for inflation based on the CMS PPS input price index. The adjustment is to reflect the increases in price index levels between the base year data and the payment system implementation year.

(C) Calculates the statewide bariatric capital payment per case amount by:

(I) Totaling the hospital-specific amounts derived in (c)(ii)(B) of this subsection for each hospital approved by the agency to provide bariatric services; and

(II) Dividing the results derived in (C)(I) of this subsection by the number of instate hospitals approved by the agency to provide bariatric services.

(iii) Defines the direct medical education standardized amount for bariatric services as the instate hospitals hospital-specific direct medical education weighted cost per case multiplied by the CMS PPS input price index. The adjustment is to reflect the increases in price index levels between the base year data and the payment system implementation year. The agency calculates the statewide bariatric direct medical education standardized payment per case by:

(A) Multiplying the hospital-specific direct medical education weighted cost per case for each hospital approved by the agency to provide bariatric services by the CMS PPS input price index; then

(B) Totaling the hospital-specific amounts derived in (iii)(A) of this subsection for each hospital approved by the agency to provide bariatric services.

(d) To determine hospital-specific bariatric payment per case amount, the agency sums for each hospital the instate statewide bariatric operating payment per case, the instate statewide bariatric capital payment per case, and the hospital-specific direct medical education payment per case. (For critical border hospitals, the direct medical education payment per case is limited at the highest direct medical education payment per case amount for the instate hospitals approved by the agency to provide bariatric services.)

(e) The agency adjusts the hospital-specific bariatric payment per case amount by a factor to achieve budget neutrality for the state's aggregate inpatient payments for all hospital inpatient services.

(f) The agency may make other necessary adjustments as directed by the legislature (e.g., rate rebasing and other changes as directed by the legislature).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-04-004, § 182-550-3470, filed 1/23/19, effective 3/1/19*
- *WSR 15-18-065, § 182-550-3470, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-3470, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. WSR 07-14-051, § 388-550-3470, filed 6/28/07, effective 8/1/07.*

##### **Wash. Admin. Code § 182-550-3600** Diagnosis-related group (DRG) payment—Hospital transfers. {#sec-182-550-3600 omnilex-key=us-wa-regs-official--title-182--182-550-3600}

(1) The rules in this section apply when an eligible client transfers from an acute care hospital or distinct unit to any of the following:

(a) Another acute care hospital or distinct unit;

(b) A skilled nursing facility (SNF);

(c) An intermediate care facility (ICF);

(d) Home care under the medicaid agency's home health program;

(e) A long-term acute care facility (LTAC);

(f) Hospice (facility-based or in the client's home);

(g) A hospital-based, medicare-approved swing bed, or another distinct unit such as a rehabilitation or psychiatric unit (see WAC 182-550-3000); or

(h) A nursing facility certified under medicaid but not medicare.

(2) The medicaid agency pays a transferring hospital the lesser of:

(a) The appropriate diagnosis-related group (DRG) payment; or

(b) The prorated DRG payment, which the agency calculates by:

(i) Using the average length of stay (ALOS) for the assigned DRG:

(A) The agency uses the Solventum national average length of stay for paying inpatient claims.

(B) The agency publishes ALOS values on its website;

(ii) Dividing the hospital's allowed payment amount for the assigned DRG by the ALOS in (b)(i) of this subsection;

(iii) Determining the client length of stay as all medically necessary days at the transferring hospital, plus one day; and

(iv) Multiplying the number in (b)(ii) of this subsection by the length of stay determined in (b)(iii) of this subsection.

(3) The agency applies the outlier payment method if a transfer case qualifies as a high outlier. To qualify for a high outlier, the costs (ratio of cost-to-charges multiplied by covered allowed charges) for the transfer must exceed the outlier threshold. The threshold is the prorated DRG amount plus $45,000. The prorated amount is the lesser of:

(a) The per diem DRG allowed amount (hospital's rate multiplied by relative weight for the DRG code assigned to the claim by the agency) divided by the average length of stay (for the DRG code assigned by the agency for the claim) multiplied by the client's length of stay plus one day; or

(b) The total DRG payment allowed amount calculation for the claim.

(4) The agency does not pay a transferring hospital for a nonemergency case when the transfer is to another acute care hospital.

(5) The agency pays the full DRG payment to the discharging hospital for a discharge to home or self-care. This is the agency's maximum payment to a discharging hospital.

(6) The agency pays an intervening hospital a per diem payment based on the method described in subsection (2) of this section.

(7) The transfer payment policy described in this section does not apply to claims grouped into DRG classifications the agency pays based on the per diem, case rate, or ratio of costs-to-charges (RCC) payment methods.

(8) The agency applies the following to the payment for each claim:

(a) All applicable adjustments for client responsibility;

(b) Any third-party liability;

(c) Medicare payments; and

(d) Any other adjustments as determined by the agency.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-09-138, s 182-550-3600, filed 4/22/26, effective 5/23/26*
- *WSR 18-12-043, § 182-550-3600, filed 5/30/18, effective 7/1/18. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-12-047, § 182-550-3600, filed 5/29/14, effective 7/1/14. WSR 11-14-075, recodified as § 182-550-3600, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-062, § 388-550-3600, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. WSR 07-14-051, § 388-550-3600, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.08.090 and 42 U.S.C. 1395x(v), 42 C.F.R. 447.271, .11303, and .2652. WSR 01-16-142, § 388-550-3600, filed 7/31/01, effective 8/31/01. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-3600, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-3700** DRG high outliers. {#sec-182-550-3700 omnilex-key=us-wa-regs-official--title-182--182-550-3700}

(1) The medicaid agency identifies a diagnosis-related group (DRG) high outlier claim based on the claim's estimated costs. The agency allows a high outlier payment for claims paid using the DRG payment method when high outlier criteria are met.

(a) To qualify as a DRG high outlier claim, the estimated costs for the claim must be greater than the outlier threshold effective for the date of admission. The outlier threshold amount is depicted in the following table:

| Dates of Admission | Pediatric | Nonpediatric | | |
| --- | --- | --- | --- | --- |
| February 1, 2011 - July 31, 2012 | | Base DRG * 1.50 | | Base DRG * 1.75 |
| August 1, 2012 - June 30, 2013 | | Base DRG * 1.429 | | Base DRG * 1.667 |
| July 1, 2013 - June 30, 2014 | | Base DRG * 1.563 | | Base DRG * 1.823 |
| July 1, 2014 - December 31, 2025 | | Base DRG + $40,000 | | Base DRG + $40,000 |
| January 1, 2026, and after | | Base DRG + $45,000 | | Base DRG + $45,000 |

(b) The agency calculates the estimated costs of the claim by multiplying the total submitted charges, minus the nonallowed charges on the claim, by the hospital's ratio of costs-to-charges (RCC).

(c) When a transferring hospital submits a transfer claim to the agency, the high outlier criteria used to determine whether the claim qualifies for high outlier payment is the prorated DRG amount for the claim before the transfer payment.

(2) The agency calculates the high outlier payment by multiplying the hospital's estimated cost above threshold (CAT) by the outlier adjustment factor. The outlier adjustment factors, which vary by dates of admission and inpatient payment policy, are depicted in the table at the end of this subsection.

(a) For inpatient claims paid under the all-patient-diagnosis-related group (AP-DRG), the agency uses a separate outlier adjustment factor for:

(i) Pediatric services, including all claims submitted by children-specialty hospitals;

(ii) Burn services; and

(iii) Nonpediatric services.

(b) For inpatient claims paid under the all-patient refined-DRG (APR-DRG), the agency uses a separate outlier adjustment factor for a:

(i) Severity of illness (SOI) of one or two; or

(ii) SOI of three or four.

| AP-DRG Dates of Admission | Pediatric | Burn | Nonpediatric |
| --- | --- | --- | --- |
| Before August 1, 2012 | CAT * 0.95 | CAT * 0.90 | CAT * 0.85 |
| August 1, 2012 - June 30, 2013 | CAT * 0.998 | CAT * 0.945 | CAT * 0.893 |
| July 1, 2013 - June 30, 2014 | CAT * 0.912 | CAT * 0.864 | CAT * 0.816 |
| APR-DRG Dates of Admission | SOI 1 or 2 | SOI 3 or 4 | |
| July 1, 2014, and after | CAT * 0.80 | CAT * 0.95 | |

(3) For state-administered programs (SAP), the agency applies the hospital-specific ratable to the outlier adjustment factor.

(4) When directed by the legislature to achieve targeted expenditure levels, as described in WAC 182-550-3000(8), the agency may apply an inpatient adjustment factor to any of the high outlier thresholds and to any of the outlier adjustment factors described in this section.

(5) The agency applies the following to the payment for each claim:

(a) All applicable adjustments for client responsibility;

(b) Any third-party liability;

(c) Medicare payments; and

(d) Any other adjustments as determined by the agency.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-09-138, s 182-550-3700, filed 4/22/26, effective 5/23/26*
- *WSR 18-12-043, § 182-550-3700, filed 5/30/18, effective 7/1/18. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-12-047, § 182-550-3700, filed 5/29/14, effective 7/1/14. WSR 11-14-075, recodified as § 182-550-3700, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-062, § 388-550-3700, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. WSR 07-14-051, § 388-550-3700, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 03-13-053, § 388-550-3700, filed 6/12/03, effective 7/13/03. Statutory Authority: RCW 74.08.090 and 42 U.S.C. 1395x(v), 42 C.F.R. 447.271, .11303, and .2652. WSR 01-16-142, § 388-550-3700, filed 7/31/01, effective 8/31/01. Statutory Authority: RCW 74.08.090, 42 U.S.C. 1395 x(v), 42 C.F.R. 447.271, 447.11303 and 447.2652. WSR 99-06-046, § 388-550-3700, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-3700, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-3800** Rebasing. {#sec-182-550-3800 omnilex-key=us-wa-regs-official--title-182--182-550-3800}

The medicaid agency redesigns (rebases) the medicaid inpatient payment system as needed. The base inpatient conversion factor and per diem rates are only updated during a detailed rebasing process, or as directed by the state legislature. Inpatient payment system factors such as the ratio of costs-to-charges (RCC), weighted costs-to-charges (WCC), and administrative day rate are rebased on an annual basis. As part of the rebasing, the agency does all of the following:

(1) Gathers data. The agency uses the following data resources considered to be the most complete and available at the time:

(a) One year of paid claim data from the agency's medicaid management information system (MMIS). The agency excludes:

(i) Claims related to state programs and paid at the Title XIX reduced rates from the claim data; and

(ii) Critical access hospital claims paid per WAC 182-550-2598; and

(b) The hospital's most current medicare cost report data from the health care cost report information system (HCRIS) maintained by the Centers for Medicare and Medicaid Services (CMS). If the hospital's medicare cost report from HCRIS is not available, the agency uses the medicare cost report provided by the hospital.

(c) FFS and managed care encounter data.

(2) Estimates costs. The agency estimates costs by multiplying the ratio of costs-to-charges (RCC) by the total billed charges.

(3) Specifies resource use with relative weights. The agency uses national relative weights designed by Solventum Corporation as part of its all-patient refined-diagnostic related group (APR-DRG) payment system. The agency periodically reviews and determines the most appropriate APR-DRG grouper version to use.

(4) Calculates base payment factors. The agency calculates the average, or base, DRG conversion factor and per diem rates. The base is calculated as the maximum amount that can be used, along with all other payment factors and adjustments described in this chapter. The agency models the rebased system to be budget neutral on a prospective basis, including global adjustments to the budget target determined by the agency. The agency ensures that base DRG conversion factors and per diem rates are sufficient to support economy, efficiency, and access to services for medicaid recipients. The agency will publish base rate factors on its website.

(5) Determines provider specific adjustments. The following adjustments are applied to the base factor or rate established in subsection (4) of this section:

(a) Wage index adjustments reflect labor costs in the cost-based statistical area (CBSA) where a hospital is located.

(i) The agency determines the labor portion by multiplying the base factor or rate by the labor factor established by medicare; then

(ii) The amount in (a)(i) of this subsection is multiplied by the most recent wage index information published by CMS at the time the rates are set; then

(iii) The agency adds the nonlabor portion of the base rate to the amount in (a)(ii) of this subsection to produce a hospital-specific wage adjusted factor.

(b) Indirect medical education factors are applied to the hospital-specific base factor or rate. The agency uses the indirect medical education factor established by medicare on the most currently available medicare cost report that exists at the time the rates are set; and

(c) Direct medical education amounts are applied to the hospital-specific base factor or rate. The agency determines a percentage of direct medical education costs to overall costs using the most currently available medicare cost report that exists at the time the rates are set.

(6) To maintain budget neutrality, the agency makes global adjustments as needed.

(7) The final, hospital-specific rate is calculated using the base rate established in subsection (4) of this section along with any applicable adjustments in subsections (5) and (6) of this section.

(8) When rebasing psychiatric per diem rates, the agency uses medicaid claims data and medicare cost report data from the calendar year base period ending two years prior to the effective date of rebasing, using the methodology described for psychiatric per diem rates effective January 1, 2024.

(a) When rebasing, the agency will determine new budget target adjusters, not to exceed a factor of 100 percent.

(b) Hospital psychiatric units with at least 200 Washington medicaid bed days in the base period will receive a cost-based rate with a psychiatric unit-specific budget target adjuster applied.

(c) Hospital psychiatric units with less than 200 Washington medicaid psychiatric bed days in the base period will receive a psychiatric per diem rate equal to the statewide average per diem.

(d) The agency conducts annual reviews for updated cost information to determine whether new or existing providers continue to meet the 200 or more bed days criteria.

(9) The agency sets psychiatric per diem rates specific to long-term civil commitments separately from other psychiatric per diem rates.

(a) In order to qualify for a provider-specific long-term civil commitment psychiatric per diem, the provider must be contracted with the agency to provide long-term civil commitment beds.

(b) The agency sets the provider-specific rate at the beginning of the state fiscal year. If a provider contracts with the agency during the state fiscal year, their initial rate will be set at the greater of:

(i) The in-state, state-wide average long-term psychiatric per diem for their category of hospital; or

(ii) Their current provider-specific short-term psychiatric per diem.

(c) The agency sets the rate for acute care hospitals under chapter 70.41 RCW with distinct psychiatric units as follows:

(i) Hospitals that have a 12-month medicare cost report with at least 200 psychiatric bed days on file with the agency receive a long-term psychiatric per diem rate equivalent to the costs documented on the medicare cost report.

(ii) Hospitals that do not have a 12-month cost report with at least 200 bed days on file with the agency receive a long-term psychiatric per diem rate equivalent to the greater of:

(A) The average long-term psychiatric per diem of all acute care hospitals providing long-term psychiatric services in-state; or

(B) Their current provider-specific short-term psychiatric per diem.

(iii) The long-term psychiatric rate is applied to agency-contracted hospitals for long-term psychiatric services. The acute care hospital long-term psychiatric per diem will be rebased annually at the beginning of the state fiscal year using most recently available medicare cost report data.

(iv) The agency sets the rate so as not to exceed the amount provided by the legislature.

(d) The agency sets the rates for free-standing psychiatric hospitals under chapter 71.12 RCW as follows:

(i) Hospitals will receive a long-term psychiatric per diem rate as approved by the legislature.

(ii) In addition to a long-term psychiatric per diem rate, the hospital may annually submit supplemental cost data to the agency for consideration by May 1st for the upcoming state fiscal year. If approved, the agency will make appropriate adjustments to the medicaid inpatient long-term psychiatric per diem payment rate of the hospital. Adjustment of costs may include any of the following:

(A) Costs associated with professional services and fees not accounted for in the hospital's medicare cost report or reimbursed separately;

(B) Costs associated with the hospital providing the long-term psychiatric patient access to involuntary treatment court services that are not reimbursed separately;

(C) Other costs associated with caring for long-term psychiatric patients that are not reimbursed separately.

(iii) The agency sets the rate so as to not exceed the amount provided by the legislature.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-23-012, s 182-550-3800, filed 11/8/24, effective 12/9/24*
- *WSR 23-20-048, § 182-550-3800, filed 9/28/23, effective 10/29/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 2021 c 334 §§ 211(46) and 215(66). WSR 22-03-008, § 182-550-3800, filed 1/6/22, effective 2/6/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2020 c 357 § 215 (24)(b). WSR 21-02-087, § 182-550-3800, filed 1/6/21, effective 2/6/21. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-12-043, § 182-550-3800, filed 5/30/18, effective 7/1/18. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-12-047, § 182-550-3800, filed 5/29/14, effective 7/1/14. WSR 11-14-075, recodified as § 182-550-3800, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. WSR 07-14-051, § 388-550-3800, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 05-06-044, § 388-550-3800, filed 2/25/05, effective 7/1/05. Statutory Authority: RCW 74.08.090 and 42 U.S.C. 1395x(v), 42 C.F.R. 447.271, .11303, and .2652. WSR 01-16-142, § 388-550-3800, filed 7/31/01, effective 8/31/01. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-3800, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-3830** Adjustments to inpatient rates. {#sec-182-550-3830 omnilex-key=us-wa-regs-official--title-182--182-550-3830}

(1) The medicaid agency updates all of the following components of a hospital's specific diagnosis-related group (DRG) factor and per diem rates at rebase:

(a) Wage index adjustment;

(b) Direct graduate medical education (DGME); and

(c) Indirect medical education (IME).

(2) Effective January 1, 2015, the agency updates the sole community hospital adjustment.

(3) The agency does not update the statewide average DRG factor between rebasing periods, except:

(a) To satisfy the budget neutrality conditions in WAC 182-550-3850; and

(b) When directed by the legislature.

(4) The agency updates the wage index to reflect current labor costs in the core-based statistical area (CBSA) where a hospital is located. The agency:

(a) Determines the labor portion by multiplying the base factor or rate by the labor factor established by medicare; then

(b) Multiplies the amount in (a) of this subsection by the most recent wage index information published by the Centers for Medicare and Medicaid Services (CMS) when the rates are set; then

(c) Adds the nonlabor portion of the base rate to the amount in (b) of this subsection to produce a hospital-specific wage adjusted factor.

(5) DGME. The agency obtains DGME information from the hospital's most recently filed medicare cost report that is available in the CMS health care cost report information system (HCRIS) dataset.

(a) The hospital's medicare cost report must cover a period of 12 consecutive months in its medicare cost report year.

(b) If a hospital's medicare cost report is not available on HCRIS, the agency may use the CMS Form 2552-10 to calculate DGME.

(c) If a hospital has not submitted a CMS medicare cost report in more than 18 months from the end of the hospital's cost reporting period, the agency considers the current DGME costs to be zero.

(d) The agency calculates the hospital-specific DGME by dividing the DGME cost reported on worksheet B, part 1 of the CMS cost report by the adjusted total costs from the CMS cost report.

(6) IME. The agency sets the IME adjustment equal to the "IME adjustment factor for Operating PPS" available in the most recent CMS final rule impact file on CMS's website as of May 1st of the rate-setting year.

(7) Sole community hospitals.

(a) For sole community hospitals' rate enhancements, the agency multiplies an in-state hospital's specific conversion factor and per diem rates by a multiplier if the hospital meets all the following criteria per RCW 74.09.5225:

(i) Be certified by CMS as a sole community hospital as of January 1, 2013;

(ii) Have a level III adult trauma service designation from the Washington state department of health (DOH) as of January 1, 2014;

(iii) Have less than 150 acute care licensed beds in fiscal year 2011;

(iv) Be owned and operated by the state or a political subdivision; and

(v) Not participate in the certified public expenditures (CPE) payment program defined in WAC 182-550-4650.

(b) Effective July 1, 2024, the enhancement multiplier equals 1.25. This may be adjusted in future years to account for legislatively approved increases. (See RCW 74.09.5225)

| Enhancement Multiplier by Year | | | | | | | |
| --- | --- | --- | --- | --- | --- | --- | --- |
| Provider Category | Effective For the Dates | | | | | | |
| 07/01/2015 - 06/30/2020 | 07/01/2020 - 06/30/2021 | 07/01/2021 - 06/30/2022 | 07/01/2022 - 06/30/2023 | 07/01/2023 - 12/31/2023 | 01/01/2024 - 06/30/2024 | 07/01/2024 | |
| Sole community hospital | 1.25 | 1.5 | 1.5 | 1.25 | 1.25 | 1.5 | 1.25 |
| Sole community hospital accepting single bed certifications | N/A | N/A | 1.5 | 1.5 | N/A | N/A | N/A |

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-18-060, § 182-550-3830, filed 8/28/24, effective 9/28/24*
- *WSR 23-20-048, § 182-550-3830, filed 9/28/23, effective 10/29/23. Statutory Authority: RCW 41.05.021, 41.05.160, and 2022 c 297 § 211(52). WSR 23-01-013, § 182-550-3830, filed 12/8/22, effective 1/8/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 2021 c 334 §§ 211(46) and 215(66). WSR 22-03-008, § 182-550-3830, filed 1/6/22, effective 2/6/22. Statutory Authority: RCW 41.05.021, 41.05.160, and 2019 c 415 § 211(14). WSR 20-01-075, § 182-550-3830, filed 12/11/19, effective 1/11/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-09-022, § 182-550-3830, filed 4/11/18, effective 5/12/18*
- *WSR 15-10-014, § 182-550-3830, filed 4/23/15, effective 5/24/15*
- *WSR 14-22-003, § 182-550-3830, filed 10/22/14, effective 11/22/14.*

##### **Wash. Admin. Code § 182-550-3850** Budget neutrality adjustment and measurement. {#sec-182-550-3850 omnilex-key=us-wa-regs-official--title-182--182-550-3850}

(1) The medicaid agency measures the effectiveness of budget neutral rebasing by applying a budget neutrality adjustment factor to the base payment rates for both inpatient and outpatient hospitals as needed to maintain aggregate payments under rebased payment systems.

(a) The agency performs budget-neutrality adjustments and measurement by prospectively adjusting conversion factors and rates to offset unintentional aggregate payment system decreases or increases. The agency publishes conversion factors and rates which reflect any required budget neutrality adjustment.

(b) The following rates and factors are not adjusted by the BNAF:

(i) Inpatient per diem;

(ii) Ratio of costs-to-charges (RCC);

(iii) Critical access hospital (CAH) weighted costs-to-charges (WCC);

(iv) Inpatient pain management and rehabilitation (PM&R);

(v) Per-case rates;

(vi) Administrative day rates;

(vii) Long-term acute care (LTAC);

(viii) Substance-using pregnant people (SUPP);

(ix) Outlier parameters;

(x) Outpatient services paid at the resource-based relative value scale (RBRVS) fee;

(xi) Outpatient corneal transplants; and

(xii) Diabetic education.

(2) The agency measures budget neutrality on an ongoing basis after rebased system implementation as follows:

(a) The agency gathers inpatient and outpatient claims and encounter data from the rebased system implementation date to the end of the measurement period.

(i) The first measurement period is the initial six months following rebased payment system implementation.

(ii) Additional measurement periods occur no more frequently than quarterly thereafter.

(iii) The agency performs a final measurement period for data received through June 30, 2016.

(b) The agency sums the aggregate payment amounts separately for inpatient and outpatient services. The agency will make the following adjustments to the base data:

(i) The agency removes any reductions due to third-party liability (TPL), client responsibility, and client spenddown from the payment summary;

(ii) The agency removes any increase awarded by RCW 74.09.611(2) from inpatient services;

(iii) The agency includes any outpatient service lines which are bundled under the enhanced ambulatory patient group (EAPG) system, but would be otherwise payable under the ambulatory payment classification (APC) system; and

(iv) Other adjustments as necessary.

(c) The agency processes all claims and encounters using the rates, factors, and policies which were in effect on June 30, 2014, with the following exceptions:

(i) The agency uses the RCC effective on the date of service;

(ii) The agency uses the most recent RBRVS values for any outpatient service paid using the RBRVS; and

(iii) The agency updates APC relative weights to reflect the most recent relative weights supplied by CMS;

(iv) The agency adjusts the outpatient budget target adjuster (BTA) to offset the inflation factor applied to OPPS in the CMS OPPS final rule; and

(v) The agency may include other adjustments as necessary to ensure accurate payment determination.

(d) The agency aggregates payment amounts calculated under (c) of this subsection separately for inpatient and outpatient services.

(3) The agency will modify the conversion factors and rates to reflect aggregate changes in the overall payment system as follows:

(a) If the amount calculated in subsection (2)(b) of this section is between 99 percent and 101 percent of the amount calculated in subsection (2)(d) of this section, no adjustment will be made to the conversion factors and rates currently in effect;

(b) If the amount calculated in subsection (2)(b) of this section is greater than 101 percent of the amount calculated in subsection (2)(d) of this section, the conversion factors and rates will be adjusted to reach a target expenditure of 101 percent from the rebased payment system implementation date to the end of the subsequent six-month period;

(c) If the amount calculated in subsection (2)(b) of this section is less than 99 percent of the amount calculated in subsection (2)(d) of this section, the conversion factors and rates will be adjusted to reach a target expenditure decrease of 99 percent from the rebased payment system implementation date to the end of the subsequent six-month period.

(4) The agency applies adjustments to the BNAF to rates prospectively at the beginning of the calendar quarter following the measurement.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-04-049, § 182-550-3850, filed 1/26/23, effective 2/26/23. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-14-049, § 182-550-3850, filed 6/25/14, effective 7/26/14.*

##### **Wash. Admin. Code § 182-550-3900** Payment method—Bordering city hospitals and critical border hospitals. {#sec-182-550-3900 omnilex-key=us-wa-regs-official--title-182--182-550-3900}

The agency uses the payment methods described in this section to pay bordering city hospitals and critical border hospitals for inpatient and outpatient claims. Bordering city hospitals and critical border hospitals are defined in WAC 182-550-1050.

(1) For inpatient hospital claims from bordering city hospitals, the agency calculates the payment for allowed covered charges related to medically necessary services, by using the lowest of the in-state inpatient hospital rates for the:

(a) Diagnosis-related group (DRG) conversion factor;

(b) Per diem payment method;

(c) Per case payment method; and

(d) Ratio of costs-to-charges (RCC) payment method.

(2) For outpatient hospital claims from bordering city hospitals, the agency calculates the payment for allowed covered charges related to medically necessary services, using the lowest of the in-state outpatient hospital rates for the outpatient prospective payment system (OPPS). Refer to WAC 182-550-7000 through 182-550-7600.

(3) Designated critical border hospitals.

(a) The agency designates certain qualifying hospitals located out-of-state as critical border hospitals. A designated critical border hospital must:

(i) Be a bordering city hospital as described in WAC 182-550-1050; and

(ii) Have submitted at least ten percent of the total nonemergency inpatient hospital claims paid to bordering city hospitals for the prior state fiscal year (SFY) for clients eligible for Washington apple health. Nonemergency inpatient hospital claims are defined as those that do not include emergency department charges (revenue code 045X series).

(b) The agency analyzes bordering city hospitals' base period claims data during the rebasing process, and annually thereafter, to determine if a bordering city hospital qualifies or continues to qualify as a critical border hospital.

(4) Critical border hospitals - Inpatient hospital claim payment methods. The agency pays inpatient critical border hospital claims as follows:

(a) The inpatient payment rates used to calculate payments to critical border hospitals are prospective payment rates. The rates are not used to pay for claims with dates of admission before the hospital qualified as a critical border hospital.

(b) The agency pays inpatient critical border hospital claims using the same payment methods and rates used for in-state hospital claims, including DRG, RCC, per diem, outliers, and per case rate, subject to the following:

(i) Inpatient payment rates used to pay critical border university hospitals for inpatient hospital claims cannot exceed the highest corresponding inpatient payment rate for an in-state university hospital;

(ii) Inpatient payment rates used to pay critical border Level 1 trauma centers for inpatient hospital claims cannot exceed the highest corresponding inpatient payment rate for an in-state Level 1 trauma center; and

(iii) Inpatient payment rates used to pay critical border hospitals that are not university hospitals or Level 1 trauma centers cannot exceed the highest corresponding in-state inpatient payment rate for in-state hospitals not designated as university hospitals or Level 1 trauma centers.

(5) Critical border hospitals - Outpatient hospital claim payment methods. The agency pays outpatient critical border hospital claims using the same payment methods used for in-state outpatient hospital claims (see WAC 182-550-7000 through 182-550-7600 and 182-550-4500), subject to the following:

(a) Outpatient rates used to pay critical border university hospitals for outpatient claims cannot exceed the highest corresponding rate for an in-state university hospital;

(b) Outpatient rates used to pay critical border Level 1 trauma centers for outpatient claims cannot exceed the highest corresponding rate for an in-state Level 1 trauma center; and

(c) Outpatient rates used to pay critical border hospitals that are not university hospitals or Level 1 trauma centers cannot exceed the highest corresponding rate for in-state hospitals not designated as university hospitals or Level 1 trauma centers.

(6) Critical border hospitals are eligible to receive payment for graduate medical education (GME). All other bordering city hospitals are not eligible to receive payment for GME.

(7) The agency makes:

(a) Claim payment adjustments, including but not limited to, third-party liability, medicare, and client responsibility; and

(b) Other necessary adjustments, as directed by the legislature (e.g., rate rebasing and other changes).

**History**
- *Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-12-047, § 182-550-3900, filed 5/29/14, effective 7/1/14. WSR 11-14-075, recodified as § 182-550-3900, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-063, § 388-550-3900, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. WSR 07-14-051, § 388-550-3900, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.09.090, 42 U.S.C. 1395x(v) and 1396r-4, 42 C.F.R. 447.271, 11303 and 2652. WSR 99-14-027, § 388-550-3900, filed 6/28/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-3900, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-4000** Payment method—Out-of-state hospitals. {#sec-182-550-4000 omnilex-key=us-wa-regs-official--title-182--182-550-4000}

This section describes the payment methods the agency uses to pay hospitals located out-of-state for providing services to eligible Washington apple health clients. This section does not apply to hospitals located in any of the designated bordering cities listed in WAC 182-501-0175. Payment methods that apply to bordering city hospitals, including critical border hospitals, are described in WAC 182-550-3900. See also WAC 182-501-0180, health care services provided outside the state of Washington - General provisions, and WAC 182-502-0120, payment for health care services provided outside the state of Washington.

(1) Emergency hospital services.

(a) For inpatient hospital claims for emergency services provided in out-of-state hospitals, the agency:

(i) Pays using the same methods used to pay in-state hospitals as specified in this chapter; and

(ii) Calculates the payment using the lowest in-state inpatient hospital rate corresponding to the payment method.

(b) For outpatient hospital claims for emergency services provided in out-of-state hospitals, the agency pays an out-of-state hospital using the following methods:

(i) The agency's outpatient prospective payment system (OPPS) described in WAC 182-550-7000; and

(ii) The maximum allowable fee schedule method described in WAC 182-550-6000. When the maximum allowable fee schedule method is used, the agency limits payment to the lesser of the:

(A) Billed charges; or

(B) Calculated payment amount.

(2) Nonemergency hospital services.

(a) The agency pays for:

(i) Contracted and prior authorized nonemergency hospital services according to the contract terms whether or not the hospital has signed a core provider agreement; and

(ii) Nonemergency hospital services authorized by the agency after the fact (subsequent to the date of admission, if the client is still at the out-of-state hospital, or after the services have been provided) according to subsections (1) and (3) of this section.

(b) The agency does not pay for:

(i) Nonemergency hospital services provided to a Washington apple health client in a hospital located out-of-state unless the hospital is contracted and prior authorized by the agency or the agency's designee for the specific service provided to a specific client; and

(ii) Unauthorized nonemergency hospital services are not paid by the agency. See WAC 182-501-0182.

(3) The agency makes claim payment adjustments including, but not limited to, client responsibility, third-party liability, and medicare. All applicable adjustments are factored into the final hospital payment amount.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-09-028, § 182-550-4000, filed 4/10/24, effective 5/11/24. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-12-047, § 182-550-4000, filed 5/29/14, effective 7/1/14. WSR 11-14-075, recodified as § 182-550-4000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-063, § 388-550-4000, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. WSR 07-14-051, § 388-550-4000, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-4000, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-4100** Payment method—New hospitals. {#sec-182-550-4100 omnilex-key=us-wa-regs-official--title-182--182-550-4100}

(1) For rate-setting purposes, the agency considers as new:

(a) A hospital which began services after the most recent rebasing; or

(b) A hospital that has not been in operation for a complete fiscal year.

(2) With the exception of determining psychiatric per diem rates as directed by the Washington state legislature (see WAC 182-550-3800(6)), the agency determines a new hospital's conversion factor, per diem rate, or per case rate, to be the statewide average rate for the conversion factor, category of per diem rate, or per case rate adjusted by the geographically appropriate hospital specific medicare wage index.

(3) The agency determines a new hospital's ratio of costs-to-charges (RCC) by calculating and using the average RCC for all current Washington in-state hospitals.

(4) When a hospital changes ownership, the agency does not consider it a new hospital.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-03-009, § 182-550-4100, filed 1/6/22, effective 2/6/22. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-12-047, § 182-550-4100, filed 5/29/14, effective 7/1/14. WSR 11-14-075, recodified as § 182-550-4100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. WSR 07-14-051, § 388-550-4100, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.09.090, 42 U.S.C. 1395x(v) and 1396r-4, 42 C.F.R. 447.271, 11303 and 2652. WSR 99-14-027, § 388-550-4100, filed 6/28/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-4100, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-4200** Change in hospital ownership. {#sec-182-550-4200 omnilex-key=us-wa-regs-official--title-182--182-550-4200}

(1) For purposes of this section, a change in hospital ownership may involve one or more, but is not limited to, the following events:

(a) A change in the composition of the partnership;

(b) A sale of an unincorporated sole proprietorship;

(c) The statutory merger or consolidation of two or more corporations;

(d) The leasing of all or part of a provider's facility if the leasing affects utilization, licensure, or certification of the provider entity;

(e) The transfer of a government-owned institution to a governmental entity or to a governmental corporation;

(f) Donation of all or part of a provider's facility to another entity if the donation affects licensure or certification of the provider entity;

(g) Disposition of all or some portion of a provider's facility or assets through sale, scrapping, involuntary conversion, demolition, or abandonment if the disposition affects licensure or certification of the provider entity; or

(h) A change in the provider's federal identification tax number.

(2) A hospital must notify the medicaid agency in writing ninety days before the date of an expected change in the hospital's ownership, but in no case later than thirty days after the change in ownership takes place.

(3) When a change in a hospital's ownership occurs, the agency sets the new provider's cost-based conversion factor (CBCF), conversion factor, per diem rates, per case rate, at the same level as the prior owner's, except as provided in subsection (4) of this section.

(4) The agency sets for a hospital formed as a result of a merger:

(a) A blended CBCF, conversion factor, per diem rate, per case rate, based on the old hospitals' rates, proportionately weighted by admissions for the old hospitals; and

(b) An RCC rate determined by combining the old hospitals' cost reports and following the process described in WAC 182-550-4500. Partial year cost reports will not be used for this purpose.

(5) The agency recaptures depreciation and acquisition costs as required by section 1861 (V)(1)(0) of the Social Security Act.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-4200, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-4200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. WSR 07-14-051, § 388-550-4200, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-4200, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-4300** Hospitals and units exempt from the DRG payment method. {#sec-182-550-4300 omnilex-key=us-wa-regs-official--title-182--182-550-4300}

(1) Except when otherwise specified, inpatient services provided by hospitals and units that are exempt from the diagnosis-related group (DRG) payment method are paid under the ratio of costs-to-charges (RCC) payment method described in WAC 182-550-4500, the per diem payment method described in WAC 182-550-3000, the per case rate payment method described in WAC 182-550-3000, or other payment methods identified in this chapter (e.g., long term acute care (LTAC), certified public expenditure (CPE), critical access hospital (CAH), etc.). Inpatient services provided by hospitals and units are exempt from the DRG payment method only if they qualify for payment methods specifically mentioned in other sections of this chapter or in this section.

(2) The agency exempts the following hospitals, units, and services from the DRG payment method for inpatient services provided to clients eligible for Washington apple health:

(a) Hospitals participating in the agency's certified public expenditure (CPE) payment program (see WAC 182-550-4650);

(b) Hospitals participating in the agency's critical access hospital program (see WAC 182-550-2598);

(c) Rehabilitation services. All rehabilitation services are paid through the per diem payment method except as indicated in (a), (b), and (d) of this subsection (see WAC 182-550-3000);

(d) Military hospitals when no other specific arrangements have been made with the agency. The agency, or the military hospital, may elect or arrange for one of the following payment methods in lieu of the RCC payment method:

(i) Per diem payment method; or

(ii) DRG payment method; and

(e) Psychiatric services. All psychiatric services are paid through the per diem payment method except as indicated in (a), (b), and (d) of this subsection (see WAC 182-550-3000). An agency designee that arranges to directly pay a hospital and/or a designated distinct psychiatric unit of a hospital may use the agency's payment methods or contract with the hospital to pay using different methods.

(3) Inpatient psychiatric services, Involuntary Treatment Act services, and withdrawal management services provided in out-of-state hospitals are not covered or paid by the agency or the agency's designee. The agency does not cover or pay for other hospital services provided to clients eligible for those services in the following programs, when the services are provided in out-of-state hospitals that are not in designated bordering cities:

(a) Medical care services; and

(b) Other state-administered programs.

(4) The agency has established an average length of stay (ALOS) for each DRG classification and publishes it on the agency's website. The agency uses the DRG ALOS as a benchmark to authorize and pay inpatient hospital stays exempt from the DRG payment method. When an inpatient hospital stay exceeds the agency's DRG ALOS benchmark or prior authorized LOS:

(a) For a psychiatric inpatient stay, the hospital must obtain approval for additional days beyond the prior authorized days from the agency or the agency's designee who prior authorized the admission. See WAC 182-550-2600;

(b) For an acute physical medicine and rehabilitation (PM&R) or a long term acute care (LTAC) stay, the hospital must obtain approval for additional days beyond the prior authorized days from the agency unit that prior authorized the admission. See WAC 182-550-2561 and 182-550-2590;

(c) For an inpatient hospital stay for withdrawal management for a substance-using pregnant people (SUPP) program client, see WAC 182-550-1100;

(d) For other medical inpatient stays for withdrawal management, see WAC 182-550-1100;

(e) For an inpatient stay in a certified public expenditure (CPE) hospital, see WAC 182-550-4690; and

(f) For an inpatient hospital stay not identified in (a) through (e) of this subsection, the agency may perform retrospective utilization review to determine if the LOS was medically necessary and at the appropriate level of care.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-04-049, § 182-550-4300, filed 1/26/23, effective 2/26/23*
- *WSR 22-03-007, § 182-550-4300, filed 1/6/22, effective 2/6/22*
- *WSR 21-15-128, § 182-550-4300, filed 7/21/21, effective 8/21/21. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-12-047, § 182-550-4300, filed 5/29/14, effective 7/1/14. WSR 11-14-075, recodified as § 182-550-4300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. WSR 07-14-051, § 388-550-4300, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 06-08-046, § 388-550-4300, filed 3/30/06, effective 4/30/06. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 05-12-132, § 388-550-4300, filed 6/1/05, effective 7/1/05. Statutory Authority: RCW 74.08.090 and 42 U.S.C. 1395x(v), 42 C.F.R. 447.271, .11303, and .2652. WSR 01-16-142, § 388-550-4300, filed 7/31/01, effective 8/31/01. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-4300, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-4400** Services—Exempt from DRG payment. {#sec-182-550-4400 omnilex-key=us-wa-regs-official--title-182--182-550-4400}

(1) Inpatient services are exempt from the diagnosis-related group (DRG) payment method only if they qualify for payment methods specifically mentioned in other sections of this chapter or in this section.

(2) Subject to the restrictions and limitations in this section, the agency exempts the following services for medicaid and CHIP clients from the DRG payment method. This policy also applies to covered services paid through medical care services (MCS) and any other state-administered program, except when otherwise indicated in this section. The exempt services are:

(a) Withdrawal management services when provided in a hospital having a withdrawal management provider agreement with the agency to perform these services.

(b) Hospital-based intensive inpatient withdrawal management, medical stabilization, and drug treatment services provided to substance-using pregnant people (SUPP) clients by an agency-approved hospital. These are medicaid program services and are not covered or funded by the agency through MCS or any other state-administered program.

(c) Acute physical medicine and rehabilitation (acute PM&R) services.

(d) Psychiatric services. An agency designee that arranges to pay a hospital directly for psychiatric services may use the agency's payment methods or contract with the hospital to pay using different methods.

(e) Chronic pain management treatment provided in a hospital approved by the agency to provide that service.

(f) Administrative day services. The agency pays administrative days for one or more days of a hospital stay in which an acute inpatient or observation level of care is not medically necessary, and a lower level of care is appropriate. The administrative day rate is based on the statewide average daily medicaid nursing facility rate, which is adjusted annually. The agency may designate part of a client's stay to be paid an administrative day rate upon review of the claim or the client's medical record, or both.

(g) Inpatient services recorded on a claim grouped by the agency to a DRG for which the agency has not published an all-patient DRG (AP-DRG) or all-patient refined DRG (APR-DRG) relative weight. The agency will deny payment for claims grouped to APR DRG 955 or APR DRG 956.

(h) Organ transplants that involve heart, intestine, kidney, liver, lung, allogeneic bone marrow, autologous bone marrow, pancreas, or simultaneous kidney/pancreas. The agency pays hospitals for these organ transplants using the ratio of costs-to-charges (RCC) payment method. The agency maintains a list of DRGs which qualify as transplants on the agency's website.

(i) Gender affirming surgery.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-18-061, § 182-550-4400, filed 8/28/24, effective 9/28/24*
- *WSR 23-08-085, § 182-550-4400, filed 4/5/23, effective 5/6/23*
- *WSR 21-15-128, § 182-550-4400, filed 7/21/21, effective 8/21/21*
- *WSR 19-04-004, § 182-550-4400, filed 1/23/19, effective 3/1/19*
- *WSR 16-04-051, § 182-550-4400, filed 1/28/16, effective 3/1/16. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-12-047, § 182-550-4400, filed 5/29/14, effective 7/1/14. WSR 11-14-075, recodified as § 182-550-4400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. WSR 07-14-051, § 388-550-4400, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-12-022, § 388-550-4400, filed 5/20/05, effective 6/20/05. Statutory Authority: RCW 74.08.090 and 42 U.S.C. 1395x(v), 42 C.F.R. 447.271, .11303, and .2652. WSR 01-16-142, § 388-550-4400, filed 7/31/01, effective 8/31/01. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-4400, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-4500** Payment method—Ratio of costs-to-charges (RCC). {#sec-182-550-4500 omnilex-key=us-wa-regs-official--title-182--182-550-4500}

(1) The medicaid agency pays hospitals using the ratio of costs-to-charges (RCC) payment method for services exempt from the following payment methods:

(a) Ambulatory payment classification (APC);

(b) Diagnosis-related group (DRG);

(c) Enhanced ambulatory patient group (EAPG);

(d) Per case;

(e) Per diem; and

(f) Maximum allowable fee schedule.

(2) The agency:

(a) Determines the payment for inpatient claims by multiplying the hospital's inpatient RCC by the allowed covered charges for medically necessary services.

(b) Deducts from the amount derived in (a) of this subsection:

(i) All applicable adjustments for client responsibility;

(ii) Any third-party liability;

(iii) Medicare payments; and

(iv) Any other adjustments as determined by the agency.

(c) Limits the RCC payment to the hospital's usual and customary charges for services allowed by the agency.

(3) The agency uses the RCC payment method to calculate the following:

(a) Payment for the following services:

(i) Organ transplant services (see WAC 182-550-4400 (4)(h));

(ii) Hospital services provided at a long-term acute care (LTAC) facility not covered under the LTAC per diem rate (see WAC 182-550-2596); and

(iii) Any other hospital service identified by the agency as being paid by the RCC payment method; and

(b) Costs for the following:

(i) High outlier qualifying claims (see WAC 182-550-3700); and

(ii) Hospital services provided in hospitals eligible for certified public expenditure (CPE) payments under WAC 182-550-4650(5).

(4) When directed by the legislature to achieve targeted expenditure levels, as described in WAC 182-550-3000(8), the agency may apply an inpatient adjustment factor to the inpatient RCC payments made for the services in subsection (3) of this section.

(5) This section explains how the agency calculates each in-state and critical border hospital's RCC. For noncritical border city hospitals, see WAC 182-550-3900. The agency:

(a) Divides adjusted costs by adjusted patient charges. The agency determines the allowable costs and associated charges.

(b) Excludes agency nonallowed costs and nonallowed charges, such as costs and charges attributable to a change in ownership.

(c) Bases the RCC calculation on data from the hospital's annual medicare cost report (Form 2552) and applicable patient revenue reconciliation data provided by the hospital. The medicare cost report must cover a period of 12 consecutive months in its medicare cost report year.

(d) Updates a hospital's inpatient RCC annually after the hospital sends its hospital fiscal year medicare cost report to the centers for medicare and medicaid services (CMS) and the agency. If medicare grants a delay in submission of the CMS medicare cost report to the medicare fiscal intermediary, the agency may determine an alternate method to adjust the RCC.

(e) Limits a noncritical access hospital's RCC to one point zero (1.0).

(6) For a hospital formed as a result of a merger (see WAC 182-550-4200), the agency combines the previous hospital's medicare cost reports and follows the process in subsection (5) of this section. The agency does not use partial year cost reports for this purpose.

(7) For newly constructed hospitals and hospitals not otherwise addressed in this chapter, the agency annually calculates a weighted average in-state RCC by dividing the sum of agency-determined costs for all in-state hospitals with RCCs by the sum of agency-determined charges for all hospitals with RCCs.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-09-028, § 182-550-4500, filed 4/10/24, effective 5/11/24*
- *WSR 23-20-048, § 182-550-4500, filed 9/28/23, effective 10/29/23. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-12-047, § 182-550-4500, filed 5/29/14, effective 7/1/14. WSR 11-14-075, recodified as § 182-550-4500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-062, § 388-550-4500, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. WSR 07-14-051, § 388-550-4500, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. WSR 03-13-055, § 388-550-4500, filed 6/12/03, effective 7/13/03. Statutory Authority: RCW 74.08.090 and 42 U.S.C. 1395x(v), 42 C.F.R. 447.271, .11303, and .2652. WSR 01-16-142, § 388-550-4500, filed 7/31/01, effective 8/31/01. Statutory Authority: RCW 74.08.090, 42 U.S.C. 1395x(v), 42 C.F.R. 447.271, 447.11303, and 447.2652. WSR 99-06-046, § 388-550-4500, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-4500, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-4550** Administrative day rate and swing bed day rate. {#sec-182-550-4550 omnilex-key=us-wa-regs-official--title-182--182-550-4550}

(1) Administrative day rate.

(a) The medicaid agency allows hospitals an administrative day rate for those days of hospital stay in which a client does not meet criteria for acute inpatient level of care, but is not discharged because:

(i) An appropriate placement outside the hospital is not available (no placement administrative day); or

(ii) The postpartum parent's newborn remains on an inpatient claim for monitoring post-in utero exposure to substances that may lead to physiologic dependence and continuous care by the postpartum parent is the appropriate first-line treatment (newborn administrative day). "Postpartum parent" means the client who delivered the baby(ies).

(b) The agency uses the annual statewide weighted average nursing facility medicaid payment rate to update the all-inclusive administrative day rate on November 1st of each year.

(c) The agency pays for pharmaceuticals when these services are provided during administrative days.

(d) The agency identifies administrative days during the length of stay review process after the client's discharge from the hospital.

(e) The agency pays for up to five newborn administrative days. The agency pays for additional days with expedited prior authorization (EPA). For EPA, a hospital must establish that the clinically appropriate EPA criteria outlined in the agency's published billing guides have been met. The hospital must use the appropriate EPA number when billing the agency.

(f) The agency pays the hospital the administrative day rate starting with the date of hospital admission if the admission is solely for a no placement administrative day stay.

(g) The agency pays the hospital the newborn administrative day rate only if:

(i) The postpartum parent rooms in with their newborn and provides parental support/care; and

(ii) The hospital provides all prescribed medications to the postpartum parent for the duration of the stay, including medications prescribed to treat substance use disorder.

(2) Swing bed day rate. The agency allows hospitals a swing bed day rate for those days when a client is receiving agency-approved nursing service level of care in a swing bed. The agency's aging and disability services administration (ADSA) determines the swing bed day rate.

(a) The agency does not pay a hospital the rate applicable to the acute inpatient level of care for those days of a hospital stay when a client is receiving agency-approved nursing service level of care in a swing bed.

(b) The agency's allowed amount for those ancillary services not covered under the swing bed day rate is based on the payment methods provided in WAC 182-550-6000 and 182-550-7200. These ancillary services may be billed by the hospital on an outpatient hospital claim, except for pharmacy services and pharmaceuticals.

(c) The agency allows pharmacy services and pharmaceuticals not covered under the swing bed day rate, that are provided to a client receiving agency-approved nursing service level of care, to be billed directly by a pharmacy through the point of sale system. The agency does not allow those pharmacy services and pharmaceuticals to be paid to the hospital through submission of a hospital outpatient claim.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 74.09.520, and 2025 c 367. WSR 26-01-069, s 182-550-4550, filed 12/12/25, effective 1/12/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 74.09.520(13). WSR 23-21-063, § 182-550-4550, filed 10/12/23, effective 1/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-13-044, § 182-550-4550, filed 6/7/22, effective 10/1/22*
- *WSR 19-18-026, § 182-550-4550, filed 8/28/19, effective 9/28/19*
- *WSR 15-18-065, § 182-550-4550, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-4550, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-062, § 388-550-4550, filed 5/28/09, effective 7/1/09.*

##### **Wash. Admin. Code § 182-550-4650** "Full cost" public hospital certified public expenditure (CPE) payment program. {#sec-182-550-4650 omnilex-key=us-wa-regs-official--title-182--182-550-4650}

(1) The medicaid agency's "full cost" public hospital certified public expenditure (CPE) inpatient payment program provides payments to participating government-operated hospitals based on the "full cost" of covered medically necessary services and requires the expenditure of local funds in lieu of state funds to qualify for federal matching funds. The agency's inpatient payments to participating hospitals equal the federal matching amount for allowable costs. The agency uses the ratio of costs-to-charges (RCC) method described in WAC 182-550-4500 to determine "full cost."

(2) To be eligible for the "full cost" public hospital CPE payment program, the hospital must be:

(a) Operated by a public hospital district in the state of Washington, not certified by the department of health (DOH) as a critical access hospital, and has not chosen to opt-out of the CPE payment program as allowed in subsection (6) of this section;

(b) Harborview Medical Center; or

(c) University of Washington Medical Center.

(3) Payments made under the inpatient CPE payment program are limited to medically necessary services provided to medical assistance clients eligible for inpatient hospital services.

(4) Each hospital described in subsection (2) of this section is responsible to provide certified public expenditures as the required state match for claiming federal medicaid funds.

(5) The agency determines the initial payment for inpatient hospital services under the CPE payment program by:

(a) Multiplying the hospital's medicaid RCC by the covered charges (to determine allowable costs), then;

(b) Subtracting the client's responsibility and any third party liability (TPL) from the amount derived in (a) of this subsection, then;

(c) Multiplying the state's federal medical assistance percentage (FMAP) by the amount derived in (b) of this subsection. If the state's applicable FMAP is zero percent, the amount derived in (b) of this subsection is multiplied by the lowest Washington state-specific medicaid FMAP in effect at the time of claim payment.

(6) A hospital may opt-out of the inpatient CPE payment program if the hospital:

(a) Meets the criteria for the inpatient rate enhancement under RCW 74.09.5225; or

(b) Is not eligible for public hospital disproportionate share hospital (PHDSH) payments under WAC 182-550-5400.

(7) To opt-out of the inpatient CPE payment program, the hospital must submit a written request to opt-out to the agency's chief financial officer by July 1st in order to be effective for January 1st of the following year.

(8) Hospitals participating in the inpatient CPE payment program must complete the applicable CPE medicaid cost reports as described in WAC 182-550-5410 for the inpatient fee-for-service cost settlements.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-10-048, § 182-550-4650, filed 4/24/24, effective 5/25/24*
- *WSR 22-09-079, § 182-550-4650, filed 4/20/22, effective 5/21/22. Statutory Authority: RCW 41.05.021, 41.05.160, and 74.09.5225(3). WSR 15-11-009, § 182-550-4650, filed 5/7/15, effective 6/7/15. Statutory Authority: RCW 41.05.021 and 42 C.F.R. 433.51(b). WSR 12-04-022, § 182-550-4650, filed 1/25/12, effective 2/25/12. WSR 11-14-075, recodified as § 182-550-4650, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 06-08-046, § 388-550-4650, filed 3/30/06, effective 4/30/06. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 05-12-132, § 388-550-4650, filed 6/1/05, effective 7/1/05.*

##### **Wash. Admin. Code § 182-550-4670** CPE payment program—"Hold harmless" provision. {#sec-182-550-4670 omnilex-key=us-wa-regs-official--title-182--182-550-4670}

To meet legislative requirements, the medicaid agency includes a "hold harmless" provision for eligible hospitals participating in certified public expenditure (CPE) payment programs under WAC 182-550-4650 and 182-550-5400. Under the provision and subject to legislative directives and appropriations, hospitals eligible for payments under CPE payment programs will receive no less in combined state and federal payments than they would have received under the methodologies otherwise in effect as described in this section. All hospital submissions pertaining to CPE payment programs including, but not limited to, cost report schedules, are subject to audit at any time by the agency or its designee.

(1) The agency:

(a) Uses historical cost and payment data trended forward to calculate prospective hold harmless grant payment amounts for the current state fiscal year (SFY); and

(b) Reconciles these hold harmless grant payment amounts when the actual claims data are available for the current fiscal year.

(2) For SFYs 2006 through 2009, the agency calculates what the hospital would have been paid under the methodologies otherwise in effect for the SFY as the sum of:

(a) The total payments for inpatient claims for patients admitted during the fiscal year, calculated by repricing the claims using:

(i) For SFYs 2006 and 2007, the inpatient payment method in effect during SFY 2005; or

(ii) For SFYs 2008 and 2009, the payment method that would otherwise be in effect during the CPE payment program year if the CPE payment program had not been enacted.

(b) The total net disproportionate share hospital and state grant payments paid for SFY 2005.

(3) For SFY 2010 and beyond, the agency calculates what the hospital would have been paid under the methodologies otherwise in effect for the SFY as the sum of:

(a) The total of the inpatient claim payment amounts that would have been paid during the SFY had the hospital not been in the CPE payment program;

(b) One-half of the indigent assistance disproportionate share hospital payment amounts paid to and retained by each hospital during SFY 2005; and

(c) All of the other disproportionate share hospital payment amounts paid to and retained by each hospital during SFY 2005 to the extent the same disproportionate share hospital programs exist in the 2009-2011 biennium.

(4) For each SFY, the agency determines total state and federal payments made under the programs, including:

(a) Inpatient claim payments;

(b) Disproportionate share hospital (DSH) payments;

(c) Supplemental upper payment limit payments, as applicable; and

(d) The federal portion of medicaid program supplemental payments received by the hospitals.

(5) A hospital may receive a hold harmless grant, subject to legislative directives and appropriations, when the following calculation results in a positive number:

(a) For SFY 2006 through SFY 2009, the amount derived in subsection (4) of this section is subtracted from the amount derived in subsection (2) of this section; or

(b) For SFY 2010 and beyond, the amount derived in subsection (4) of this section is subtracted from the amount derived in subsection (3) of this section.

(6) The agency calculates interim hold harmless and final hold harmless grant amounts as follows:

(a) An interim hold harmless grant amount is calculated approximately ten months after the end of the SFY to include the paid claims for the same SFY admissions. Claims are subject to utilization review prior to the interim hold harmless calculation. Prospective grant payments made under subsection (1) of this section are deducted from the calculated interim hold harmless grant amount to determine the net grant payment amount due to or due from the hospital.

(b) The final hold harmless grant amount is calculated at such time as the final allowable federal portions of program payments are determined. The procedure is the same as the interim grant calculation, but it includes all additional claims that have been paid or adjusted since the interim hold harmless calculation. Claims are subject to utilization review and audit prior to the final calculation of the hold harmless amount. Interim grant payments determined under (a) of this subsection are deducted from this final calculation to determine the net final hold harmless amount due to or due from the hospital.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2022 c 297 § 211(21). WSR 22-23-162, § 182-550-4670, filed 11/23/22, effective 1/1/23. Statutory Authority: RCW 41.05.021, 41.05.160, and 74.09.5225(3). WSR 15-11-009, § 182-550-4670, filed 5/7/15, effective 6/7/15. WSR 11-14-075, recodified as § 182-550-4670, filed 6/30/11, effective 7/1/11. Statutory Authority: 2009 c 564 §§ 201 and 209, RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. WSR 10-11-032, § 388-550-4670, filed 5/11/10, effective 6/11/10. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 08-20-032, § 388-550-4670, filed 9/22/08, effective 10/23/08*
- *WSR 07-14-090, § 388-550-4670, filed 6/29/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.500, and 2005 c 518 § 209(9). WSR 06-11-100, § 388-550-4670, filed 5/17/06, effective 6/17/06.*

##### **Wash. Admin. Code § 182-550-4690** Authorization requirements and utilization review for hospitals eligible for CPE payments. {#sec-182-550-4690 omnilex-key=us-wa-regs-official--title-182--182-550-4690}

This section does not apply to psychiatric certified public expenditure (CPE) inpatient hospital admissions. See WAC 182-550-2600.

(1) CPE inpatient hospital claims submitted to the medicaid agency must meet all authorization and program requirements in WAC and current agency-published issuances.

(2) The agency performs utilization reviews of inpatient hospital:

(a) Admissions under the requirements of 42 C.F.R. 456, subparts A through C; and

(b) Claims for compliance with medical necessity, appropriate level of care and the agency's (or an agency designee's) established length of stay (LOS) standards.

(3) For CPE inpatient admissions before August 1, 2007, the agency performs utilization reviews using the professional activity study (PAS) length of stay (LOS) standard in WAC 182-550-4300 on claims that qualified for ratio of costs-to-charges (RCC) payment before July 1, 2005.

(4) For claims identified in this subsection, the agency may request a copy of the client's hospital medical records and itemized billing statements. The agency sends written notification to the hospital detailing the agency's findings. Any day of a client's hospital stay that exceeds the LOS standard:

(a) Is paid under a non-DRG payment method if the agency determines it to be medically necessary for the client at the acute level of care;

(b) Is paid as an administrative day (see WAC 182-550-1050 and 182-550-4500(8)) if the agency determines it to be medically necessary for the client at the subacute level of care; and

(c) Is not eligible for payment if the agency determines it was not medically necessary.

(5) For CPE inpatient admissions after July 31, 2007, CPE hospital claims are subject to the same utilization review rules as non-CPE hospital claims.

(a) LOS reviews may be performed under WAC 182-550-4300.

(b) All claims are subject to the agency's medical necessity review under WAC 182-550-1700(2).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-01-204, § 182-550-4690, filed 12/23/15, effective 1/23/16*
- *WSR 15-18-065, § 182-550-4690, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-4690, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 08-20-032, § 388-550-4690, filed 9/22/08, effective 10/23/08. Statutory Authority: RCW 74.08.090, 74.09.500, and 2005 c 518 § 209(9). WSR 06-11-100, § 388-550-4690, filed 5/17/06, effective 6/17/06.*

##### **Wash. Admin. Code § 182-550-4800** Hospital payment methods—State-administered programs. {#sec-182-550-4800 omnilex-key=us-wa-regs-official--title-182--182-550-4800}

This section does not apply to out-of-state hospitals unless they are border hospitals (critical or noncritical).

(1) The medicaid agency:

(a) Pays for services provided to a client eligible for a state-administered program (SAP) based on SAP rates;

(b) Establishes SAP rates independently from the process used in setting the medicaid payment rates;

(c) Calculates a ratable each year to adjust each hospital's SAP rates for their percentage of community-based dollars to the total revenues for all hospitals;

(d) Calculates an equivalency factor (EF) to keep the SAP payment rates at the same level before and after the medicaid rates were rebased.

(2) The agency has established the following:

(a) SAP diagnosis-related group (DRG) conversion factor (CF) for claims grouped under DRG classifications services;

(b) SAP per diem rates for claims grouped under the following specialty service categories:

(i) Substance-using pregnant people (SUPP);

(ii) Detoxification;

(iii) Physical medicine and rehabilitation (PM&R); and

(iv) Psychiatric.

(c) SAP ratio of costs-to-charges (RCC) for claims grouped under transplant services.

(3) This subsection describes the SAP DRG CF and payment calculation processes used by the agency to pay claims using the DRG payment method. The agency pays for services grouped to a DRG classification provided to clients eligible for a SAP based on the use of a DRG CF, a DRG relative weight, and a maximum service adjustor. This process is similar to the payment method used to pay for medicaid and CHIP services grouped to a DRG classification.

(a) The agency's SAP DRG CF calculation process is as follows:

(i) The hospital's specific DRG CF used to calculate payment for a SAP claim is the medicaid DRG CF multiplied by the applicable EF multiplied by the ratable;

(ii) For hospitals that do not have a ratable or an EF, the SAP CF is the hospital's specific medicaid CF multiplied by the average EF and the average ratable; and

(iii) For noncritical border hospitals, the SAP DRG CF is the lowest in-state medicaid DRG CF multiplied by the average ratable and the average EF.

(b) The agency calculates the SAP DRG EF as follows:

(i) The hospital-specific current SAP DRG CF is divided by the rebased medicaid DRG CF and then divided by the ratable factor to compute the preliminary EF.

(ii) The current SAP DRG payment is determined by multiplying the hospital-specific SAP DRG CF by the APR-DRG relative weight.

(iii) The current aggregate DRG payment is determined by summing the current SAP DRG payments for all hospitals.

(iv) The hospital projected SAP DRG payment is determined by multiplying the hospital-specific current SAP DRG CF by the APR-DRG relative weights and the maximum service adjustor.

(v) The projected aggregate DRG payment is determined by summing the projected SAP program DRG payments for all hospitals.

(vi) The aggregate amounts derived in (b)(iii) and (v) of this subsection are compared to identify a neutrality factor that keeps the projected aggregate SAP DRG payment (based on APR-DRG relative weights) at the same level as the previous aggregate SAP DRG payment (based on APR-DRG relative weights).

(vii) The neutrality factor is multiplied by the hospital-specific preliminary EF to determine the hospital-specific final EF that is used to determine the SAP DRG conversion factors for the rebased system implementation.

(c) The agency calculates the DRG payment for services paid under the DRG payment method as follows:

(i) The agency calculates the allowed amount for the inlier portion of the SAP DRG payment by multiplying the SAP DRG CF by the DRG relative weight and the maximum service adjustor.

(ii) SAP claims are also subject to outlier pricing. See WAC 182-550-3700 for details on outlier pricing.

(4) This subsection describes how the agency calculates the SAP per diem rate and payment for SUPP, detoxification, PM&R, and psychiatric services.

(a) The agency calculates the SAP per diem rate for in-state and critical border hospitals by multiplying the hospital's specific medicaid per diem by the ratable and the per diem EF.

(b) The agency calculates the SAP per diem rate for noncritical border hospitals by multiplying the lowest in-state medicaid per diem rate by the average ratable and the average per diem EF.

(c) For hospitals with more than 20 nonpsychiatric SAP per diem paid services during SFY 2011, the agency calculates a per diem EF for each hospital using the individual hospital's claims as follows:

(i) The agency calculates a SAP average payment per day by dividing the total current SAP per diem payments by the total number of days associated with the payments.

(ii) The agency calculates a medicaid average payment per day by dividing the aggregate payments based on the rebased medicaid rates by the total number of days associated with the aggregate payments (same claims used in (c)(i) of this subsection).

(iii) The agency divides the hospital estimated SAP average payment per day in (a) of this subsection by the hospital medicaid average payment per day in (b) of this subsection.

(iv) The agency divides the result of (c)(iii) of this subsection by the hospital-specific ratable factor to determine the EF.

(d) For hospitals with 20 or less nonpsychiatric SAP per diem paid services during SFY 2011, the EF is an average for all hospitals. The agency uses the following process to determine the average EF:

(i) The agency calculates a SAP average payment per day by dividing the total current SAP per diem payments for all hospitals by the total number of days associated with the aggregate payments.

(ii) The agency calculates a medicaid average payment per day by dividing the aggregate payments based on the rebased medicaid rates by the total number of days associated with the aggregate payment (same claims used in (d)(i) of this subsection).

(iii) The agency divides the SAP average per day in (a) of this subsection by the medicaid average payment per day in (b) of this subsection.

(iv) The agency divides the result of (d)(iii) of this subsection by the hospital-specific ratable factor to determine the EF. The EF is an average based on claims for all the hospitals in the group.

(e) The agency uses a psychiatric EF to keep SAP psychiatric rates at the level required by the Washington state legislature. The agency's SAP psychiatric rates are eighty-five and four one hundredths of a percent (85.04%) of the agency's medicaid psychiatric rates. The factor is applied to all hospitals.

(f) The agency calculates the SAP per diem allowed amount for SUPP, detoxification, PM&R, and psychiatric services by multiplying the hospital's SAP per diem rate by the agency's allowed patient days.

(g) The agency does not apply the high outlier or transfer policy to the payment calculations for SUPP, detoxification, PM&R, and psychiatric services.

(5) The agency calculates the SAP RCC by multiplying the medicaid RCC by the hospital's ratable.

(6) The agency annually establishes the hospital-specific ratable factor used in the calculation of SAP payment rate based on the most current hospital revenue data available from the department of health (DOH). The agency uses the following process to determine the hospital ratable factor:

(a) The agency adds the hospital's medicaid revenue, medicare revenue, charity care, and bad debts as reported in DOH data.

(b) The agency determines the hospital's community care dollars by subtracting the hospital's low-income disproportionate share hospital (LIDSH) payments from the amount derived in (a) of this subsection.

(c) The agency calculates the hospital net revenue by subtracting the hospital-based physician revenue (based on information available from the hospital's medicare cost report or provided by the hospitals) from the DOH total hospital revenue report.

(d) The agency calculates the preliminary hospital-specific ratable by dividing the amount derived in (b) of this subsection by the amount derived in (c) of this subsection.

(e) The agency determines a neutrality factor by comparing the hospital-specific medicaid revenue (used in (a) of this subsection) multiplied by the preliminary ratable to the hospital-specific medicaid revenue (used in (a) of this subsection) multiplied by the prior year ratable. The neutrality factor is used to keep the projected SAP payments at the same current payment level.

(f) The agency determines the final hospital-specific ratable by multiplying the hospital-specific preliminary ratable by the neutrality factor.

(g) The agency applies to the allowable for each SAP claim all applicable adjustments for client responsibility, any third-party liability, medicare payments, and any other adjustments as determined by the agency.

(7) The agency does not pay a SAP claim paid by the DRG method at greater than the billed charges.

(8) SAP rates do not apply to the critical access hospital (CAH) program's weighted cost-to-charges, to the long-term acute care (LTAC) program's per diem rate, or to the certified public expenditure (CPE) program's RCC (except as the RCC applies to the CPE hold harmless described under WAC 182-550-4670).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-19-011, s 182-550-4800, filed 9/4/25, effective 10/5/25*
- *WSR 21-22-045, § 182-550-4800, filed 10/27/21, effective 11/27/21*
- *WSR 19-04-004, § 182-550-4800, filed 1/23/19, effective 3/1/19*
- *WSR 18-12-043, § 182-550-4800, filed 5/30/18, effective 7/1/18. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-12-047, § 182-550-4800, filed 5/29/14, effective 7/1/14. WSR 11-14-075, recodified as § 182-550-4800, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. WSR 07-14-051, § 388-550-4800, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 05-12-132, § 388-550-4800, filed 6/1/05, effective 7/1/05. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 04-19-113, § 388-550-4800, filed 9/21/04, effective 10/22/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. WSR 02-21-019, § 388-550-4800, filed 10/8/02, effective 11/8/02. Statutory Authority: RCW 74.08.090 and 42 U.S.C. 1395x(v), 42 C.F.R. 447.271, .11303, and .2652. WSR 01-16-142, § 388-550-4800, filed 7/31/01, effective 8/31/01. Statutory Authority: RCW 74.09.080, 74.09.730, 42 U.S.C. 1395x(v) and 1396r-4, 42 C.F.R. 447.271 and 2652. WSR 99-14-026, § 388-550-4800, filed 6/28/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 42 U.S.C. 1395 x(v), 42 C.F.R. 447.271, 447.11303, and 447.2652. WSR 99-06-046, § 388-550-4800, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-4800, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-4900** Disproportionate share hospital (DSH) payments—General provisions. {#sec-182-550-4900 omnilex-key=us-wa-regs-official--title-182--182-550-4900}

(1) As required by Section 1902 (a)(13)(A) of the Social Security Act (42 U.S.C. 1396 (a)(13)(A)) and RCW 74.09.730, the medicaid agency makes payment adjustments to eligible hospitals that serve a disproportionate number of low-income clients. These adjustments are also known as disproportionate share hospital (DSH) payments.

(2) No hospital has a legal entitlement to any DSH payment. A hospital may receive DSH payments only if:

(a) It satisfies the requirements of 42 U.S.C. 1396r-4;

(b) It satisfies all the requirements of agency rules and policies; and

(c) The legislature appropriates sufficient funds.

(3) For purposes of eligibility for DSH payments, the following definitions apply:

(a) "Case mix index (CMI)" means the average of diagnosis related group (DRG) weights for all of an individual hospital's DRG-paid medicaid claims during the SFY two years prior to the SFY for which the DSH application is being made.

(b) "Charity care" means necessary hospital care rendered to persons unable to pay for the hospital services or unable to pay the deductibles or coinsurance amounts required by a third-party payer. The charity care amount is determined in accordance with the hospital's published charity care policy.

(c) "Hospital-specific DSH cap" means the maximum amount of DSH payments a hospital may receive from the agency during a SFY. If a hospital does not qualify for DSH, the agency will not calculate the hospital-specific DSH cap and the hospital will not receive DSH payments.

(d) "Inpatient medicaid days" means inpatient days attributed to clients eligible for Title XIX medicaid programs. Excluded from this count are inpatient days attributed to clients eligible for state administered programs, medicare Part A, Title XXI, the refugee program and the family planning only programs.

(e) "Low income utilization rate (LIUR)" means the sum of the following two percentages used to determine whether a hospital is DSH-eligible:

(i) The ratio of payments received by the hospital for patient services provided to clients under medicaid (including managed care), plus cash subsidies received by the hospital from state and local governments for patient services, divided by total payments received by the hospital from all patient categories; plus

(ii) The ratio of inpatient charity care charges, less inpatient cash subsidies received by the hospital from state and local governments, less contractual allowances and discounts, divided by total charges for inpatient services.

(f) "Medicaid inpatient utilization rate (MIUR)" means the calculation (expressed as a percentage) used to determine whether a hospital is DSH-eligible. The numerator of which is the hospital's number of inpatient days attributable to clients who (for such days) were eligible for medical assistance during the base year (regardless of whether such clients received medical assistance on a fee-for-service basis or through a managed care organization), and the denominator of which is the total number of the hospital's inpatient days in that period. "Inpatient days" include each day in which a person (including a newborn) is an inpatient in the hospital, whether or not the person is in a specialized ward and whether or not the person remains in the hospital for lack of suitable placement elsewhere.

(g) "Medicare cost report year" means the 12-month period included in the annual cost report a medicare-certified hospital or institutional provider is required by law to submit to its fiscal intermediary.

(h) "Nonrural hospital" means a hospital that:

(i) Is not participating in the "full cost" public hospital certified public expenditure (CPE) payment program as described in WAC 182-550-4650;

(ii) Is not designated as an "institution for mental diseases (IMD)" as defined in WAC 182-500-0050;

(iii) Is not a small rural hospital as defined in (n) of this subsection; and

(iv) Is located in the state of Washington or in a designated bordering city. For DSH purposes, the agency considers as nonrural any hospital located in a designated bordering city.

(i) "Obstetric services" means routine, nonemergency obstetric services and the delivery of babies.

(j) "Service year" means the one-year period used to measure the costs and associated charges for hospital services. The service year may refer to a hospital's fiscal year or medicare cost report year, or to a state fiscal year.

(k) "Statewide disproportionate share hospital (DSH) cap" means the maximum amount per SFY that the state can distribute in DSH payments to all qualifying hospitals during a SFY.

(l) "Small rural hospital" means a hospital that:

(i) Is not participating in the "full cost" public hospital certified public expenditure (CPE) payment program as described in WAC 182-550-4650;

(ii) Is not designated as an "institution for mental diseases (IMD)" as defined in WAC 182-500-0050;

(iii) Has fewer than 75 acute beds;

(iv) Is located in the state of Washington; and

(v) Is located in a city or town with a nonstudent population of no more than 17,806 in calendar year 2008, as determined by population data reported by the Washington state office of financial management population of cities, towns and counties used for the allocation of state revenues. This nonstudent population is used for SFY 2010, which begins July 1, 2009. For each subsequent SFY, the nonstudent population is increased by two percent.

(4) To be considered for a DSH payment for each SFY, a hospital must meet the criteria in this section:

(a) DSH application requirements.

(i) Only a hospital located in the state of Washington or in a designated bordering city is eligible to apply for and receive DSH payments. An institution for mental disease (IMD) owned and operated by the state of Washington is exempt from the DSH application requirement.

(ii) A hospital that meets DSH program criteria is eligible for DSH payments in any SFY only if the agency receives the hospital's DSH application by the published deadline.

(b) The DSH application review and correction period.

(i) This subsection applies only to DSH applications that meet the requirements under (a) of this subsection.

(ii) The agency reviews and may verify any information provided by the hospital on a DSH application. However, each hospital has the responsibility for ensuring its DSH application is complete and accurate.

(iii) If the agency finds that a hospital's application is incomplete or contains incorrect information, the agency will notify the hospital. The hospital must submit a new, corrected application. The agency must receive the new DSH application from the hospital by the published deadline.

(iv) If a hospital finds that its application is incomplete or contains incorrect information, it may choose to submit changes and/or corrections to the DSH application. The agency must receive the corrected, complete, and signed DSH application from the hospital by the published deadline.

(c) Official DSH application.

(i) The agency considers as official the last signed DSH application submitted by the hospital as of the deadline for corrected DSH applications. A hospital cannot change its official DSH application. Only those hospitals with an official DSH application are eligible for DSH payments.

(ii) If the agency finds that a hospital's official DSH application is incomplete or contains inaccurate information that affects the hospital's LIDSH payment(s), the hospital does not qualify for, will not receive, and cannot retain, LIDSH payment(s). Refer to WAC 182-550-5000.

(5) A hospital is a disproportionate share hospital for a specific SFY if the hospital satisfies the medicaid inpatient utilization rate (MIUR) requirement (discussed in (a) of this subsection), and the obstetric services requirement (discussed in (b) of this subsection).

(a) The hospital must have an MIUR of one percent or more; and

(b) Unless one of the exceptions described in (i)(A) or (B) of this subsection applies, the hospital must have at least two obstetricians who have staff privileges at the hospital and who have agreed to provide obstetric services to eligible clients.

(i) The obstetric services requirement does not apply to a hospital that:

(A) Provides inpatient services predominantly to clients younger than age 18; or

(B) Did not offer nonemergency obstetric services to the general public as of December 22, 1987, when section 1923 of the Social Security Act was enacted.

(ii) For hospitals located in rural areas, "obstetrician" means any physician with staff privileges at the hospital to perform nonemergency obstetric procedures.

(6) To determine a hospital's MIUR, the agency uses the applicable year medicare cost report, as filed by the hospital.

(7) The agency administers the following DSH programs (depending on legislative budget appropriations):

(a) Low income disproportionate share hospital (LIDSH);

(b) Medical care services disproportionate share hospital (MCSDSH);

(c) Small rural disproportionate share hospital (SRDSH);

(d) Public hospital disproportionate share hospital (PHDSH); and

(e) Children's health program disproportionate share hospital (CHPDSH).

(8) The agency allows a hospital to receive any one or all of the DSH payment it qualifies for, up to the individual hospital's DSH cap (see subsection (10) of this section) and provided that total DSH payments do not exceed the statewide DSH cap. To be eligible for payment under multiple DSH programs, a hospital must meet:

(a) The basic requirements in subsection (5) of this section; and

(b) The eligibility requirements for the particular DSH payment, as discussed in the applicable DSH program WAC.

(9) For each SFY, the agency calculates DSH payments for each DSH program for eligible hospitals using data from each hospital's base year. The agency does not use base year data for MCSDSH and CHPDSH payments, which are calculated based on specific claims data.

(10) The agency's total DSH payments to a hospital for any given SFY cannot exceed the hospital-specific DSH cap for that SFY. Except for critical access hospitals (CAHs), the agency determines a hospital's DSH cap as follows. The agency:

(a) Uses the overall ratio of costs-to-charges (RCC) to determine costs for:

(i) Medicaid services, including medicaid services provided under managed care organization (MCO) plans; and

(ii) Uninsured charges; then

(b) Subtracts all payments related to the costs derived in (a) of this subsection; then

(c) Makes any adjustments required and/or authorized by federal statute or regulation.

(11) A CAH's DSH cap is based strictly on the cost to the hospital of providing services to medicaid clients served under MCO plans, and uninsured patients. To determine a CAH's DSH cap amount, the agency:

(a) Uses the overall RCC to determine costs for:

(i) Medicaid services provided under MCO plans; and

(ii) Uninsured charges; then

(b) Subtracts the total payments made by, or on behalf of, the medicaid clients serviced under MCO plans, and uninsured patients.

(12) In any given federal fiscal year, the total of the agency's DSH payments cannot exceed the statewide DSH cap as published in the federal register.

(13) If the agency's DSH payments for any given federal fiscal year exceed the statewide DSH cap, the agency will adjust DSH payments to each hospital to account for the amount overpaid. The agency makes adjustments in the following program order:

(a) PHDSH;

(b) SRDSH;

(c) MCSDSH;

(d) CHPDSH; and

(e) LIDSH.

(14) If the statewide DSH cap is exceeded, the agency will recoup DSH payments made under the various DSH programs, in the order of precedence described in subsection (13) of this section, starting with PHDSH, until the amount exceeding the statewide DSH cap is reduced to zero. See specific program regulations in the Washington Administrative Code for description of how amounts to be recouped are determined.

(15) The total amount the agency may distribute annually under a particular DSH program is capped by legislative appropriation. Any changes in payment amount to a hospital in a particular DSH program means a redistribution of payments within that DSH program. When necessary, the agency will recoup from hospitals to make additional payments to other DSH-eligible hospitals within that DSH program.

(16) If funds in a specific DSH program need to be redistributed because of legislative, administrative, or other state action, only those hospitals eligible for that DSH program will be involved in the redistribution.

(a) If an individual hospital has been overpaid by a specified amount, the agency will recoup that overpayment amount from the hospital and redistribute it among the other eligible hospitals in the DSH program. The additional DSH payment to be given to each of the other hospitals from the recouped amount is proportional to each hospital's share of the particular DSH program.

(b) If an individual hospital has been underpaid by a specified amount, the agency will pay that hospital the additional amount owed by recouping from the other hospitals in the DSH program. The amount to be recouped from each of the other hospitals is proportional to each hospital's share of the particular DSH program.

(c) This subsection does not apply to the DSH independent audit findings and recoupment process described in WAC 182-550-4940.

(17) All information related to a hospital's DSH application is subject to audit by the agency or its designee. The agency determines the extent and timing of the audits. For example, the agency or its designee may choose to do an audit of an individual hospital's DSH application and/or supporting documentation, or audit all hospitals that qualified for a particular DSH program after payments have been distributed under that program.

(18) If a hospital's submission of incorrect information or failure to submit correct information results in DSH overpayment to that hospital, the agency will recoup the overpayment amount as allowed in RCW 74.09.220 and chapter 41.05A RCW.

(19) DSH calculations use fiscal year data, and DSH payments are distributed based on funding for a specific SFY. Therefore, unless otherwise specified, changes and clarifications to DSH program rules apply for the full SFY in which the rules are adopted.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-14-035, s 182-550-4900, filed 6/25/25, effective 7/26/25*
- *WSR 25-07-061, s 182-550-4900, filed 3/13/25, effective 4/13/25*
- *WSR 23-11-007, § 182-550-4900, filed 5/4/23, effective 6/4/23. Statutory Authority: RCW 41.05.021 and 42 C.F.R. Part 455, Subpart F. WSR 15-01-037, § 182-550-4900, filed 12/8/14, effective 1/8/15. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4. WSR 14-08-038, § 182-550-4900, filed 3/26/14, effective 4/26/14. Statutory Authority: RCW 41.05.021. WSR 12-20-029, § 182-550-4900, filed 9/26/12, effective 10/27/12. WSR 11-14-075, recodified as § 182-550-4900, filed 6/30/11, effective 7/1/11. Statutory Authority: 2009 c 564 §§ 201 and 209, RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. WSR 10-11-032, § 388-550-4900, filed 5/11/10, effective 6/11/10. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-090, § 388-550-4900, filed 6/29/07, effective 8/1/07*
- *WSR 06-08-046, § 388-550-4900, filed 3/30/06, effective 4/30/06. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 05-12-132, § 388-550-4900, filed 6/1/05, effective 7/1/05. Statutory Authority: RCW 74.08.090, 74.04.050, and 2003 1st sp.s. c 25. WSR 04-12-044, § 388-550-4900, filed 5/28/04, effective 7/1/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. WSR 03-13-055, § 388-550-4900, filed 6/12/03, effective 7/13/03. Statutory Authority: RCW 74.08.090, 74.09.730 and 42 U.S.C. 1396r-4. WSR 99-14-040, § 388-550-4900, filed 6/30/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-4900, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-4925** Eligibility for DSH programs—New hospital providers. {#sec-182-550-4925 omnilex-key=us-wa-regs-official--title-182--182-550-4925}

To be eligible for disproportionate share hospital (DSH) payments, a new hospital provider must have claims data, audited financial statements, and an "as filed" or finalized medicare cost report for the hospital base year used by the medicaid agency in calculating DSH payments for the state fiscal year (SFY) for which the hospital provider is applying. See WAC 182-550-4900(9).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-4925, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-4925, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-090, § 388-550-4925, filed 6/29/07, effective 8/1/07.*

##### **Wash. Admin. Code § 182-550-4935** DSH eligibility—Change in hospital ownership. {#sec-182-550-4935 omnilex-key=us-wa-regs-official--title-182--182-550-4935}

(1) For purposes of eligibility for disproportionate share hospital (DSH) payments, a change in hospital ownership has occurred if any of the criteria in WAC 182-550-4200(1) is met.

(2) To be considered eligible for DSH, a hospital whose ownership has changed must notify the medicaid agency in writing no later than 30 days after the change in ownership becomes final. The notice must include the new entity's fiscal year end.

(3) A hospital that did not offer nonemergency obstetric services to the general public as of December 22, 1987, when section 1923 of the Social Security Act was enacted, and changes ownership after that date is not eligible for DSH unless it continues to be classified as an acute care hospital serving pediatric and/or adult patients. See WAC 182-550-4900(5) for the obstetric services and utilization rate requirements for DSH eligibility.

(4) If the fiscal year reported on a hospital's medicare cost report does not exactly match the fiscal year reported on the hospital's DSH application to the agency, and if therefore the utilization data reported to the agency do not agree, the agency will use as the data source the document that gives the higher number of total inpatient hospital days for purposes of calculating the hospital's medicaid inpatient utilization rate (MIUR). See WAC 182-550-4900(6).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-07-061, s 182-550-4935, filed 3/13/25, effective 4/13/25*
- *WSR 15-18-065, § 182-550-4935, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-4935, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-090, § 388-550-4935, filed 6/29/07, effective 8/1/07.*

##### **Wash. Admin. Code § 182-550-4940** Disproportionate share hospital independent audit findings and recoupment process. {#sec-182-550-4940 omnilex-key=us-wa-regs-official--title-182--182-550-4940}

(1) In order to comply with federal law and regulation (42 U.S.C. 1396r-4 (j)(2); 42 C.F.R. Part 455, Subpart D), the medicaid agency contracts with an independent auditor to conduct an annual, independent, certified audit of the agency's disproportionate share hospital (DSH) payments. Chapter 182-502A WAC is not applicable to the independent, certified audits described in this section.

(2) Under this section, a hospital may only dispute an overpayment, not an underpayment. Appeal rights and process follow WAC 182-502-0230.

(3) Hospitals must comply with the agency's or the auditor's requests for documentation. A hospital's failure to provide requested documentation will result in a finding that any or all of the DSH payments for the audited year are overpayments.

(4) Beginning in state fiscal year 2011, an audit finding that demonstrates DSH payments made to a hospital in that year exceeded the documented hospital-specific DSH cap (as defined in WAC 182-550-4900), is considered a discovery of an overpayment under 42 C.F.R. Part 433, Subpart F.

(5) Hospitals must return overpayments to the agency for redistribution to qualifying hospitals. A qualifying hospital is defined as a disproportionate share hospital that has a positive hospital-specific DSH cap.

(6) The additional DSH payment to be given to each of the other qualifying hospitals from the recouped amount is proportional to each hospital's share of the particular DSH program. Only the recouped payments are redistributed among those eligible DSH hospitals that have a remaining positive hospital-specific DSH cap.

(7) The independent auditor will provide preliminary audit results to each hospital that received DSH payments, including a statement as to whether the hospital's payments did or did not exceed the hospital's DSH cap. Hospitals identified as receiving DSH payments exceeding their hospital-specific DSH cap may request additional information on the preliminary audit results. The agency must receive the hospital's request for the additional information on the preliminary audit results no later than 10 days from the initial notification which is sent electronically to the hospital.

(8) In response to a hospital's timely request under subsection (7) of this section, the independent auditor will provide the hospital with at least the following information specific to the requesting hospital:

(a) Calculation of the medicaid inpatient utilization rate (MIUR);

(b) Regular inpatient and outpatient medicaid fee for service basic rate payments;

(c) Supplemental/enhanced inpatient and outpatient medicaid payments;

(d) Total medicaid payments;

(e) Total cost of care;

(f) Total cost of care of the uninsured; and

(g) A schedule of annual reporting requirements (SARR), required by 42 C.F.R. Sec. 447.299, Subpart E, upon request from the hospital.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-07-061, s 182-550-4940, filed 3/13/25, effective 4/13/25. Statutory Authority: RCW 41.05.021 and 42 C.F.R. Part 455, Subpart F. WSR 15-01-037, § 182-550-4940, filed 12/8/14, effective 1/8/15.*

##### **Wash. Admin. Code § 182-550-5000** Payment method—Low income disproportionate share hospital (LIDSH). {#sec-182-550-5000 omnilex-key=us-wa-regs-official--title-182--182-550-5000}

(1) The medicaid agency makes low income disproportionate share hospital (LIDSH) payments to qualifying hospitals through the disproportionate share hospital (DSH) program.

(2) To qualify for an LIDSH payment, a hospital must:

(a) Not be a hospital eligible for public disproportionate share (PHDSH) payments (see WAC 182-550-5400);

(b) Not be designated as an "institution for mental diseases (IMD)" as defined in WAC 182-550-2600 (2)(d);

(c) Meet the criteria in WAC 182-550-4900 (4) and (5);

(d) Be an in-state hospital. A hospital located out-of-state or in a designated bordering city is not eligible to receive LIDSH payments; and

(e) Meet at least one of the following requirements. The hospital must:

(i) Have a medicaid inpatient utilization rate (MIUR) as defined in WAC 182-550-4900(3) at least one standard deviation above the mean medicaid inpatient utilization rate of in-state hospitals that receive medicaid payments; or

(ii) Have a low income utilization rate (LIUR) as defined in WAC 182-550-4900(3) that exceeds 25 percent.

(3) The agency pays hospitals qualifying for LIDSH payments from a legislatively appropriated pool. The maximum amount of LIDSH payments in any state fiscal year (SFY) is the funding set by the state's appropriations act for LIDSH. The amount that the state appropriates for LIDSH may vary from year to year.

(4) The agency determines LIDSH payments to each LIDSH eligible hospital using the following factors from the specific hospital's base year:

(a) The hospital's medicaid inpatient utilization rate (MIUR) (see WAC 182-550-4900 for how the agency calculates the MIUR).

(b) The hospital's medicaid case mix index (CMI). The agency calculates the CMI by:

(i) Using the DRG weight for each of the hospital's paid inpatient claims assigned in the year the claim was paid;

(ii) Summing the DRG weights; and

(iii) Dividing this total by the number of claims.

The CMI the agency uses for LIDSH calculations is not the same as the CMI the agency uses in other hospital rate calculations.

(c) The number of the hospital's Title XIX medicaid discharges. The agency includes in this number only the discharges pertaining to Washington state medicaid clients.

(5) The agency calculates the LIDSH payment to an eligible hospital as follows.

(a) The agency:

(i) Divides the hospital's MIUR by the average MIUR of all LIDSH-eligible hospitals; then

(ii) Multiplies the result derived in (a) of this section by the CMI (see (4)(b) of this section), and then by the discharges (see (4)(c) of this section); then

(iii) Converts the product to a percentage of the sum of all such products for individual hospitals; and

(iv) Multiplies this percentage by the legislatively appropriated amount for LIDSH.

(b) If a hospital's calculated LIDSH payment is more than the hospital-specific DSH cap, the payment to the hospital is limited to the hospital-specific DSH cap, and the agency:

(i) Subtracts the LIDSH payment calculated for the hospital to determine the remaining LIDSH appropriation to distribute to the other qualifying hospitals; and

(ii) Proportionately distributes the remaining LIDSH appropriation under the factors in (a) of this subsection.

(6) A hospital receiving LIDSH payments must comply with an agency request for uninsured logs (uninsured logs are documentation of payments, charges, and other information for uninsured patients) to verify its hospital-specific DSH cap.

(7) The agency will not make changes in the LIDSH payment distribution after the applicable SFY has ended. The agency recalculates the LIDSH payment distribution only when the applicable SFY has not yet ended at the time the alleged need for an LIDSH adjustment is identified, and if the agency considers the recalculation necessary and appropriate under its regulations.

(8) Consistent with the provisions of subsection (7) of this section, the agency applies any adjustments to the DSH payment distribution required by legislative, administrative, or other state action, to other DSH programs under WAC 182-550-4900 (13) through (16).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-14-035, s 182-550-5000, filed 6/25/25, effective 7/26/25*
- *WSR 25-07-061, s 182-550-5000, filed 3/13/25, effective 4/13/25*
- *WSR 15-18-065, § 182-550-5000, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-5000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 74.09.730(2). WSR 10-17-095, § 388-550-5000, filed 8/17/10, effective 9/17/10. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-090, § 388-550-5000, filed 6/29/07, effective 8/1/07*
- *WSR 06-08-046, § 388-550-5000, filed 3/30/06, effective 4/30/06. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. WSR 03-13-055, § 388-550-5000, filed 6/12/03, effective 7/13/03. Statutory Authority: RCW 74.08.090, 74.09.730 and 42 U.S.C. 1396r-4. WSR 99-14-040, § 388-550-5000, filed 6/30/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-5000, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-5130** Payment method—Institution for mental diseases disproportionate share hospital (IMDDSH) and institution for mental diseases (IMD) state grants. {#sec-182-550-5130 omnilex-key=us-wa-regs-official--title-182--182-550-5130}

(1) A psychiatric hospital owned and operated by the state of Washington is eligible to receive payments under the institution for mental diseases disproportionate share hospital (IMDDSH) program.

(2) For the purposes of the IMDDSH program, the following definitions apply:

(a) "Institution for mental diseases (IMD)" means a hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of people with mental diseases, including medical attention, nursing care, and related services.

(b) "Psychiatric community hospital" means a psychiatric hospital other than a state-owned and operated hospital.

(c) "Psychiatric hospital" means an institution which is primarily engaged in providing psychiatric services for the diagnosis and treatment of mentally ill people. The term applies to a medicare-certified distinct psychiatric care unit, a medicare-certified psychiatric hospital, or a state-designated pediatric distinct psychiatric unit in a medicare-certified acute care hospital.

(d) "State-owned and operated psychiatric hospital" means eastern state hospital and western state hospital.

(3) Except as provided in subsection (4) of this section, a psychiatric community hospital, regardless of location, is not eligible to receive:

(a) IMDDSH payments; or

(b) Any other disproportionate share hospital (DSH) payment from the medicaid agency. See WAC 182-550-4800 regarding payment for psychiatric claims for clients eligible under the medical care services programs.

(4) A psychiatric community hospital within the state of Washington that is designated by the agency as an IMD is eligible to receive IMDDSH payment if:

(a) IMDDSH funds remain available after the amounts appropriated for state-owned and operated psychiatric hospitals are exhausted; and

(b) The legislature provides funds specifically for this purpose.

(5) Under federal law, 42 U.S.C. 1396r-4 (h)(2), the state's annual IMDDSH expenditures are capped at 33 percent of the state's annual statewide DSH cap. This amount represents the maximum that the state can spend in any given fiscal year on IMDDSH, but the state is under no obligation to actually spend that amount.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-21-166, s 182-550-5130, filed 10/23/24, effective 11/23/24*
- *WSR 15-18-065, § 182-550-5130, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-5130, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-090, § 388-550-5130, filed 6/29/07, effective 8/1/07.*

##### **Wash. Admin. Code § 182-550-5150** Payment method—Medical care services disproportionate share hospital (MCSDSH). {#sec-182-550-5150 omnilex-key=us-wa-regs-official--title-182--182-550-5150}

(1) A hospital is eligible for the medical care services disproportionate share hospital (MCSDSH) payment if the hospital:

(a) Meets the criteria in WAC 182-550-4900;

(b) Is an in-state or designated bordering city hospital;

(c) Provides services to clients eligible under the medical care services program; and

(d) Has a medicaid inpatient utilization rate (MIUR) of one percent or more.

(2) The medicaid agency determines the MCSDSH payment for each eligible hospital in accordance with WAC 182-550-4800 for inpatient hospital claims submitted for medical care services (MCS) clients.

(3) The agency makes MCSDSH payments to a hospital on a claim-specific basis for inpatient services.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-07-061, s 182-550-5150, filed 3/13/25, effective 4/13/25. Statutory Authority: RCW 41.05.021. WSR 12-20-029, § 182-550-5150, filed 9/26/12, effective 10/27/12. WSR 11-14-075, recodified as § 182-550-5150, filed 6/30/11, effective 7/1/11. Statutory Authority: 2009 c 564 §§ 201 and 209, RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.500. WSR 10-11-032, § 388-550-5150, filed 5/11/10, effective 6/11/10. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-090, § 388-550-5150, filed 6/29/07, effective 8/1/07*
- *WSR 06-08-046, § 388-550-5150, filed 3/30/06, effective 4/30/06. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. WSR 03-13-055, § 388-550-5150, filed 6/12/03, effective 7/13/03. Statutory Authority: RCW 74.08.090, 74.09.730, chapter 74.46 RCW and 42 U.S.C. 1396r-4. WSR 99-14-025, § 388-550-5150, filed 6/28/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-5150, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-5200** Payment method—Small rural disproportionate share hospital (SRDSH). {#sec-182-550-5200 omnilex-key=us-wa-regs-official--title-182--182-550-5200}

(1) The medicaid agency makes small rural disproportionate share hospital (SRDSH) payments to qualifying small rural hospitals through the disproportionate share hospital (DSH) program.

(2) To qualify for an SRDSH payment, a hospital must:

(a) Not be participating in the "full cost" public hospital certified public expenditure (CPE) payment program as described in WAC 182-550-4650;

(b) Not be designated as an "institution for mental diseases (IMD)" as defined in WAC 182-500-0050;

(c) Meet the criteria in WAC 182-550-4900 (4) and (5);

(d) Have fewer than 75 acute beds;

(e) Be an in-state hospital. A hospital located out-of-state or in a designated bordering city is not eligible to receive SRDSH payments; and

(f) Be located in a city or town with a nonstudent population of no more than 17,806 in calendar year 2008, as determined by population data reported by the Washington state office of financial management population of cities, towns, and counties used for the allocation of state revenues. This nonstudent population is used for state fiscal year (SFY) 2010, which began July 1, 2009. For each subsequent SFY, the nonstudent population is increased by two percent.

(3) The agency pays hospitals qualifying for SRDSH payments. The agency determines each hospital's individual SRDSH payment from the total dollars using percentages established as follows:

(a) At the time the SRDSH payment is to be made, the agency calculates each hospital's profitability margin based on the hospital's base year data and audited financial statements.

(b) The agency determines the average profitability margin for the qualifying hospitals.

(c) Any hospital with a profitability margin of less than 110 percent of the average profitability margin for qualifying hospitals receives a profit factor of 1.1. All other hospitals receive a profit factor of 1.0.

(d) The agency:

(i) Identifies the medicaid payment amounts made by the agency to the individual hospital during the SFY two years before the current SFY for which DSH application is being made. These medicaid payment amounts are based on historical data considered to be complete; then

(ii) Multiplies the total medicaid payment amount determined in (d)(i) of this subsection by the individual hospital's assigned profit factor (1.1 or 1.0) to identify a revised medicaid payment amount; and

(iii) Divides the revised medicaid payment amount for the individual hospital by the sum of the revised medicaid payment amounts for all qualifying hospitals during the same period.

(4) The agency's SRDSH payments to a hospital may not exceed 100 percent of the projected cost of care for medicaid clients and uninsured patients for that hospital unless an exception is required by federal statute or regulation.

(5) The agency reallocates dollars as defined in the state plan.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-07-061, s 182-550-5200, filed 3/13/25, effective 4/13/25*
- *WSR 15-18-065, § 182-550-5200, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-5200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 74.09.730(2). WSR 10-17-095, § 388-550-5200, filed 8/17/10, effective 9/17/10. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-090, § 388-550-5200, filed 6/29/07, effective 8/1/07*
- *WSR 06-08-046, § 388-550-5200, filed 3/30/06, effective 4/30/06. Statutory Authority: RCW 74.08.090, 74.04.050, and 2003 1st sp.s. c 25. WSR 04-12-044, § 388-550-5200, filed 5/28/04, effective 7/1/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. WSR 03-13-055, § 388-550-5200, filed 6/12/03, effective 7/13/03. Statutory Authority: RCW 74.08.090, 74.09.730, chapter 74.46 RCW and 42 U.S.C. 1396r-4. WSR 99-14-025, § 388-550-5200, filed 6/28/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-5200, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-5300** Payment method—Children's health program disproportionate share hospital (CHPDSH). {#sec-182-550-5300 omnilex-key=us-wa-regs-official--title-182--182-550-5300}

(1) Effective July 1, 2011, a hospital is eligible for the children's health program disproportionate share hospital (CHPDSH) payment if funding is legislatively appropriated and if the hospital:

(a) Meets the criteria in WAC 182-550-4900;

(b) Is an in-state or designated bordering city hospital; or

(c) Provides services to low-income, children's health program (CHP) clients who, because of their citizenship status, are not eligible for medicaid nonemergency health coverage and who are encountering a nonemergency medical condition.

(2) Hospitals qualifying for CHPDSH payments will receive a per claim payment for inpatient and outpatient claims at the equivalent medicaid rate.

(3) The agency determines the CHPDSH payment for each eligible hospital in accordance with:

(a) WAC 182-550-2900 through 182-550-3000 and other sections in chapter 182-550 WAC that pertain to inpatient hospital claims submitted for CHP clients; and

(b) WAC 182-550-7000 through 182-550-7600 and other sections in chapter 182-550 WAC that pertain to outpatient hospital claims submitted for CHP clients.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-07-061, s 182-550-5300, filed 3/13/25, effective 4/13/25. Statutory Authority: RCW 41.05.021. WSR 12-20-029, § 182-550-5300, filed 9/26/12, effective 10/27/12.*

##### **Wash. Admin. Code § 182-550-5400** Payment method—Public hospital disproportionate share hospital (PHDSH). {#sec-182-550-5400 omnilex-key=us-wa-regs-official--title-182--182-550-5400}

(1) The medicaid agency's public hospital disproportionate share hospital (PHDSH) program is a certified public expenditure program for government-operated hospitals. To be eligible for PHDSH, a hospital must qualify for disproportionate share hospital (DSH) payments under WAC 182-550-4900 and be:

(a) Operated by a public hospital district in the state of Washington and participating in the "full cost" public hospital certified public expenditure (CPE) payment program described in WAC 182-550-4650;

(b) Harborview Medical Center; or

(c) University of Washington Medical Center.

(2) The PHDSH payments to a hospital eligible under this program may not exceed the hospital's disproportionate share hospital (DSH) cap calculated according to WAC 182-550-4900. The hospital receives only the federal medical assistance percentage of the total computable payment amount.

(3) Hospitals receiving payment under the PHDSH program must provide the local match for the federal funds through certified public expenditures (CPE). Payments are limited to costs incurred by the participating hospitals.

(4) A hospital receiving payment under the PHDSH program must submit to the agency federally required medicaid cost report schedules apportioning inpatient and outpatient costs, beginning with the services provided during state fiscal year 2006. See WAC 182-550-5410.

(5) PHDSH payments are subject to the availability of DSH funds under the statewide DSH cap. If the statewide DSH cap is exceeded, the agency will recoup PHDSH payments first, but only from hospitals that received total inpatient and DSH payments above the hold harmless level, and only to the extent of the excess amount above the hold harmless level. See WAC 182-550-4900 (13) and (14), and 182-550-4670.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-07-061, s 182-550-5400, filed 3/13/25, effective 4/13/25. Statutory Authority: RCW 41.05.021, 41.05.160, and 74.09.5225(3). WSR 15-11-009, § 182-550-5400, filed 5/7/15, effective 6/7/15. Statutory Authority: RCW 41.05.021 and 42 C.F.R. 433.51(b). WSR 12-04-022, § 182-550-5400, filed 1/25/12, effective 2/25/12. WSR 11-14-075, recodified as § 182-550-5400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-090, § 388-550-5400, filed 6/29/07, effective 8/1/07*
- *WSR 06-08-046, § 388-550-5400, filed 3/30/06, effective 4/30/06. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 05-12-132, § 388-550-5400, filed 6/1/05, effective 7/1/05. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. WSR 03-13-055, § 388-550-5400, filed 6/12/03, effective 7/13/03. Statutory Authority: RCW 74.08.090, 74.09.730, chapter 74.46 RCW and 42 U.S.C. 1396r-4. WSR 99-14-025, § 388-550-5400, filed 6/28/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-5400, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-5410** CPE medicaid cost report and settlements. {#sec-182-550-5410 omnilex-key=us-wa-regs-official--title-182--182-550-5410}

(1) For patients discharged after June 30, 2005, a certified public expenditure (CPE) hospital must annually submit to the medicaid agency federally required medicaid cost report schedules, using schedules approved by the centers for medicare and medicaid services (CMS), that apportion inpatient and outpatient costs to medicaid clients and uninsured patients for the service year, as follows:

(a) Title XIX fee-for-service claims;

(b) Medicaid managed care organization (MCO) plan claims;

(c) Uninsured patients. The cost report schedules for uninsured patients must not include services that medicaid would not have covered had the patients been medicaid eligible (see WAC 182-550-1400 and 182-550-1500); and

(d) State-administered program patients. State-administered program patients are reported separately and are not to be included on the uninsured patient cost report schedule. The agency will provide provider statistics and reimbursements (PS&R) reports for the state-administered program claims.

(2) A CPE hospital must:

(a) Use the information on individualized PS&R reports provided by the agency when completing the medicaid cost report schedules. The agency provides the hospital with the PS&R reports at least thirty calendar days before the appropriate deadline.

(i) For state fiscal year (SFY) 2006, the deadline for all CPE hospitals to submit the federally required medicaid cost report schedules is June 30, 2007.

(ii) For hospitals with a December 31 year end, partial year medicaid cost report schedules for the period July 1, 2005 through December 31, 2005 must be submitted to the agency by August 31, 2007.

(iii) For SFY 2007 and thereafter, each CPE hospital must submit the medicaid cost report schedules to the agency within thirty calendar days after the medicare cost report is due to its medicare fiscal intermediary or medicare administrative contractor, whichever applies.

(b) Complete the cost report schedules for uninsured patients and medicaid clients enrolled in an MCO plan using the hospital provider's records.

(c) Comply with the agency's instructions regarding how to complete the required medicaid cost report schedules.

(3) The medicaid cost report schedules must be completed using the medicare cost report for the same reporting year.

(a) The ratios of costs-to-charges and per diem costs from the "as filed" medicare cost report are used to allocate the medicaid and uninsured costs on the "as filed" medicaid cost report schedules, unless expressly allowed for medicaid.

(b) After the medicare cost report is finalized by the medicare fiscal intermediary or medicare administrative contractor (whichever applies), final medicaid cost report schedules must be submitted to the agency incorporating the adjustments to the medicare cost report, unless expressly allowed for medicaid. CPE hospitals must submit finalized medicare cost reports with the notice of amount of program reimbursement (NPR) within thirty calendar days of receipt. The agency will then provide the hospitals with updated PS&R reports for medicaid and state program claims processed by the agency for the medicaid cost report period. The hospitals will update the data for uninsured patients and medicaid clients enrolled in an MCO plan.

(4) The medicaid cost report schedules and supporting documentation are subject to audit by the agency or its designee to verify that claimed costs qualify under federal and state rules governing the CPE payment program. The documentation required includes, but is not limited to:

(a) The revenue codes assigned to specific cost centers on the medicaid cost report schedules.

(b) The inpatient charges by revenue codes for uninsured patients and medicaid clients enrolled in an MCO plan.

(c) The outpatient charges by revenue codes for uninsured patients and medicaid clients enrolled in an MCO plan.

(d) All payments received for the inpatient and outpatient charges in (b) and (c) of this subsection including, but not limited to, payments for third party liability, uninsured patients, and medicaid clients enrolled in an MCO plan.

(5) The agency:

(a) Performs cost settlements for both the "as filed" and "final" medicaid cost report schedules for all CPE hospitals;

(b) Reports to CMS as an adjustment any difference between the payments of federal funds made to the CPE hospitals and the federal share of the certified public expenditures; and

(c) Recoups from the CPE hospitals the federal payments that exceed the hospitals' costs, unless the hold harmless provision in WAC 182-550-4670 applies.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-5410, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-5410, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 08-20-032, § 388-550-5410, filed 9/22/08, effective 10/23/08*
- *WSR 07-14-090, § 388-550-5410, filed 6/29/07, effective 8/1/07.*

##### **Wash. Admin. Code § 182-550-5450** Supplemental distributions to approved trauma service centers. {#sec-182-550-5450 omnilex-key=us-wa-regs-official--title-182--182-550-5450}

(1) The trauma care fund (TCF) is an amount appropriated to the medicaid agency each state fiscal year (SFY), at the legislature's sole discretion, for the purpose of supplementing the agency's payments to eligible trauma service centers for providing qualified trauma services to medicaid clients.

(2) Encounter data, for trauma care provided to medicaid clients enrolled in an agency-contracted managed care organization, may be included when calculating supplemental distributions from the TCF, so long as the beginning dates of service for trauma care are on and after July 1, 2013.

(3) To qualify for supplemental distributions from the TCF, a hospital must:

(a) Be designated or recognized by the department of health (DOH) as an approved Level I, Level II, or Level III adult or pediatric trauma service center;

(b) Meet the provider requirements in this section and other applicable rules;

(c) Meet the billing requirements in this section and other applicable rules;

(d) Submit all information the agency requires to monitor the program; and

(e) Comply with DOH's Trauma Registry reporting requirements.

(4) Supplemental distributions from the TCF are:

(a) Allocated into five payment pools. Timing of payments is described in subsection (5) of this section. Distributions from the payment pools to the individual hospitals are determined by first summing the agency's qualifying payments to each eligible hospital since the beginning of the service year. This amount is then expressed as a percentage of the agency's total payments to all eligible hospitals for qualifying services provided during the service year-to-date. For TCF purposes, service year is defined as the SFY. Each hospital's qualifying payment percentage for the service year-to-date is multiplied by the available amount for the service year-to-date, and then the agency subtracts what has been allocated to each hospital for the service year-to-date to determine the portion of the current payment pool to be paid to each qualifying hospital. Eligible hospitals and qualifying payments are described in (a)(i) through (iii) of this subsection. Qualifying payments are the agency's payments to:

(i) Level I, Level II, and Level III trauma service centers for qualified medicaid trauma cases since the beginning of the service year. The agency determines the countable payment for trauma care provided to medicaid clients based on date of service, not date of payment;

(ii) The Level I, Level II, and Level III hospitals for trauma cases transferred to these facilities since the beginning of the service year. A Level I, Level II, or Level III hospital that receives a transferred trauma case from any lower level hospital is eligible for an enhanced payment, regardless of the client's injury severity score (ISS); and

(iii) Level II and Level III hospitals for qualified trauma cases (those that meet or exceed the ISS criteria in (b) of this subsection) transferred by these hospitals since the beginning of the service year to a trauma service center with a higher designation level.

(b) Paid only for a medicaid trauma case that meets:

(i) The ISS of thirteen or greater for an adult trauma patient (a client age fifteen or older);

(ii) The ISS of nine or greater for a pediatric trauma patient (a client younger than age fifteen); or

(iii) The conditions of (c) of this subsection.

(c) Made to hospitals, as follows, for a trauma case that is transferred:

(i) A hospital that receives the transferred trauma case qualifies for payment regardless of the ISS if the hospital is designated or recognized by DOH as an approved Level I, Level II, or Level III adult or pediatric trauma service center;

(ii) A hospital that transfers the trauma case qualifies for payment only if:

(A) The hospital is designated or recognized by DOH as an approved Level II or Level III adult or pediatric trauma service center; and

(B) The ISS requirements in (b)(i) or (ii) of this subsection are met.

(iii) A hospital that DOH designates or recognizes as an approved Level IV or Level V trauma service center does not qualify for supplemental distributions for trauma cases that are transferred in or transferred out, even when the transferred cases meet the ISS criteria in (b) of this subsection.

(d) Not funded by disproportionate share hospital (DSH) funds; and

(e) Not distributed by the agency to:

(i) Trauma service centers designated or recognized as Level IV or Level V;

(ii) Critical access hospitals (CAHs), except when the CAH is also a Level III trauma service center; or

(iii) Any facility for follow-up services related to the qualifying trauma incident but provided to the client after the client has been discharged from the initial hospitalization for the qualifying injury.

(5) Distributions for an SFY are paid as follows:

(a) The first supplemental distribution from the TCF is made three to six months after the SFY begins;

(b) Subsequent distributions are made approximately every two to four months after the first distribution is made, except as described in (c) of this subsection;

(c) The final distribution from the TCF for an SFY is:

(i) Made one year after the end of the SFY;

(ii) Limited to the remaining balance of the agency's TCF appropriation for that SFY; and

(iii) Distributed based on each eligible hospital's percentage share of the total payments made by the agency to all designated trauma service centers for qualified trauma services provided during the relevant SFY.

(6) For purposes of the supplemental distributions from the TCF, all of the following apply:

(a) At its discretion, and with sufficient public notice, the agency may adjust the deadline for submission and/or adjustment of trauma claims in response to budgetary program needs;

(b) The agency considers a provider's request for a trauma claim adjustment only if the adjustment request is received by the agency within three hundred sixty-five calendar days from the date of the initial trauma service;

(c) Except as provided in (a) of this subsection, the deadline for making adjustments to a trauma claim is the same as the deadline for submitting the initial claim to the agency as specified in WAC 182-502-0150(3). See WAC 182-502-0150 (11) and (12) for other time limits applicable to TCF claims;

(d) All claims and claim adjustments are subject to federal and state audit and review requirements; and

(e) The total amount of supplemental distributions from the TCF disbursed to eligible hospitals by the agency in any SFY cannot exceed the amount appropriated by the legislature for that SFY. The agency has the authority to take whatever actions necessary to ensure the department stays within the TCF appropriation.

**History**
- *Statutory Authority: RCW 41.05.021 and Washington State Plan Amendment 13-15. WSR 14-10-002, § 182-550-5450, filed 4/23/14, effective 5/24/14. Statutory Authority: RCW 41.05.021. WSR 13-17-017, § 182-550-5450, filed 8/9/13, effective 9/9/13*
- *WSR 12-14-041, § 182-550-5450, filed 6/27/12, effective 7/28/12. WSR 11-14-075, recodified as § 182-550-5450, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 70.168.040, 74.08.090, and 74.09.500. WSR 10-12-013, § 388-550-5450, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.160, 74.09.500, and 70.168.040. WSR 08-08-065, § 388-550-5450, filed 3/31/08, effective 5/1/08. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-14-090, § 388-550-5450, filed 6/29/07, effective 8/1/07*
- *WSR 06-08-046, § 388-550-5450, filed 3/30/06, effective 4/30/06*
- *WSR 04-19-113, § 388-550-5450, filed 9/21/04, effective 10/22/04.*

##### **Wash. Admin. Code § 182-550-5550** Public notice for changes in medicaid payment rates for hospital services. {#sec-182-550-5550 omnilex-key=us-wa-regs-official--title-182--182-550-5550}

(1) The purpose and intent of this section is to describe how the medicaid agency, pertaining to medicaid hospital rates, will comply with section 4711(a) of the federal Balanced Budget Act of 1997, Public Law 105-33, as codified at 42 U.S.C. 1396a (a)(13)(A).

(2) For purposes of this section, the term:

(a) "Stakeholders" means providers, beneficiaries, representatives of beneficiaries, and other concerned state residents.

(b) "Rate" means the medicaid payment amount to a provider for a particular hospital service, except for disproportionate share payments not mandated by federal law.

(c) "Methodology" underlying the establishment of a medicaid hospital rate means (unless otherwise noted) the principles, procedures, limitations, and formulas detailed in WAC 182-550-2900 through 182-550-5500.

(d) "Justification" means an explanation of why the agency is proposing or implementing a medicaid rate change based on a change in medicaid rate setting methodology.

(e) "Reasonable opportunity to review and provide written comments" means a period of 14 calendar days in which stakeholders may provide written comments to the agency.

(f) "Hospital services" means those services that are performed in a hospital facility for an inpatient client and which are payable only to the hospital entity, not to individual performing providers.

(g) "Website" means the agency's internet home page on the worldwide web: http://www.hca.wa.gov/ is the internet address.

(3) The agency will notify stakeholders of proposed and final changes in individual medicaid hospital rates for hospital services, as follows:

(a) Publish the proposed medicaid hospital rates, the methodologies underlying the establishment of the rates, and justifications for the rates;

(b) Give stakeholders a reasonable opportunity to review and provide written comments on the proposed medicaid hospital rates, the methodologies underlying the establishment of the rates, and justifications for the rates; and

(c) Publish the final medicaid hospital rates, the methodologies underlying the establishment of such rates, and justifications for such rates.

(4)(a) Except as otherwise provided in this section, the agency will determine the manner of publication of proposed or final medicaid hospital rates.

(b) Publication of proposed medicaid hospital rates will occur as follows:

(i) The agency will send each provider's proposed rate to the affected provider via email at least 15 calendar days before the proposed date for implementing the rates; and

(ii) For other stakeholders, the agency will post proposed rates on the agency's website.

(c) Publication of final medicaid hospital rates will occur as follows:

(i) The agency will send each provider's final rate to the affected provider via email at least one calendar day before implementing the rate; and

(ii) For other stakeholders, the agency will post final rates on the agency's website.

(d) The publications required by subsections (4)(b) and (c) of this section will refer to the appropriate sections of chapter 182-550 WAC for information on the methodologies underlying the proposed and final rates.

(5) The agency, when it proposes amendments to the methodologies underlying the establishment of medicaid hospital rates as described in WAC 182-550-2900 through 182-550-5500, will adhere to the notice and comment provisions of the Administrative Procedure Act (chapter 34.05 RCW).

(6) Stakeholders who wish to receive notice of either proposed and final medicaid hospital rates or proposed and final amendments to WAC 182-550-2900 through 182-550-5500 must notify the agency in writing. The agency will send notice of all the actions to the stakeholders postage prepaid by regular mail.

(7)(a) The notice and publication provisions of section 4711(a) of the Balanced Budget Act of 1997 do not apply when a rate change is:

(i) Necessary to conform to medicare rules, methods, or levels of reimbursement for clients who are eligible for both medicare and medicaid;

(ii) Required by Congress, the legislature, or court order, and no further rule making is necessary to implement the change; or

(iii) Part of a nonmedicaid program.

(b) Although notice and publication are not required for medicaid rate changes described in subsection (7)(a) of this section, the agency will attempt to timely notify stakeholders of these rate changes.

(8) The following rules apply when the agency and an individual hospital negotiate or contractually agree to medicaid rates for hospital services:

(a) Receipt by the hospital of the contract or contract amendment form for signature constitutes notice to the hospital of proposed medicaid rates.

(b) Receipt by the hospital of the contract or contract amendment form signed by both parties constitutes notice to the hospital of final medicaid rates.

(c) Notwithstanding subsection (4)(c) of this section, final medicaid contract rates are effective on the date contractually agreed to by the agency and the individual hospital.

(d) Before the execution of the contract, the agency will not publish negotiated contract prices that are agreed to between the agency and an individual provider to anyone other than the individual provider. Within 15 calendar days after the execution of any such contract, the agency will publish the negotiated contract prices on its website.

(9) The following rules apply when a hospital provider or other stakeholder wishes to challenge the adequacy of the public notification process followed by the agency in proposing or implementing a change to medicaid hospital rates, the methodologies underlying the establishment of the rates, or the justification for the rates:

(a) If any such challenge is limited solely to the adequacy of the public notification process, then the challenge will:

(i) Not be pursued in any administrative appeal or dispute resolution procedure established in rule by the agency; and

(ii) Be pursued only in a court of proper jurisdiction as may be provided by law.

(b) If a hospital provider brings any such challenge in conjunction with an appeal of its medicaid rate, then the hospital provider may pursue the challenge in an administrative appeal or dispute resolution procedure established in rule by the agency under which hospital providers may appeal their medicaid rates.

**History**
- *Statutory Authority: RCW 41.05.021 (1)(m)(i), (iv), and 41.05.160. WSR 25-14-023, s 182-550-5550, filed 6/24/25, effective 7/25/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-5550, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-5550, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.09.500 and 42 U.S.C. 1396a (a)(13)(A). WSR 98-23-036, § 388-550-5550, filed 11/10/98, effective 12/11/98.*

##### **Wash. Admin. Code § 182-550-5600** Dispute resolution process for hospital rate reimbursement. {#sec-182-550-5600 omnilex-key=us-wa-regs-official--title-182--182-550-5600}

The dispute resolution process for hospital rate reimbursement follows the procedures as stated in WAC 182-502-0220.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-5600, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-5600, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. WSR 03-13-055, § 388-550-5600, filed 6/12/03, effective 7/13/03. Statutory Authority: RCW 74.08.090 and 74.09.730. WSR 99-16-070, § 388-550-5600, filed 8/2/99, effective 9/2/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-5600, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-5700** Hospital reports and audits. {#sec-182-550-5700 omnilex-key=us-wa-regs-official--title-182--182-550-5700}

(1) In-state and border area hospitals will complete and submit a copy of their annual medicare cost reports (HCFA 2552) to the medicaid agency. These hospital providers will:

(a) Maintain adequate records for audit and review purposes, and assure the accuracy of their cost reports;

(b) Complete their annual medicare HCFA 2552 cost report according to the applicable medicare statutes, regulations, and instructions; and

(c) Submit a copy to the agency:

(i) Within 150 days from the end of the hospital's fiscal year; or

(ii) If the hospital provider's contract is terminated, within 150 days of effective termination date; or

(d) Request up to a 30-day extension of the time for submitting the cost report in writing at least 10 days before the due date of the report. Hospital providers will include in the extension request the completion date of the report, and the circumstances prohibiting compliance with the report due date;

(2) If a hospital provider improperly completes a cost report or the cost report is received after the due date or approved extension date, the agency may withhold all or part of the payments due the hospital until the agency receives the properly completed or late report.

(3) Hospitals will submit other financial information required by the agency to establish rates.

(4) The agency will periodically audit the financial and statistical records of participating providers as needed.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 42 C.F.R. Part 447, Subpart C, § 447.253(g). WSR 24-06-036, § 182-550-5700, filed 2/29/24, effective 3/31/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-5700, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-5700, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-5700, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-5800** Outpatient and emergency hospital services. {#sec-182-550-5800 omnilex-key=us-wa-regs-official--title-182--182-550-5800}

The medicaid agency will cover outpatient services, emergent outpatient surgical care, and other emergency care performed on an outpatient basis in a hospital for categorically needy or limited casualty program-medically needy clients.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-5800, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-5800, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-5800, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-6000** Outpatient hospital services—Conditions of payment and payment methods. {#sec-182-550-6000 omnilex-key=us-wa-regs-official--title-182--182-550-6000}

(1) The medicaid agency pays hospitals for covered outpatient hospital services provided to eligible clients when the services meet the provisions in WAC 182-550-1700. All professional medical services must be billed according to chapter 182-531 WAC.

(2) To be paid for covered outpatient hospital services, a hospital provider must:

(a) Have a current core provider agreement with the agency;

(b) Bill the agency according to the conditions of payment under WAC 182-502-0100;

(c) Bill the agency according to the time limits under WAC 182-502-0150; and

(d) Meet program requirements in other applicable WAC and the agency's published issuances.

(3) The agency does not pay separately for any services:

(a) Included in a hospital's room charges;

(b) Included as covered under the agency's definition of room and board (e.g., nursing services). See WAC 182-550-1050; or

(c) Related to an inpatient hospital admission and provided within one calendar day of a client's inpatient admission.

(4) The agency does not pay:

(a) A hospital for outpatient hospital services when a managed care plan is contracted with the agency to cover these services;

(b) More than the "acquisition cost" ("A.C.") for HCPCS (health care common procedure coding system) codes noted in the outpatient fee schedule; or

(c) For cast room, emergency room, labor room, observation room, treatment room, and other room charges in combination when billing periods for these charges overlap.

(5) The agency uses the outpatient weighted costs-to-charges (OWCC) rate to pay for covered outpatient services provided in a critical access hospital (CAH). See WAC 182-550-2598.

(6) Hospitals must provide documentation as required or requested by the agency.

(7) All hospital providers must present final charges to the agency within 365 days of the "statement covers period from date" shown on the claim. The state of Washington is not liable for payment based on billed charges received beyond 365 days from the "statement covers period from date" shown on the claim.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-14-040, § 182-550-6000, filed 6/27/22, effective 7/28/22*
- *WSR 22-04-051, § 182-550-6000, filed 1/27/22, effective 2/27/22*
- *WSR 15-18-065, § 182-550-6000, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-6000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-13-100, § 388-550-6000, filed 6/20/07, effective 8/1/07*
- *WSR 04-20-060, § 388-550-6000, filed 10/1/04, effective 11/1/04. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and Public Law 104-191. WSR 03-19-044, § 388-550-6000, filed 9/10/03, effective 10/11/03. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. WSR 02-21-019, § 388-550-6000, filed 10/8/02, effective 11/8/02. Statutory Authority: RCW 74.09.090, 42 U.S.C. 1395x(v), 42 C.F.R. 447.271 and 42 C.F.R. 11303. WSR 99-14-028, § 388-550-6000, filed 6/28/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 42 U.S.C. 1395 x(v), 42 C.F.R. 447.271, 447.11303, and 447.2652. WSR 99-06-046, § 388-550-6000, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-6000, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-6100** Outpatient hospital physical therapy. {#sec-182-550-6100 omnilex-key=us-wa-regs-official--title-182--182-550-6100}

(1) The medicaid agency pays for physical therapy provided to eligible clients as an outpatient hospital service according to WAC 182-545-200 and 182-550-6000.

(2) A hospital must bill outpatient hospital physical therapy services using appropriate billing codes listed in the agency's current published billing instructions. The agency does not pay outpatient hospitals a facility fee for these services.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-6100, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-6100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and Public Law 104-191. WSR 03-19-043, § 388-550-6100, filed 9/10/03, effective 10/11/03. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-6100, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-6150** Outpatient hospital occupational therapy. {#sec-182-550-6150 omnilex-key=us-wa-regs-official--title-182--182-550-6150}

(1) The medicaid agency pays for occupational therapy provided as an outpatient hospital service to eligible clients according to WAC 182-545-200 and 182-550-6000.

(2) The hospital must bill outpatient hospital occupational therapy services using appropriate billing codes listed in the agency's current published billing instructions. The agency does not pay outpatient hospitals a facility fee for these services.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-6150, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-6150, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and Public Law 104-191. WSR 03-19-043, § 388-550-6150, filed 9/10/03, effective 10/11/03. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-6150, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-6200** Outpatient hospital speech therapy services. {#sec-182-550-6200 omnilex-key=us-wa-regs-official--title-182--182-550-6200}

(1) The medicaid agency pays for speech therapy services provided to eligible clients as an outpatient hospital service according to this section and WAC 182-545-200 and 182-550-6000.

(2) The agency requires swallowing (dysphagia) evaluations to be performed by a speech/language pathologist who holds a master's degree in speech pathology and who has received extensive training in the anatomy and physiology of the swallowing mechanism, with additional training in the evaluation and treatment of dysphagia.

(3) The agency requires a swallowing evaluation to include:

(a) An oral-peripheral exam to evaluate the anatomy and function of the structures used in swallowing;

(b) Dietary recommendations for oral food and liquid intake therapeutic or management techniques;

(c) Therapeutic or management techniques; and

(d) Videofluoroscopy, when necessary, for further evaluation of swallowing status and aspiration risks.

(4) A hospital must bill outpatient hospital speech therapy services using appropriate billing codes listed in the agency's current published billing instructions. The agency does not pay the outpatient hospital a facility fee for these services.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-6200, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-6200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and Public Law 104-191. WSR 03-19-043, § 388-550-6200, filed 9/10/03, effective 10/11/03. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-6200, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-6250** Pregnancy—Enhanced outpatient benefits. {#sec-182-550-6250 omnilex-key=us-wa-regs-official--title-182--182-550-6250}

The medicaid agency will provide outpatient substance use disorder treatment in programs qualified under WAC 182-538C-230 and certified under chapter 246-341 WAC or its successor. See RCW 71.24.385.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-18-059, § 182-550-6250, filed 8/26/21, effective 9/26/21*
- *WSR 15-18-065, § 182-550-6250, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-6250, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-6250, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-6300** Outpatient nutritional counseling. {#sec-182-550-6300 omnilex-key=us-wa-regs-official--title-182--182-550-6300}

See chapter 182-555 WAC for medical nutrition therapy.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-060, § 182-550-6300, filed 10/31/18, effective 1/1/19*
- *WSR 15-18-065, § 182-550-6300, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-6300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-6300, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-6450** Outpatient hospital weight loss program. {#sec-182-550-6450 omnilex-key=us-wa-regs-official--title-182--182-550-6450}

The medicaid agency may pay for an outpatient weight loss program only when provided through an outpatient weight loss facility approved by the agency. The agency will deny payment for services provided by nonapproved providers.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-6450, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-6450, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-6450, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-6500** Blood and blood components. {#sec-182-550-6500 omnilex-key=us-wa-regs-official--title-182--182-550-6500}

(1) The medicaid agency pays a hospital only for:

(a) Blood bank service charges for processing and storage of blood and blood components; and

(b) Blood administration charges.

(2) The agency does not pay for blood and blood components.

(3) The agency does not pay a hospital separately for the services identified in subsection (1) when these services are included and paid using the diagnosis-related group (DRG), per diem, or per case rate payment rates.

(4) The agency pays a hospital no more than the hospital's cost, as determined by the agency, for the services identified in subsection (1) when the hospital is paid using the ratio of costs-to-charges (RCC) or weighted costs-to-charges WCC payment method.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-6500, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-6500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-13-100, § 388-550-6500, filed 6/20/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-6500, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-6600** Hospital-based physician services. {#sec-182-550-6600 omnilex-key=us-wa-regs-official--title-182--182-550-6600}

See chapter 182-531 WAC regarding rules for inpatient and outpatient physician services.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-6600, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-6600, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-6600, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-6700** Hospital services provided out-of-state. {#sec-182-550-6700 omnilex-key=us-wa-regs-official--title-182--182-550-6700}

(1) The agency pays:

(a) For dates of admission before August 1, 2007, for only emergency care for an eligible medicaid and CHIP client who goes to another state, except specified border cities, specifically for the purpose of obtaining medical care that is available in the state of Washington. See WAC 182-501-0175 for a list of border cities.

(b) For dates of admission on and after August 1, 2007, for both emergency and nonemergency out-of-state hospital services, including those provided in bordering city hospitals and critical border hospitals, for eligible medicaid and CHIP clients based on the medical necessity and utilization review standards and limits established by the agency.

(i) Prior authorization by the agency is required for the nonemergency out-of-state hospital medical care provided to medicaid and CHIP clients.

(ii) Bordering city hospitals are considered the same:

(A) As instate hospitals for coverage of hospital services; and

(B) As out-of-state hospitals for payment methodology. Agency designated critical border hospitals are paid as instate hospitals. See WAC 182-550-3900 and 182-550-4000.

(c) For out-of-state voluntary psychiatric inpatient hospital services for eligible medicaid and CHIP clients based on authorization by a division of behavioral health designee.

(d) Based on the agency's limitations on hospital coverage under WAC 182-550-1100 and 182-550-1200 and other applicable rules.

(2) The agency authorizes and pays for comparable hospital services for a medicaid and CHIP client who is temporarily outside the state to the same extent that such services are furnished to an eligible medicaid client in the state, subject to the exceptions and limitations in this section. See WAC 182-550-3900 and 182-550-4000.

(3) The agency limits out-of-state hospital coverage for persons eligible under state-administered programs as follows:

(a) For a person who receives services under the Involuntary Treatment Act (ITA), the agency does not pay for hospital services provided in any hospital outside the state of Washington (including bordering city and critical border hospitals).

(b) For a person eligible under an agency's general assistance program, the agency pays only for hospital services covered under the person's medical care services' program scope of care that are provided in a bordering city hospital or a critical border hospital. The agency does not pay for hospital services provided to persons eligible under a general assistance program in other hospitals located outside the state of Washington. The agency or its designee may require prior authorization for hospital services provided in a bordering city hospital or a critical border hospital. See WAC 182-550-1200.

(4) The agency covers hospital care provided to medicaid or CHIP clients in areas of Canada as described in WAC 182-501-0180, and based on the limitations described in the state plan.

(5) The agency may review all cases involving out-of-state hospital services, including those provided in bordering city hospitals and critical border hospitals, to determine whether the services are within the scope of the person's WAH program.

(6) If the person can claim deductible or coinsurance portions of medicare, the provider must submit the claim to the intermediary or carrier in the provider's own state on the appropriate medicare billing form. If the state of Washington is checked on the form as the party responsible for medical bills, the intermediary or carrier may bill on behalf of the provider or may return the claim to the provider for submission to the state of Washington.

(7) For payment for out-of-state inpatient hospital services, see WAC 182-550-3900 and 182-550-4000.

(8) Out-of-state providers, including bordering city hospitals and critical border hospitals, must present final charges to the agency within three hundred sixty-five days of the "statement covers period from date" shown on the claim. The state of Washington is not liable for payment of charges received beyond three hundred sixty-five days from the "statement covers period from date" shown on the claim.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-019, § 182-550-6700, filed 7/24/14, effective 8/24/14. WSR 11-14-075, recodified as § 182-550-6700, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. WSR 07-14-051, § 388-550-6700, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.08.090. WSR 01-02-075, § 388-550-6700, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-6700, filed 12/18/97, effective 1/18/98.*

##### **Wash. Admin. Code § 182-550-7000** Outpatient prospective payment system (OPPS)—General. {#sec-182-550-7000 omnilex-key=us-wa-regs-official--title-182--182-550-7000}

(1) The medicaid agency pays for outpatient services using an outpatient prospective payment system (OPPS) for all hospitals that do not qualify as in-state critical access hospitals per WAC 182-550-2598.

(2) The agency uses the enhanced ambulatory payment group (EAPG) software provided by 3MTM Health Information Systems to group OPPS claims based on services performed and resource intensity.

(3) The agency uses the group established in subsection (2) of this section to determine payment for OPPS claims.

**History**
- *Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-14-049, § 182-550-7000, filed 6/25/14, effective 7/26/14. WSR 11-14-075, recodified as § 182-550-7000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-13-100, § 388-550-7000, filed 6/20/07, effective 8/1/07*
- *WSR 04-20-061, § 388-550-7000, filed 10/1/04, effective 11/1/04.*

##### **Wash. Admin. Code § 182-550-7200** OPPS—Billing requirements and payment method. {#sec-182-550-7200 omnilex-key=us-wa-regs-official--title-182--182-550-7200}

This section describes hospital provider billing requirements and the payment methods the medicaid agency uses to pay for covered outpatient hospital services provided by hospitals included in the outpatient prospective payment system (OPPS).

(1) Providers must bill according to national correct coding initiative (NCCI) standards maintained by the Centers for Medicare and Medicaid Services (CMS).

ENHANCED AMBULATORY PATIENT GROUP (EAPG) METHOD

(2) The agency uses the enhanced ambulatory patient group (EAPG) method as the primary payment method for OPPS. Examples of services paid by the EAPG method include:

(a) Surgeries;

(b) Significant procedures;

(c) Observation services;

(d) Medical visits;

(e) Dental procedures; and

(f) Ancillary services.

OPPS MAXIMUM ALLOWABLE FEE SCHEDULE

(3) The agency pays using the outpatient fee schedule for:

(a) Covered services exempted from the EAPG payment method due to agency policy;

(b) Covered services for which there are no established relative weights, such as:

(i) Durable medical equipment procedures grouped to EAPG type 7; and

(ii) Physical therapy procedures grouped to EAPG type 21;

(c) Corneal tissue acquisition; and

(d) Other services as identified by the agency and posted on the agency's website.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-20-048, § 182-550-7200, filed 9/28/23, effective 10/29/23. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-14-049, § 182-550-7200, filed 6/25/14, effective 7/26/14. WSR 11-14-075, recodified as § 182-550-7200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.09.500, and 74.09.530. WSR 10-08-023, § 388-550-7200, filed 3/30/10, effective 4/30/10. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-13-100, § 388-550-7200, filed 6/20/07, effective 8/1/07*
- *WSR 04-20-061, § 388-550-7200, filed 10/1/04, effective 11/1/04.*

##### **Wash. Admin. Code § 182-550-7300** OPPS—Payment limitations. {#sec-182-550-7300 omnilex-key=us-wa-regs-official--title-182--182-550-7300}

(1) The medicaid agency limits payment for covered outpatient hospital services to the current published maximum allowable units of services listed in the outpatient fee schedule published on the agency's website, subject to the following limitations:

(a) To receive payment for services, providers must bill claims according to national correct coding initiative (NCCI) standards. When a unit limit for services is not stated in the outpatient fee schedule, the agency pays for services according to the program's unit limits stated in applicable WAC and published provider guides.

(b) The average resource, including units of service, are factored into the enhanced ambulatory patient group (EAPG) weight determination, and the allowable units of service for EAPGs is equal to one.

(2) The following service categories are included in the EAPG payment for significant procedure(s) on the claim and do not receive separate payments under EAPG:

(a) Services classified as the same or clinically related to the main significant procedure;

(b) Routine ancillary services;

(c) Chemotherapy services grouped as class I, class II, or minor; and

(d) Pharmacotherapy services grouped as class I, class II, or minor.

(3) The agency reduces the EAPG payment by fifty percent based on the default EAPG grouper settings for services subject to one or more of the following discounts:

(a) Multiple procedures;

(b) Repeat ancillary services; or

(c) A terminated procedure.

(4) The agency limits outpatient services billing to one claim per episode of care. If any line of the claim is denied, or a service that was provided was not stated on the initial submitted claim, the agency requires the entire claim to be adjusted.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-09-022, § 182-550-7300, filed 4/11/18, effective 5/12/18. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-14-049, § 182-550-7300, filed 6/25/14, effective 7/26/14. WSR 11-14-075, recodified as § 182-550-7300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.09.500, and 74.09.530. WSR 10-08-023, § 388-550-7300, filed 3/30/10, effective 4/30/10. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-13-100, § 388-550-7300, filed 6/20/07, effective 8/1/07*
- *WSR 04-20-061, § 388-550-7300, filed 10/1/04, effective 11/1/04.*

##### **Wash. Admin. Code § 182-550-7400** OPPS EAPG relative weights. {#sec-182-550-7400 omnilex-key=us-wa-regs-official--title-182--182-550-7400}

(1) The medicaid agency uses national relative weights established by 3MTM as part of its enhanced ambulatory patient group (EAPG) payment system.

(2) The agency may update the relative weights used for calculating OPPS payments on July 1st of each year, beginning on July 1, 2015.

(3) The agency may update relative weights more frequently for newly added EAPGs in order to maintain current EAPG grouper system functionality.

(4) The agency will post all relative weights used on the agency's website.

**History**
- *Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-14-049, § 182-550-7400, filed 6/25/14, effective 7/26/14. WSR 11-14-075, recodified as § 182-550-7400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-13-100, § 388-550-7400, filed 6/20/07, effective 8/1/07*
- *WSR 04-20-061, § 388-550-7400, filed 10/1/04, effective 11/1/04.*

##### **Wash. Admin. Code § 182-550-7450** OPPS budget target adjustor. {#sec-182-550-7450 omnilex-key=us-wa-regs-official--title-182--182-550-7450}

The medicaid agency may apply an outpatient prospective payment system (OPPS) budget target adjustor to the enhanced ambulatory patient group (EAPG) payment. The agency calculates the OPPS budget target adjustor based on legislative direction to achieve the legislature's targeted expenditure levels for outpatient hospital services. The legislative direction may take the form of express language in the Biennial Appropriations Act or may be reflected in the level of funding appropriated to the agency in the Biennial Appropriations Act.

**History**
- *Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-14-049, § 182-550-7450, filed 6/25/14, effective 7/26/14. WSR 11-14-075, recodified as § 182-550-7450, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-062, § 388-550-7450, filed 5/28/09, effective 7/1/09.*

##### **Wash. Admin. Code § 182-550-7500** OPPS rate. {#sec-182-550-7500 omnilex-key=us-wa-regs-official--title-182--182-550-7500}

(1) The medicaid agency calculates hospital-specific outpatient prospective payment system (OPPS) rates using all of the following:

(a) A base conversion factor established by the agency;

(b) An adjustment for direct graduate medical education (DGME); and

(c) The latest wage index information established and published by the centers for medicare and medicaid services (CMS) when the OPPS rates are set for the upcoming year. Wage index information reflects labor costs in the cost-based statistical area (CBSA) where a hospital is located.

(2) Base conversion factors. The agency calculates the base enhanced ambulatory patient group (EAPG) conversion factor during a hospital payment system rebasing. The base is calculated as the maximum amount that can be used, along with all other payment factors and adjustments described in this chapter, to maintain aggregate payments across the system. The agency will publish base conversion factors on its website.

(3) Wage index adjustments reflect labor costs in the CBSA where a hospital is located.

(a) The agency determines the labor portion of the base rate by multiplying the base rate by the labor factor established by medicare; then

(b) Multiplying the amount in (a) of this subsection is multiplied by the most recent wage index information published by CMS when the rates are set; then

(c) The agency adds the nonlabor portion of the base rate to the amount in (b) of this subsection to produce a hospital-specific wage adjusted factor.

(4) DGME. The agency obtains the DGME information from the hospital's most recently filed medicare cost report as available in the CMS health care cost report information system (HCRIS) dataset.

(a) The hospital's medicare cost report must cover a period of twelve consecutive months in its medicare cost report year.

(b) If a hospital's medicare cost report is not available on HCRIS, the agency may use the CMS Form 2552-10 to calculate DGME.

(c) In the case where a hospital has not submitted a CMS medicare cost report in more than eighteen months from the end of the hospital's cost reporting period, the agency may remove the hospital's DGME adjustment.

(d) The agency calculates the hospital-specific DGME by dividing the DGME cost reported on worksheet B, part 1 of the CMS cost report by the adjusted total costs from the CMS cost report.

(5) The formula for calculating the hospital's final specific conversion factor is:

EAPG base rate × (.6(wage index) + .4)/(1-DGME)

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2022 c 297 § 211(52). WSR 23-01-014, § 182-550-7500, filed 12/8/22, effective 1/8/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 2021 c 334 §§ 211(46) and 215(66). WSR 22-03-008, § 182-550-7500, filed 1/6/22, effective 2/6/22. Statutory Authority: RCW 41.05.021, 41.05.160, and 2019 c 415 § 211(14). WSR 20-01-075, § 182-550-7500, filed 12/11/19, effective 1/11/20. Statutory Authority: RCW 41.05.021, 41.05.160, and 2018 c 299 § 213 (1)(fff). WSR 18-16-059, § 182-550-7500, filed 7/26/18, effective 8/26/18. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 14-22-003, § 182-550-7500, filed 10/22/14, effective 11/22/14. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-14-049, § 182-550-7500, filed 6/25/14, effective 7/26/14. WSR 11-14-075, recodified as § 182-550-7500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-062, § 388-550-7500, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-13-100, § 388-550-7500, filed 6/20/07, effective 8/1/07*
- *WSR 04-20-061, § 388-550-7500, filed 10/1/04, effective 11/1/04.*

##### **Wash. Admin. Code § 182-550-7550** OPPS payment enhancements. {#sec-182-550-7550 omnilex-key=us-wa-regs-official--title-182--182-550-7550}

(1) Pediatric adjustment.

(a) The medicaid agency establishes a policy adjustor to be applied to all enhanced ambulatory patient group (EAPG) services for clients under age 18 years.

(b) Effective July 1, 2014, this adjustor equals one point thirty-five (1.35).

(2) Chemotherapy and combined chemotherapy/pharmacotherapy adjustment.

(a) The agency establishes a policy adjustor to be applied to services grouped as chemotherapy drugs or combined chemotherapy and pharmacotherapy drugs.

(b) Effective July 1, 2014, this adjustor equals one point one (1.1).

(3) Sole community hospitals.

(a) For sole community hospital's rate enhancements, the agency multiplies the in-state hospital's specific EAPG conversion factor by a multiplier if the hospital meets all of the following criteria per RCW 74.09.5225:

(i) Be certified by CMS as a sole community hospital as of January 1, 2013;

(ii) Have a level III adult trauma service designation from the Washington state department of health (DOH) as of January 1, 2014;

(iii) Have less than 150 acute care licensed beds in fiscal year 2011; and

(iv) Be owned and operated by the state or a political subdivisions.

(b) Effective July 1, 2024, the enhancement multiplier equals 1.25. This may be adjusted in future years to account for legislatively approved increases. (See RCW 74.09.5225)

| Enhancement Multiplier by Year | | | | | | | |
| --- | --- | --- | --- | --- | --- | --- | --- |
| Provider Category | Effective For the Dates | | | | | | |
| 07/01/2015 - 06/30/2020 | 07/01/2020 - 06/30/2021 | 07/01/2021 - 06/30/2022 | 07/01/2022 - 06/30/2023 | 07/01/2023 - 12/31/2023 | 01/01/2024 - 06/30/2024 | 07/01/2024 | |
| Sole community hospital | 1.25 | 1.5 | 1.5 | 1.25 | 1.25 | 1.50 | 1.25 |
| Sole community hospital accepting single bed certifications | N/A | N/A | 1.5 | 1.5 | N/A | N/A | N/A |

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-18-060, § 182-550-7550, filed 8/28/24, effective 9/28/24*
- *WSR 23-20-048, § 182-550-7550, filed 9/28/23, effective 10/29/23. Statutory Authority: RCW 41.05.021, 41.05.160, and 2022 c 297 § 211(52). WSR 23-01-014, § 182-550-7550, filed 12/8/22, effective 1/8/23. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-14-049, § 182-550-7550, filed 6/25/14, effective 7/26/14.*

##### **Wash. Admin. Code § 182-550-7600** OPPS payment calculation. {#sec-182-550-7600 omnilex-key=us-wa-regs-official--title-182--182-550-7600}

(1) The medicaid agency calculates the enhanced ambulatory patient group (EAPG) payment as follows:

EAPG payment =

EAPG relative weight x

Hospital-specific conversion factor x

Discount factor (if applicable) x

Policy adjustor (if applicable)

(2) The total OPPS claim payment is the sum of the EAPG payments plus the sum of the allowed amounts for each nonEAPG service.

(3) If a client's third-party liability insurance has made a payment on a service, the agency subtracts any such payments made from the medicaid allowed amount.

**History**
- *Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-14-049, § 182-550-7600, filed 6/25/14, effective 7/26/14. WSR 11-14-075, recodified as § 182-550-7600, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-062, § 388-550-7600, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-13-100, § 388-550-7600, filed 6/20/07, effective 8/1/07*
- *WSR 04-20-061, § 388-550-7600, filed 10/1/04, effective 11/1/04.*

##### **Wash. Admin. Code § 182-550-8000** Hospital safety net program (HSNP)—Purpose. {#sec-182-550-8000 omnilex-key=us-wa-regs-official--title-182--182-550-8000}

Chapter 74.60 RCW establishes the hospital safety net program (HSNP). The HSNP provides funding that is used solely to increase funding from all other sources and support additional payments to hospitals as authorized by chapter 74.60 RCW. The medicaid agency has authority to issue rules associated with the HSNP under RCW 41.05.021 (1)(m)(iv) and 74.60.050(1).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-20-048, § 182-550-8000, filed 9/28/23, effective 10/29/23. Statutory Authority: RCW 41.05.021, 41.05.160, and 74.60.050. WSR 20-14-054, § 182-550-8000, filed 6/26/20, effective 7/27/20.*

##### **Wash. Admin. Code § 182-550-8100** Assessment notices—Process and timelines. {#sec-182-550-8100 omnilex-key=us-wa-regs-official--title-182--182-550-8100}

(1) Notification. The medicaid agency sends hospital safety net program (HSNP) assessment notices on or about 30 calendar days prior to the end of each quarter as required by RCW 74.60.030 (1)(a).

(2) Payment due date. Each hospital must pay its assessment in full by the due date listed in the HSNP notice.

(3) First past-due notification. If a hospital does not pay its HSNP assessment in full by the due date, the agency sends the hospital a past-due notice. The past-due notice informs the hospital of the actions the agency may take if the hospital's assessment becomes 60 calendar days past due.

(4) Final past-due notification. If a hospital does not pay its assessment in full within 60 calendar days of its due date stated in the HSNP notice, the agency sends the hospital a final past-due notice.

(a) The final past-due notice informs the hospital of the actions the agency takes, as required by RCW 74.60.050(2), to offset funds from the agency's scheduled payments to the hospital.

(b) The agency does not offset funds from managed care capitation payments, as described in RCW 74.60.130.

(5) Appeal. A hospital may appeal the actions the agency takes to offset funds by following the process outlined in WAC 182-502-0050.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-20-048, § 182-550-8100, filed 9/28/23, effective 10/29/23. Statutory Authority: RCW 41.05.021, 41.05.160, and 74.60.050. WSR 20-14-054, § 182-550-8100, filed 6/26/20, effective 7/27/20.*

## **Chapter 182-551** Alternatives to hospital services. {#struct-chapter-182-551}

##### **Wash. Admin. Code § 182-551-1000** Hospice program—General. {#sec-182-551-1000 omnilex-key=us-wa-regs-official--title-182--182-551-1000}

(1) The medicaid agency's hospice program is a 24 hour a day program that allows a terminally ill client to choose physical, pastoral/spiritual, and psychosocial comfort care and a focus on quality of life. A hospice interdisciplinary team communicates with the client's nonhospice care providers to ensure the client's needs are met through the hospice plan of care. Hospitalization is used only for acute symptom management.

(2) A client, a physician, or an authorized health care representative may initiate hospice care.

(3) Hospice care is provided in a client's temporary or permanent place of residence.

(4) Hospice care ends when:

(a) The client or an authorized health care representative revokes the hospice care;

(b) The hospice agency discharges the client;

(c) The client's physician determines hospice care is no longer appropriate; or

(d) The client dies.

(5) Hospice care includes the provision of emotional and spiritual comfort and bereavement support to the client's family member(s).

(6) Medicaid agency-approved hospice agencies must meet the general requirements in chapter 182-502 WAC, Administration of medical programs—Providers.

(7) A client enrolled in a medicaid agency-contracted managed care organization (MCO) must receive all hospice services, including facility room and board, directly through that MCO.

(8) The MCO is responsible for arranging and providing all hospice services for an MCO client consistent with the rules in this chapter.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1000, filed 7/25/25, effective 9/1/25. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1000, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1000, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. WSR 99-09-007, § 388-551-1000, filed 4/9/99, effective 5/10/99.*

##### **Wash. Admin. Code § 182-551-1010** Hospice program—Definitions. {#sec-182-551-1010 omnilex-key=us-wa-regs-official--title-182--182-551-1010}

The following definitions and abbreviations and those found in chapter 182-500 WAC, Medical definitions, apply to this subchapter.

"Authorized health care representative" - A person who has authority under RCW 7.70.065 to provide informed consent to terminate medical care or to elect or revoke the election of hospice care on behalf of a terminally ill individual who lacks capacity.

"Biologicals" - Medicinal preparations including serum, vaccine autotoxins, and biotechnological drugs made from living organisms and their products.

"Brief period" - Six days or less within a 30 consecutive-day period.

"Community services office (CSO)" - An office of the department of social and health services (DSHS) that administers social and health services at the community level.

"Concurrent care" - Medically necessary services delivered at the same time as hospice services, providing a blend of curative and palliative services to clients 20 years of age and younger who are enrolled in hospice. See WAC 182-551-1860.

"Curative care" - Treatment aimed at achieving a disease-free state.

"Discharge" - A hospice agency ends hospice care for a client.

"Election period" - The time, 90 or 60 calendar days, that the client is certified as eligible for and chooses to receive hospice care.

"Family" - A person or people who are important to the client and need not be relatives.

"Home and community services (HCS) office" - A department of social and health services (DSHS) home and community living administration office that manages the state's comprehensive long-term care system which provides in-home, residential, and nursing home services to clients with functional disabilities.

"Hospice agency" - A person or entity administering or providing hospice services directly or through a contract arrangement to people in places of temporary or permanent residence under the direction of an interdisciplinary team composed of at least a nurse, social worker, physician, spiritual counselor, and volunteer. (Note: For the purposes of this subchapter, requirements for hospice agencies also apply to hospice care centers.)

"Hospice aide" - A person registered or certified as a nursing assistant under chapter 18.88A RCW who, under the direction and supervision of a registered nurse, physical therapist, occupational therapist, or speech therapist, assists in the delivery of nursing or therapy related activities, or both, to patients of a hospice agency or hospice care center.

"Hospice aide services" - Services provided by hospice aides employed by an in-home services agency licensed to provide hospice or hospice care center services under the supervision of a registered nurse, physical therapist, occupational therapist, or speech therapist. Such care may include ambulation and exercise, medication assistance level 1 and level 2, reporting changes in client's conditions and needs, completing appropriate records, personal care or homemaker services, and other nonmedical tasks, as defined in this section.

"Hospice care center" - A homelike noninstitutional facility where hospice services are provided that meets the requirements for operation under RCW 70.127.280 and applicable rules.

"Hospice services" - Symptom and pain management provided to a terminally ill person, and emotional, spiritual, and bereavement support for the person and their family in a place of temporary or permanent residence.

"Interdisciplinary team" - The group of people involved in client care providing hospice services or hospice care center services including, at a minimum, a physician, registered nurse, social worker, spiritual counselor, and volunteer.

"Palliative" - Medical treatment designed to reduce pain or increase comfort, rather than cure.

"Plan of care (POC)" - A written document based on assessment of client needs that identifies services to meet these needs.

"Related condition(s)" - Any health condition(s) that manifests secondary to or exacerbates symptoms associated with the progression of the condition and/or disease, the treatment being received, or the process of dying. (Examples of related conditions: Medication management of nausea and vomiting secondary to pain medication; skin breakdown prevention/treatment due to peripheral edema.)

"Residence" - A client's home or place of living.

"Revoke" or "revocation" - The choice to stop receiving hospice care.

"Terminally ill" - The client has a life expectancy of six months or less, assuming the client's disease process runs its natural course.

"24-hour day" - A day beginning and ending at midnight.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1010, filed 7/25/25, effective 9/1/25. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1010, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1010, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1010, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. WSR 99-09-007, § 388-551-1010, filed 4/9/99, effective 5/10/99.*

##### **Wash. Admin. Code § 182-551-1200** Client eligibility for hospice care. {#sec-182-551-1200 omnilex-key=us-wa-regs-official--title-182--182-551-1200}

(1) Subject to the requirements and limitations in this chapter and other medicaid agency rules, a person who elects to receive hospice care must be eligible for:

(a) One of the Washington apple health programs listed in the table in WAC 182-501-0060 with hospice as a covered benefit; or

(b) The alien emergency medical (AEM) program (see WAC 182-507-0110).

(2) A client who is eligible for hospice under medicare part A is not eligible for hospice care through the medicaid agency's hospice program.

(3) The medicaid agency pays hospice nursing facility room and board if the client is:

(a) Admitted to a nursing facility or hospice care center (HCC); and

(b) Not receiving general inpatient care or inpatient respite care. See also WAC 182-551-1530.

(4) A client who meets the requirements in this section is eligible to receive hospice care through the medicaid agency's hospice program when all the following requirements are met:

(a) The client's physician certifies the client has a life expectancy of six months or less, which is supported by medical records, including documentation that the person's condition is declining;

(b) The client or an authorized health care representative on the client's behalf elects to receive hospice care and agrees to the conditions of the "election statement" as described in WAC 182-551-1310;

(c) The client's hospice agency must:

(i) Notify the medicaid agency's hospice program within five business days of the client's admission. The hospice agency must give notice for clients with the following types of eligibility:

(A) Medicaid-only;

(B) Medicaid-medicare dual eligible;

(C) Medicaid with third-party insurance; and

(D) Medicaid-medicare dual eligible with third-party insurance.

(ii) Meet the hospice agency requirements in WAC 182-551-1300 and 182-551-1305;

(d) The hospice agency provides additional information for a diagnosis when the medicaid agency requests and determines, on a case-by-case basis, the information that is needed for further review.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1200, filed 7/25/25, effective 9/1/25. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148). WSR 14-07-042, § 182-551-1200, filed 3/12/14, effective 4/12/14. Statutory Authority: RCW 41.05.021. WSR 13-04-094, § 182-551-1200, filed 2/6/13, effective 3/9/13. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1200, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1200, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. WSR 99-09-007, § 388-551-1200, filed 4/9/99, effective 5/10/99.*

##### **Wash. Admin. Code § 182-551-1210** Covered services, including core services and supplies reimbursed through the hospice daily rate. {#sec-182-551-1210 omnilex-key=us-wa-regs-official--title-182--182-551-1210}

(1) The medicaid agency reimburses a hospice agency for providing covered services through the medicaid agency's hospice daily rate.

(2) Covered services include core services and supplies described in this section, subject to the requirements and limitations described in this section and other WAC. See WAC 182-551-1860 for pediatric concurrent care.

(3) To qualify for reimbursement, covered services, including core services and supplies in the hospice daily rate, must be:

(a) Related to the client's hospice diagnosis;

(b) Identified by the client's hospice interdisciplinary team;

(c) Written in the client's plan of care (POC); and

(d) Made available to the client by the hospice agency on a 24-hour basis.

(4) The hospice daily rate includes the following core services:

(a) Physician services related to POC administration.

(b) Nursing care provided by:

(i) A registered nurse (RN); or

(ii) A licensed practical nurse (LPN) under the supervision of an RN.

(c) Medical social services provided by a social worker under the direction of a physician.

(d) Counseling services provided to a client and the client's family members or caregivers.

(5) Core services must be provided by hospice agency staff. If necessary, a contracted hospice agency may provide core services to supplement services provided by hospice staff to meet client needs:

(a) During a period of peak patient loads; or

(b) Under extraordinary circumstances.

(6) Covered services and supplies may be provided by a service organization or an individual provider when contracted through a hospice agency.

(7) To be reimbursed the hospice daily rate, a hospice agency must:

(a) Ensure all contracted staff meet the regulatory qualification requirements;

(b) Have a written agreement with the service organization or person providing the services and supplies; and

(c) Maintain professional, financial, and administrative responsibility.

(8) The following covered services and supplies are included in the appropriate hospice daily rate as described in WAC 182-551-1510, subject to the requirements and limitations described in this section and other WAC:

(a) Skilled nursing care;

(b) Drugs, biologicals, and over-the-counter medications used for the relief of pain and symptom control of a client's terminal illness and related conditions;

(c) Communication with nonhospice providers about care not related to the client's terminal illness to ensure the client's plan of care needs are met and not compromised;

(d) Durable medical equipment and related supplies, prosthetics, orthotics, medical supplies, related services, or related repairs and labor charges. See chapter 182-543 WAC. These services and equipment are paid by the hospice agency for the palliation and management of a client's terminal illness and related conditions and are included in the daily hospice rate;

(e) Hospice aide services that meet the following criteria:

(i) Ordered by a client's physician and documented in the POC;

(ii) Provided through the hospice agency to meet a client's extensive needs due to the client's terminal illness; and

(iii) Provided by a qualified hospice aide and are an extension of skilled nursing or therapy services. See 42 C.F.R. Part 484;

(f) Physical therapy, occupational therapy, and speech-language therapy to manage symptoms or enable a client to safely perform ADLs (activities of daily living) and basic functional skills;

(g) Medical transportation services, including ambulance (see WAC 182-546-5550 (1)(e));

(h) A brief period of inpatient care, for general or respite care provided in a medicare-certified hospice care center, hospital, or nursing facility; and

(i) Other services or supplies that are documented as necessary for the palliation and management of a client's terminal illness and related conditions;

(9) A hospice agency is responsible to determine if a nursing facility has requested authorization for medical supplies or medical equipment, including wheelchairs, for a client who becomes eligible for the hospice program.

(10) The medicaid agency does not pay separately for medical equipment or supplies that were previously authorized by the medicaid agency and delivered on or after the date the medicaid agency enrolls the client in the hospice program.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1210, filed 7/25/25, effective 9/1/25. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1210, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1210, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1210, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. WSR 99-09-007, § 388-551-1210, filed 4/9/99, effective 5/10/99.*

##### **Wash. Admin. Code § 182-551-1300** Requirements for a medicaid-approved hospice agency. {#sec-182-551-1300 omnilex-key=us-wa-regs-official--title-182--182-551-1300}

(1) To become medicaid-approved, a hospice agency must be medicare, Title XVIII-certified by the department of health (DOH) as a hospice agency.

(2) A medicaid-approved hospice agency must, at all times, meet the requirements in chapter 182-551 WAC, subchapter I, Hospice services, and the requirements under the Title XVIII medicare program.

(3) To ensure quality of care for Washington apple health clients, the medicaid agency's clinical staff conducts hospice agency site visits.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1300, filed 7/25/25, effective 9/1/25*
- *WSR 16-03-035, § 182-551-1300, filed 1/12/16, effective 2/12/16. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1300, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.520. WSR 05-18-033, § 388-551-1300, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. WSR 99-09-007, § 388-551-1300, filed 4/9/99, effective 5/10/99.*

##### **Wash. Admin. Code § 182-551-1305** Requirements for becoming a medicaid-approved hospice care center (HCC). {#sec-182-551-1305 omnilex-key=us-wa-regs-official--title-182--182-551-1305}

(1) To become a medicaid-approved hospice care center, the hospice agency must be medicare-certified by the department of health (DOH) as a hospice care center and provides one or more of the following levels of hospice care (levels of care are described in WAC 182-551-1500):

(a) Routine home care;

(b) Inpatient respite care; and

(c) General inpatient care.

(2) A medicaid-approved hospice care center must at all times meet the requirements in chapter 182-551 WAC, subchapter I, Hospice services, and the requirements under the Title XVIII medicare program.

(3) A hospice agency qualifies as a medicaid-approved hospice care center when:

(a) All the requirements in this section are met; and

(b) The medicaid agency provides the hospice agency with written notification.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1305, filed 7/25/25, effective 9/1/25. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1305, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1305, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1305, filed 8/30/05, effective 10/1/05.*

##### **Wash. Admin. Code § 182-551-1310** Hospice election periods and election statements. {#sec-182-551-1310 omnilex-key=us-wa-regs-official--title-182--182-551-1310}

(1) Hospice coverage is available for two 90-day election periods followed by an unlimited number of 60-day election periods.

(2) A client or a client's authorized health care representative must sign an election statement to initiate or reinitiate an election period for hospice care.

(3) The election statement must be filed in the client's hospice medical record within two calendar days following the day the hospice care begins and requires all of the following:

(a) Name and address of the hospice agency that will provide the care;

(b) Documentation that the client or the client's authorized health care representative is fully informed and understands hospice care and waiver of other medicaid and/or medicare services;

(c) Effective date of the election; and

(d) Signature of the client or the client's authorized health care representative.

(4) When a client's hospice coverage ends within an election period (e.g., the client revokes hospice care), the remainder of that election period is forfeited.

(5) The client or the client's authorized health care representative may reinstate the hospice benefit at any time by providing an election statement and meeting the certification process requirements.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1310, filed 7/25/25, effective 9/1/25. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1310, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1310, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1310, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. WSR 99-09-007, § 388-551-1310, filed 4/9/99, effective 5/10/99.*

##### **Wash. Admin. Code § 182-551-1315** Hospice certification process. {#sec-182-551-1315 omnilex-key=us-wa-regs-official--title-182--182-551-1315}

(1) The following describes the hospice certification process:

(a) When a client or the client's authorized health care representative elects to receive hospice care, the medicaid agency requires a hospice agency to:

(i) Obtain a signed written certification from a physician of the client's terminal illness; or

(ii) Document in the client's medical file that the hospice agency obtained verbal certification, followed up with a written certification signed by:

(A) The medical director of the hospice agency or a physician staff member of the interdisciplinary team; and

(B) The client's attending physician if the client has one;

(iii) Place the signed written certification of the client's terminal illness in the client's medical file:

(A) Within 60 calendar days following the day the hospice care begins; and

(B) Before billing the medicaid agency for the hospice services.

(b) For a subsequent election period, the medicaid agency requires a hospice physician or hospice nurse practitioner to:

(i) Have a face-to-face encounter with every hospice client:

(A) Within 30 calendar days prior to the 180th-day recertification; and

(B) Prior to each subsequent recertification to determine continued eligibility of the client for hospice care; and

(ii) Attest that the face-to-face encounter took place.

(c) The hospice agency must:

(i) Document in the client's medical file that it obtained a verbal certification, followed up with a written certification signed by:

(A) The medical director of the hospice agency; or

(B) A physician staff member of the hospice agency;

(ii) Place the written certification of the client's terminal illness in the client's medical file before billing the medicaid agency for the hospice services; and

(iii) Submit the written certification to the medicaid agency with the hospice claim related to the recertification.

(2) The medicaid agency does not pay for face-to-face encounters to recertify a hospice client.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1315, filed 7/25/25, effective 9/1/25.*

##### **Wash. Admin. Code § 182-551-1320** Hospice plan of care. {#sec-182-551-1320 omnilex-key=us-wa-regs-official--title-182--182-551-1320}

(1) A hospice agency must establish a written plan of care (POC) for a client that describes the hospice care to be provided. The POC must be in accordance with department of health (DOH) requirements as described in WAC 246-335-640, and meet the requirements in this section.

(2) A registered nurse or physician must conduct an initial physical assessment of a client and develop the POC with at least one other member of the hospice interdisciplinary team.

(3) At least two other hospice interdisciplinary team members must review the POC no later than two business days after it is developed.

(4) The POC must be reviewed and updated every two weeks by at least three members of the hospice interdisciplinary team that includes:

(a) A registered nurse;

(b) A social worker; and

(c) One other hospice interdisciplinary team member.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1320, filed 7/25/25, effective 9/1/25. WSR 11-14-075, recodified as § 182-551-1320, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1320, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. WSR 99-09-007, § 388-551-1320, filed 4/9/99, effective 5/10/99.*

##### **Wash. Admin. Code § 182-551-1330** Hospice—Client care and responsibilities of hospice agencies. {#sec-182-551-1330 omnilex-key=us-wa-regs-official--title-182--182-551-1330}

(1) A hospice agency must facilitate a client's continuity of care with nonhospice providers to ensure that medically necessary care, both related and not related to the terminal illness, is met.

This includes:

(a) Determining if the medicaid agency has approved a request for prescribed medical equipment, such as a wheelchair. If the prescribed item is not delivered to the client before the client becomes covered by a hospice agency, the medicaid agency rescinds the approval. See WAC 182-543-9000(17).

(b) Communicating with other medicaid programs and documenting the services a client receives to prevent duplication of payment and to ensure continuity of care. Other medicaid programs include, but are not limited to, programs administered by the department of social and health services (DSHS) home and community living administration.

(c) Documenting each contact with nonhospice providers.

(2) When a client resides in a nursing facility, the hospice agency must:

(a) Coordinate the client's care with all providers, including pharmacies and medical vendors; and

(b) Provide the same level of hospice care the hospice agency provides to a client residing in their home.

(3) Once a client chooses hospice care, hospice agency staff must notify and inform the client of the following:

(a) By choosing hospice care from a hospice agency, the client gives up the right to:

(i) Covered medicaid hospice service and supplies received at the same time from another hospice agency; and

(ii) Any covered medicaid services and supplies received from any other provider that are necessary for the palliation and management of the terminal illness and related medical conditions.

(b) Services and supplies are not paid through the hospice daily rate if they are:

(i) Proven to be clinically unrelated to the palliation and management of the client's terminal illness and related medical conditions (see WAC 182-551-1210(3));

(ii) Not covered by the hospice daily rate;

(iii) Provided under a Title XIX medicaid program when the services are similar or duplicate the hospice care services; or

(iv) Not necessary for the palliation and management of the client's terminal illness and related medical conditions.

(4) A hospice agency must have written agreements with all contracted providers.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1330, filed 7/25/25, effective 9/1/25. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1330, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1330, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1330, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. WSR 99-09-007, § 388-551-1330, filed 4/9/99, effective 5/10/99.*

##### **Wash. Admin. Code § 182-551-1340** When a client leaves hospice without notice. {#sec-182-551-1340 omnilex-key=us-wa-regs-official--title-182--182-551-1340}

When a client chooses to leave hospice care or the client's authorized health care representative removes the client from hospice care and refuses hospice care without giving the hospice agency a revocation statement, as required by WAC 182-551-1360, the hospice agency must do all of the following:

(1) Within five business days of becoming aware of the client's or the authorized health care representative's decision, inform and notify the medicaid hospice program manager in writing (see WAC 182-551-1400 for further requirements);

(2) Complete a Medicaid Hospice Notification form (HCA 13-746) and forward a copy to the appropriate department of social and health services (DSHS) home and community services (HCS) office or community services office (CSO) to notify that the client is discharging from the program;

(3) Notify the client, or the client's authorized health care representative, that the client's discharge has been reported to the medicaid agency; and

(4) Document the effective date and details of the discharge in the client's hospice record.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1340, filed 7/25/25, effective 9/1/25. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1340, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1340, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1340, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. WSR 99-09-007, § 388-551-1340, filed 4/9/99, effective 5/10/99.*

##### **Wash. Admin. Code § 182-551-1350** Discharges from hospice care. {#sec-182-551-1350 omnilex-key=us-wa-regs-official--title-182--182-551-1350}

(1) A hospice agency may discharge a client from hospice care when the:

(a) Client is no longer certified for hospice care;

(b) Client is no longer appropriate for hospice care; or

(c) Hospice agency's medical director determines the client is seeking treatment for the terminal illness outside the plan of care (POC).

(2) At the time of a client's discharge, a hospice agency must:

(a) Within five business days, complete a Medicaid Hospice Notification form (HCA 13-746) and forward the form to the medicaid hospice program manager (see WAC 182-551-1400 for additional requirements), and a copy to the appropriate DSHS home and community services office (HCS) or community services office (CSO);

(b) Keep the discharge statement in the client's hospice record;

(c) Provide the client with a copy of the discharge statement; and

(d) Inform the client that the discharge statement must be:

(i) Presented with the client's current services card when obtaining medicaid-covered health care services or supplies, or both; and

(ii) Used until the medicaid agency removes the hospice restriction from the client's information available online through the ProviderOne system.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1350, filed 7/25/25, effective 9/1/25. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1350, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1350, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-551-1350, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1350, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. WSR 99-09-007, § 388-551-1350, filed 4/9/99, effective 5/10/99.*

##### **Wash. Admin. Code § 182-551-1360** Ending hospice care (revocations). {#sec-182-551-1360 omnilex-key=us-wa-regs-official--title-182--182-551-1360}

(1) A client or a client's authorized health care representative may decide to stop hospice care at any time by signing a revocation statement.

(2) The revocation statement documents the client's decision to stop medicaid hospice care. The revocation statement must include all of the following:

(a) Client's signature (or the client's authorized health care representative's signature if the client is unable to sign);

(b) Date the revocation was signed; and

(c) Actual date that the client decided to stop receiving hospice care.

(3) The hospice agency must keep any explanation supporting any difference in the signature and revocation dates in the client's hospice records.

(4) When a client revokes hospice care, the hospice agency must:

(a) Notify in writing the medicaid agency's hospice program, within five business days of becoming aware of the client's decision (see WAC 182-551-1400 for additional requirements) by completing the Medicaid Hospice Notification form (HCA 13-746);

(b) Notify the appropriate department of social and health services (DSHS) home and community services (HCS) office or community services office (CSO) of the revocation by completing and forwarding a copy of the Medicaid Hospice Notification form (HCA 13-746) to the appropriate DSHS CSO;

(c) Keep the revocation statement in the client's hospice record;

(d) Provide the client with a copy of the revocation statement; and

(e) Inform the client that the revocation statement must be:

(i) Presented with the client's current services card when obtaining medicaid-covered health care services or supplies, or both; and

(ii) Used until the medicaid agency issues a new services card that identifies that the client is no longer a hospice client.

(5) After a client revokes hospice care, the remaining days within the current election period are forfeited. The client may immediately enter the next consecutive election period. The client does not have to wait for the forfeited days to pass before entering the next consecutive election period.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1360, filed 7/25/25, effective 9/1/25. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1360, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1360, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1360, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. WSR 99-09-007, § 388-551-1360, filed 4/9/99, effective 5/10/99.*

##### **Wash. Admin. Code § 182-551-1370** When a hospice client dies. {#sec-182-551-1370 omnilex-key=us-wa-regs-official--title-182--182-551-1370}

When a client dies, the hospice agency must:

(1) Within five business days, notify the medicaid agency by completing the Medicaid Hospice Notification form (HCA 13-746) to the medicaid agency; and

(2) Notify the appropriate department of social and health services (DSHS) home and community services (HCS) office or community services office (CSO) of the client's date of death by completing and forwarding a copy of the Medicaid Hospice Notification form (HCA 13-746) to the appropriate DSHS HCS office or CSO.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1370, filed 7/25/25, effective 9/1/25. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1370, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1370, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1370, filed 8/30/05, effective 10/1/05.*

##### **Wash. Admin. Code § 182-551-1400** Notification requirements for hospice agencies. {#sec-182-551-1400 omnilex-key=us-wa-regs-official--title-182--182-551-1400}

(1) To be reimbursed for providing hospice services, the hospice agency must:

(a) Complete a Medicaid Hospice Notification form (HCA 13-746); and

(b) Forward the form to the medicaid agency's hospice program within five business days from the date a Washington apple health client begins hospice care, or has a change in hospice status.

(c) Notify the medicaid hospice program of:

(i) The name and address of the hospice agency;

(ii) The date of the client's first day of hospice care;

(iii) A change in the client's primary physician;

(iv) A client's revocation of the hospice benefit (home or institutional);

(v) The date a client leaves hospice without notice;

(vi) A client's discharge from hospice care;

(vii) A client who admits to a nursing facility (this does not apply to an admit for inpatient respite care or general inpatient care);

(viii) A client who discharges from a nursing facility (this does not apply to an admit for inpatient respite care or general inpatient care);

(ix) A client who is eligible for or becomes eligible for medicare or third-party liability (TPL) insurance;

(x) A client who dies; or

(xi) A client who transfers to another hospice agency. Both the former hospice agency and current hospice agency must provide the medicaid agency with:

(A) The client's name, the name of the former hospice agency serving the client, and the effective date of the client's discharge; and

(B) The name of the current hospice agency serving the client, the hospice agency's provider number, and the effective date of the client's admission.

(2) The medicaid agency does not require a hospice agency to notify the hospice program when a hospice client is admitted to a hospital for palliative care.

(3) When a hospice agency does not notify the medicaid agency's hospice program within five business days of the date of the client's first day of hospice care as required in subsection (1) of this section, the medicaid agency authorizes the hospice daily rate reimbursement effective the fifth business day before the date of notification.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1400, filed 7/25/25, effective 9/1/25*
- *WSR 16-03-035, § 182-551-1400, filed 1/12/16, effective 2/12/16. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1400, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1400, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. WSR 99-09-007, § 388-551-1400, filed 4/9/99, effective 5/10/99.*

##### **Wash. Admin. Code § 182-551-1500** Hospice daily rate—Four levels of hospice care. {#sec-182-551-1500 omnilex-key=us-wa-regs-official--title-182--182-551-1500}

All services, supplies and equipment related to the client's terminal illness and related conditions are included in the hospice daily rate. The medicaid agency pays for only one of the following four levels of hospice care per day (see WAC 182-551-1510 for payment methods):

(1) Routine home care. Routine home care includes daily care administered to the client at the client's residence. The services are not restricted in length or frequency of visits, are dependent on the client's needs, and are provided to achieve palliation or management of acute symptoms.

(2) Continuous home care. Continuous home care includes acute skilled care provided to an unstable client during a brief period of medical crisis to maintain the client in the client's residence and is limited to:

(a) A minimum of eight hours of acute care provided during a 24-hour day;

(b) Nursing care that must be provided by a registered or licensed practical nurse for more than half the period of care;

(c) Homemaker, hospice aide, and attendant services that may be provided as supplements to the nursing care; and

(d) In-home care only (not care in a nursing facility or a hospice care center).

(3) Inpatient respite care. Inpatient respite care includes room and board services provided to a client in a medicaid-approved hospice care center, nursing facility, or hospital. Respite care is intended to provide relief to the client's primary caregiver and is limited to:

(a) No more than six consecutive days; and

(b) A client not currently residing in a hospice care center, nursing facility, or hospital.

(4) General inpatient hospice care. General inpatient hospice care includes services administered to a client for pain control or management of acute symptoms. In addition:

(a) The services must conform to the client's written plan of care (POC).

(b) This benefit is limited to brief periods of care in medicaid agency-approved:

(i) Hospitals;

(ii) Nursing facilities; or

(iii) Hospice care centers.

(c) There must be documentation in the client's medical record to support the need for general inpatient level of hospice care.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1500, filed 7/25/25, effective 9/1/25*
- *WSR 16-03-035, § 182-551-1500, filed 1/12/16, effective 2/12/16. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1500, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1500, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. WSR 99-09-007, § 388-551-1500, filed 4/9/99, effective 5/10/99.*

##### **Wash. Admin. Code § 182-551-1510** Rates methodology and payment method for hospice agencies. {#sec-182-551-1510 omnilex-key=us-wa-regs-official--title-182--182-551-1510}

This section describes rates methodology and payment methods for hospice care provided to hospice clients.

(1) The medicaid agency uses the same rates methodology as medicare uses for the four levels of hospice care identified in WAC 182-551-1500.

(2) Each of the four levels of hospice care has the following three rate components:

(a) Wage component;

(b) Wage index; and

(c) Unweighted amount.

(3) To allow hospice payment rates to be adjusted for regional differences in wages, the medicaid agency bases payment rates on the core-based statistical area (CBSA) county location. CBSAs are identified in the medicaid agency's provider guides.

(4) The medicaid agency pays hospice agencies for services,not room and board, at a daily rate methodology as follows:

(a) Payments for services delivered in a client's residence (routine and continuous home care) are based on the county location of the client's residence.

(b) Payments for routine home care are based on a two-tiered payment methodology.

(i) Days one through 60 are paid at the base routine home care rate.

(ii) Days 61 and after are paid at a lower routine home care rate.

(iii) If a client discharges and readmits to a hospice agency's program within 60 calendar days of that discharge, the prior hospice days continue to follow the client and count towards the client's eligible days in determining whether the hospice agency may bill at the base or lower routine home care rate.

(iv) If a client discharges from a hospice agency's program for more than 60 calendar days, a readmit to the hospice agency's program resets the client's hospice days.

(c) Hospice services are eligible for an end-of-life service intensity add-on payment when the following criteria are met:

(i) The day on which the services are provided is a routine home care level of care;

(ii) The day on which the service is provided occurs during the last seven days of life, and the client is discharged deceased;

(iii) The service is provided by a registered nurse or social worker that day for at least 15 minutes and up to four hours total; and

(iv) The service is not provided by the social worker via telephone.

(d) Payments for respite and general inpatient care are based on the county location of the providing hospice agency.

(5) The medicaid agency:

(a) Pays for routine home care, continuous home care, respite care, or general inpatient care for the day of death;

(b) Does not pay room and board for the day of death; and

(c) Does not pay hospice agencies for the client's last day of hospice care when the last day is for the client's discharge, revocation, or transfer.

(6) Hospice agencies must bill the medicaid agency for their services using hospice-specific revenue codes.

(7) For hospice clients in a nursing facility:

(a) The medicaid agency pays nursing facility room and board payments at a daily rate directly to the hospice agency at 95 percent of the nursing facility's current medicaid daily rate in effect on the date the services were provided; and

(b) The hospice agency pays the nursing facility at a daily rate no more than the nursing facility's current medicaid daily rate.

(8) The medicaid agency:

(a) Pays a hospice care center a daily rate for room and board based on the average room and board rate for all nursing facilities in effect on the date the services were provided.

(b) Does not pay hospice agencies or hospice care centers a nursing facility room and board payment for:

(i) A client's last day of hospice care (e.g., client's discharge, revocation, or transfer); or

(ii) The day of death.

(9) The daily rate for authorized out-of-state hospice services is the same as for in-state non-CBSA hospice services.

(10) The medicaid agency reduces hospice payments by two percent for providers who did not comply with the annual medicare quality data reporting program as required under 42 U.S.C. Sec. 1395f (i)(5)(A)(i). The payment reduction is effective for the fiscal reporting year in which the provider failed to submit data required for the annual medicare quality reporting program.

(a) The two percent payment reduction applies to routine home care, including the service intensity add-on, continuous home care, inpatient respite care, and general inpatient care.

(b) The two percent payment reduction does not apply to pediatric palliative care, the hospice care center daily rate, and the nursing facility room and board rate.

(c) Any provider affected by the two percent payment reduction receives written notification.

(d) Any provider affected by the two percent payment reduction may appeal the rate reduction per WAC 182-502-0220.

(11) The client's notice of action (award) letter states the amount the client is responsible to pay each month towards the total cost of hospice care. The hospice agency receives a copy of the award letter and:

(a) Is responsible to collect the correct amount that the client is required to pay, if any; and

(b) Must show the client's monthly required payment on the hospice claim. (Hospice providers may refer to the medicaid agency's provider guides for how to bill a hospice claim.) If a client has a required payment amount that is not reflected on the claim and the medicaid agency reimburses the amount to the hospice agency, the amount is subject to recoupment by the medicaid agency.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1510, filed 7/25/25, effective 9/1/25. Statutory Authority: RCW 41.05.021, 41.05.160, and 42 U.S.C. Sec. 1395f (i)(5)(A)(i). WSR 17-03-073, § 182-551-1510, filed 1/11/17, effective 2/11/17. Statutory Authority: RCW 41.05.021, 41.05.160, and 42 C.F.R. 418 Subpart G. WSR 16-14-009, § 182-551-1510, filed 6/23/16, effective 7/24/16. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-03-035, § 182-551-1510, filed 1/12/16, effective 2/12/16. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1510, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1510, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1510, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. WSR 99-09-007, § 388-551-1510, filed 4/9/99, effective 5/10/99.*

##### **Wash. Admin. Code § 182-551-1520** Payment method for nonhospice providers. {#sec-182-551-1520 omnilex-key=us-wa-regs-official--title-182--182-551-1520}

(1) The medicaid agency pays hospitals that provide inpatient care to clients in the hospice program for medical conditions not related to their terminal illness according to chapter 182-550 WAC, Hospital services.

(2) The medicaid agency pays providers who are attending physicians and not employed by the hospice agency the usual amount through the physician-related services fee schedule:

(a) For direct physician care services provided to a hospice client;

(b) When the provided services are not related to the terminal illness; and

(c) When the client's providers, including the hospice agency, coordinate the health care provided.

(3) The department of social and health services (DSHS) home and community living administration pays for services provided to a client eligible under the community options program entry system (COPES) directly to the COPES provider.

(a) The client's monthly participation amount for services provided under COPES, if there is one, is paid separately to the COPES provider; and

(b) Hospice agencies must bill the medicaid agency's hospice program directly for hospice services, not the COPES program.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1520, filed 7/25/25, effective 9/1/25. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1520, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1520, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1520, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. WSR 99-09-007, § 388-551-1520, filed 4/9/99, effective 5/10/99.*

##### **Wash. Admin. Code § 182-551-1530** Payment method for medicaid-medicare dual eligible clients. {#sec-182-551-1530 omnilex-key=us-wa-regs-official--title-182--182-551-1530}

(1) The medicaid agency does not pay the portion of hospice care for a client who is covered under medicare part A. Nursing home room and board charges described in WAC 182-551-1510 that are not covered under medicare part A may be covered by the medicaid agency.

(2) The medicaid agency may pay for hospice care provided to a client:

(a) Covered by medicaid part B (medical insurance); and

(b) Not covered by medicare part A.

(3) For hospice care provided to a medicaid-medicare dual eligible client, hospice agencies are responsible to bill:

(a) Medicare before billing the medicaid agency;

(b) The medicaid agency for hospice nursing facility room and board;

(c) The medicaid agency for hospice care center room and board; and

(d) Medicare for general inpatient care or inpatient respite care.

(4) All the limitations and requirements related to hospice care described in subchapter I apply to the payments described in this section.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1530, filed 7/25/25, effective 9/1/25*
- *WSR 16-03-035, § 182-551-1530, filed 1/12/16, effective 2/12/16. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1530, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1530, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1530, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520 and 74.08.090, 42 C.F.R. 418.22 and 418.24. WSR 99-09-007, § 388-551-1530, filed 4/9/99, effective 5/10/99.*

##### **Wash. Admin. Code § 182-551-1800** Pediatric palliative care (PPC) case management/coordination services—General. {#sec-182-551-1800 omnilex-key=us-wa-regs-official--title-182--182-551-1800}

Through a hospice agency, the medicaid agency's pediatric palliative care (PPC) case management/coordination services provide the care coordination and skilled care services to clients who have life-limiting medical conditions. Family members and caregivers of clients eligible for pediatric palliative care services may also receive support through care coordination when the services are related to the client's medical needs.

**History**
- *Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1800, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1800, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1800, filed 8/30/05, effective 10/1/05.*

##### **Wash. Admin. Code § 182-551-1810** Pediatric palliative care (PPC) case management/coordination services—Client eligibility. {#sec-182-551-1810 omnilex-key=us-wa-regs-official--title-182--182-551-1810}

To receive pediatric palliative care (PPC) case management/coordination services, a person must:

(1) Be 20 years of age or younger;

(2) Be a current recipient of the:

(a) Alternative benefit plan (ABP);

(b) Categorically needy program (CNP);

(c) Limited casualty program - Medically needy program (LCP-MNP);

(d) CNP - Alien emergency medical;

(e) LCP-MNP - Alien emergency medical; or

(f) Children's health insurance program (CHIP); and

(3) Have a life-limiting medical condition that requires case management and coordination of medical services due to at least three of the following circumstances:

(a) An immediate medical need during a time of crisis;

(b) Coordination with family member(s) and providers required in more than one setting (i.e., school, home, and multiple medical offices or clinics);

(c) A life-limiting medical condition that impacts cognitive, social, and physical development;

(d) A medical condition with which the family is unable to cope;

(e) A family member(s) and/or caregiver who needs additional knowledge or assistance with the client's medical needs; or

(f) Therapeutic goals focused on quality of life, comfort, and family stability.

(4) See WAC 182-551-1860 for concurrent palliative and curative care for hospice clients age 20 and younger.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1810, filed 7/25/25, effective 9/1/25. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1810, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1810, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1810, filed 8/30/05, effective 10/1/05.*

##### **Wash. Admin. Code § 182-551-1820** Pediatric palliative care (PPC) contact—Services included and limitations to coverage. {#sec-182-551-1820 omnilex-key=us-wa-regs-official--title-182--182-551-1820}

(1) The medicaid agency's pediatric palliative care (PPC) case management/coordination services allows, without prior authorization, up to six pediatric palliative care contacts per client, per calendar month, subject to the limitations in this section and other applicable WAC. See WAC 182-501-0169 for limitation extension requests.

(2) One pediatric palliative care contact consists of:

(a) One visit with a registered nurse, social worker, or therapist (for the purpose of this section, the medicaid agency defines therapist as a licensed physical therapist, occupational therapist, or speech/language therapist) with the client in the client's residence to address:

(i) Pain and symptom management;

(ii) Psychosocial counseling; or

(iii) Education/training.

(b) Two hours or more per month of case management or coordination services to include any combination of the following:

(i) Psychosocial counseling services, including grief support provided to the client, client's family member(s), or client's caregiver prior to the client's death;

(ii) Establishing or implementing care conferences;

(iii) Arranging, planning, coordinating, and evaluating community resources to meet the client's needs;

(iv) Visits lasting 20 minutes or less (for example, visits to give injections, drop off supplies, or make appointments for other PPC-related services.); and

(v) Visits not provided in the client's home.

(3) The medicaid agency does not pay for a pediatric palliative care contact described in subsection (2) of this section when a client is receiving services from any of the following:

(a) Home health program;

(b) Hospice program;

(c) Private duty nursing (private duty nursing can subcontract with PPC to provide services)/medical intensive care;

(d) Disease case management program; or

(e) Any other medicaid program that provides similar services.

(4) The medicaid agency does not pay for a pediatric palliative care contact that includes providing counseling services to a client's family member or the client's caregiver for grief or bereavement for dates of service after a client's death.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1820, filed 7/25/25, effective 9/1/25. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1820, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1820, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1820, filed 8/30/05, effective 10/1/05.*

##### **Wash. Admin. Code § 182-551-1830** How to become a medicaid-approved pediatric palliative care (PPC) case management/coordination services provider. {#sec-182-551-1830 omnilex-key=us-wa-regs-official--title-182--182-551-1830}

This section applies to medicaid-approved providers who currently do not provide pediatric palliative care (PPC) services to medicaid clients.

(1) To apply to become a medicaid-approved provider of PPC services, a provider must:

(a) Be a medicaid-approved hospice agency (see WAC 182-551-1300 and 182-551-1305); and

(b) Submit a letter to the medicaid agency's hospice/PPC program manager requesting to become a medicaid-approved provider of PPC and include a copy of the provider's policies and position descriptions with minimum qualifications specific to pediatric palliative care.

(2) A hospice agency qualifies to provide PPC services when:

(a) All the requirements in this section are met; and

(b) The medicaid agency provides the hospice agency with written notification.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1830, filed 7/25/25, effective 9/1/25. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1830, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1830, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1830, filed 8/30/05, effective 10/1/05.*

##### **Wash. Admin. Code § 182-551-1840** Pediatric palliative care (PPC) case management/coordination services—Provider requirements. {#sec-182-551-1840 omnilex-key=us-wa-regs-official--title-182--182-551-1840}

(1) An eligible provider of pediatric palliative care (PPC) case management/coordination services must:

(a) Meet the requirements in WAC 182-551-1300;

(b) Confirm that a client meets the eligibility criteria in WAC 182-551-1810 prior to providing the pediatric palliative care services;

(c) Place in the client's medical record a written order for PPC from the client's physician;

(d) Determine and document in the client's medical record the medical necessity for the initial and ongoing care coordination of pediatric palliative care services;

(e) Document in the client's medical record:

(i) A palliative plan of care (POC);

(ii) The medical necessity for those services to be provided in the client's residence; and

(iii) Discharge planning.

(f) Provide medically necessary skilled interventions and psychosocial counseling services by qualified interdisciplinary hospice team members;

(g) Assign and make available a PPC case manager (nurse, social worker or therapist) to implement care coordination with community-based providers to assure clarity, effectiveness, and safety of the client's POC;

(h) Complete and fax the pediatric palliative care (PPC) referral and 5-Day Notification form (HCA 13-752) to the medicaid agency's PPC program manager within five business days from date of occurrence of the client's:

(i) Date of enrollment in PPC.

(ii) Discharge from the hospice agency or PPC program when the client:

(A) No longer meets PPC criteria;

(B) Is able to receive all care in the community;

(C) Does not require any services for 60 calendar days; or

(D) Discharges from the PPC program and enrolls in the medicaid hospice program.

(iii) Transfer to another hospice agency for pediatric palliative care services.

(iv) Death.

(i) Maintain the client's file which includes the POC, visit notes, and all of the following:

(i) The client's start of care date and dates of service;

(ii) Discipline and services provided (in-home or place of service);

(iii) Case management activity and documentation of hours of work; and

(iv) Specific documentation of the client's and/or the client's family's response to the palliative care and its effectiveness. For example, the client might have required acute care or hospital emergency room visits without the pediatric palliative care services; and

(j) Provide, when requested by the medicaid agency's PPC program manager, a copy of the client's POC, visit notes, and any other documents listing the information identified in subsection (1)(i) of this section.

(2) If the medicaid agency determines the POC, visit notes, and/or other required information do not meet the criteria for a client's PPC eligibility or does not justify the billed amount, any payment to the provider is subject to recoupment by the medicaid agency.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1840, filed 7/25/25, effective 9/1/25. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1840, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1840, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1840, filed 8/30/05, effective 10/1/05.*

##### **Wash. Admin. Code § 182-551-1850** Pediatric palliative care (PPC) case management/coordination services—Rates methodology. {#sec-182-551-1850 omnilex-key=us-wa-regs-official--title-182--182-551-1850}

(1) The medicaid agency determines the reimbursement rate for a pediatric palliative care (PPC) contact described in WAC 182-551-1820 using the average of statewide metropolitan statistical area (MSA) home health care rates for skilled nursing, physical therapy, speech-language therapy and occupational therapy.

(2) The medicaid agency makes adjustments to the reimbursement rate for PPC contacts when the legislature grants a vendor rate change. New rates become effective as directed by the legislature and are effective until the next rate change.

(3) The reimbursement rate for authorized out-of-state PPC services is the same as the in-state non-MSA rate.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-03-035, § 182-551-1850, filed 1/12/16, effective 2/12/16. WSR 11-14-075, recodified as § 182-551-1850, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.520. WSR 05-18-033, § 388-551-1850, filed 8/30/05, effective 10/1/05.*

##### **Wash. Admin. Code § 182-551-1860** Concurrent care for hospice clients age 20 and younger. {#sec-182-551-1860 omnilex-key=us-wa-regs-official--title-182--182-551-1860}

(1) In accordance with 42 U.S.C. 1396d (o)(1)(C), a client age 20 and younger may voluntarily elect hospice care without waiving any rights to services that the client is entitled to under Title XIX Medicaid and Title XXI Children's Health Insurance Program (CHIP) that are related to the treatment of the client's condition for which a diagnosis of terminal illness has been made.

(2) The related services in subsection (1) of this section and medications requested for clients age 20 and younger are subject to the medicaid agency's specific program rules governing those services or medications.

(3) When a noncovered service is recommended based on the early periodic screening, diagnosis, and treatment (EPSDT) program for a child age 20 and younger, providers must follow the rules in chapter 182-534 WAC.

(4) If the medicaid agency denies a request for a covered service, refer to WAC 182-502-0160, billing a client, for when a client may be responsible to pay for a covered service.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-16-015, s 182-551-1860, filed 7/25/25, effective 9/1/25*
- *WSR 18-24-008, § 182-551-1860, filed 11/26/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160, section 2302 of the Patient Protection and Affordable Care Act of 2010, 42 U.S.C. 1396d (o)(1)(C). WSR 17-12-082, § 182-551-1860, filed 6/5/17, effective 7/6/17. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1860, filed 4/17/12, effective 5/18/12.*

##### **Wash. Admin. Code § 182-551-2000** General. {#sec-182-551-2000 omnilex-key=us-wa-regs-official--title-182--182-551-2000}

(1) The purpose of the medicaid agency's home health services program is to reduce the costs of health care services by providing equally effective, less restrictive quality care to the client in any setting where normal life activities take place, subject to the restrictions and limitations in subchapter II. See also 42 C.F.R. 440.70.

(2) Home health services include the following services and items:

(a) Nursing services, see WAC 182-551-2100;

(b) Home health aide service, see WAC 182-551-2120;

(c) Medical supplies, equipment, and appliances suitable for use in any setting where normal life activities take place, see chapter 182-543 WAC;

(d) Physical therapy, occupational therapy, or speech therapy, see WAC 182-551-2110, and audiology services, see WAC 182-531-0375; and

(e) Medical social services, see WAC 182-551-2115.

(3) A client does not have to be homebound or need nursing or therapy services to receive services under this chapter.

(4) Home health skilled services are acute, intermittent, short-term, and intensive courses of treatment. See chapters 182-514 and 388-71 WAC for programs administered to clients who need chronic, long-term maintenance care.

(5) Home health visits require a written order from an authorized practitioner, unless there is a verbal order that is:

(a) Documented before the visit; and

(b) Signed by the ordering authorized practitioner within 45 calendar days of the order being given.

(6) The medicaid agency evaluates requests for home health services based on medical necessity and other program rules related to medicaid funded services including those found in this chapter, chapters 182-501 and 182-502 WAC.

(7) Home health services, delivered through fee-for-service or managed care, involving an in-home visit by a provider, require the provider to comply with electronic visit verification requirements. See WAC 182-551-2220.

(8) The medicaid agency does not pay for administrative costs billed above the visit rate.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-551-2000, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-05-048, § 182-551-2000, filed 2/9/22, effective 3/12/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Section 440.70. WSR 18-24-023, § 182-551-2000, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-03-035, § 182-551-2000, filed 1/12/16, effective 2/12/16. WSR 11-14-075, recodified as § 182-551-2000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, chapter 74.09 RCW, and 2009 c 326. WSR 10-10-087, § 388-551-2000, filed 5/3/10, effective 6/3/10. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. WSR 02-15-082, § 388-551-2000, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. WSR 99-16-069, § 388-551-2000, filed 8/2/99, effective 9/2/99.*

##### **Wash. Admin. Code § 182-551-2010** Definitions. {#sec-182-551-2010 omnilex-key=us-wa-regs-official--title-182--182-551-2010}

The following definitions and abbreviations and those found in chapter 182-500 WAC apply to subchapter II:

"Acute care" means care provided by a home health agency for clients who are not medically stable or have not attained a satisfactory level of rehabilitation. These clients require frequent intervention by a registered nurse or licensed therapist.

"Authorized practitioner" means:

(a) A physician, nurse practitioner, clinical nurse specialist, or physician assistant who may order and conduct home health services, including face-to-face encounter services; or

(b) A certified nurse midwife under 42 C.F.R. 440.70 when furnished by a home health agency that meets the conditions of participation for medicare who may conduct home health services, including face-to-face encounter services.

"Brief skilled nursing visit" means a registered nurse, or a licensed practical nurse under the supervision of a registered nurse, performs only one of the following activities during a visit to a client:

(a) An injection;

(b) Blood draw; or

(c) Placement of medications in containers.

"Chronic care" means long-term care for medically stable clients.

"Electronic visit verification (EVV)" means, with respect to home health services, a system under which in-home visits conducted as part of delivery of such services are electronically verified with respect to:

(a) The type of service performed;

(b) The individual receiving the service;

(c) The date of the service;

(d) The location of service delivery;

(e) The individual providing the service; and

(f) The time the service begins and ends.

"Full skilled nursing visit" means a registered nurse, or a licensed practical nurse under the supervision of a registered nurse, performs one or more of the following activities during a visit to a client:

(a) Observation;

(b) Assessment;

(c) Treatment;

(d) Teaching;

(e) Training;

(f) Management; and

(g) Evaluation.

"Home health agency" means an agency or organization that attests to the satisfaction of the medicaid agency that it meets the requirements for participation in medicare or is certified under the medicare program to provide comprehensive health care on an intermittent or part-time basis to a patient in any setting where the patient's normal life activities take place.

"Home health aide" means a person registered or certified as a nursing assistant under chapter 18.88 RCW who, under the direction and supervision of a registered nurse or licensed therapist, assists in the delivery of nursing or therapy related activities, or both.

"Home health aide services" means services provided by a home health aide only when a client has an acute, intermittent, short-term need for the services of a registered nurse, physical therapist, occupational therapist, or speech therapist who is employed by or under contract with a home health agency. These services are provided under the supervision of the previously identified authorized practitioners and include, but are not limited to, ambulation and exercise, assistance with self-administered medications, reporting changes in a client's condition and needs, and completing appropriate records.

"Home health skilled services" means skilled health care (nursing, specialized therapy, and home health aide) services provided on an intermittent or part-time basis by a home health agency. See also WAC 182-551-2000.

"Long-term care" is a generic term referring to various programs and services, including services provided in home and community settings, administered directly or through contract by the department of social and health services' (DSHS) division of developmental disabilities (DDD) or aging and long-term support administration (ALTSA) through home and community services (HCS).

"Medical social services" are services delivered by a medical social worker that are intended to resolve social or emotional problems that are expected to be an impediment to the effective treatment of the client's medical condition or rate of recovery.

"Medical social worker" has the same meaning given for "social worker" in WAC 246-335-510.

"Plan of care (POC)" (also known as "plan of treatment (POT)") means a written plan of care that is established and periodically reviewed and signed by both an authorized practitioner and a home health agency provider. The plan describes the home health care to be provided in any setting where the client's normal life activities take place. See WAC 182-551-2210.

"Review period" means the three-month period the medicaid agency assigns to a home health agency, based on the address of the agency's main office, during which the medicaid agency reviews all claims submitted by that home health agency.

"Specialized therapy" means skilled therapy services provided to clients that include:

(a) Physical;

(b) Occupational; or

(c) Speech/audiology services.

(See WAC 182-551-2110.)

"Telemedicine" - See WAC 182-501-0300 and 182-551-2125.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-551-2010, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and 2021 c 157. WSR 23-04-048, § 182-551-2010, filed 1/26/23, effective 2/26/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-05-048, § 182-551-2010, filed 2/9/22, effective 3/12/22*
- *WSR 21-23-044, § 182-551-2010, filed 11/9/21, effective 12/10/21. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Section 440.70. WSR 18-24-023, § 182-551-2010, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-03-035, § 182-551-2010, filed 1/12/16, effective 2/12/16. WSR 11-14-075, recodified as § 182-551-2010, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, chapter 74.09 RCW, and 2009 c 326. WSR 10-10-087, § 388-551-2010, filed 5/3/10, effective 6/3/10. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. WSR 02-15-082, § 388-551-2010, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. WSR 99-16-069, § 388-551-2010, filed 8/2/99, effective 9/2/99.*

##### **Wash. Admin. Code § 182-551-2020** Eligibility. {#sec-182-551-2020 omnilex-key=us-wa-regs-official--title-182--182-551-2020}

(1) Washington apple health clients are eligible for home health services as identified in the table in WAC 182-501-0060 and subject to the provisions in this chapter.

(2) Clients enrolled in an agency-contracted managed care organization (MCO) receive all home health services through their designated plan. EVV requirements are applicable to the in-home delivery of home health services for clients enrolled in a managed care organization.

(3) The agency covers home health services for clients in the alien emergency medical program under WAC 182-507-0120.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-551-2020, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and 42 C.F.R. Section 440.70. WSR 18-24-023, § 182-551-2020, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148). WSR 14-07-042, § 182-551-2020, filed 3/12/14, effective 4/12/14. WSR 11-14-075, recodified as § 182-551-2020, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, chapter 74.09 RCW, and 2009 c 326. WSR 10-10-087, § 388-551-2020, filed 5/3/10, effective 6/3/10. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. WSR 02-15-082, § 388-551-2020, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. WSR 99-16-069, § 388-551-2020, filed 8/2/99, effective 9/2/99.*

##### **Wash. Admin. Code § 182-551-2030** Skilled services—Requirements. {#sec-182-551-2030 omnilex-key=us-wa-regs-official--title-182--182-551-2030}

(1) The medicaid agency covers home health skilled services provided to eligible clients, subject to the provisions in this section and other applicable published WAC.

(2) Home health skilled services provided to eligible clients must:

(a) Meet the definition of "acute care" in WAC 182-551-2010;

(b) Provide for the treatment of an illness, injury, or disability;

(c) Be medically necessary as defined in WAC 182-500-0070 and the process outlined in WAC 182-501-0165;

(d) Be reasonable, based on the community standard of care, in amount, duration, and frequency;

(e) Meet face-to-face requirements described in WAC 182-551-2040;

(f) Be provided under a plan of care (POC), as defined in WAC 182-551-2010 and described in WAC 182-551-2210. Any statement in the POC must be supported by documentation in the client's medical records;

(g) Be used to prevent placement in a more restrictive setting;

(h) Be provided in any setting where normal life activities take place; and

(i) The client's medical records must justify the medical reason or reasons that the services should be provided where the client's normal life activities take place instead of at an ordering physician's office, clinic, or other outpatient setting.

(3) Clients in residential facilities contracted with the state and paid by other programs, such as home and community programs to provide skilled nursing services, are eligible for skilled nursing services

only on a short-term, temporary basis while authorization of these services is pending with the other state programs. Prior authorization is required.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-551-2030, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Section 440.70. WSR 18-24-023, § 182-551-2030, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-03-035, § 182-551-2030, filed 1/12/16, effective 2/12/16. WSR 11-14-075, recodified as § 182-551-2030, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, chapter 74.09 RCW, and 2009 c 326. WSR 10-10-087, § 388-551-2030, filed 5/3/10, effective 6/3/10. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. WSR 02-15-082, § 388-551-2030, filed 7/15/02, effective 8/15/02.*

##### **Wash. Admin. Code § 182-551-2040** Face-to-face encounter requirements. {#sec-182-551-2040 omnilex-key=us-wa-regs-official--title-182--182-551-2040}

(1) The medicaid agency pays for home health services provided under this chapter only when the face-to-face encounter requirements in this section are met.

(2) The face-to-face encounter requirements of this section may be met using telemedicine services. See WAC 182-551-2125.

(3) For initiation of home health services, with the exception of medical equipment under WAC 182-551-2122, the face-to-face encounter must be related to the primary reason the client requires home health services and must occur within 90 calendar days before or within the 30 calendar days after the start of the home health services.

(4) For the initiation of medical equipment under WAC 182-551-2122, the face-to-face encounter must be related to the primary reason the client requires medical equipment and must occur no more than six months before the start of services.

(5) The face-to-face encounter may be conducted by:

(a) A physician;

(b) A nurse practitioner;

(c) A clinical nurse specialist;

(d) A certified nurse midwife under 42 C.F.R. 440.70 when furnished by a home health agency that meets the conditions of participation for medicare;

(e) A physician assistant; or

(f) The attending acute, or post-acute physician, for beneficiaries admitted to home health immediately after an acute or post-acute stay.

(6) Services may be ordered by:

(a) Physicians;

(b) Nurse practitioners;

(c) Clinical nurse specialists; or

(d) Physician assistants.

(7) For all home health services except medical equipment under WAC 182-551-2122, the physician, nurse practitioner, clinical nurse specialist, or physician assistant responsible for ordering the services must:

(a) Document that the face-to-face encounter, which is related to the primary reason the client requires home health services, occurred within the required time frames described in subsection (3) of this section prior to the start of home health services; and

(b) Indicate the practitioner who conducted the encounter, and the date of the encounter.

(8) For medical equipment under WAC 182-551-2122, an ordering physician, nurse practitioner, clinical nurse specialist, physician assistant, or the attending physician when a client is discharged from an acute hospital stay, must:

(a) Document that the face-to-face encounter, which is related to the primary reason the client requires home health services, occurred within the required time frames described in subsection (4) of this section prior to the start of home health services; and

(b) Indicate the practitioner who conducted the encounter, and the date of the encounter.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-551-2040, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and 2021 c 157. WSR 23-04-048, § 182-551-2040, filed 1/26/23, effective 2/26/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. § 440.70. WSR 21-12-051, § 182-551-2040, filed 5/26/21, effective 6/26/21*
- *WSR 18-24-023, § 182-551-2040, filed 11/27/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-551-2100** Skilled nursing services. {#sec-182-551-2100 omnilex-key=us-wa-regs-official--title-182--182-551-2100}

(1) The medicaid agency covers home health skilled nursing services up to service limitations without prior authorization. See WAC 182-501-0169 for information on limitation extension.

(2) The home health skilled nursing services must be furnished by a qualified provider in any setting where normal life activities take place.

(3) The medicaid agency pays for the following home health skilled nursing services, subject to program rules and the provisions in this section:

(a) Full skilled nursing services that require the skills of a registered nurse or a licensed practical nurse under the supervision of a registered nurse, if the services involve one or more of the following:

(i) Observation;

(ii) Assessment;

(iii) Treatment;

(iv) Teaching;

(v) Training;

(vi) Management; and

(vii) Evaluation.

(b) A brief skilled nursing visit if only one of the following activities is performed during the visit:

(i) An injection;

(ii) Blood draw; or

(iii) Placement of medications in containers (e.g., envelopes, cups, medisets).

(c) Home infusion therapy only if the client:

(i) Is willing and capable of learning and managing the client's infusion care; or

(ii) Has a volunteer caregiver willing and capable of learning and managing the client's infusion care.

(d) Infant phototherapy for an infant diagnosed with hyperbilirubinemia:

(i) When provided by a medicaid agency-approved home health agency with an infant phototherapy provider; and

(ii) For up to five skilled nursing visits per infant.

(e) Limited high-risk obstetrical services:

(i) For a medical diagnosis that complicates pregnancy and may result in a poor outcome for the birth parent, unborn, or newborn;

(ii) For up to three home health visits per pregnancy if enrolled in or referred to a first steps maternity support services (MSS) provider. The visits are provided by a registered nurse who has either:

(A) National perinatal certification; or

(B) A minimum of one year of labor, delivery, and postpartum experience at a hospital within the last five years.

(4) The medicaid agency pays for up to two skilled nursing visits, per client, per day.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-551-2100, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and 42 C.F.R. Section 440.70. WSR 18-24-023, § 182-551-2100, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-03-035, § 182-551-2100, filed 1/12/16, effective 2/12/16. WSR 11-14-075, recodified as § 182-551-2100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, chapter 74.09 RCW, and 2009 c 326. WSR 10-10-087, § 388-551-2100, filed 5/3/10, effective 6/3/10. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. WSR 02-15-082, § 388-551-2100, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. WSR 99-16-069, § 388-551-2100, filed 8/2/99, effective 9/2/99.*

##### **Wash. Admin. Code § 182-551-2110** Specialized therapy. {#sec-182-551-2110 omnilex-key=us-wa-regs-official--title-182--182-551-2110}

(1) The medicaid agency covers outpatient rehabilitation and habilitative services only when provided:

(a) By a home health agency; and

(b) In any setting where normal life activities take place.

(2) Outpatient rehabilitation and habilitative services are described in chapter 182-545 WAC. Specialized therapy is defined in WAC 182-551-2010.

(3) The medicaid agency limits payment of the same type of specialized therapy to one per day for eligible clients.

(4) The medicaid agency limits payment of specialized therapy to once per day when there are two or more providers performing the same or similar procedure or procedures for the same client.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-551-2110, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and 42 C.F.R. Section 440.70. WSR 18-24-023, § 182-551-2110, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-04-026, § 182-551-2110, filed 1/25/16, effective 3/1/16. Statutory Authority: RCW 41.05.021. WSR 11-21-066, § 182-551-2110, filed 10/17/11, effective 11/17/11. WSR 11-14-075, recodified as § 182-551-2110, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, chapter 74.09 RCW, and 2009 c 326. WSR 10-10-087, § 388-551-2110, filed 5/3/10, effective 6/3/10. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. WSR 02-15-082, § 388-551-2110, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. WSR 99-16-069, § 388-551-2110, filed 8/2/99, effective 9/2/99.*

##### **Wash. Admin. Code § 182-551-2115** Medical social services. {#sec-182-551-2115 omnilex-key=us-wa-regs-official--title-182--182-551-2115}

(1) The medicaid agency covers medical social services under program rules, including the rules in this chapter.

(2) Medical social services include the following:

(a) Assessment of the social and emotional factors related to the client's illness;

(b) Need for care, response to treatment, and adjustment to care;

(c) Evaluation of the client's home situation, financial resources, and availability of community resources;

(d) Assistance in obtaining available community resources and financial resources; and

(e) Counseling the client and family to address emotional issues related to the illness.

(3) The medicaid agency pays for up to eight 15-minute units per 365-day period without prior authorization.

(4) The medicaid agency may authorize additional services on a case-by-case basis under WAC 182-501-0169.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-551-2115, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-05-048, § 182-551-2115, filed 2/9/22, effective 3/12/22.*

##### **Wash. Admin. Code § 182-551-2120** Aide services. {#sec-182-551-2120 omnilex-key=us-wa-regs-official--title-182--182-551-2120}

(1) The medicaid agency covers home health aide services.

(2) The agency pays for one visit per client, per day under program rules, including the rules in this chapter.

(3) The medicaid agency may authorize additional services on a case-by-case basis under WAC 182-501-0169.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-551-2120, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and 42 C.F.R. Section 440.70. WSR 18-24-023, § 182-551-2120, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-03-035, § 182-551-2120, filed 1/12/16, effective 2/12/16. WSR 11-14-075, recodified as § 182-551-2120, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, chapter 74.09 RCW, and 2009 c 326. WSR 10-10-087, § 388-551-2120, filed 5/3/10, effective 6/3/10. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. WSR 02-15-082, § 388-551-2120, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. WSR 99-16-069, § 388-551-2120, filed 8/2/99, effective 9/2/99.*

##### **Wash. Admin. Code § 182-551-2122** Medical supplies, equipment, and appliances. {#sec-182-551-2122 omnilex-key=us-wa-regs-official--title-182--182-551-2122}

The medicaid agency covers medical supplies, equipment, and appliances, as defined and described in chapter 182-543 WAC.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-551-2122, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and 42 C.F.R. Section 440.70. WSR 18-24-023, § 182-551-2122, filed 11/27/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-551-2125** Home health services delivered using telemedicine. {#sec-182-551-2125 omnilex-key=us-wa-regs-official--title-182--182-551-2125}

(1) The medicaid agency pays for the delivery of one home health service through telemedicine, per eligible client, per day, under WAC 182-501-0300 and the requirements in this section.

(2) For clients to be eligible to receive home health services through telemedicine, the medicaid agency requires the client to:

(a) Be diagnosed with an unstable condition causing the client to be at risk for hospitalization or a more costly level of care; and

(b) Have a diagnosis or diagnoses where there is a high risk of sudden change in clinical status which could compromise health outcomes.

(3) To receive payment for the delivery of home health services through telemedicine, the services must involve:

(a) An assessment, problem identification, and evaluation which includes:

(i) Assessment and monitoring of clinical data including, but not limited to, vital signs, pain levels and other biometric measures specified in the plan of care. Also includes assessment of response to previous changes in the plan of care; and

(ii) Detection of condition changes based on the telemedicine encounter that may indicate the need for a change in the plan of care; and

(b) Implementation of a management plan through one or more of the following:

(i) Teaching regarding medication management, as appropriate;

(ii) Teaching regarding other interventions as appropriate to both the patient and the caregiver;

(iii) Management and evaluation of the plan of care including changes in visit frequency or addition of other skilled services;

(iv) Coordination of care with the ordering physician regarding findings;

(v) Coordination and referral to other medical providers as needed; and

(vi) Referral to the emergency room as needed.

(4) The medicaid agency does not require prior authorization for the delivery of home health services through telemedicine.

(5) The medicaid agency does not pay for the purchase, rental, or repair of telemedicine equipment.

(6) Electronic visit verification requirements are not applicable to home health services delivered through telemedicine. Other program rules may apply similar or the same record requirements to providers of home health services.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-551-2125, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and 2021 c 157. WSR 23-04-048, § 182-551-2125, filed 1/26/23, effective 2/26/23. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Section 440.70. WSR 18-24-023, § 182-551-2125, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-03-035, § 182-551-2125, filed 1/12/16, effective 2/12/16. WSR 11-14-075, recodified as § 182-551-2125, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, chapter 74.09 RCW, and 2009 c 326. WSR 10-10-087, § 388-551-2125, filed 5/3/10, effective 6/3/10.*

##### **Wash. Admin. Code § 182-551-2130** Noncovered services. {#sec-182-551-2130 omnilex-key=us-wa-regs-official--title-182--182-551-2130}

(1) The medicaid agency does not cover the following home health services under the home health program:

(a) Chronic long-term care skilled nursing visits or specialized therapy visits for a medically stable client when a long-term care skilled nursing plan or specialized therapy plan is in place through the department of social and health services' aging and long-term support administration (ALTSA).

(i) Prior to ALTSA implementing a long-term care skilled nursing plan or specialized therapy plan, the medicaid agency may consider a short-term authorization of these services as an exception to rule (ETR); and

(ii) Any services authorized are subject to the provisions in this section and other applicable WAC.

(b) Social work services that are not "medical social services" as defined in WAC 182-551-2010 or listed as covered in WAC 182-551-2115.

(c) Psychiatric skilled nursing services.

(d) Prenatal and postpartum skilled nursing services, except as listed under WAC 182-551-2100.

(e) Well-baby follow-up care.

(f) Services performed in hospitals, correctional facilities, skilled nursing facilities, or a residential facility with skilled nursing services available.

(g) Health care for a medically stable client.

(h) Home health specialized therapies and home health aide visits for AEM clients in the following programs:

(i) Categorically needy - Emergency medical only; and

(ii) Medically needy - Emergency medical only.

(2) The medicaid agency evaluates a request for home health services that are listed as noncovered:

(a) For a person age 21 and older, under WAC 182-501-0160;

(b) For a person age 20 and younger, under the early and periodic screening diagnosis and treatment (EPSDT) provisions in chapter 182-534 WAC; and

(c) For a person age 19 or older that is under emergency related services only, under WAC 182-507-0120.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-551-2130, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-05-048, § 182-551-2130, filed 2/9/22, effective 3/12/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Section 440.70. WSR 18-24-023, § 182-551-2130, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-03-035, § 182-551-2130, filed 1/12/16, effective 2/12/16. WSR 11-14-075, recodified as § 182-551-2130, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, chapter 74.09 RCW, and 2009 c 326. WSR 10-10-087, § 388-551-2130, filed 5/3/10, effective 6/3/10. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-551-2130, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. WSR 02-15-082, § 388-551-2130, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. WSR 99-16-069, § 388-551-2130, filed 8/2/99, effective 9/2/99.*

##### **Wash. Admin. Code § 182-551-2200** Eligible providers. {#sec-182-551-2200 omnilex-key=us-wa-regs-official--title-182--182-551-2200}

The following may contract with the medicaid agency to provide home health services through the home health program, subject to the requirements and limitations in this section and other applicable published WAC:

(1) A home health agency that:

(a) Is Title XVIII (medicare)-certified, or if the services being provided are not covered by medicare, the provider may attest to the medicaid agency it meets the requirements for participation in medicare;

(b) Is licensed by the department of health (DOH) as a home health agency;

(c) Submits a completed, signed core provider agreement to the medicaid agency and is enrolled; and

(d) Has a home health taxonomy on their provider file in the medicaid agency's claim payment system.

(2) A registered nurse (RN) who:

(a) Is prior authorized by the medicaid agency to provide intermittent nursing services when no home health agency exists in the area where the client's normal life activities take place;

(b) Cannot contract with a medicare-certified home health agency;

(c) Submits a completed, signed core provider agreement to the medicaid agency and is enrolled; and

(d) Has an RN home health taxonomy on their provider file in the medicaid agency's claim payment system.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-551-2200, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and 42 C.F.R. Section 440.70. WSR 18-24-023, § 182-551-2200, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-03-035, § 182-551-2200, filed 1/12/16, effective 2/12/16. WSR 11-14-075, recodified as § 182-551-2200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, chapter 74.09 RCW, and 2009 c 326. WSR 10-10-087, § 388-551-2200, filed 5/3/10, effective 6/3/10. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. WSR 02-15-082, § 388-551-2200, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. WSR 99-16-069, § 388-551-2200, filed 8/2/99, effective 9/2/99.*

##### **Wash. Admin. Code § 182-551-2210** Provider requirements. {#sec-182-551-2210 omnilex-key=us-wa-regs-official--title-182--182-551-2210}

(1) For any home health services to be payable, the medicaid agency requires home health providers to develop and implement an individualized plan of care (POC) for the client that must:

(a) Be documented in writing and be located in the client's home health medical record;

(b) Be developed, supervised, and signed by a licensed registered nurse or licensed therapist;

(c) Reflect the authorized practitioner's orders and client's current health status;

(d) Contain specific goals and treatment plans;

(e) Be reviewed and revised by an authorized practitioner at least every 60 calendar days;

(f) Be signed by the authorized practitioner within 45 days if a verbal order is given; and

(g) Be available to medicaid agency staff or its designated contractor(s) on request.

(2) The provider must include all the following in the POC:

(a) The client's name, date of birth, and addressto include name of residential care facility, if applicable;

(b) The primary diagnosis (the diagnosis that is most related to the reason the client qualifies for home health services) or the diagnosis that is the reason for the visit frequency;

(c) All secondary medical diagnoses, including date or dates of onset or exacerbation;

(d) The prognosis;

(e) The type or types of equipment required;

(f) A description of each planned service and goals related to the services provided;

(g) Specific procedures and modalities;

(h) A description of the client's mental status;

(i) A description of the client's rehabilitation potential;

(j) A list of permitted activities;

(k) A list of safety measures taken on behalf of the client; and

(l) A list of medications which indicates:

(i) Any new prescription; and

(ii) Which medications are changed for dosage or route of administration.

(3) The provider must include in or attach to the POC:

(a) A description of the client's functional limits and the effects;

(b) Documentation that justifies why the medical services should be provided in any setting where the client's life activities take place instead of an authorized practitioner's office, clinic, or other outpatient setting;

(c) Significant clinical findings;

(d) Dates of recent hospitalization;

(e) Notification to the department of social and health services (DSHS) case manager of admittance;

(f) A discharge plan, including notification to the DSHS case manager of the planned discharge date and client disposition at time of discharge; and

(g) Order for the delivery of home health services through telemedicine, as appropriate.

(4) The individual client medical record must comply with community standards of practice, and must include documentation of:

(a) Visit notes for every billed visit;

(b) Supervisory visits for home health aide services as described in WAC 182-551-2120;

(c) All medications administered and treatments provided;

(d) All authorized practitioner's orders, new orders, and change orders, with notation that the order was received before treatment;

(e) Signed authorized practitioner's new orders and change orders;

(f) Home health aide services as indicated by a registered nurse or licensed therapist in a home health aide care plan;

(g) Interdisciplinary and multidisciplinary team communications;

(h) Inter-agency and intra-agency referrals;

(i) Medical tests and results;

(j) Pertinent medical history; and

(k) Notations and charting with signature and title of writer.

(5) The provider must document at least the following in the client's medical record:

(a) Skilled interventions per the POC;

(b) Client response to the POC;

(c) Any clinical change in client status;

(d) Follow-up interventions specific to a change in status with significant clinical findings;

(e) Any communications with the attending authorized practitioner; and

(f) Telemedicine findings, as appropriate.

(6) The provider must include the following documentation in the client's visit notes when appropriate:

(a) Any teaching, assessment, management, evaluation, client compliance, and client response; and

(b) The client's physical system assessment as identified in the POC.

(7) For any in-home delivered home health services to be payable, the medicaid agency requires home health providers to meet the electronic visit verification requirements.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-551-2210, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and 2021 c 157. WSR 23-04-048, § 182-551-2210, filed 1/26/23, effective 2/26/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-23-044, § 182-551-2210, filed 11/9/21, effective 12/10/21. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Section 440.70. WSR 18-24-023, § 182-551-2210, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-03-035, § 182-551-2210, filed 1/12/16, effective 2/12/16. WSR 11-14-075, recodified as § 182-551-2210, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, chapter 74.09 RCW, and 2009 c 326. WSR 10-10-087, § 388-551-2210, filed 5/3/10, effective 6/3/10. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. WSR 02-15-082, § 388-551-2210, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. WSR 99-16-069, § 388-551-2210, filed 8/2/99, effective 9/2/99.*

##### **Wash. Admin. Code § 182-551-2220** Provider payments. {#sec-182-551-2220 omnilex-key=us-wa-regs-official--title-182--182-551-2220}

(1) To be reimbursed, the home health provider must bill the medicaid agency according to medicaid program rules, including chapter 182-502 WAC and agency published billing instructions.

(2) Payment to home health providers is:

(a) A set rate per visit for each discipline provided to a client;

(b) Based on the county location of the providing home health agency; and

(c) Updated by general vendor rate changes.

(3) For clients eligible for both medicaid and medicare, the medicaid agency may pay for services described in this chapter only when medicare does not cover those services or pays less than the medicaid maximum payment. The maximum payment for each service is medicaid's maximum payment.

(4) The medicaid agency does not pay for services provided to clients at a hospital, adult day care, skilled nursing facility, or intermediate care facility for individuals with intellectual disabilities, or any setting in which payment is made under medicaid for inpatient services that include room and board.

(a) Residential facilities contracted with the state to provide services are not reimbursed separately for those same services under the medicaid agency's home health program.

(b) It is the responsibility of the home health agency to request coverage for a client when the services are not available to the client in the community or through long-term care.

(5) Providers must submit documentation to the medicaid agency during the home health agency's review period. Documentation includes, but is not limited to, the requirements listed in WAC 182-551-2210.

(6) After the medicaid agency receives the documentation, the medicaid agency or the agency's designee reviews the client's medical records for program compliance and quality of care.

(7) The medicaid agency may take back or deny payment for any insufficiently documented home health care service when the medicaid agency or the agency's designee determines that:

(a) The service did not meet the conditions described in WAC 182-550-2030; or

(b) The service was not in compliance with program policy.

(8) For any in-home home health services to be payable, the medicaid agency requires claims to meet the electronic visit verification requirements. The claims must electronically verify the following data points:

(a) Type of service performed;

(b) Individual receiving the service;

(c) Date of the service;

(d) Location of service delivery;

(e) Individual providing the service; and

(f) Time services begin and the time services end.

(9) Covered home health services for clients enrolled in an agency-contracted managed care organization (MCO) are paid for by that MCO.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-551-2220, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and 42 C.F.R. Section 440.70. WSR 18-24-023, § 182-551-2220, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-03-035, § 182-551-2220, filed 1/12/16, effective 2/12/16. WSR 11-14-075, recodified as § 182-551-2220, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, chapter 74.09 RCW, and 2009 c 326. WSR 10-10-087, § 388-551-2220, filed 5/3/10, effective 6/3/10. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. WSR 02-15-082, § 388-551-2220, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. WSR 99-16-069, § 388-551-2220, filed 8/2/99, effective 9/2/99.*

##### **Wash. Admin. Code § 182-551-3000** Private duty nursing for clients age seventeen and younger—General. {#sec-182-551-3000 omnilex-key=us-wa-regs-official--title-182--182-551-3000}

(1) The medically intensive children's program (MICP) provides private duty nursing to clients, either through fee-for-service or an agency-contracted managed care organization (MCO).

(2) The MICP is available to clients age seventeen and younger, whose complex medical needs cannot be managed within the scope of intermittent home health services.

(3) Managed care clients receive private duty nursing services through their agency-contracted MCO. (See chapter 182-538 WAC). Providers must follow the policies and procedures of the client's MCO, including the authorization of services.

(4) For clients with third-party liability (TPL) coverage (see WAC 182-500-0105) that includes private duty nursing, the procedures and policies in subchapter III, titled Private Duty Nursing, apply when determining coverage of additional hours under MICP.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-15-010, § 182-551-3000, filed 7/6/18, effective 9/1/18. WSR 11-14-075, recodified as § 182-551-3000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-551-3000, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090 and 74.09.520. WSR 01-05-040, § 388-551-3000, filed 2/14/01, effective 3/17/01.*

##### **Wash. Admin. Code § 182-551-3050** Private duty nursing for clients age seventeen and younger—Definitions. {#sec-182-551-3050 omnilex-key=us-wa-regs-official--title-182--182-551-3050}

The following definitions and those found in chapter 182-500 WAC apply to this subchapter.

"Nursing care consultant" means a registered nurse employed by the department of social and health services (DSHS) to evaluate clinical eligibility for the medically intensive children's program (MICP) and provide a written assessment summary.

"Private duty nursing" means skilled nursing care and services provided in the home for clients with complex medical needs that cannot be managed within the scope of intermittent home health services.

"Skilled nursing care" means the medical care provided by a licensed nurse or delegate working under the direction of a physician as described in RCW 18.79.260.

"Skilled nursing services" means the management and administration of skilled nursing care requiring the specialized judgment, knowledge, and skills of a registered nurse or licensed practical nurse as described in RCW 18.79.040 and 18.79.060.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-15-010, § 182-551-3050, filed 7/6/18, effective 9/1/18.*

##### **Wash. Admin. Code § 182-551-3100** Private duty nursing for clients age 17 and younger—Client eligibility. {#sec-182-551-3100 omnilex-key=us-wa-regs-official--title-182--182-551-3100}

(1) To be eligible for private duty nursing under the medically intensive children's program (MICP), clients must:

(a) Be age 17 or younger;

(b) Meet financial eligibility under subsection (2) of this section;

(c) Meet medical eligibility under subsection (3) of this section;

(d) Have informal support by a person who has been trained to provide designated skilled nursing care and is able to perform the care as required;

(e) Have prior authorization from the department of social and health services/developmental disabilities community services (DSHS/DDCS); and

(f) Have exhausted all other funding sources for private duty nursing, according to RCW 74.09.185, prior to accessing these services through the medically intensive children's program (MICP).

(2) To be financially eligible for private duty nursing, clients must meet medicaid eligibility requirements under the categorically needy program, the medically needy program, or alternative benefits plan program (see WAC 182-501-0060).

(3) To be medically eligible for private duty nursing under fee-for-service, clients must be assessed by a DSHS/DDCS nursing care consultant and determined medically eligible for MICP.

(4) Clients must meet the following criteria to be medically eligible for MICP:

(a) Require four or more continuous hours of active skilled nursing care with consecutive tasks at a level that:

(i) Cannot be delegated at the time of the initial assessment; and

(ii) Can be provided safely outside of a hospital in a less restrictive setting.

(b) Require two or more tasks of complex skilled nursing care such as:

(i) System assessments, including multistep approaches of systems (e.g., respiratory assessment, airway assessment, vital signs, nutritional and hydration assessment, complex gastrointestinal assessment and management, seizure management requiring intervention, or level of consciousness);

(ii) Administration of treatment for complex respiratory issues related to technological dependence requiring multistep approaches on a day-to-day basis (e.g., ventilator tracheostomy);

(iii) Assessment of complex respiratory issues and interventions with use of oximetry, titration of oxygen, ventilator settings, humidification systems, fluid balance, or any other cardiopulmonary critical indicators based on medical necessity;

(iv) Skilled nursing interventions of intravenous/parenteral administration of multiple medications and nutritional substances on a continuing or intermittent basis with frequent interventions; or

(v) Skilled nursing interventions of enteral nutrition and medications requiring multistep approaches daily.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-551-3100, filed 11/4/25, effective 12/5/25*
- *WSR 18-15-010, § 182-551-3100, filed 7/6/18, effective 9/1/18.*

##### **Wash. Admin. Code § 182-551-3200** Private duty nursing for clients age 17 and younger—Provider requirements. {#sec-182-551-3200 omnilex-key=us-wa-regs-official--title-182--182-551-3200}

Providers qualified to deliver private duty nursing under the medically intensive children's program must have the following:

(1) An in-home services license with the state of Washington to provide private duty nursing;

(2) A contract with the department of social and health services/developmental disabilities community services (DSHS/DDCS) to provide private duty nursing; and

(3) A signed core provider agreement with the medicaid agency.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-551-3200, filed 11/4/25, effective 12/5/25*
- *WSR 18-15-010, § 182-551-3200, filed 7/6/18, effective 9/1/18.*

##### **Wash. Admin. Code § 182-551-3300** Private duty nursing for clients age 17 and younger—Application requirements. {#sec-182-551-3300 omnilex-key=us-wa-regs-official--title-182--182-551-3300}

Clients requesting private duty nursing through fee-for-service must submit a complete signed medically intensive children's program (MICP) application (DSHS form 15-398). The MICP application must include the following:

(1) DSHS 14-012 consent form;

(2) DSHS 14-151 request for DDCS eligibility determination form for clients not already determined DDCS eligible;

(3) DSHS 03-387 notice of practices for client medical information;

(4) Appropriate and current medical documentation including medical plan of treatment or plan of care (WAC 246-335-080) with the client's age, medical history, diagnoses, and the parent/guardian contact information including address and phone number;

(5) A list of current treatments or treatment records;

(6) Information about ventilator, bilevel positive airway pressure (BiPAP), or continuous positive airway pressure (CPAP) hours per day or frequency of use;

(7) History and physical from current hospital admission, recent discharge summary, or recent primary physician exam;

(8) A recent interim summary, discharge summary, or clinical summary;

(9) Recent nursing charting within the past five to seven days of hospitalization or in-home nursing documentation;

(10) Current nursing care plan that may include copies of current daily nursing notes that describe nursing care activities;

(11) An emergency medical plan that includes strategies to address loss of power and environmental disasters such as methods to maintain life-saving medical equipment supporting the client. The plan may include notification of electric and gas companies and the local fire department;

(12) A psycho-social history/summary with the following information, as available:

(a) Family arrangement and current situation;

(b) Available personal support systems; and

(c) Presence of other stresses within and upon the family.

(13) Statement that the home care plan is safe for the child and is agreed to by the child's parent or legal guardian;

(14) Information about other family supports such as medicaid, school hours, or hours paid by a third-party insurance or trust; and

(15) For a client with third-party insurance or a managed care organization (MCO), a denial letter from the third-party insurance or MCO that states the private duty nursing will not be covered.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-551-3300, filed 11/4/25, effective 12/5/25*
- *WSR 18-15-010, § 182-551-3300, filed 7/6/18, effective 9/1/18.*

##### **Wash. Admin. Code § 182-551-3400** Private duty nursing for clients age 17 and younger—Authorization. {#sec-182-551-3400 omnilex-key=us-wa-regs-official--title-182--182-551-3400}

(1) Private duty nursing when provided through fee-for-service requires prior authorization from the department of social and health services/developmental disabilities community services (DSHS/DDCS).

(2) DSHS/DDCS authorizes requests for private duty nursing on a case-by-case basis when:

(a) The application requirements under WAC 182-551-3300 are met; and

(b) The nursing care consultant determines the services to be medically necessary, as defined in WAC 182-500-0070 and according to the process in WAC 182-501-0165.

(3) DSHS/DDCS authorizes only the number of private duty nursing hours that are medically necessary.

(a) Services are limited to 16 hours of private duty nursing per day.

(b) DSHS/DDCS may adjust the number of authorized hours when the client's condition or situation changes.

(c) Additional hours beyond 16 per day are subject to review as a limitation extension under WAC 182-501-0169.

(4) Private duty nursing provided to the client in excess of the authorized hours may be the financial responsibility of the client, the client's family, or the client's guardian. Providers must follow the provisions of WAC 182-502-0160.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-551-3400, filed 11/4/25, effective 12/5/25*
- *WSR 18-15-010, § 182-551-3400, filed 7/6/18, effective 9/1/18.*

## **Chapter 182-552** Respiratory care. {#struct-chapter-182-552}

##### **Wash. Admin. Code § 182-552-0001** Respiratory care—General. {#sec-182-552-0001 omnilex-key=us-wa-regs-official--title-182--182-552-0001}

(1) The respiratory care, equipment, and supplies described in this chapter applies to:

(a) Medicaid clients who require respiratory care in their homes, community residential settings, and skilled nursing facilities;

(b) Providers who supply respiratory care to medicaid clients; and

(c) Licensed health care professionals whose scope of practice allows for the provision of respiratory care.

(2) The agency covers the respiratory care listed in this chapter according to the limitations and requirements in this chapter.

(3) The agency pays for respiratory care for medicaid clients when it is:

(a) Covered;

(b) Within the scope of the eligible client's medical care program;

(c) Medically necessary, as defined under chapter 182-500 WAC;

(d) Prescribed by a physician, advanced registered nurse practitioner (ARNP), or physician assistant within the scope of their licensure;

(e) Authorized, as required within this chapter, chapters 182-501 and 182-502 WAC, and the agency's published medicaid billing guides and provider alerts;

(f) Billed according to this chapter, chapters 182-501 and 182-502 WAC, and the agency's published medicaid billing guides and provider alerts; and

(g) Provided and used within accepted medical or respiratory care community standards of practice.

(4) The agency does not require prior authorization for requests for covered respiratory care for medicaid clients that meets the clinical criteria set forth in this chapter.

(5) The agency requires prior authorization for covered respiratory care for medicaid clients when the clinical criteria set forth in this chapter are not met, including the criteria associated with the expedited prior authorization process.

(a) The agency evaluates requests requiring prior authorization on a case-by-case basis to determine whether they are medically necessary, according to the process found in WAC 182-501-0165.

(b) Refer to WAC 182-552-1300, 182-552-1325, 182-552-1350, and 182-552-1375 for specific details regarding authorization.

(6) The agency evaluates on a case-by-case basis for medical necessity and appropriateness items, procedures, and services that do not have an established procedure code available and which are billed using miscellaneous procedure codes.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-21-163, s 182-552-0001, filed 10/23/24, effective 11/23/24. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. 431.16 Section 1903 (i)(27) of the Social Security Act. WSR 19-21-087, § 182-552-0001, filed 10/14/19, effective 11/14/19. Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-0001, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-0005** Respiratory care—Definitions. {#sec-182-552-0005 omnilex-key=us-wa-regs-official--title-182--182-552-0005}

The following definitions and those in chapter 182-500 WAC apply to this chapter.

"Adult family home" - A residential home licensed to care for up to six residents that provides rooms, meals, laundry, supervision, assistance with activities of daily living, and personal care. In addition to these services, some homes provide nursing or other special care and services.

"Apnea" - The cessation of airflow for at least 10 seconds.

"Apnea-hypopnea index (AHI)" - The average number of episodes of apnea and hypopnea per hour of sleep without the use of a positive airway pressure device. For purposes of this chapter, respiratory effort related arousals (RERAs) are not included in the calculation.

"Arterial PaO2" - Measurement of partial pressure of arterial oxygen.

"Authorized prescriber" - A health care practitioner authorized by law or rule in the state of Washington to prescribe oxygen and respiratory care equipment, supplies, and services.

"Base year" - As used in this chapter, means the year in which the respiratory care current fee schedule is adopted.

"Bi-level respiratory assist device with backup rate" - A device that allows independent setting of inspiratory and expiratory pressures to deliver positive airway pressure (within a single respiratory cycle) by way of tubing and a noninvasive interface (such as a nasal or oral facial mask) to assist spontaneous respiratory efforts and supplement the volume of inspired air into the lungs. In addition, these devices have a timed backup feature to deliver this air pressure whenever sufficient spontaneous inspiratory efforts fail to occur.

"Bi-level respiratory assist device without backup rate" - A device that allows independent setting of inspiratory and expiratory pressures to deliver positive airway pressure (within a single respiratory cycle) by way of tubing and a noninvasive interface (such as a nasal, oral, or facial mask) to assist spontaneous respiratory efforts and supplement the volume of inspired air into the lungs.

"Blood gas study" - For the purposes of this chapter, is either an oximetry test or an arterial blood gas test.

"Boarding home" - Adult residential care (ARC) facility, enhanced adult residential care (EARC) facility, or assisted living (AL) facility.

"Central sleep apnea (CSA)" - Is defined as:

(1) An apnea-hypopnea index (AHI) greater than or equal to five; and

(2) Central apneas/hypopneas greater than 50 percent of the total apneas/hypopneas; and

(3) Central apneas or hypopneas greater than or equal to five times per hour; and

(4) Symptoms of either excessive sleepiness or disrupted sleep.

"Chronic obstructive pulmonary disease (COPD)" - Any disorder that persistently obstructs bronchial airflow. COPD mainly involves two related diseases: Chronic bronchitis and emphysema. Both cause chronic obstruction of air flowing through the airways and in and out of the lungs. The obstruction is generally permanent and worsens over time.

"Complex sleep apnea (CompSA)" - A form of central apnea specifically identified by the persistence or emergence of central apneas or hypopneas, upon exposure to CPAP or a bi-level respiratory assist device without a back-up rate feature, when obstructive events have disappeared. These clients have predominantly obstructive or mixed apneas during the diagnostic sleep study occurring at greater than or equal to five times per hour. With use of a CPAP or bi-level respiratory assist device without a back-up rate feature, the client shows a pattern of apneas and hypopneas that meets the definition of central sleep apnea (CSA).

"Continuous positive airway pressure (CPAP)" - A single-level device which delivers a constant level of positive air pressure (within a single respiratory cycle) by way of tubing and an interface to assist spontaneous respiratory efforts and supplement the volume of inspired air into the lungs.

"Dependent edema" - Fluid in the tissues, usually ankles, wrists, and the arms.

"Emergency oxygen" - The immediate, short-term administration of oxygen to a client who normally does not receive oxygen but is experiencing an acute episode which requires oxygen.

"Erythrocythemia" - More hematocrit (red blood cells) than normal.

"FIO2" - The fractional concentration of oxygen delivered to the client for inspiration. For the purpose of this policy, the client's prescribed FIO2 refers to the oxygen concentration the client normally breathes when not undergoing testing to qualify for coverage of a respiratory assist device (RAD). That is, if the client does not normally use supplemental oxygen, their prescribed FIO2 is that found in room air.

"FEV1" - The forced expired volume in one second.

"FVC" - The forced vital capacity.

"Group I" - Clinical criteria, set by medicare, to identify clients requiring oxygen. The agency follows the Group I clinical criteria listed in the Centers for Medicare and Medicaid Services National Coverage Determination for Home Use of Oxygen, which is found in the Medicare Coverage Database.

"Group II" - Clinical criteria, set by medicare, to identify clients who require oxygen. Their blood oxygen levels may be within normal range, however, they have complicating conditions that require supplemental oxygen use. The agency follows the Group II clinical criteria listed in the Centers for Medicare and Medicaid Services National Coverage Determination for Home Use of Oxygen, which is found in the Medicare Coverage Database.

"Group III" – Clients for whom intermittent home oxygen therapy is considered medically necessary to treat cluster headaches. These clients also have a documented clinical history that includes all of the following:

• At least five attacks of severe, strictly unilateral pain that is orbital, supraorbital, temporal, or in any combination of these sites, lasting 15 to 180 minutes, and occurring at least once every other day up to eight times a day;

• At least one of the following symptoms or signs, ipsilateral to the headache:

- Conjunctival injection and/or lacrimation;

- Nasal congestion and/or rhinorrhea;

- Eyelid edema;

- Forehead and facial sweating; or

- Miosis and/or ptosis;

• Occurring with a frequency at least once every other day up to eight times per day;

• Not better accounted for by another ICHD-3 diagnosis;

• Prevents ability to function in all activities; and

• Other treatment has failed.

"Home and community residential settings" - In-home, adult family home, or boarding home.

"Hypopnea" - A temporary reduction of airflow lasting at least 10 seconds and accompanied with a 30 percent reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a four percent decrease in oxygen saturation. The AHI is the average number of episodes of apnea and hypopnea per hour of sleep without the use of a positive airway pressure device.

"Hypoxemia" - Less than normal level of oxygen in the blood.

"Maximum allowable" - The maximum dollar amount the medicaid agency reimburses a provider for a specific service, supply, or piece of equipment.

"Month" - For the purposes of this chapter, means 30 days.

"Nebulizer" - A medical device which administers drugs for inhalation therapy for clients with respiratory conditions such as asthma or emphysema.

"Obstructive sleep apnea (OSA)" - This syndrome refers to the interruption of breathing during sleep, due to obstructive tissue in the upper airway that collapses into the air passage with respiration.

"Oxygen" - Medical grade liquid or gaseous oxygen.

"Oxygen concentrator" - A medical device that removes nitrogen from room air and retains almost pure oxygen (87 percent to 95 percent) for delivery to a client.

"Oxygen system" - All equipment necessary to provide oxygen to a client.

"Portable oxygen system" - A system which allows the client to be independent of the stationary system for several hours, thereby providing mobility for the client.

"Pulmonary hypertension" - High blood pressure in the vessels that feed through the lungs, causing the right side of the heart to work harder to oxygenate blood.

"Respiratory care" - The care of a client with respiratory needs and all related equipment, oxygen, services, and supplies.

"Respiratory care practitioner" - A person licensed by the department of health according to chapter 18.89 RCW and chapter 246-928 WAC as a respiratory therapist (RT) or respiratory care practitioner (RCP).

"Respiratory effort related arousals (RERA)" - These occur when there is a sequence of breaths that lasts at least 10 seconds, characterized by increasing respiratory effort or flattening of the nasal pressure waveform, which lead to an arousal from sleep. However, they do not meet the criteria of an apnea or hypopnea.

"Restrictive thoracic disorders" - This refers to a variety of neuromuscular and anatomical anomalies of the chest/rib cage area that may result in hypoventilation, particularly while the client sleeps at night.

"Reasonable useful lifetime (RUL)" - For 36 month capped oxygen equipment, the RUL is five years. The RUL is not based on the chronological age of the equipment. It starts on the initial date of the rental and runs for five years from that date.

"Stationary oxygen system" - Equipment designed to be used in one location, generally for the purpose of continuous use or frequent intermittent use.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-064, § 182-552-0005, filed 6/28/23, effective 8/1/23. Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-0005, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-0100** Respiratory care—Client eligibility. {#sec-182-552-0100 omnilex-key=us-wa-regs-official--title-182--182-552-0100}

(1) To receive respiratory care, a person must be eligible for one of the Washington apple health programs listed in the table in WAC 182-501-0060 or be eligible for the alien emergency medical (AEM) program (as described in WAC 182-507-0110).

(2) Persons who are enrolled in an agency-contracted managed care organization (MCO) must arrange for all respiratory care directly through his or her MCO.

(3) For persons residing in skilled nursing facilities, boarding homes, and adult family homes, see WAC 182-552-0150.

(4) Persons who are eligible for services under medicare and medicaid (medically needy program-qualified medicare beneficiaries) are eligible for respiratory care.

**History**
- *Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148). WSR 14-07-042, § 182-552-0100, filed 3/12/14, effective 4/12/14. Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-0100, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-0150** Respiratory care—Clients residing in skilled nursing facilities, boarding homes, and adult family homes. {#sec-182-552-0150 omnilex-key=us-wa-regs-official--title-182--182-552-0150}

For eligible clients who reside in skilled nursing facilities, boarding homes, and adult family homes:

(1) The medicaid agency pays, according to the requirements in this chapter, for the chronic use of medically necessary respiratory care.

(2) The medicaid agency does not pay separately for the following:

(a) Emergency oxygen equipment and supplies; and

(b) Licensed respiratory care staff.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-0150, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-0200** Respiratory care—Provider requirements. {#sec-182-552-0200 omnilex-key=us-wa-regs-official--title-182--182-552-0200}

(1) To receive payment for respiratory care equipment and supplies under this chapter, a provider must:

(a) Meet the general provider requirements in chapter 182-502 WAC;

(b) Obtain prior authorization from the medicaid agency, if required, before delivery to the client and before billing the agency;

(c) Keep initial and subsequent prescriptions according to the requirements within this chapter;

(d) Provide instructions to the client and/or caregiver on the safe and proper use of equipment provided;

(e) Have a licensed health care professional whose scope of practice allows for the provision of respiratory care. The licensed health care professional must also:

(i) Check equipment and ensure equipment settings continue to meet the client's needs; and

(ii) Communicate with the client's authorized prescriber if there are any concerns or recommendations.

(f) Verify that the client has a valid prescription.

(i) To be valid, a prescription must:

(A) Be written, and signed and dated by a physician, advanced registered nurse practitioner (ARNP), or physician's assistant certified (PAC); and

(B) State the specific items or services requested, including the quantity, frequency, and duration/length of need. Prescriptions that only state "as needed" or "PRN" are not sufficient; and

(C) For an initial prescription, not be older than three months from the date the prescriber signed the prescription; or

(D) For subsequent prescriptions, not be older than one year from the date the initial prescription was signed. (See WAC 182-552-0800 for exceptions.)

(2) The medicaid agency does not pay for respiratory care equipment and/or supplies furnished to the agency's clients when:

(a) The authorized prescriber who provides medical justification to the agency for the item provided to the client is an employee of, has a contract with, or has any financial relationship with the provider of the item; or

(b) The authorized prescriber who performs a client evaluation is an employee of, has a contract with, or has any financial relationship with a provider of respiratory care equipment, supplies, and related items.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-064, § 182-552-0200, filed 6/28/23, effective 8/1/23. Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-0200, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-0250** Respiratory care—Proof of delivery. {#sec-182-552-0250 omnilex-key=us-wa-regs-official--title-182--182-552-0250}

(1) When a provider delivers equipment directly to the client or the client's authorized representative, the provider must furnish the proof of delivery when the medicaid agency requests that information.

(2) The medicaid agency requires the proof of delivery to:

(a) Be signed and dated by the client or the client's authorized representative (the date of signature must be the date the item was received by the client); and

(b) Include the client's name and a detailed description of the item(s) delivered, including the quantity, brand name, and serial number.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-0250, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-0300** Respiratory care—Covered—Apnea monitors and supplies. {#sec-182-552-0300 omnilex-key=us-wa-regs-official--title-182--182-552-0300}

(1) The medicaid agency covers, without prior authorization, the rental of an apnea monitor (cardiorespiratory monitor) with recording feature for a maximum of six months when:

(a) The client is less than one year of age and meets at least one of the following clinical criteria:

(i) Born less than thirty-seven weeks gestation, and the infant is not more than forty-three weeks corrected gestational age;

(ii) Had an apparent life-threatening apneic event (defined as requiring mouth-to-mouth resuscitation or vigorous stimulation);

(iii) Has been diagnosed with bradycardia and is being treated with caffeine, theophylline, or other stimulating agents;

(iv) Has documented gastro-esophageal reflux which results in apnea, bradycardia, or oxygen desaturation;

(v) Has documented apnea greater than twenty seconds in duration;

(vi) Has apnea for periods less than twenty seconds in duration and accompanied by bradycardia, cyanosis, or pallor;

(vii) Has bradycardia (defined as heart rate less than one hundred beats per minute);

(viii) Has oxygen desaturation below ninety percent;

(ix) Has neurologic/anatomic/metabolic or respiratory diseases affecting respiratory drive; or

(x) Is a subsequent sibling of an infant who died of sudden infant death syndrome (SIDS), until the client is one month older than the age at which the earlier sibling died and the client remains event-free; and

(b) The vendor has a licensed clinician with competency in pediatric respiratory care responsible for management of the client's apnea monitoring.

(2) For each subsequent rental period, the client must continue to meet the clinical criteria in subsection (1) of this section and the vendor must obtain prior authorization from the medicaid agency.

(3) Documentation of the result of the use of an apnea monitor must be kept in the client's record.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-0300, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-0400** Respiratory care—Continuous positive airway pressure (CPAP) device and supplies. {#sec-182-552-0400 omnilex-key=us-wa-regs-official--title-182--182-552-0400}

(1) The medicaid agency covers, without prior authorization, one continuous positive airway pressure (CPAP) device including related supplies, per client, every five years. The CPAP device must have a data card and the client must meet the following clinical criteria:

(a) The client is diagnosed with obstructive sleep apnea (OSA) using a clinical evaluation and a positive attended polysomnogram (PSG) performed in a sleep laboratory or an unattended home sleep test; and

(b) For clients age twenty-one and older:

(i) The client's polysomnogram or home sleep test demonstrates an apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) greater than or equal to fifteen events per hour; or

(ii) The client's polysomnogram or home sleep test demonstrates the AHI or RDI is greater than or equal to five and less than or equal to fourteen events per hour with clinical documentation of:

(A) Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or

(B) Hypertension, ischemic heart disease, or history of stroke.

(c) For clients age twenty and younger, the clinical criteria is considered met when there is a documented diagnosis of OSA and polysomnography demonstrates an apnea index (AI) or AHI equal to or greater than one and:

(i) Adenotonsillectomy has been unsuccessful in relieving OSA; or

(ii) Adenotonsillar tissue is minimal; or

(iii) Adenotonsillectomy is inappropriate based on OSA being attributable to another underlying cause (e.g., craniofacial anomaly, obesity) or adenotonsillectomy is contraindicated; or

(iv) Family does not wish to pursue surgical intervention.

(2) If a client meets the criteria in subsection (1) of this section but a CPAP device has been tried and proven ineffective, the medicaid agency will cover a bi-level respiratory assist device (RAD) without the back-up rate. Ineffective, in this case, is defined as documented failure to meet therapeutic goals using a CPAP during the titration portion of a facility-based study or during home use despite optimal therapy (i.e., proper mask selection and fitting and appropriate pressure setting).

(3) The AHI is calculated on the average number of events per hour. If the AHI is calculated based on less than two hours of sleep, the total number of recorded events used to calculate the AHI must be at least the number of events that would have been required in a two-hour period (i.e., must reach greater than or equal to thirty events without symptoms or greater than or equal to ten events with symptoms). The medicaid agency pays for an initial three-month rental period for CPAP devices.

(4) The medicaid agency purchases a CPAP device after the three-month rental period when the following documentation of clinical benefit is recorded in the client's file:

(a) A face-to-face clinical reevaluation of the client by the authorized prescriber which documents that symptoms of obstructive sleep apnea are improved; and

(b) A review of objective evidence by the authorized prescriber of the client's adherence to use of the CPAP device. Adherence is defined as use of the CPAP device greater than or equal to four hours per night on seventy percent of nights during a consecutive thirty-day period anytime during the first three months of initial usage.

(5) The medicaid agency does not pay for a CPAP device when the client is diagnosed with upper airway resistance syndrome (UARS).

(6) The medicaid agency pays for the purchase of a heated humidifier for a CPAP device, once every five years from the date the item was deemed purchased, per client.

(7) Replacement of CPAP device.

(a) The medicaid agency requires prior authorization for the replacement of a CPAP device if the client has had the device for less than five years.

(b) After five years, the client must have a face-to-face evaluation with the treating authorized prescriber that documents that the client continues to use and benefit from the device. The medicaid agency does not require a new PSG (sleep test), trial period, or prior authorization.

(c) Replacement supplies - The medicaid agency pays for replacement supplies for a CPAP device as follows:

(i) Full face mask, limit one every six months;

(ii) Face mask interface for full face mask, limit one every three months;

(iii) Nasal interface (mask or cannula type), with or without head strap, limit one every six months;

(iv) Cushion for use on nasal mask interface, limit one every three months;

(v) Pillow for use on nasal cannula type interface, limit one pair every three months;

(vi) Headgear, chin strap, and tubing with or without integrated heating element, limit one every six months;

(vii) Filters - Disposable, limit two every thirty days;

(viii) Filters - Nondisposable, limit one every six months; and

(ix) Water chamber for humidifier, limit one every six months.

(d) Prior authorization is required if the client does not meet the clinical criteria in this section or if the medicaid agency has purchased a bi-level respiratory assist device for the client within the last five years.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-20-057, § 182-552-0400, filed 10/1/15, effective 11/1/15. Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-0400, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-0450** Mandibular advancement device. {#sec-182-552-0450 omnilex-key=us-wa-regs-official--title-182--182-552-0450}

The agency covers the purchase of a mandibular advancement device for a client when the provider determines that the use of a continuous positive airway pressure (CPAP) device is medically contraindicated or the client cannot medically tolerate a CPAP device. Prior authorization is required for all eligible clients.

(1) The agency considers a mandibular advancement device to be medical equipment subject to the same billing requirements, restrictions, and limitations as other medical equipment according to chapter 182-543 WAC.

(2) For clients:

(a) Who have natural dentition, the agency pays for one custom-made mandibular advancement device every five years. The client must:

(i) Complete a face-to-face evaluation with a sleep medicine physician in an agency-designated center of excellence (COE) prior to sleep testing;

(ii) Be diagnosed with obstructive sleep apnea (OSA) using a clinical evaluation and positive attended polysomnogram (PSG); and

(iii) Meet the sleep testing criteria described in WAC 182-552-0400.

(b) Age 20 and younger, providers must follow the rules for the early periodic screening, diagnosis, and treatment (EPSDT) program, see chapter 182-534 WAC.

(3) The prescriber must keep the following in the client's record:

(a) Documentation of a CPAP trial lasting at least six consecutive months; and

(b) A description of why CPAP failed or an explanation of why CPAP is not the appropriate treatment.

(4) The mandibular advancement device must be titrated by a licensed provider who has documented experience in titrating these devices.

(5) The mandibular advancement device must be provided and billed by a licensed dentist who:

(a) Holds a certification in dental sleep medicine from the American Board of Dental Sleep Medicine (ABDSM); or

(b) Is the dental director of a dental sleep medicine facility accredited by the ABDSM; or

(c) Has completed agency-recognized continuing education in dental sleep medicine provided by the ABDSM or a comparable organization within the two years prior to providing the mandibular advancement device.

(6) The agency evaluates requests for authorization for mandibular advancement devices that exceed the limitations in this section on a case-by-case basis in accordance with WAC 182-501-0169.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-21-142, s 182-552-0450, filed 10/21/25, effective 11/21/25*
- *WSR 19-18-049, § 182-552-0450, filed 8/30/19, effective 10/1/19.*

##### **Wash. Admin. Code § 182-552-0500** Respiratory care—Covered—Bi-level respiratory assist devices and supplies. {#sec-182-552-0500 omnilex-key=us-wa-regs-official--title-182--182-552-0500}

(1) The medicaid agency covers, without prior authorization, one bi-level respiratory assist device (RAD), with or without a back-up rate feature, per client every five years. The client must have a clinical disorder characterized as one of the following and meet the clinical criteria for the specific condition as listed in subsections (2) through (5) of this section.

(a) Restrictive thoracic disorders (e.g., neuromuscular diseases or severe thoracic cage abnormalities); or

(b) Severe chronic obstructive pulmonary disease (COPD); or

(c) Central sleep apnea or complex sleep apnea; or

(d) Hypoventilation syndrome.

(2) Restrictive thoracic disorders - The medicaid agency pays for, without prior authorization, a bi-level RAD either with or without the back-up rate feature, when all of the following clinical criteria are met:

(a) The client has been diagnosed with a neuromuscular disease (e.g., amyotrophic lateral sclerosis (ALS)) or a severe thoracic cage abnormality (e.g., post-thoracoplasty for tuberculosis); and

(b) Chronic obstructive pulmonary disease (COPD) does not contribute significantly to the individual's pulmonary limitation; and

(c) One or more of the following criteria are met:

(i) An arterial blood gas PaCO2, done while awake and breathing the client's prescribed FIO2 (fractionated inspired oxygen concentration) is greater than or equal to forty-five mm Hg; or

(ii) Sleep oximetry demonstrates oxygen saturation less than or equal to eighty-eight percent for greater than or equal to five minutes of nocturnal recording time (minimum record time of two hours), done while breathing the client's prescribed recommended FIO2; or

(iii) For a neuromuscular disease (only), either of the following:

(A) Maximal inspiratory pressure is less than sixty cm H2O; or

(B) Forced vital capacity is less than or equal to fifty percent predicted.

(3) Severe chronic obstructive pulmonary disease (COPD).

(a) The medicaid agency pays, without prior authorization, for a bi-level RAD, without the back-up rate feature, when all of the following clinical criteria are met:

(i) An arterial blood gas PaCO2, done while awake and breathing the client's prescribed FIO2, is greater than or equal to fifty-two mm Hg; and

(ii) Sleep oximetry demonstrates oxygen saturation less than or equal to eighty-eight percent for greater than or equal to five minutes of nocturnal recording time (minimum recording time of two hours), done while breathing oxygen at two LPM or the client's prescribed FIO2, whichever is higher; and

(iii) Prior to initiating therapy, obstructive sleep apnea and treatment with CPAP has been considered and ruled out.

(b) The medicaid agency pays, without prior authorization, for a bi-level RAD, with the back-up rate feature, for clients with COPD who qualified for a bi-level RAD under (3)(a) of this section when:

(i) Started any time after a period of initial use of the bi-level RAD without the back-up rate feature when both of the following clinical criteria are met:

(A) An arterial blood gas PaCO2, done while awake and breathing the client's prescribed FIO2, shows that the client's PaCO2 worsens greater than or equal to seven mm Hg compared to the original result from criterion in subsection (3)(a)(i) of this section; and

(B) A facility-based PSG demonstrates oxygen saturation less than or equal to eighty-eight percent for greater than or equal to five minutes of nocturnal recording time (minimum recording time of two hours) while using a bi-level RAD without the back-up rate feature that is not caused by obstructive upper airway events, i.e., AHI less than five; or

(ii) Started at a time no sooner than sixty-one days after initial issue of the bi-level RAD without the back-up rate feature, when both of the following clinical criteria are met:

(A) An arterial blood gas PaCO2 is done while awake and breathing the client's prescribed FIO2, still remains greater than or equal to fifty-two mm Hg; and

(B) Sleep oximetry while breathing with the bi-level RAD without back-up rate feature, demonstrates oxygen saturation less than or equal to eighty-eight percent for greater than or equal to five minutes of nocturnal recording time (minimum recording time of two hours), done while breathing oxygen at two LPM or the client's prescribed FIO2, whichever is higher.

(4) Central sleep apnea or complex sleep apnea (i.e., not due to airway obstruction). The medicaid agency pays for, without prior authorization, a bi-level RAD with or without the back-up rate feature, when the client's polysomnogram test reveal all of the following:

(a) The diagnosis of central sleep apnea (CSA) or complex sleep apnea (CompSA);

(b) Significant improvement of the sleep-associated hypoventilation with the use of a bi-level RAD with or without the back-up rate feature on the settings that will be prescribed for initial use at home, while breathing the client's prescribed FIO2.

(5) Hypoventilation syndrome.

(a) The medicaid agency pays for, without prior authorization, a bi-level RAD without the back-up rate feature, when the clinical criteria in (a)(i) and (ii) of this subsection, or either (a)(iii) or (iv) of this subsection are met:

(i) An initial arterial blood gas PaCO2, done while awake and breathing the client's prescribed FIO2, is greater than or equal to forty-five mm Hg; and

(ii) Spirometry shows an FEV1/FVC greater or equal to seventy percent and an FEV1 greater than or equal to fifty percent of predicted; or

(iii) An arterial blood gas PaCO2, done during sleep or immediately upon awakening, and breathing the client's prescribed FIO2, shows the client's PaCO2 worsened greater than or equal to seven mm Hg compared to the original result in (a) of this subsection; or

(iv) A facility-based PSG demonstrates oxygen saturation less than or equal to eighty-eight percent for greater than or equal to five continuous minutes of nocturnal recording time (minimum recording time of two hours) that is not caused by obstructive upper airway events, i.e., AHI less than five.

(b) The medicaid agency pays for, without prior authorization, a bi-level RAD with the back-up rate feature, when the clinical criteria in (b)(i) and (ii) of this subsection, and either (b)(iii) or (iv) of this subsection are met:

(i) A covered bi-level RAD without the back-up rate feature is being used; and

(ii) Spirometry shows an FEV1/FVC greater than or equal to seventy percent and an FEV1 greater than or equal to fifty percent of predicted; and

(iii) An arterial blood gas PaCO2, done while awake and breathing the client's prescribed FIO2, shows that the client's PaCO2 worsens greater than or equal to seven mm Hg compared to the ABG result performed to qualify the client for the bi-level RAD without the back-up rate feature; or

(iv) A facility-based PSG demonstrates oxygen saturation less than or equal to eighty-eight percent for greater than or equal to five continuous minutes of nocturnal recording time (minimum recording time of two hours) that is not caused by obstructive upper airway events, i.e., AHI less than five while using a bi-level RAD without the back-up rate feature.

(6) For a bi-level RAD without the back-up rate feature, the medicaid agency pays as follows:

(a) An initial three-month rental period. In accordance with medicare's guidelines, the medicaid agency requires a face-to-face clinical reevaluation of the client by the treating authorized prescriber, between day thirty-one and day ninety-one of the rental period, which documents the following in the client's file to continue rental:

(i) The progress of the client's relevant symptoms; and

(ii) The client's compliance with using the device.

(b) Purchases after the requirements of (a) of this subsection are met.

(7) For a bi-level RAD with the back-up rate feature used with:

(a) An invasive interface, the medicaid agency pays for the rental only.

(b) A noninvasive interface, the medicaid agency pays as follows:

(i) An initial three-month rental period. In accordance with medicare's guidelines, the medicaid agency requires a face-to-face clinical reevaluation of the client by the treating authorized prescriber, between day thirty-one and day ninety-one of the rental period, which documents the following in the client's file to continue rental:

(ii) The progress of the client's relevant symptoms; and

(iii) The client's compliance with using the device.

(iv) Purchase after a total of thirteen months of rental.

(8) Prior authorization is required if the client does not meet the clinical criteria in this section or if the medicaid agency has purchased a CPAP device or other respiratory assist device for the client within the last five years.

(9) Replacement of bi-level RAD. The medicaid agency's policy for replacement of a bi-level RAD is the same as for a CPAP device. See WAC 182-552-0400(6).

**History**
- *Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-0500, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-0600** Respiratory care—Covered—Airway clearance devices. {#sec-182-552-0600 omnilex-key=us-wa-regs-official--title-182--182-552-0600}

Chest physiotherapy (CPT), which is also known as percussion and postural drainage (P/PD), is traditionally seen as the standard of care of secretion clearance methods. There are client instances when conventional manual CPT is unavailable, ineffective, or not tolerated. The medicaid agency then covers the following types of airway clearance devices when medically necessary for an individual with a diagnosis that is characterized by excessive mucus production and difficulty clearing secretions:

(1) Mechanical percussors. One per client, per lifetime;

(2) Oscillatory positive expiratory pressure devices. One per client every one hundred and eighty days;

(3) Positive expiratory pressure devices. Requires prior authorization (PA);

(4) Cough stimulating device, alternating positive and negative airway pressure. Requires PA; and

(5) High frequency chest wall oscillation air-pulse generator system. Requires PA.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-0600, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-0650** Respiratory care—Covered—Nebulizers, humidifiers, and accessories. {#sec-182-552-0650 omnilex-key=us-wa-regs-official--title-182--182-552-0650}

(1) The medicaid agency covers, without prior authorization, the purchase of a nebulizer and related compressor, with limits, when the following medicare clinical criteria are met.

(a) Small volume nebulizer and related compressor for the administration of inhalation drugs for:

(i) The management of obstructive pulmonary disease;

(ii) A client with cystic fibrosis or bronchiectasis;

(iii) A client with HIV, pneumocystosis, or complications of organ transplants; or

(iv) Persistent, thick, or tenacious pulmonary secretions.

(b) Large volume nebulizer and related compressor to deliver humidity to a client with thick, tenacious secretions and who has one or more of the following:

(i) Cystic fibrosis;

(ii) Bronchiectasis;

(iii) A tracheostomy; or

(iv) A tracheobronchial stent.

(c) Filtered nebulizer when necessary to administer pentamidine to clients with HIV, pneumocystosis, or complications of organ transplants.

(2) The medicaid agency limits payments, per client, as follows:

(a) Compressor - One every five years. Requires thirteen months rental first. After thirteen months, the compressor is considered purchased.

(b) Nebulizer with compressor - One every five years. Reimbursement includes instruction on the proper use and cleaning of the equipment.

(3) The medicaid agency pays separately for medically necessary accessories as follows:

(a) Administration set. Purchase only.

(i) With small volume filtered or nonfiltered pneumatic nebulizer, disposable. Limited to one per client every thirty days.

(ii) With small volume nonfiltered pneumatic nebulizer, nondisposable. Limited to one per client every six months.

(b) Aerosol mask, used with nebulizer. Purchase only. Limited to one per client every thirty days.

(c) Corrugated tubing, used with large volume nebulizer. Purchase only.

(i) Disposable, limited to one unit (one hundred feet) per client every sixty days.

(ii) Nondisposable, limited to one unit (ten feet) per client every twelve months.

(d) Face tent. Purchase only. Limited to one per client every thirty days.

(e) Filter. Purchase only.

(i) Disposable, limited to two per client every thirty days.

(ii) Nondisposable, limited to one per client every ninety days.

(f) Large volume nebulizer, disposable, unfilled, used with aerosol compressor. Limited to ten per client every thirty days.

(g) Small volume nonfiltered pneumatic nebulizer, disposable. Purchase only. Limited to two per client every thirty days.

(h) Tracheostomy mask, each. Purchase only. Limited to four per client every thirty days.

(i) Heated humidifier with temperature monitor and alarm for clients who have a tracheostomy but who are not ventilator dependent. Monthly rental only. Prior authorization is required.

(j) Water collection device, used with large volume nebulizer. Purchase only. Limited to eight per client every thirty days.

(k) Water, distilled, used with large volume nebulizer, 1000 ml. Limited to fifty units per client every thirty days.

(l) Immersion external heater for a nebulizer. Purchase only. Prior authorization is required.

(4) Providers must monitor the amount of supplies and accessories a client is actually using and assure that the client has nearly exhausted the supply on hand prior to dispensing any additional items.

(5) The medicaid agency does not pay for a large volume nebulizer, related compressor/generator, and water or saline when used predominantly to provide room humidification.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-0650, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-0700** Respiratory care—Covered—Inhalation drugs and solutions. {#sec-182-552-0700 omnilex-key=us-wa-regs-official--title-182--182-552-0700}

Inhalation drugs and solutions are included in the medicaid agency's prescription drug program. Refer to chapter 182-530 WAC.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-0700, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-0800** Respiratory care—Covered—Oxygen and oxygen equipment. {#sec-182-552-0800 omnilex-key=us-wa-regs-official--title-182--182-552-0800}

(1) The medicaid agency covers oxygen and oxygen equipment as provided in this chapter.

(2) The agency pays for the rental of a stationary oxygen system and/or a portable oxygen system, as follows:

(a) For clients, age 20 and younger, when prescribed by the client's treating practitioner; or

(b) For clients, age 21 and older, when prescribed by a practitioner and the client meets:

(i) Medicare's Group I or Group II clinical criteria; or

(ii) The Group III clinical criteria described in WAC 182-552-0005.

(c) If a client age 21 and older does not meet the clinical criteria in this subsection, prior authorization is required. The agency reviews requests for prior authorization under WAC 182-501-0165.

(3) Oxygen and oxygen equipment - Capped rental:

(a) Capped rental applies to in-home oxygen use only;

(b) The medicaid agency's payment for stationary oxygen system equipment and/or portable oxygen system equipment is limited to 36-monthly rental payments. During the rental period, the medicaid agency's payment includes any supplies, accessories, oxygen contents, delivery and associated costs, instructions, maintenance, servicing, and repairs;

(c) Oxygen systems are deemed capped rental (provider continues to own the equipment) after 36 months.

(i) The supplier who provides the oxygen equipment for the first month must continue to provide any necessary oxygen equipment and related items and services through the 36-month rental period unless one of the exceptions in (e) of this subsection is met.

(ii) The same provider is required to continue to provide the client with properly functioning oxygen equipment (including maintenance and repair), and associated supplies for the remaining 24 months of the equipment's reasonable useful lifetime (RUL).

(iii) The same provider may bill the medicaid agency for oxygen contents, disposable supplies, and maintenance fees only. Maintenance fee payment is limited to one every six months.

(d) At any time after the end of the five-year RUL for the oxygen equipment, the provider may replace the equipment, thus beginning a new 36-month rental period.

(e) A 36-month rental period may restart before the end of the five-year RUL in the following situations only. Providers must follow the medicaid agency's expedited prior authorization process, see WAC 182-552-1300, Respiratory care—Authorization.

(i) The initial provider is no longer providing oxygen equipment or services;

(ii) The initial provider's core provider agreement with the medicaid agency is terminated or expires;

(iii) The client moves to an area which is not part of the provider's service area (this applies to medicaid only clients);

(iv) The client moves into a permanent residential setting; or

(v) The pediatric client is transferred to an adult provider.

(f) The medicaid agency may restart the 36-month rental period when equipment is replaced under WAC 182-501-0050(7). Providers must obtain prior authorization from the medicaid agency.

(4) Stationary oxygen systems/contents.

(a) The medicaid agency pays a maximum of one rental payment for stationary oxygen systems including contents, per client, every 30 days. The medicaid agency considers a stationary oxygen system as one of the following:

(i) Compressed gaseous oxygen;

(ii) Stationary liquid oxygen; or

(iii) A concentrator.

(b) Contents only: The medicaid agency pays a maximum of one payment for stationary oxygen contents, per client, every 30 days, when the client owns the stationary oxygen system or the capped monthly rental period is met.

(c) Maintenance: The medicaid agency pays for one maintenance fee of 50 percent of the monthly rental rate for a stationary oxygen concentrator and oxygen transfilling equipment every six months only when the capped rental period is met or the client owns the stationary oxygen concentrator.

(5) Portable oxygen systems/oxygen contents:

(a) The medicaid agency pays a maximum of one rental payment for portable oxygen systems including oxygen contents, per client, every 30 days. The medicaid agency considers a portable oxygen system to be either gas or liquid.

(b) Contents only: The medicaid agency pays a maximum of one payment for portable oxygen contents, per client, every 30 days, when the client owns the portable oxygen system or when the capped monthly rental period is met.

(c) Maintenance: The medicaid agency pays for one maintenance fee of 50 percent of the monthly rental rate for a portable oxygen concentrator and oxygen transfilling equipment every six months only when the capped rental period is met or the client owns the portable oxygen concentrator.

(6) The medicaid agency does not pay for oxygen therapy and related services, equipment or supplies for clients 21 years of age and older, with, but not limited to, the following conditions:

(a) Angina pectoris in the absence of hypoxemia;

(b) Dyspnea without cor pulmonale or evidence of hypoxemia; and

(c) Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities but in the absence of systemic hypoxemia.

(7) The medicaid agency does not pay separately for humidifiers with rented oxygen equipment. All accessories, such as humidifiers necessary for the effective use of oxygen equipment are included in the monthly rental payment.

(8) The medicaid agency does not pay separately for spare tanks of oxygen and related supplies as backup or for travel.

(9) The medicaid agency requires a valid prescription for oxygen in accordance with WAC 182-552-200.

(a) For both initial and ongoing prescriptions for the use of oxygen, the medicaid agency requires documented verification that oxygen saturations or lab values substantiate the need for continued oxygen use for each client.

(b) The medicaid agency does not accept lifetime certificates of medical need (CMNs).

(10) The medicaid agency requires that documentation of oxygen saturation and lab values taken to substantiate the medical necessity of continued oxygen be kept in the client's record.

(11) Oxygen supplies - Replacement. The medicaid agency pays for replacement oxygen supplies after the 36 month capped rental period or if the client owns the equipment as follows:

(a) Nasal cannula, limited to two per client every 30 days;

(b) Tubing (oxygen), limited to one replacement per client every 30 days; and

(c) Variable concentration mask, limited to two per client every 30 days.

(12) See WAC 182-552-1200, Respiratory care—Noncovered services.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-064, § 182-552-0800, filed 6/28/23, effective 8/1/23. Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-0800, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-0900** Respiratory care—Covered—Oximeters. {#sec-182-552-0900 omnilex-key=us-wa-regs-official--title-182--182-552-0900}

(1) The medicaid agency covers the purchase of oximeters for clients eighteen years of age and older with prior authorization as follows:

(a) One standard oximeter, per client, every twenty-four months; or

(b) One enhanced oximeter, per client, every thirty-six months.

(2) The medicaid agency covers the purchase of oximeters for clients seventeen years of age and younger, in the home, as follows:

(a) When the client meets one of the following clinical criteria:

(i) Has chronic lung disease and is on supplemental oxygen;

(ii) Has a compromised or artificial airway; or

(iii) Has chronic lung disease requiring ventilator or bi-level respiratory assist device; and

(b) The following limitations apply:

(i) One standard oximeter, per client, every twenty-four months, without prior authorization; or

(ii) One enhanced oximeter, per client, every thirty-six months, with expedited prior authorization.

(3) The medicaid agency pays for replacement supplies as follows:

(a) Cables for enhanced oximeter only, limited to two per client per year. Prior authorization (PA) is required.

(b) Probes.

(i) Nondisposable, limited to one per client every one hundred eighty days.

(ii) Disposable, limited to four per client every thirty days.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-0900, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-1000** Covered—Respiratory and ventilator equipment and supplies. {#sec-182-552-1000 omnilex-key=us-wa-regs-official--title-182--182-552-1000}

(1) The medicaid agency covers the rental of a ventilator, equipment, and disposable ventilator supplies when the client requires periodic or continuous mechanical ventilation for the treatment of chronic respiratory failure resulting from hypoxemia or hypercapnia.

(2) The agency's payment for the monthly rental includes ventilator maintenance and accessories including, but not limited to, humidifiers, nebulizers, alarms, temperature probes, batteries, chargers, adapters, connectors, fittings, tubing, disposable circuits, and filters. The agency does not pay separately for ventilator accessories unless the client owns the ventilator system, see subsection (5) of this section.

(3) To receive payment, ventilators, equipment, and related disposable supplies must:

(a) Be used exclusively by the client for whom it is requested;

(b) Be FDA-approved; and

(c) Not be included in any other reimbursement methodology such as, but not limited to, a diagnosis-related group (DRG).

(4) The agency pays for a back-up (secondary) ventilator at fifty percent of the monthly rental rate when one or more of the following clinical criteria are met:

(a) The client cannot maintain spontaneous or adequate ventilations for four or more consecutive hours;

(b) The client lives in an area where a replacement ventilator cannot be provided within two hours;

(c) The client requires mechanical ventilation during mobility as prescribed in their plan of care.

(5) The agency pays for the purchase of the following replacement ventilator accessories only for client-owned ventilator systems:

(a) Gel-cell battery charger - One every twenty-four months;

(b) Gel-cell heavy-duty battery - One every twenty-four months;

(c) Battery cables - Once every twenty-four months; and

(d) Breathing circuits - Four every thirty days.

(6) All ventilators require expedited prior authorization (EPA), as described in WAC 182-552-1375.

(a) At the time of authorization, the following information must be documented in the client's record and made available to the agency upon request:

(i) Medical history, unless request is for continuation of services;

(ii) Diagnosis and degree of impairment;

(iii) Degree of ventilatory support required; and

(iv) Ventilator settings and parameters including mode and type of ventilator ordered at the time of the authorization.

(b) If the client has no clinical potential for being weaned from ventilatory support, the EPA is valid for twelve months;

(c) If the client has the potential to be weaned, the EPA is valid for six months.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-14-081, § 182-552-1000, filed 7/2/18, effective 8/2/18. Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-1000, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-1100** Respiratory care—Covered—Suction pumps and supplies. {#sec-182-552-1100 omnilex-key=us-wa-regs-official--title-182--182-552-1100}

(1) The medicaid agency covers suction pumps and supplies when medically necessary for airway clearance or tracheostomy suctioning.

(2) The medicaid agency pays for a maximum of two suction devices per client in a five-year period as follows:

(a) The medicaid agency rents one primary suction device (stationary or portable) per client, for use in the home and one secondary suction device, per client, for backup or portability.

(b) The medicaid agency considers the suction devices purchased after twelve months rental.

(3) The medicaid agency pays for supplies for suction devices as follows:

(a) Catheter - Closed system. Limit one per day per client.

(b) Catheter - Any type other than closed system:

(i) Clients eight years of age and older, one hundred fifty per client, every thirty days;

(ii) Clients seven years of age and younger, three hundred per client, every thirty days.

(c) Oropharyngeal suction catheter, limited to four per client every thirty days.

(d) Canister - Disposable:

(i) Limited to five per client every thirty days for primary suction device;

(ii) Limited to five per client every thirty days for secondary suction device.

(e) Canister - Nondisposable. Limited to one per client every twelve months.

(f) Tubing. Limited to fifteen per client every thirty days.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-1100, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-1200** Respiratory care—Noncovered services. {#sec-182-552-1200 omnilex-key=us-wa-regs-official--title-182--182-552-1200}

(1) The medicaid agency pays for respiratory care only when listed as covered in this chapter. In addition to the noncovered services found in WAC 182-501-0070, the medicaid agency does not cover:

(a) Emergency or stand-by oxygen systems;

(b) Portable nebulizers;

(c) Kits and concentrates for use in cleaning respiratory equipment;

(d) Intrapulmonary percussive ventilation systems and related accessories;

(e) Batteries for a CPAP;

(f) Items or services which primarily serve as a convenience for the client or caregiver;

(g) Oximetry checks;

(h) Loaner equipment.

(2) The medicaid agency evaluates a request for respiratory care listed as noncovered in this chapter under the provisions of WAC 182-501-0160.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-1200, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-1300** Respiratory care—Authorization. {#sec-182-552-1300 omnilex-key=us-wa-regs-official--title-182--182-552-1300}

(1) The medicaid agency requires providers to obtain authorization for covered respiratory care as required in this chapter, chapters 182-501 and 182-502 WAC, and in published agency medicaid provider guides and/or provider notices or when the clinical criteria required in this chapter are not met.

(a) For prior authorization (PA), a provider must submit a written request to the medicaid agency as specified in the agency's published respiratory care medicaid provider guide.

(b) For expedited prior authorization (EPA), a provider must document that the client has met the clinically appropriate EPA criteria outlined in the medicaid provider guide. The appropriate EPA number must be used when the provider bills the medicaid agency.

(c) Upon request, a provider must provide documentation to the medicaid agency showing how the client's condition met the criteria for PA or EPA.

(2) Authorization requirements in this chapter are not a denial of service.

(3) When a service requires authorization, the provider must properly request authorization in accordance with the medicaid agency's rules, medicaid provider guides, and provider notices.

(4) When authorization is not properly requested, the medicaid agency rejects and returns the request to the provider for further action. The medicaid agency does not consider the rejection of the request to be a denial of service.

(5) The medicaid agency's authorization of service(s) does not necessarily guarantee payment.

(6) The medicaid agency evaluates requests for authorization of covered respiratory care equipment and supplies that exceed limitations in this chapter on a case-by-case basis in accordance with WAC 182-501-0169.

(7) The medicaid agency may recoup any payment made to a provider if the agency later determines that the service was not properly authorized or did not meet the EPA criteria. Refer to WAC 182-502-0100 (1)(c).

**History**
- *Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-1300, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-1325** Prior authorization. {#sec-182-552-1325 omnilex-key=us-wa-regs-official--title-182--182-552-1325}

(1) The medicaid agency requires providers to obtain prior authorization for certain items and services before delivering that item or service to the client, except when the items and services are covered by a third-party payer. The item or service must also be delivered to the client before the provider bills the medicaid agency.

(2) All prior authorization requests must be accompanied by a completed General Information for Authorization form (HCA 13-835), in addition to any program specific medicaid agency forms as required within this chapter. Agency forms are available online at http://hrsa.dshs.wa.gov/mpforms.shtml.

(3) When the medicaid agency receives the initial request for prior authorization, the prescription(s) for those items or services must not be older than three months from the date the agency receives the request.

(4) The medicaid agency requires certain information from providers in order to prior authorize the purchase or rental of equipment. This information includes, but is not limited to, the following:

(a) The manufacturer's name;

(b) The equipment model; and

(c) A detailed description of the item.

(5) For prior authorization requests, the medicaid agency requires the prescribing provider to furnish client-specific justification for respiratory care. The medicaid agency does not accept general standards of care or industry standards for generalized equipment as justification.

(6) The medicaid agency considers requests for new respiratory care that do not have assigned health care common procedure coding system (HCPCS) codes and are not listed in the agency's published issuances, including medicaid provider guides and provider notices. These items require prior authorization. The provider must furnish all of the following information to the medicaid agency to establish medical necessity:

(a) A detailed description of the item(s) or service(s) to be provided;

(b) The cost or charge for the item(s);

(c) A copy of the manufacturer's invoice, price list or catalog with the product description for the item(s) being provided; and

(d) A detailed explanation of how the requested item(s) differs from an already existing code description.

(7) The medicaid agency does not pay for the purchase, rental, or repair of respiratory care equipment that duplicates equipment the client already owns or rents. If the provider believes the purchase, rental, or repair of respiratory care equipment is not duplicative, the provider must request prior authorization and submit the following to the medicaid agency:

(a) Why the existing equipment no longer meets the client's medical needs; or

(b) Why the existing equipment could not be repaired or modified to meet the client's medical needs; and

(c) Upon request, documentation showing how the client's condition met the criteria for PA or EPA.

(8) A provider may resubmit a request for prior authorization for an item or service that the medicaid agency has denied. The medicaid agency requires the provider to include new documentation that is relevant to the request.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-1325, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-1350** Limitation extension (LE). {#sec-182-552-1350 omnilex-key=us-wa-regs-official--title-182--182-552-1350}

(1) The medicaid agency limits the amount, frequency, or duration of certain covered respiratory care, and reimburses up to the stated limit without requiring prior authorization.

(2) Certain covered items have limitations on quantity and frequency. These limits are designed to avoid the need for prior authorization for items normally considered medically necessary and for quantities sufficient for a thirty-day supply for one client.

(3) The medicaid agency requires a provider to request prior authorization for a limitation extension (LE) in order to exceed the stated limits for respiratory care. All requests for prior authorization must be accompanied by a completed General Information for Authorization form (HCA 13-835) in addition to any program specific medicaid agency forms as required within this chapter. Agency forms are available online at http://hrsa.dshs.wa.gov/mpforms.shtml.

(4) The medicaid agency evaluates such requests for LE under the provisions of WAC 182-501-0169.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-1350, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-1375** Expedited prior authorization (EPA). {#sec-182-552-1375 omnilex-key=us-wa-regs-official--title-182--182-552-1375}

(1) The expedited prior authorization (EPA) process is designed to eliminate the need for written requests for prior authorization for selected respiratory care procedure codes.

(2) The medicaid agency requires a provider to create an authorization number for EPA for selected respiratory care procedure codes. The process and criteria used to create the authorization number is explained in the agency published respiratory care medicaid provider guide. The authorization number must be used when the provider bills the medicaid agency.

(3) Upon request, a provider must provide documentation to the medicaid agency showing how the client's condition met the criteria for EPA.

(4) A written request for prior authorization is required when a situation does not meet the EPA criteria for selected respiratory care procedure codes.

(5) The medicaid agency may recoup any payment made to a provider under this section if the provider did not follow the EPA process and criteria.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-1375, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-1400** Respiratory care—Reimbursement—General. {#sec-182-552-1400 omnilex-key=us-wa-regs-official--title-182--182-552-1400}

(1) The medicaid agency pays qualified providers who meet all of the conditions in WAC 182-502-0100, for covered respiratory care provided on a fee-for-service (FFS) basis as follows:

(a) To medicaid agency-enrolled medical equipment and supplies providers, pharmacies, and home health agencies under their national provider identifier (NPI) numbers, subject to the limitations of this chapter, and according to the procedures and codes in the agency's current respiratory care medicaid billing guide; and

(b) In accordance with the health care common procedure coding system (HCPCS) guidelines for product classification and code assignment.

(2) The medicaid agency may adopt policies, procedure codes, and rates that are inconsistent with those set by medicare if the agency determines that such actions are necessary to:

(i) Assure that payments are sufficient to enlist providers and maintain access to care and services; or

(ii) Comply with legislative budget directives.

(3) The medicaid agency's maximum payment for respiratory care is the lesser of either of the following:

(a) Provider's usual and customary charges; or

(b) Established rates, except as provided in WAC 182-502-0110(3).

(4) The medicaid agency is the payer of last resort for clients with medicare or third-party insurance.

(5) The medicaid agency does not pay for respiratory care provided to a client who is enrolled in an agency-contracted managed care organization (MCO), but who did not use one of the MCO's participating providers.

(6) The medicaid agency's payment rate for covered oxygen and respiratory equipment and supplies includes all of the following:

(a) Any adjustments or modifications to the equipment that are required within three months of the date of delivery or are covered under the manufacturer's warranty. This does not apply to adjustments required because of changes in the client's medical condition;

(b) Any pick-up and delivery fees or associated costs (e.g., mileage, travel time, gas, etc.);

(c) Telephone calls;

(d) Shipping, handling, and postage;

(e) Maintenance for rented equipment including, but not limited to, testing, cleaning, regulating, and assessing the client's equipment;

(f) Fitting or setup, or both; and

(g) Instruction to the client or client's caregiver in the appropriate use of the respiratory care.

(7) Respiratory care equipment, supplies, and related repairs and labor charges that are supplied to eligible clients under the following payment methodologies are included in those methodologies and are not reimbursed under fee-for-service (FFS):

(a) Hospice provider's per diem reimbursement;

(b) Hospital's diagnosis-related group (DRG) reimbursement;

(c) Managed care organization's capitation rate;

(d) Skilled nursing facilities per diem rate; and

(e) Professional service's resource-based relative value system reimbursement (RBRVS) rate.

(8) The provider must make warranty information, including date of purchase, applicable serial number, model number or other unique identifier of the respiratory care equipment, and warranty period, available to the medicaid agency upon request.

(9) The dispensing provider who furnishes respiratory care equipment or supplies to a client is responsible for any costs incurred to have a different provider repair the equipment when:

(a) Any equipment or supply that the medicaid agency considers purchased requires repair during the applicable warranty period;

(b) The provider refuses or is unable to fulfill the warranty; and

(c) The respiratory care equipment or supply continues to be medically necessary.

(10) If rental respiratory equipment or supplies must be replaced during the warranty period, the medicaid agency recoups fifty percent of the total amount previously paid toward rental and eventual purchase of the respiratory equipment or supply provided to the client if:

(a) The provider is unwilling or unable to fulfill the warranty; and

(b) The respiratory care equipment or supply continues to be medically necessary.

(11) The medicaid agency does not pay for respiratory care equipment and supplies, or related repairs and labor charges under FFS when the client is any of the following:

(a) An inpatient hospital client;

(b) Terminally ill and receiving hospice care; or

(c) Enrolled in a risk-based MCO that includes coverage for such items or services, or both.

(12) The medicaid agency rescinds any purchase order for a prescribed item if the equipment or supply was not supplied to the client before the client:

(a) Dies;

(b) Loses medical eligibility;

(c) Becomes covered by a hospice agency; or

(d) Becomes covered by an MCO.

(13) See also WAC 182-543-9000 for general reimbursement.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. 431.16 Section 1903 (i)(27) of the Social Security Act. WSR 19-21-087, § 182-552-1400, filed 10/14/19, effective 11/14/19. Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-1400, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-1500** Respiratory care equipment and supplies—Reimbursement—Decision to rent or purchase. {#sec-182-552-1500 omnilex-key=us-wa-regs-official--title-182--182-552-1500}

(1) The medicaid agency bases the decision to rent or purchase respiratory care equipment and supplies for a client, or pay for repairs and associated labor for client-owned equipment, on cost and on the length of time the client needs the equipment.

(2) A provider must not bill the medicaid agency for the rental or purchase of equipment supplied to the provider at no cost by suppliers/manufacturers.

(3) The medicaid agency purchases new equipment only.

(a) A new item that is placed with a client initially as a rental item is considered a new item by the medicaid agency at the time of purchase.

(b) A used item that is placed with a client initially as a rental item must be replaced by the supplier with a new item prior to purchase by the medicaid agency.

(4) The medicaid agency requires a dispensing provider to ensure the item rented to a client is:

(a) In good working order; and

(b) Comparable to equipment the provider rents to individuals with similar medical equipment needs who are either private pay or who have other third-party coverage.

(5) The medicaid agency's minimum rental period for covered respiratory care equipment and supplies is one day.

(6) The medicaid agency's reimbursement amount for rented respiratory care equipment and supplies includes all of the following:

(a) A full service warranty;

(b) Cost of delivery to, or pick up from, the client's residence and, when appropriate, to and from the room in which the equipment will be used;

(c) Fitting, setup, adjustments, and modifications;

(d) Maintenance, repair and/or replacement, and cleaning of the equipment;

(e) Instructions to the client and/or client's caregiver for safe and proper use of the equipment; and

(f) All medically necessary accessories, contents, and disposable supplies, unless separately billable according to the agency's current respiratory care medicaid provider guide.

(7) The medicaid agency considers some rented equipment to be purchased after twelve months' rental unless the equipment is restricted as rental only; this equipment is identified in the respiratory care medicaid provider guide.

(8) Respiratory care equipment and supplies purchased by the medicaid agency for a client are the client's property, unless identified as capped rental items by the agency. Capped rental items are considered the property of the provider and are identified in the respiratory care medicaid provider guide.

(9) The medicaid agency stops paying for any rented equipment effective the date of a client's death. The medicaid agency prorates monthly rentals as appropriate.

(10) For a client who is eligible for both medicare and medicaid, the medicaid agency pays only the client's coinsurance and deductibles. The medicaid agency discontinues paying client's coinsurance and deductibles for rental equipment when either of the following applies:

(a) The reimbursement amount reaches medicare's reimbursement cap for the equipment; or

(b) Medicare considers the equipment purchased.

(11) The medicaid agency does not obtain or pay for insurance coverage against liability, loss and/or damage to rental equipment that a provider supplies to a client.

(12) The medicaid agency does not pay for:

(a) Defective equipment;

(b) The cost of materials covered under the manufacturer's warranty or administrative fees charged by the manufacturer to perform warranty or repair work; or

(c) Repair or replacement of equipment as a result of the client's carelessness, negligence, recklessness, or misuse in accordance with WAC 182-501-0050(7). The medicaid agency may request documentation (e.g., police report, etc.) at its discretion.

(13) Capped rental oxygen equipment and client-owned equipment:

(a) Capped rental oxygen equipment is considered to have a reasonable useful lifetime of five years. The medicaid agency will pay for new equipment on capped rental items for eligible clients after five years of continuous use, at which point the capped rental period of thirty-six months will start again.

(b) Equipment is considered to be client-owned if it is not identified as a capped rental item in the agency's respiratory care medicaid provider guide and if the medicaid agency has reached the maximum reimbursement for the item.

(c) The agency pays for the repair of client-owned respiratory equipment with prior authorization. The age of the equipment is considered, and all of the following criteria must be met:

(i) All warranties are expired;

(ii) The cost of the repair is less than fifty percent of the cost of a new item and the provider has supporting documentation; and

(iii) The repair has a warranty for a minimum of ninety days.

**History**
- *Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-1500, filed 6/25/12, effective 8/1/12.*

##### **Wash. Admin. Code § 182-552-1600** Respiratory care equipment and supplies—Reimbursement—Methodology for purchase, rental, and repair. {#sec-182-552-1600 omnilex-key=us-wa-regs-official--title-182--182-552-1600}

(1) The medicaid agency sets, evaluates, and updates the maximum allowable fees for respiratory care equipment and supplies at least once yearly, unless otherwise directed by the legislature or determined necessary by the agency.

(2) The agency sets the rates for medical equipment codes subject to the federal financial participation (FFP) limitation at the lesser of medicare's prevailing payment rates in the durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) fee schedule or competitive bid area (CBA) rate. For all other procedure codes, the agency sets rates using one of the following:

(a) Medicare fee schedules;

(b) Legislative direction;

(c) Input from stakeholders or relevant sources that the agency determines to be reliable and appropriate;

(d) Pricing clusters; or

(e) A by-report (BR) basis.

(3) When there is only a rental rate on the DMEPOS fee schedule, the agency sets the maximum allowable purchase rate at the DMEPOS rate multiplied by ten. The agency sets the maximum allowable fee for daily rental at one three-hundredth of the new purchase price or one-thirtieth of the monthly rental rate on the DMEPOS fee schedule.

(4) When establishing payment rates for respiratory care equipment and supplies based on pricing clusters for a specific health care common procedure coding system (HCPCS) code, the maximum allowable fee is the median or average amount of all items in the cluster. The pricing cluster is made up of all the brands/models for which the agency obtains pricing information. However, the agency may limit the number of brands/models included in the pricing cluster due to any one or more of the following:

(a) A client's medical needs;

(b) Product quality;

(c) Introduction, substitution, or discontinuation of certain brands/models; or

(d) Cost.

(5) The agency evaluates a by-report (BR) item, procedure, or service for its medical necessity, appropriateness, and payment value on a case-by-case basis. The agency's payment rate is eighty percent of the manufacturer's list price or manufacturer's suggested retail price (MSRP), or one hundred percent (oxygen only) or one hundred twenty-five percent (all other respiratory items) of the wholesale acquisition cost (AC).

(6) The agency pay for repairs of client-owned equipment only, with prior authorization (PA). In addition to agency-specific forms identified in the agency's respiratory care billing guide, providers must meet all of the following requirements to receive PA and payment for a repair of client-owned equipment:

(a) The provider must submit a manufacturer pricing sheet showing the manufacturer's list price, MSRP, or manufacturer invoice showing the cost of the repair, identifying and itemizing the parts. The invoice must indicate the wholesale AC, the manufacturer's list price, or MSRP for all parts used in the repair for which payment is being sought.

(b) The provider must follow HCPCS coding guidelines and submit a PA request accordingly with actual labor units identified and supported by documentation.

(7) The agency pays for actual labor charges according to the agency's current fee schedule. The agency does not pay for base labor charges or other administrative-like fees.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. 431.16 Section 1903 (i)(27) of the Social Security Act. WSR 19-21-087, § 182-552-1600, filed 10/14/19, effective 11/14/19. Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-1600, filed 6/25/12, effective 8/1/12.*

## **Chapter 182-553** Home infusion therapy/parenteral nutrition program. {#struct-chapter-182-553}

##### **Wash. Admin. Code § 182-553-100** Home infusion therapy and parenteral nutrition program—General. {#sec-182-553-100 omnilex-key=us-wa-regs-official--title-182--182-553-100}

The medicaid agency's home infusion therapy and parenteral nutrition program provides the supplies and equipment necessary for parenteral infusion of therapeutic agents to Washington apple health clients. An eligible client receives equipment, supplies, and parenteral administration of therapeutic agents in a qualified setting to improve or sustain the client's health.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-15-152, § 182-553-100, filed 7/21/15, effective 8/21/15*
- *WSR 15-08-103, § 182-553-100, filed 4/1/15, effective 5/2/15. WSR 11-14-075, recodified as § 182-553-100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-553-100, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.530. WSR 04-11-007, § 388-553-100, filed 5/5/04, effective 6/5/04.*

##### **Wash. Admin. Code § 182-553-200** Home infusion therapy/parenteral nutrition program—Definitions. {#sec-182-553-200 omnilex-key=us-wa-regs-official--title-182--182-553-200}

The following terms and definitions apply to the home infusion therapy/parenteral nutrition program:

"Infusion therapy" means the provision of therapeutic agents or nutritional products to individuals by parenteral infusion for the purpose of improving or sustaining a client's health.

"Intradialytic parenteral nutrition (IDPN)" means intravenous nutrition administered during hemodialysis. IDPN is a form of parenteral nutrition.

"Parenteral infusion" means the introduction of a substance by means other than the gastrointestinal tract, referring particularly to the introduction of substances by intravenous, subcutaneous, intramuscular or intramedullary means.

"Parenteral nutrition" (also known as total parenteral nutrition (TPN)) means the provision of nutritional requirements intravenously.

**History**
- *WSR 11-14-075, recodified as § 182-553-200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.530. WSR 04-11-007, § 388-553-200, filed 5/5/04, effective 6/5/04.*

##### **Wash. Admin. Code § 182-553-300** Home infusion therapy/parenteral nutrition program—Client eligibility and assignment. {#sec-182-553-300 omnilex-key=us-wa-regs-official--title-182--182-553-300}

(1) To receive home infusion therapy and parenteral nutrition, subject to the limitations and restrictions in this section and other applicable WAC, a person must be eligible for one of the Washington apple health programs listed in the table in WAC 182-501-0060.

(2) Persons enrolled in an agency-contracted managed care organization (MCO) are eligible for home infusion therapy and parenteral nutrition through that plan.

(3) Persons eligible for home health program services may receive home infusion related services according to WAC 182-551-2000 through 182-551-3000.

(4) To receive home infusion therapy, a person must:

(a) Have a written physician order for all solutions and medications to be administered.

(b) Be able to manage their infusion in one of the following ways:

(i) Independently;

(ii) With a volunteer caregiver who can manage the infusion; or

(iii) By choosing to self-direct the infusion with a paid caregiver (see WAC 388-71-0580).

(c) Be clinically stable and have a condition that does not warrant hospitalization.

(d) Agree to comply with the protocol established by the infusion therapy provider for home infusions. If the person is not able to comply, the person's caregiver may comply.

(e) Consent, if necessary, to receive solutions and medications administered in the home through intravenous, enteral, epidural, subcutaneous, or intrathecal routes. If the person is not able to consent, the person's legal representative may consent.

(f) Reside in a residence that has adequate accommodations for administering infusion therapy including:

(i) Running water;

(ii) Electricity;

(iii) Telephone access; and

(iv) Receptacles for proper storage and disposal of drugs and drug products.

(5) To receive parenteral nutrition, a person must meet the conditions in subsection (4) of this section and:

(a) Have one of the following that prevents oral or enteral intake to meet the person's nutritional needs:

(i) Hyperemesis gravidarum; or

(ii) An impairment involving the gastrointestinal tract that lasts three months or longer.

(b) Be unresponsive to medical interventions other than parenteral nutrition; and

(c) Be unable to maintain weight or strength.

(6) A person who has a functioning gastrointestinal tract is not eligible for parenteral nutrition program services when the need for parenteral nutrition is only due to:

(a) A swallowing disorder;

(b) Gastrointestinal defect that is not permanent unless the person meets the criteria in subsection (7) of this section;

(c) A psychological disorder (such as depression) that impairs food intake;

(d) A cognitive disorder (such as dementia) that impairs food intake;

(e) A physical disorder (such as cardiac or respiratory disease) that impairs food intake;

(f) A side effect of medication; or

(g) Renal failure or dialysis, or both.

(7) A person with a gastrointestinal impairment that is expected to last less than three months is eligible for parenteral nutrition only if:

(a) The person's physician or appropriate medical provider has documented in the person's medical record the gastrointestinal impairment is expected to last less than three months;

(b) The person meets all the criteria in subsection (4) of this section;

(c) The person has a written physician order that documents the person is unable to receive oral or tube feedings; and

(d) It is medically necessary for the gastrointestinal tract to be totally nonfunctional for a period of time.

(8) A person is eligible to receive intradialytic parenteral nutrition (IDPN) solutions when:

(a) The parenteral nutrition is not solely supplemental to deficiencies caused by dialysis; and

(b) The person meets the criteria in subsection (4) and (5) of this section and other applicable WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148). WSR 14-07-042, § 182-553-300, filed 3/12/14, effective 4/12/14. WSR 11-14-075, recodified as § 182-553-300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-553-300, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.530. WSR 04-11-007, § 388-553-300, filed 5/5/04, effective 6/5/04.*

##### **Wash. Admin. Code § 182-553-400** Home infusion therapy and parenteral nutrition program—Provider requirements. {#sec-182-553-400 omnilex-key=us-wa-regs-official--title-182--182-553-400}

(1) Eligible providers of home infusion supplies and equipment and parenteral nutrition solutions must:

(a) Have a signed core provider agreement with the medicaid agency; and

(b) Be one of the following provider types:

(i) Pharmacy provider;

(ii) Durable medical equipment (DME) provider; or

(iii) Infusion therapy provider.

(2) The agency pays eligible providers for home infusion supplies and equipment and parenteral nutrition solutions only when the providers:

(a) Are able to provide home infusion therapy within their scope of practice;

(b) Have evaluated each client in collaboration with the client's physician, pharmacist, or nurse to determine whether home infusion therapy and parenteral nutrition is an appropriate course of action;

(c) Have determined that the therapies prescribed and the client's needs for care can be safely met;

(d) Have assessed the client and obtained a written physician order for all solutions and medications administered to the client in the client's residence or in a dialysis center through intravenous, epidural, subcutaneous, or intrathecal routes;

(e) Meet the requirements in WAC 182-502-0020, including keeping legible, accurate, and complete client charts, and providing the following documentation in the client's medical file:

(i) For a client receiving infusion therapy, the file must contain:

(A) A copy of the written prescription for the therapy;

(B) The client's age, height, and weight; and

(C) The medical necessity for the specific home infusion service.

(ii) For a client receiving parenteral nutrition, the file must contain:

(A) All the information listed in (e)(i) of this subsection;

(B) Oral or enteral feeding trials and outcomes, if applicable;

(C) Duration of gastrointestinal impairment; and

(D) The monitoring and reviewing of the client's lab values:

(I) At the initiation of therapy;

(II) At least once per month; and

(III) When the client, the client's lab results, or both, are unstable.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-15-152, § 182-553-400, filed 7/21/15, effective 8/21/15*
- *WSR 15-08-103, § 182-553-400, filed 4/1/15, effective 5/2/15. WSR 11-14-075, recodified as § 182-553-400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-553-400, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.530. WSR 04-11-007, § 388-553-400, filed 5/5/04, effective 6/5/04.*

##### **Wash. Admin. Code § 182-553-500** Home infusion therapy and parenteral nutrition program—Coverage, services, limitations, prior authorization, and reimbursement. {#sec-182-553-500 omnilex-key=us-wa-regs-official--title-182--182-553-500}

(1) The home infusion therapy and parenteral nutrition program covers the following for eligible clients, subject to the limitations and restrictions listed:

(a) A one-month supply of home infusion, per client, per calendar month.

(b) A one-month supply of parenteral nutrition solution, per client, per calendar month.

(c) One type of infusion pump, one type of parenteral pump, and one type of insulin pump per client, per calendar month and as follows:

(i) All rent-to-purchase infusion, parenteral, and insulin pumps must be new equipment at the beginning of the rental period.

(ii) The agency covers the rental payment for each type of infusion, parenteral, or insulin pump for up to 12 months. The agency considers a pump purchased after 12 months of rental payments.

(iii) The agency covers only one purchased infusion pump or parenteral pump per client in a five-year period.

(iv) The agency covers only one purchased insulin pump per client in a four-year period.

(2) Covered supplies and equipment that are within the described limitations listed in subsection (1) of this section do not require prior authorization for reimbursement.

(3) The agency pays for FDA-approved continuous glucose monitoring systems and related monitoring equipment and supplies using the expedited prior authorization process when the client meets the following criteria:

(a) Is age 18 and younger;

(b) Is age 19 and older with Type 1 diabetes;

(c) Is age 19 and older with Type 2 diabetes who is:

(i) Unable to achieve target HbA1C despite adherence to an appropriate glycemic management plan after six months of intensive insulin therapy and testing blood glucose four or more times per day;

(ii) Suffering from one or more severe episodes of hypoglycemia despite adherence to an appropriate glycemic management plan; or

(iii) Unable to recognize, or communicate about, symptoms of hypoglycemia.

(d) Is pregnant with:

(i) Type 1 diabetes; or

(ii) Type 2 diabetes and on insulin prior to pregnancy;

(iii) Type 2 diabetes and whose blood glucose does not remain well controlled on diet or oral medication during pregnancy and requires insulin; or

(iv) Gestational diabetes with blood glucose that is not well controlled (HbA1C above target or experiencing episodes of hyperglycemia or hypoglycemia) and requires insulin.

(4) Requests for supplies or equipment that exceed the limitations or restrictions listed in this section require prior authorization and are evaluated on a case-by-case basis under WAC 182-501-0165 and 182-501-0169.

(5) The agency may adopt policies, procedure codes, and rates inconsistent with those set by medicare.

(6) Agency reimbursement for equipment rentals and purchases includes the following:

(a) Instructions to a client, a caregiver, or both, on the safe and proper use of equipment provided;

(b) Full service warranty;

(c) Delivery and pickup; and

(d) Setup, fitting, and adjustments.

(7) For clients residing in a state-owned facility (i.e., state school, developmental disabilities facility, mental health facility, Western State Hospital, and Eastern State Hospital) payment for home infusion supplies, equipment, and parenteral nutrition solutions are the responsibility of the state-owned facility to provide.

(8) For clients who are eligible for and have elected to receive the agency's hospice benefit, the agency pays for home infusion or parenteral nutrition supplies and equipment separately from the hospice per diem rate when:

(a) The client has a preexisting diagnosis that requires parenteral support; and

(b) The preexisting diagnosis is not related to the diagnosis that qualifies the client for hospice.

(9) For clients residing in a nursing facility, infusion pumps, parenteral nutrition pumps, insulin pumps, solutions, and insulin infusion supplies are not included in the nursing facility per diem rate. The agency pays for these items separately.

(10) For clients age 20 and younger, see the early periodic screening, diagnosis, and treatment (EPSDT) program described in chapter 182-534 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-07-031, s 182-553-500, filed 3/11/26, effective 4/11/26*
- *WSR 19-01-024, § 182-553-500, filed 12/10/18, effective 2/1/19*
- *WSR 15-14-063, § 182-553-500, filed 6/26/15, effective 7/27/15. Statutory Authority: RCW 41.05.021. WSR 12-16-059, § 182-553-500, filed 7/30/12, effective 8/30/12. WSR 11-14-075, recodified as § 182-553-500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-553-500, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.530. WSR 04-11-007, § 388-553-500, filed 5/5/04, effective 6/5/04.*

## **Chapter 182-554** Enteral nutrition program. {#struct-chapter-182-554}

##### **Wash. Admin. Code § 182-554-100** Enteral nutrition—General. {#sec-182-554-100 omnilex-key=us-wa-regs-official--title-182--182-554-100}

(1) The agency covers the enteral nutrition products, equipment, and related supplies listed in this chapter, according to medicaid agency rules and subject to the limitations and requirements in this chapter.

(2) The agency pays for covered enteral nutrition products, equipment and related supplies if they are:

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

(b) Medically necessary under WAC 182-500-0070; and

(c) Authorized and billed, as required within this chapter, chapters 182-501 and 182-502 WAC, and the agency's published billing instructions.

(3) The agency requires prior authorization (PA) for covered enteral nutrition products, equipment and related supplies when the clinical criteria described in this chapter are not met, including the criteria associated with the expedited prior authorization process. The agency evaluates requests requiring PA on a case-by-case basis to determine whether they are medically necessary under WAC 182-501-0165.

(4) The agency evaluates a request for a covered service that is experimental or investigational under WAC 182-531-0550 and 182-501-0165.

(5) The agency may terminate a provider's core provider agreement under chapter 182-502 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-08-009, § 182-554-100, filed 3/24/17, effective 5/1/17. WSR 11-14-075, recodified as § 182-554-100, filed 6/30/11, effective 7/1/11. Statutory Authority: 2009 c 564 § 1109, RCW 74.04.050, and 74.08.090. WSR 10-01-138, § 388-554-100, filed 12/21/09, effective 1/21/10. Statutory Authority: RCW 74.08.090, 74.09.530 and chapter 74.09 RCW. WSR 05-04-059, § 388-554-100, filed 1/28/05, effective 3/1/05.*

##### **Wash. Admin. Code § 182-554-200** Enteral nutrition—Definitions. {#sec-182-554-200 omnilex-key=us-wa-regs-official--title-182--182-554-200}

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.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-08-009, § 182-554-200, filed 3/24/17, effective 5/1/17. WSR 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. WSR 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. WSR 05-04-059, § 388-554-200, filed 1/28/05, effective 3/1/05.*

##### **Wash. Admin. Code § 182-554-300** Enteral nutrition—Client eligibility. {#sec-182-554-300 omnilex-key=us-wa-regs-official--title-182--182-554-300}

(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.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-08-009, § 182-554-300, filed 3/24/17, effective 5/1/17. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148). WSR 14-07-042, § 182-554-300, filed 3/12/14, effective 4/12/14. WSR 11-14-075, recodified as § 182-554-300, filed 6/30/11, effective 7/1/11. Statutory Authority: 2009 c 564 § 1109, RCW 74.04.050, and 74.08.090. WSR 10-01-138, § 388-554-300, filed 12/21/09, effective 1/21/10. Statutory Authority: RCW 74.08.090, 74.09.530 and chapter 74.09 RCW. WSR 05-04-059, § 388-554-300, filed 1/28/05, effective 3/1/05.*

##### **Wash. Admin. Code § 182-554-400** Enteral nutrition—Provider requirements. {#sec-182-554-400 omnilex-key=us-wa-regs-official--title-182--182-554-400}

(1) The following providers are eligible to enroll or contract with the medicaid agency to provide orally administered and tube-delivered enteral nutrition products, equipment, and related supplies:

(a) A pharmacy provider; or

(b) A durable medical equipment provider.

(2) To receive payment for orally administered or tube-delivered enteral nutrition products, equipment and related supplies, a provider must:

(a) Meet the requirements under chapters 182-501 and 182-502 WAC.

(b) Provide only those services that are within the scope of the provider's license.

(c) Obtain prior authorization from the agency, if required, before delivery to the client and before billing the agency.

(d) Deliver enteral nutritional products in quantities sufficient to meet the client's authorized needs, not to exceed a one-month supply.

(e) Confirm with the client or the client's caregiver that the next month's delivery of authorized orally administered enteral nutrition products is necessary and document the confirmation in the client's file. The agency does not pay for automatic periodic delivery of products.

(f) Furnish clients with new or used equipment that includes full manufacturer and dealer warranties for at least one year.

(g) Notify the client's primary care provider if the client has indicated the enteral nutrition product is not being used as prescribed and document the notification in the client's file.

(h) Have a valid prescription. To be valid, a prescription must be:

(i) Written, dated and signed (including the prescriber's credentials) by the prescriber on or before the date of delivery of the product, equipment or related supplies;

(ii) No older than one year from the date the prescriber signed the prescription; and

(iii) State the specific item or service requested, the client's diagnosis and estimated length of need, quantity and units of measure, frequency and directions for use.

(i) Have proof of delivery.

(i) When a client or the client's authorized representative receives the product directly from the provider, the provider must furnish the proof of delivery upon agency request. The proof of delivery must:

(A) Be signed and dated by the client or the client's authorized representative. The date of the signature must be the date the item was received by the client; and

(B) Include the client's name and a detailed description of the item(s) delivered, including the quantity and brand name.

(ii) When a provider uses a shipping service to deliver items, the provider must furnish proof of delivery upon agency request. The proof of delivery must include:

(A) The client's name or other client identifier;

(B) The delivery service package identification number;

(C) The delivery address; and

(D) The quantity, a detailed description, and brand name of the item being shipped.

(j) Bill the agency in accordance with agency rules and billing instructions using one of the following dates of service:

(i) If the provider used a shipping service, the provider must use the shipping date as the date of service; or

(ii) If the client or the client's authorized representative received the product directly from the provider, the provider must use the date of receipt as the date of service.

(k) The agency allows up to a 10-day overlap in dates of service for the processing of claims for refills delivered/shipped prior to the client exhausting their supply.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-16-084, § 182-554-400, filed 8/1/22, effective 9/1/22*
- *WSR 17-08-009, § 182-554-400, filed 3/24/17, effective 5/1/17. WSR 11-14-075, recodified as § 182-554-400, filed 6/30/11, effective 7/1/11. Statutory Authority: 2009 c 564 § 1109, RCW 74.04.050, and 74.08.090. WSR 10-01-138, § 388-554-400, filed 12/21/09, effective 1/21/10. Statutory Authority: RCW 74.08.090, 74.09.530 and chapter 74.09 RCW. WSR 05-04-059, § 388-554-400, filed 1/28/05, effective 3/1/05.*

##### **Wash. Admin. Code § 182-554-500** Covered orally administered enteral nutrition products, equipment and related supplies—Clients age twenty and younger only. {#sec-182-554-500 omnilex-key=us-wa-regs-official--title-182--182-554-500}

(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.

(3) With expedited prior authorization, the agency covers orally administered enteral nutrition products for a one-time, initial one-month supply if the client:

(a) Has or is at risk of growth or nutrient deficits due to a condition that prevents the client from meeting their needs using food, over-the-counter nutrition products, standard infant formula, or standard toddler formula; and

(b) Has completed the agency's enteral nutrition products prescription form (HCA 13-961).

(4) With prior authorization (PA), the agency covers a monthly supply of orally administered enteral nutrition products if the client:

(a) Has or is at risk of growth or nutrient deficits due to a condition that prevents the client from meeting their needs using food, over-the-counter nutrition products, standard infant formula, or standard toddler formula;

(b) Has a valid prescription that states the product is medically necessary as defined in WAC 182-500-0070; and

(c) Has a nutrition assessment from a registered dietitian (RD) that includes all of the following:

(i) Evaluation of the client's nutritional status, including growth and nutrient analysis;

(ii) An explanation about why the product is medically necessary as defined in WAC 182-500-0070;

(iii) A nutrition care plan that monitors the client's nutrition status, and includes plans for transitioning the client to food or food products, if possible; and

(iv) Recommendations, as necessary, for the primary care provider to refer the client to other health care providers (for example, gastrointestinal specialists, allergists, speech therapists, occupational therapists, applied behavioral analysis providers, and mental health providers) who will address the client's growth or nutrient deficits as described in (a) of this subsection, and facilitate the client's transition to food or food products.

(5) If a client requires orally administered enteral nutrition products for longer than one month, the client must continue to meet criteria in subsection (4) of this section and receive periodic reevaluations from an RD. Periodic reevaluations:

(a) Must be performed at least three times a year for a client age three or younger;

(b) Must be performed at least two times a year for a client older than age three; and

(c) May be performed face-to-face, or by medical record and growth data review and phone contact with the client or the client's caregiver.

(6) If a client requires orally administered enteral nutrition products for longer than one month, the DME or pharmacy provider must obtain PA from the agency. The request for PA must include all of the following:

(a) Documentation of the client's diagnosis that supports the client's need for the orally administered enteral nutrition product;

(b) The client's nutrition care plan, which must monitor the client's nutrition status, and transition the client to food or food products, if possible, or document why the client cannot transition to food or food products;

(c) Updates to the client's nutrition care plan resulting from subsequent reevaluations;

(d) Updates to the client's growth chart;

(e) Documentation that shows through regular follow up and weight checks how the prescribed product is treating the client's growth or nutrient deficits, or is necessary to maintain the client's growth or nutrient status;

(f) Referrals, if necessary, to other health care providers (for example, gastrointestinal specialists, allergists, speech therapists, occupational therapists, applied behavioral analysis providers, and mental health providers) and show communication of recommendations and treatment plans for the client; and

(g) Documentation of any communication the treating provider has had with other providers, such as those in subsection (4)(c)(iv) of this section, directly or indirectly treating the client's growth or nutrient deficits while the client is receiving orally administered enteral nutrition products.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-08-009, § 182-554-500, filed 3/24/17, effective 5/1/17. WSR 11-14-075, recodified as § 182-554-500, filed 6/30/11, effective 7/1/11. Statutory Authority: 2009 c 564 § 1109, RCW 74.04.050, and 74.08.090. WSR 10-01-138, § 388-554-500, filed 12/21/09, effective 1/21/10. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-554-500, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.530 and chapter 74.09 RCW. WSR 05-04-059, § 388-554-500, filed 1/28/05, effective 3/1/05.*

##### **Wash. Admin. Code § 182-554-525** Covered orally administered enteral nutrition products, equipment and related supplies—Thickeners. {#sec-182-554-525 omnilex-key=us-wa-regs-official--title-182--182-554-525}

(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.

(2) The agency covers, with expedited prior authorization (EPA), thickeners for clients with dysphagia who are older than age one. The provider must keep the following in the client's file:

(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.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-08-009, § 182-554-525, filed 3/24/17, effective 5/1/17.*

##### **Wash. Admin. Code § 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. {#sec-182-554-550 omnilex-key=us-wa-regs-official--title-182--182-554-550}

(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.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-08-009, § 182-554-550, filed 3/24/17, effective 5/1/17.*

##### **Wash. Admin. Code § 182-554-600** Covered enteral nutrition products, equipment and related supplies—Tube-delivered. {#sec-182-554-600 omnilex-key=us-wa-regs-official--title-182--182-554-600}

(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.

(2) Limitations. The following limitations apply to the agency's payment for covered tube-delivered enteral nutrition products, equipment and related supplies. The agency pays for:

(a) One purchased pump, per client, in a five-year period;

(b) One purchased nondisposable intravenous pole required for enteral nutrition product delivery, per client, per lifetime; and

(c) No more than twelve months of equipment rental. After twelve months the agency considers the equipment purchased and it becomes the client's property.

(3) Women, infants, and children (WIC) program.

(a) If the client is age four or younger, the client must have a signed and dated written notification from the WIC program to receive tube delivered enteral nutrition products. The notice must verify:

(i) The client is not eligible for the WIC program; or

(ii) The client is eligible for the WIC program, but the client's need for a tube delivered enteral nutrition product exceeds WIC's allowed amount.

(b) If the client is age four or younger and is unable to receive a necessary tube delivered enteral nutrition product from WIC, the provider must keep the following information in the client's file:

(i) Documentation that the requested tube delivered product is not available through the WIC program; or

(ii) Reasons why a similar WIC product does not meet the client's needs.

(4) Authorization.

(a) If the client meets the criteria in subsection (1) of this section, the provider must follow the agency's expedited prior authorization (EPA) process to receive payment.

(b) If the client does not meet the criteria in subsection (1) of this section, the provider must submit a request for prior authorization (PA). The PA request must meet the requirements under WAC 182-554-700(3).

(c) The agency pays for enteral equipment replacement parts with PA if the equipment is:

(i) Owned by the client;

(ii) Less than five years old; and

(iii) No longer under warranty.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-08-009, § 182-554-600, filed 3/24/17, effective 5/1/17. WSR 11-14-075, recodified as § 182-554-600, filed 6/30/11, effective 7/1/11. Statutory Authority: 2009 c 564 § 1109, RCW 74.04.050, and 74.08.090. WSR 10-01-138, § 388-554-600, filed 12/21/09, effective 1/21/10. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-554-600, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.530 and chapter 74.09 RCW. WSR 05-04-059, § 388-554-600, filed 1/28/05, effective 3/1/05.*

##### **Wash. Admin. Code § 182-554-700** Enteral nutrition products, equipment and related supplies—Authorization. {#sec-182-554-700 omnilex-key=us-wa-regs-official--title-182--182-554-700}

(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.

(2) Prior authorization. PA is required for:

(a) Orally administered enteral nutrition products under WAC 182-554-500; and

(b) Tube-delivered enteral equipment, replacement parts and related supplies under WAC 182-554-600(3).

(3) Prior authorization request form. The provider must submit a request for PA on the Oral Enteral Nutrition Worksheet Prior Authorization Request form. This form is available online at http://www.hca.wa.gov/medicaid/forms/Pages/index.aspx. This form must be:

(a) Complete, with all fields full;

(b) Completed by the prescribing physician, advanced registered nurse practitioner, or physician assistant;

(c) Written, dated, and signed (including the prescriber's credentials) by the prescriber on the same day, and before the date of delivery. This form must not be backdated; and

(d) Submitted within three months of the date the prescriber signed the prescription.

(4) Expedited prior authorization. For EPA, a provider must establish that the client's condition meets the clinically appropriate EPA criteria outlined in this chapter and in the agency's published billing instructions. The provider must use the appropriate EPA number when billing the agency.

(5) If a fee-for-service client enrolls with an agency-contracted managed care organization (MCO) before the purchase or rental of authorized equipment is complete:

(a) The agency stops paying for the equipment on the last day of the month before the month in which the client enrolls in the managed care plan; and

(b) The MCO may reevaluate the client's need for the equipment.

(6) The agency may rescind authorization for enteral equipment if the client:

(a) Enrolls in, or becomes eligible for, an MCO;

(b) Becomes covered by a hospice agency and the equipment is used in the treatment of the terminal diagnosis or related condition(s);

(c) Loses eligibility; or

(d) Dies.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-08-009, § 182-554-700, filed 3/24/17, effective 5/1/17. WSR 11-14-075, recodified as § 182-554-700, filed 6/30/11, effective 7/1/11. Statutory Authority: 2009 c 564 § 1109, RCW 74.04.050, and 74.08.090. WSR 10-01-138, § 388-554-700, filed 12/21/09, effective 1/21/10. Statutory Authority: RCW 74.08.090, 74.09.530 and chapter 74.09 RCW. WSR 05-04-059, § 388-554-700, filed 1/28/05, effective 3/1/05.*

##### **Wash. Admin. Code § 182-554-800** Noncovered—Enteral nutrition products, equipment, and related supplies. {#sec-182-554-800 omnilex-key=us-wa-regs-official--title-182--182-554-800}

(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 21 and older.

(2) A provider may request an exception to rule under WAC 182-501-0160 for a noncovered service.

(3) For children age 20 and younger, providers must follow the rules for the early periodic screening, diagnosis, and treatment (EPSDT) program, see chapter 182-534 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-21-142, s 182-554-800, filed 10/21/25, effective 11/21/25*
- *WSR 17-08-009, § 182-554-800, filed 3/24/17, effective 5/1/17. WSR 11-14-075, recodified as § 182-554-800, filed 6/30/11, effective 7/1/11. Statutory Authority: 2009 c 564 § 1109, RCW 74.04.050, and 74.08.090. WSR 10-01-138, § 388-554-800, filed 12/21/09, effective 1/21/10. Statutory Authority: RCW 74.08.090, 74.09.530 and chapter 74.09 RCW. WSR 05-04-059, § 388-554-800, filed 1/28/05, effective 3/1/05.*

##### **Wash. Admin. Code § 182-554-900** Reimbursement—Enteral nutrition products, equipment, and related supplies. {#sec-182-554-900 omnilex-key=us-wa-regs-official--title-182--182-554-900}

(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.

(2) The agency pays for covered enteral nutrition products, equipment and related supplies according to a set fee schedule. The agency's payment includes all of the following:

(a) Any adjustment or modification to the equipment within three months of the date of delivery as long as the adjustment is not caused by a change in the client's medical condition;

(b) Instructions to the client or caregiver on the safe and proper use of equipment provided;

(c) Full service warranty;

(d) Delivery and pick-up; and

(e) Fitting and adjustments.

(3) If changes in circumstance occur during the rental period, such as death or ineligibility, the agency discontinues payment effective on the date of the change in circumstance.

(4) The agency does not pay for simultaneous rental and purchase of any item.

(5) The agency does not reimburse for equipment a provider receives at no cost.

(6) The provider who furnishes enteral nutrition equipment to a client is responsible for any costs incurred to have another provider repair equipment if all of the following apply:

(a) Any equipment that the agency considers purchased requires repair during the applicable warranty period;

(b) The provider refuses or is unable to fulfill the warranty; and

(c) The client still needs the equipment.

(7) If the rental equipment must be replaced during the warranty period, the agency recoups fifty percent of the total amount previously paid toward rental and eventual purchase of the equipment delivered to the client if:

(a) The provider is unwilling or unable to fulfill the warranty; and

(b) The client still needs the equipment.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-08-009, § 182-554-900, filed 3/24/17, effective 5/1/17. WSR 11-14-075, recodified as § 182-554-900, filed 6/30/11, effective 7/1/11. Statutory Authority: 2009 c 564 § 1109, RCW 74.04.050, and 74.08.090. WSR 10-01-138, § 388-554-900, filed 12/21/09, effective 1/21/10.*

## **Chapter 182-555** Medical nutrition therapy. {#struct-chapter-182-555}

##### **Wash. Admin. Code § 182-555-0100** General. {#sec-182-555-0100 omnilex-key=us-wa-regs-official--title-182--182-555-0100}

The medical nutrition therapy program ensures that clients have access to medically necessary outpatient medical nutrition therapy and associated follow-ups.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-060, § 182-555-0100, filed 10/31/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-555-0200** Definitions. {#sec-182-555-0200 omnilex-key=us-wa-regs-official--title-182--182-555-0200}

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).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-060, § 182-555-0200, filed 10/31/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-555-0300** Eligibility. {#sec-182-555-0300 omnilex-key=us-wa-regs-official--title-182--182-555-0300}

(1) 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).

(2) For clients age 20 and younger, see the early periodic screening, diagnosis, and treatment (EPSDT) program described in chapter 182-534 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-07-031, s 182-555-0300, filed 3/11/26, effective 4/11/26*
- *WSR 23-07-132, § 182-555-0300, filed 3/22/23, effective 4/22/23*
- *WSR 18-22-060, § 182-555-0300, filed 10/31/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-555-0400** Provider requirements. {#sec-182-555-0400 omnilex-key=us-wa-regs-official--title-182--182-555-0400}

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).

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-060, § 182-555-0400, filed 10/31/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-555-0500** Covered services. {#sec-182-555-0500 omnilex-key=us-wa-regs-official--title-182--182-555-0500}

(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.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-07-132, § 182-555-0500, filed 3/22/23, effective 4/22/23*
- *WSR 18-22-060, § 182-555-0500, filed 10/31/18, effective 1/1/19.*

##### **Wash. Admin. Code § 182-555-0600** Documentation requirements. {#sec-182-555-0600 omnilex-key=us-wa-regs-official--title-182--182-555-0600}

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.

(3) Any correspondence with the referring provider;

(4) Information on associated medical conditions; and

(5) Information concerning the medical need.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-060, § 182-555-0600, filed 10/31/18, effective 1/1/19.*

## **Chapter 182-556** Chiropractic services. {#struct-chapter-182-556}

##### **Wash. Admin. Code § 182-556-0200** Chiropractic services for children. {#sec-182-556-0200 omnilex-key=us-wa-regs-official--title-182--182-556-0200}

(1) The medicaid agency covers chiropractic services for clients age 20 and younger only. Providers must follow the rules for the early period screening, diagnosis, and treatment (EPSDT) program, see chapter 182-534 WAC.

(2) To be paid, chiropractic services must be:

(a) Provided by a chiropractor licensed in the state where services are provided;

(b) Within the scope of the chiropractor's license; and

(c) Limited to:

(i) Chiropractic manipulative treatments of the spine; and

(ii) X-rays of the spine.

(3) Chiropractic services are paid according to fees established by the agency using methodology set out in WAC 182-531-1850.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-21-142, s 182-556-0200, filed 10/21/25, effective 11/21/25*
- *WSR 15-10-018, § 182-556-0200, filed 4/24/15, effective 5/25/15. WSR 11-14-075, recodified as § 182-556-0200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-556-0200, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.035. WSR 00-16-031, § 388-556-0200, filed 7/24/00, effective 8/24/00.*

## **Chapter 182-557** Health homes. {#struct-chapter-182-557}

##### **Wash. Admin. Code § 182-557-0050** Health home—General. {#sec-182-557-0050 omnilex-key=us-wa-regs-official--title-182--182-557-0050}

(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.

(2) The health home program offers six care coordination activities to assist participants in self-managing their conditions and navigating the health care system:

(a) Comprehensive or intensive care management including, but not limited to, assessing participant's readiness for self-management, promoting self-management skills, coordinating interventions tailored to meet the participant's needs, and facilitating improved outcomes and appropriate use of health care services;

(b) Care coordination and health promotion;

(c) Comprehensive transitional care between care settings including, but not limited to, after discharge from an inpatient facility (hospital, rehabilitative, psychiatric, skilled nursing, substance use disorder treatment or residential habilitation setting);

(d) Individual and family support services to provide health promotion, education, training and coordination of covered services for participants and their support network;

(e) Referrals to community and support services; and

(f) Use of health information technology (HIT) to link services between the health home and participants' providers.

(3) The agency's health home program does not:

(a) Change the scope of services for which a participant is eligible under medicare or a Title XIX medicaid program;

(b) Interfere with the relationship between a participant and his or her chosen agency-enrolled provider(s);

(c) Duplicate case management activities the participant is receiving from other providers or programs; or

(d) Substitute for established activities that are available through other programs administered by the agency or other state agencies.

(4) Qualified health home providers must:

(a) Contract with the agency to provide services under this chapter to eligible participants;

(b) Accept the terms and conditions in the agency's contract;

(c) Be able to meet the network and quality standards established by the agency;

(d) Accept the rates established by the agency; and

(e) Comply with all applicable state and federal requirements.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-17-065, § 182-557-0050, filed 8/14/15, effective 9/14/15. Statutory Authority: RCW 41.05.021. WSR 13-21-048, § 182-557-0050, filed 10/11/13, effective 11/11/13. Statutory Authority: RCW 41.05.021 and 2011 c 316. WSR 13-12-002, § 182-557-0050, filed 5/22/13, effective 7/1/13. WSR 11-14-075, recodified as § 182-557-0050, 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. WSR 07-20-048, § 388-557-0050, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-557-0100** Health home program—Definitions. {#sec-182-557-0100 omnilex-key=us-wa-regs-official--title-182--182-557-0100}

The following terms and definitions and those found in chapter 182-500 WAC apply to this chapter:

Action - For the purposes of this chapter, means one or more of the following:

(a) The denial of eligibility for health home services.

(b) The denial or limited authorization by the qualified health home of a requested health home service, including a type or level of health home service.

(c) The reduction, suspension, or termination by the qualified health home of a previously authorized health home service.

(d) The failure of a qualified health home to provide authorized health home services or provide health home services as quickly as the participant's condition requires.

Agency - See WAC 182-500-0010.

Chronic condition - Means mental health conditions, substance use disorders, asthma, diabetes, heart disease, cancer, cerebrovascular disease, coronary artery disease, dementia or Alzheimer's disease, intellectual disability, HIV/AIDS, renal failure, chronic respiratory conditions, neurological disease, gastrointestinal, hematological, and musculoskeletal conditions.

Client - For the purposes of this chapter, means a person who is eligible to receive health home services under this chapter.

Clinical eligibility tool - Means an electronic spreadsheet that determines a client's risk score using the client's age, gender, diagnoses, and medications.

Coverage area - Means a geographical area composed of one or more counties within Washington state. The map of the coverage areas and the list of the qualified health homes is located at https://www.hca.wa.gov/billers-providers/programs-and-services/health-homes.

Fee-for-service (FFS) - See WAC 182-500-0035.

Full dual eligible - For the purpose of this chapter, means a fee-for-service client who receives qualified medicare beneficiary coverage or specified low-income medicare beneficiary coverage and categorically needy health care coverage.

Grievance - Means an expression of a participant's dissatisfaction about any matter other than an action. Possible subjects for grievances include the quality of health home services provided when an employee of a qualified health home provider is rude to the participant or shares confidential information about the participant without their permission.

Health action plan - Means a plan that lists the participant's goals to improve and self-manage their health conditions and steps needed to reach those goals.

Health home care coordinator - Means staff employed by or subcontracted by the qualified health home to provide one or more of the six defined health home care coordination benefits listed in WAC 182-557-0050.

Health home services - Means services described in WAC 182-557-0050 (2)(a) through (f).

Medicaid - See WAC 182-500-0070.

Participant - Means a client who has agreed to receive health home services under the requirements of this chapter.

Qualified health home - Means an organization that contracts with the agency to provide health home services to participants in one or more coverage areas and meets the requirements in WAC 182-557-0050(4).

Risk score - Means a measure of the expected costs of the health care a client is likely to incur in the next twelve months that the agency calculates using an algorithm developed by the department of social and health services (DSHS) or the clinical eligibility tool.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-24-111, § 182-557-0100, filed 12/6/17, effective 1/6/18*
- *WSR 15-17-065, § 182-557-0100, filed 8/14/15, effective 9/14/15. Statutory Authority: RCW 41.05.021 and 2011 c 316. WSR 13-12-002, § 182-557-0100, filed 5/22/13, effective 7/1/13. WSR 11-14-075, recodified as § 182-557-0100, 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. WSR 07-20-048, § 388-557-0100, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-557-0200** Health home program—Eligibility. {#sec-182-557-0200 omnilex-key=us-wa-regs-official--title-182--182-557-0200}

(1) To be eligible for the health home program, a client must:

(a) Be a recipient of categorically needy health care coverage or be eligible for services under an alternative benefits plan (ABP), as described in WAC 182-501-0060, through:

(i) Fee-for-service, including full dual eligible clients; or

(ii) An agency-contracted managed care organization.

(b) Have one or more chronic conditions as defined in WAC 182-557-0100; and

(c) Have a risk score of 1.5 or greater measured either with algorithms developed by the department of social and health services or the agency's clinical eligibility tool located at https://www.hca.wa.gov/assets/billers-and-providers/Clinical_Eligibility_Tool.xls.

(2) A person is ineligible to receive health home services when:

(a) The person is enrolled in a third-party medical insurance plan. For purposes of this section, a medical insurance plan does not include plans that offer only dental, vision, pregnancy, or maternity care services.

(b) The person has a risk score of less than 1.0 for six consecutive months and has not received health home services.

(3) When the agency determines a client is eligible for health home services, the agency enrolls the client with a qualified health home in the coverage area where the client lives.

(a) The client may decline health home services or change to a different qualified health home or a different health home care coordinator.

(b) If the client chooses to participate in the health home program, a health home care coordinator will:

(i) Work with the participant to develop a health action plan that describes the participant's health goals and includes a plan for reaching those goals; and

(ii) Provide health home services at a level appropriate to the participant's needs.

(4) A participant who does not agree with a decision regarding health home services, including a decision regarding the client's eligibility to receive health home services, has the right to an administrative hearing as described in chapter 182-526 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-04-041, s 182-557-0200, filed 1/29/25, effective 3/1/25*
- *WSR 17-24-111, § 182-557-0200, filed 12/6/17, effective 1/6/18*
- *WSR 15-17-065, § 182-557-0200, filed 8/14/15, effective 9/14/15. Statutory Authority: RCW 41.05.021 and 2011 c 316. WSR 13-12-002, § 182-557-0200, filed 5/22/13, effective 7/1/13. WSR 11-14-075, recodified as § 182-557-0200, 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. WSR 07-20-048, § 388-557-0200, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-557-0225** Health home services—Methodology for calculating a person's risk score. {#sec-182-557-0225 omnilex-key=us-wa-regs-official--title-182--182-557-0225}

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).

(2) Step 2. Group ICD diagnosis codes into chronic illness and disability payment system risk categories.

(a) To group ICD diagnosis codes into the CDPS risk categories (see Table 1 in (b) of this subsection), the agency uses an ICD diagnosis code to CDPS risk categories crosswalk in subsection (1)(b)(ii)(A) of this section. Each of the ICD diagnosis codes listed is assigned to one risk category. If an ICD diagnosis code is not listed in the crosswalk it does not map to a risk category that is used in the calculation of the risk score.

(b) Table 1. Titles of Chronic Illness and Disability Payment System Risk Categories

| CARVH | Cardiovascular, very high |
| --- | --- |
| CARM | Cardiovascular, medium |
| CARL | Cardiovascular, low |
| CAREL | Cardiovascular, extra low |
| PSYH | Psychiatric, high |
| PSYM | Psychiatric, medium |
| PSYML | Psychiatric, medium low |
| PSYL | Psychiatric, low |
| SKCM | Skeletal, medium |
| SKCL | Skeletal, low |
| SKCVL | Skeletal, very low |
| CNSH | Central Nervous System, high |
| CNSM | Central Nervous System, medium |
| CNSL | Central Nervous System, low |
| PULVH | Pulmonary, very high |
| PULH | Pulmonary, high |
| PULM | Pulmonary, medium |
| PULL | Pulmonary, low |
| GIH | Gastro, high |
| GIM | Gastro, medium |
| GIL | Gastro, low |
| DIA1H | Diabetes, type 1 high |
| DIA1M | Diabetes, type 1 medium |
| DIA2M | Diabetes, type 2 medium |
| DIA2L | Diabetes, type 2 low |
| SKNH | Skin, high |
| SKNL | Skin, low |
| SKNVL | Skin, very low |
| RENEH | Renal, extra high |
| RENVH | Renal, very high |
| RENM | Renal, medium |
| RENL | Renal, low |
| SUBL | Substance abuse, low |
| SUBVL | Substance abuse, very low |
| CANVH | Cancer, very high |
| CANH | Cancer, high |
| CANM | Cancer, medium |
| CANL | Cancer, low |
| DDM | Developmental Disability, medium |
| DDL | Developmental Disability, low |
| GENEL | Genital, extra low |
| METH | Metabolic, high |
| METM | Metabolic, medium |
| METVL | Metabolic, very low |
| PRGCMP | Pregnancy, complete |
| PRGINC | Pregnancy, incomplete |
| EYEL | Eye, low |
| EYEVL | Eye, very low |
| CERL | Cerebrovascular, low |
| AIDSH | AIDS, high |
| INFH | Infectious, high |
| HIVM | HIV, medium |
| INFM | Infectious, medium |
| INFL | Infectious, low |
| HEMEH | Hematological, extra high |
| HEMVH | Hematological, very high |
| HEMM | Hematological, medium |
| HEML | Hematological, low |

(3) Step 3. Group national drug codes (NDCs) into MRx risk categories.

(a) To group the NDC codes into MRx risk categories (see Table 2 in (b) of this subsection), the agency uses a NDC code to MRx risk categories crosswalk in subsection (1)(b)(ii)(B) of this section.

(b) Table 2. Titles of Medicaid Rx Risk Categories

| MRx1 | Alcoholism |
| --- | --- |
| MRx2 | Alzheimer's |
| MRx3 | Anti-coagulants |
| MRx4 | Asthma/COPD |
| MRx5 | Attention Deficit |
| MRx6 | Burns |
| MRx7 | Cardiac |
| MRx8 | Cystic Fibrosis |
| MRx9 | Depression/Anxiety |
| MRx10 | Diabetes |
| MRx11 | EENT |
| MRx12 | ESRD/Renal |
| MRx13 | Folate Deficiency |
| MRx14 | CMV Retinitis |
| MRx15 | Gastric Acid Disorder |
| MRx16 | Glaucoma |
| MRx17 | Gout |
| MRx18 | Growth Hormone |
| MRx19 | Hemophilia/von Willebrands |
| MRx20 | Hepatitis |
| MRx21 | Herpes |
| MRx22 | HIV |
| MRx23 | Hyperlipidemia |
| MRx24 | Infections, high |
| MRx25 | Infections, medium |
| MRx26 | Infections, low |
| MRx27 | Inflammatory/Autoimmune |
| MRx28 | Insomnia |
| MRx29 | Iron Deficiency |
| MRx30 | Irrigating Solution |
| MRx31 | Liver Disease |
| MRx32 | Malignancies |
| MRx33 | Multiple Sclerosis/Paralysis |
| MRx34 | Nausea |
| MRx35 | Neurogenic Bladder |
| MRx36 | Osteoporosis/Pagets |
| MRx37 | Pain |
| MRx38 | Parkinsons/Tremor |
| MRx39 | Prenatal Care |
| MRx40 | Psychotic Illness/Bipolar |
| MRx41 | Replacement Solution |
| MRx42 | Seizure Disorders |
| MRx43 | Thyroid Disorder |
| MRx44 | Transplant |
| MRx45 | Tuberculosis |

(4) Step 4. Remove duplicate risk categories. After mapping all diagnosis and drug codes to the risk categories, the agency eliminates duplicates of each client's risk categories so that there is only one occurrence of any risk category for each client.

(5) Step 5. Select the highest CDPS risk category within a disease group.

(a) The agency organizes CPDS risk categories into risk category groups of different intensity levels. The high risk category in each group is used in the calculation of the risk score. The lower level risk categories are eliminated from further calculations.

(b) Table 3. Chronic Disease Payment System Risk Category Groups

| Group Description | Risk Categories (Ordered Highest to Lowest Intensity) |
| --- | --- |
| AIDS/HIV and Infection | AIDSH, INFH, HIVM, INFM, INFL |
| Cancer | CANVH, CANH, CANM, CANL |
| Cardiovascular | CARVH, CARM, CARL, CAREL |
| Central Nervous System | CNSH, CNSM, CNSL |
| Diabetes | DIA1H, DIA1M, DIA2M, DIA2L |
| Developmental Disability | DDM, DDL |
| Eye | EYEL, EYEVL |
| Gastrointestinal | GIH, GIM, GIL |
| Hematological | HEMEH, HEMVH, HEMM, HEML |
| Metabolic | METH, METM, METVL |
| Pregnancy | PRGCMP, PRGINC |
| Psychiatric | PSYH, PSYM, PSYML, PSYL |
| Substance Abuse | SUBL, SUBVL |
| Pulmonary | PULVH, PULH, PULM, PULL |
| Renal | RENEH, RENVH, RENM, RENL |
| Skeletal | SKCM, SKCL, SKCVL |
| Skin | SKNH, SKNL, SKNVL |

(6) Step 6. Determine age/gender category.

(a) For each client, the agency selects the appropriate age/gender category. The 11 categories are listed in Table 4 in (b) of this subsection. The categories for ages below five and above 65 are gender neutral.

(b) Table 4. Age/Gender Categories

| Age | Gender | | |
| --- | --- | --- | --- |
| | Age <1 | | |
| | Age 1 to 4 | | |
| | Age 5 to 14 | | Male |
| | Age 5 to 14 | | Female |
| | Age 15 to 24 | | Male |
| | Age 15 to 24 | | Female |
| | Age 25 to 44 | | Male |
| | Age 25 to 44 | | Female |
| | Age 45 to 64 | | Male |
| | Age 45 to 64 | | Female |
| | Age 65+ | | |

(7) Step 7. Apply risk weights.

(a) The agency assigns each risk category and age/gender category a weight. The weight comes from either the model for clients who are age 17 and younger or from the model for clients age 18 and older.

(b) In each model there are three types of weights.

(i) Age/gender – Weights that correspond to the age/gender category of a client.

(ii) CDPS – Weights that correspond to 58 of the CDPS risk categories.

(iii) MRx – Weights that correspond to 45 of the MRx risk categories.

(c) Table 5. Risk Score Weights

| Category Type | Category | Description | Weights for Children (age <18) | Weights for Adults (age 18+) |
| --- | --- | --- | --- | --- |
| Age/Gender | Age <1 | Clients of age less than 1 | 0.91261 | 0.00000 |
| | Age 1 to 4 | Clients age 1 to 4 | 0.31764 | 0.00000 |
| | Age 5 to 14, Male | Male clients age 5 to 14 | 0.25834 | 0.00000 |
| | Age 5 to 14, Female | Female clients age 5 to 14 | 0.26338 | 0.00000 |
| | Age 15 to 24, Male | Male clients age 15 to 24 | 0.25662 | -0.01629 |
| | Age 15 to 24, Female | Female clients age 15 to 24 | 0.29685 | 0.03640 |
| | Age 25 to 44, Male | Male clients age 25 to 44 | 0.00000 | 0.04374 |
| | Age 25 to 44, Female | Female clients age 25 to 44 | 0.00000 | 0.06923 |
| | Age 45 to 64, Male | Male clients age 45 to 64 | 0.00000 | 0.13321 |
| | Age 45 to 64, Female | Female clients age 45 to 64 | 0.00000 | 0.06841 |
| | Age 65+ | Clients age 65 and older | 0.00000 | -0.05623 |
| CDPS | CARVH | Cardiovascular, very high | 0.84325 | 2.86702 |
| | CARM | Cardiovascular, medium | 0.33428 | 0.73492 |
| | CARL | Cardiovascular, low | 0.12835 | 0.24620 |
| | CAREL | Cardiovascular, extra low | 0.04307 | 0.06225 |
| | PSYH | Psychiatric, high | 0.40351 | 0.27085 |
| | PSYM | Psychiatric, medium | 0.23892 | 0.00000 |
| | PSYML | Psychiatric, medium low | 0.13796 | 0.00000 |
| | PSYL | Psychiatric, low | 0.07675 | 0.00000 |
| | SKCM | Skeletal, medium | 0.21071 | 0.42212 |
| | SKCL | Skeletal, low | 0.08343 | 0.15467 |
| | SKCVL | Skeletal, very low | 0.06244 | 0.06773 |
| | CNSH | Central Nervous System, high | 0.80483 | 0.78090 |
| | CNSM | Central Nervous System, medium | 0.31945 | 0.40886 |
| | CNSL | Central Nervous System, low | 0.15106 | 0.18261 |
| | PULVH | Pulmonary, very high | 1.14056 | 4.01723 |
| | PULH | Pulmonary, high | 0.34356 | 0.39309 |
| | PULM | Pulmonary, medium | 0.35587 | 0.31774 |
| | PULL | Pulmonary, low | 0.11315 | 0.13017 |
| | GIH | Gastro, high | 0.65934 | 1.34924 |
| | GIM | Gastro, medium | 0.24699 | 0.24372 |
| | GIL | Gastro, low | 0.09767 | 0.05104 |
| | DIA1H | Diabetes, type 1 high | 0.27018 | 1.04302 |
| | DIA1M | Diabetes, type 1 medium | 0.27018 | 0.23620 |
| | DIA2M | Diabetes, type 2 medium | 0.13647 | 0.17581 |
| | DIA2L | Diabetes, type 2 low | 0.13647 | 0.09635 |
| | SKNH | Skin, high | 0.56322 | 0.37981 |
| | SKNL | Skin, low | 0.23664 | 0.45155 |
| | SKNVL | Skin, very low | 0.05697 | 0.02119 |
| | RENEH | Renal, extra high | 1.80489 | 3.41999 |
| | RENVH | Renal, very high | 0.59311 | 0.69251 |
| | RENM | Renal, medium | 0.28630 | 0.92846 |
| | RENL | Renal, low | 0.21048 | 0.17220 |
| | SUBL | Substance Abuse, low | 0.15170 | 0.16104 |
| | SUBVL | Substance Abuse, very low | 0.01794 | 0.08784 |
| | CANVH | Cancer, very high | 1.19700 | 2.80074 |
| | CANH | Cancer, high | 0.51985 | 0.97173 |
| | CANM | Cancer, medium | 0.22164 | 0.38022 |
| | CANL | Cancer, low | 0.10350 | 0.22625 |
| | DDM | Developmental Disability, medium | 0.50073 | 0.27818 |
| | DDL | Developmental Disability, low | 0.19696 | 0.05913 |
| | GENEL | Genital, extra low | 0.00790 | 0.01121 |
| | METH | Metabolic, high | 0.47167 | 0.47226 |
| | METM | Metabolic, medium | 0.26297 | 0.11310 |
| | METVL | Metabolic, very low | 0.11546 | 0.18678 |
| | PRGCMP | Pregnancy, complete | 0.00244 | 0.00000 |
| | PRGINC | Pregnancy, incomplete | 0.12631 | 0.51636 |
| | EYEL | Eye, low | 0.09919 | 0.13271 |
| | EYEVL | Eye, very low | 0.02835 | 0.00000 |
| | CERL | Cerebrovascular, low | 0.14294 | 0.00000 |
| | AIDSH | AIDS, high | 0.70597 | 0.47361 |
| | INFH | Infectious, high | 0.70597 | 0.79689 |
| | HIVM | HIV, medium | 0.26129 | 0.07937 |
| | INFM | Infectious, medium | 0.26129 | 0.79689 |
| | INFL | Infectious, low | 0.07784 | 0.05617 |
| | HEMEH | Hematological, extra high | 5.37808 | 12.71981 |
| | HEMVH | Hematological, very high | 0.72873 | 3.08836 |
| | HEMM | Hematological, medium | 0.37824 | 0.63211 |
| | HEML | Hematological, low | 0.18676 | 0.25601 |
| MRx | MRx1 | Alcoholism | 0.05982 | 0.01924 |
| | MRx2 | Alzheimer's | 0.00000 | 0.08112 |
| | MRx3 | Anti-coagulants | 0.34428 | 0.13523 |
| | MRx4 | Asthma/COPD | 0.08758 | 0.05751 |
| | MRx5 | Attention Deficit | 0.00000 | 0.00779 |
| | MRx6 | Burns | 0.16633 | 0.00000 |
| | MRx7 | Cardiac | 0.0906 | 0.06425 |
| | MRx8 | Cystic Fibrosis | 0.50399 | 0.37265 |
| | MRx9 | Depression/Anxiety | 0.06743 | 0.09436 |
| | MRx10 | Diabetes | 0.1519 | 0.17046 |
| | MRx11 | EENT | 0.00000 | 0.00072 |
| | MRx12 | ESRD/Renal | 1.24598 | 1.20707 |
| | MRx13 | Folate Deficiency | 0.17973 | 0.11899 |
| | MRx14 | CMV Retinitis | 0.37762 | 0.00000 |
| | MRx15 | Gastric Acid Disorder | 0.10082 | 0.15470 |
| | MRx16 | Glaucoma | 0.04221 | 0.12971 |
| | MRx17 | Gout | 0.00000 | 0.00000 |
| | MRx18 | Growth Hormone | 0.9741 | 1.59521 |
| | MRx19 | Hemophilia/von Willebrands | 13.56192 | 89.14461 |
| | MRx20 | Hepatitis | 0.03018 | 0.00000 |
| | MRx21 | Herpes | 0.0348 | 0.01725 |
| | MRx22 | HIV | 0.65537 | 1.01178 |
| | MRx23 | Hyperlipidemia | 0.00000 | 0.03791 |
| | MRx24 | Infections, high | 1.38405 | 1.51663 |
| | MRx25 | Infections, medium | 0.07462 | 0.06192 |
| | MRx26 | Infections, low | 0.00000 | 0.00918 |
| | MRx27 | Inflammatory/Autoimmune | 0.08075 | 0.20046 |
| | MRx28 | Insomnia | 0.07093 | 0.06437 |
| | MRx29 | Iron Deficiency | 0.13306 | 0.15054 |
| | MRx30 | Irrigating Solution | 0.87573 | 0.16387 |
| | MRx31 | Liver Disease | 0.45314 | 0.22681 |
| | MRx32 | Malignancies | 0.36859 | 0.44200 |
| | MRx33 | Multiple Sclerosis/Paralysis | 0.0345 | 0.04353 |
| | MRx34 | Nausea | 0.18219 | 0.17120 |
| | MRx35 | Neurogenic Bladder | 0.15282 | 0.07675 |
| | MRx36 | Osteoporosis/Pagets | 0.00000 | 0.00000 |
| | MRx37 | Pain | 0.0295 | 0.04151 |
| | MRx38 | Parkinsons/Tremor | 0.17163 | 0.06257 |
| | MRx39 | Prenatal Care | 0.00000 | 0.13192 |
| | MRx40 | Psychotic Illness/Bipolar | 0.22819 | 0.20274 |
| | MRx41 | Replacement Solution | 0.58622 | 1.49405 |
| | MRx42 | Seizure Disorders | 0.23997 | 0.19837 |
| | MRx43 | Thyroid Disorder | 0.03948 | 0.06326 |
| | MRx44 | Transplant | 0.37388 | 0.05810 |
| | MRx45 | Tuberculosis | 0.20006 | 0.00000 |

(8) Step 8. Sum risk weights to obtain the risk score.

After obtaining the weights that correspond to a client's age/gender category and set of risk categories, the agency takes a sum of the values of all of the weights. This sum is the risk score for a client.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-17-166, § 182-557-0225, filed 8/24/22, effective 9/24/22*
- *WSR 17-24-111, § 182-557-0225, filed 12/6/17, effective 1/6/18*
- *WSR 15-17-065, § 182-557-0225, filed 8/14/15, effective 9/14/15.*

##### **Wash. Admin. Code § 182-557-0300** Health home services—Confidentiality and data sharing. {#sec-182-557-0300 omnilex-key=us-wa-regs-official--title-182--182-557-0300}

(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.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-17-065, § 182-557-0300, filed 8/14/15, effective 9/14/15. Statutory Authority: RCW 41.05.021 and 2011 c 316. WSR 13-12-002, § 182-557-0300, filed 5/22/13, effective 7/1/13. WSR 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. WSR 07-20-048, § 388-557-0300, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-557-0350** Health home—Grievance and appeals. {#sec-182-557-0350 omnilex-key=us-wa-regs-official--title-182--182-557-0350}

(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.

(2) Grievance process.

(a) Only a participant or the participant's authorized representative may file a grievance with the qualified health home orally or in writing. A health home care coordinator may not file a grievance for the participant unless the participant gives the health home care coordinator written consent to act on the participant's behalf.

(b) The qualified health home must:

(i) Accept, document, record, and process grievances that it receives from the participant, the participant's representative, or the agency;

(ii) Acknowledge receipt of each grievance, either orally or in writing, within two business days of receiving the grievance;

(iii) Assist the participant with all grievance processes;

(iv) Cooperate with any representative authorized in writing by the participant;

(v) Ensure that decision makers on grievances were not involved in the activity or decision being grieved, or any review of that activity or decision by qualified health home staff;

(vi) Consider all information submitted by the participant or the participant's authorized representative;

(vii) Investigate and resolve all grievances;

(viii) Complete the disposition of a grievance and notice to the affected parties as quickly as the participant's health condition requires, but no later than forty-five calendar days from receipt of the grievance;

(ix) Notify the participant, either orally or in writing, of the disposition of grievances within five business days of determination. Notification must be in writing if the grievance is related to a quality of care issue.

(3) Appeal process.

(a) The qualified health home must give the participant written notice of an action.

(b) The written notice must:

(i) State what action the qualified health home intends to take and the effective date of the action;

(ii) Explain the specific facts and reasons for the decision to take the intended action;

(iii) Explain the specific rule or rules that support the decision, or the specific change in federal or state law that requires the action;

(iv) Explain the participant's right to appeal the action according to chapter 182-526 WAC;

(v) State that the participant must request a hearing within ninety calendar days from the date that the notice of action is mailed.

(c) The qualified health home must send the written notice to the participant no later than ten days before the date of action. The written notice may be sent by the qualified health home no later than the date of the action it describes only if:

(i) The qualified health home has factual information confirming the death of a participant; or

(ii) The qualified health home receives a written statement signed by a participant that:

(A) The participant no longer wishes to receive health home services; or

(B) Provides information that requires termination or reduction of health home services and which indicates that the participant understands that supplying the information will result in health home services being ended or reduced.

(d) A health home care coordinator may not file an appeal for the participant.

(e) If the agency receives a request to appeal an action of the qualified health home, the agency will provide the qualified health home notice of the request.

(f) The agency will process the participant's appeal in accordance with chapter 182-526 WAC.

(g) Continued coverage. If a participant appeals an action by a qualified health home, the participant's health home services will continue consistent with WAC 182-504-0130.

(h) Reinstated coverage. If the agency ends or changes the participant's qualified health home coverage without advance notice, the agency will reinstate coverage consistent with WAC 182-504-0135.

(i) If the participant requests a hearing, the qualified health home must provide to the agency and the participant, upon request, and within three working days, all documentation related to the appeal.

(j) The qualified health home is an independent party and is responsible for its own representation in any administrative hearing, subsequent review process, and judicial proceedings.

(k) If a final order, as defined in WAC 182-526-0010, requires a qualified health home to provide the participant health home services that were not provided while the appeal was pending, the qualified health home must authorize or provide the participant those health home services promptly. A qualified health home cannot seek further review of a final order issued in a participant's administrative appeal of an action taken by the qualified health home.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-17-065, § 182-557-0350, filed 8/14/15, effective 9/14/15.*

##### **Wash. Admin. Code § 182-557-0400** Health home—Payment. {#sec-182-557-0400 omnilex-key=us-wa-regs-official--title-182--182-557-0400}

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.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-17-065, § 182-557-0400, filed 8/14/15, effective 9/14/15. Statutory Authority: RCW 41.05.021 and 2011 c 316. WSR 13-12-002, § 182-557-0400, filed 5/22/13, effective 7/1/13. WSR 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. WSR 07-20-048, § 388-557-0400, filed 9/26/07, effective 11/1/07.*

##### **Wash. Admin. Code § 182-557-0500** Involuntary disenrollment from a health home. {#sec-182-557-0500 omnilex-key=us-wa-regs-official--title-182--182-557-0500}

(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.

(b) The agency does not approve requests to end enrollment that are solely due to uncooperative or disruptive behavior resulting from a client's special needs, disability, or behavioral health condition, except when continued enrollment in the health home seriously impairs the health home's ability to furnish services to the client or other clients.

(c) Health homes requesting disenrollment must provide a client's assessment with any reasonable modifications attempted or made of policies, practices, procedures, or the provision of auxiliary aids or services, based on available evidence, in light of a client's special needs, disability, or behavioral health condition.

(d) A client's involuntary disenrollment is for one year, beginning on the first day of the month following the date on the notice of involuntary disenrollment.

(2) Disenrollment request. The agency grants a request from a qualified health home to involuntarily disenroll a client when the request is submitted to the agency in writing and includes documentation for the agency to determine that the criteria under subsection (1) of this section is met.

(3) Client notification and appeal rights. The agency notifies the qualified health home of the agency's decision within ten business days. If the request is approved, the agency sends a written notice of involuntary disenrollment to the client. The notice includes:

(a) The client's administrative hearing rights as described in chapter 182-526 WAC;

(b) The specific factual basis for disenrolling the client;

(c) The applicable provision under subsection (1) of this section, and any other applicable rule on which the disenrollment is based; and

(d) Any other information required by WAC 182-518-0005.

(4) Reenrollment. The agency may reenroll a client with a qualified health home within one year if:

(a) All of the concerns that led to the involuntary disenrollment are resolved; and

(b) The client continues to meet the health home eligibility criteria in this chapter.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-11-030, § 182-557-0500, filed 5/12/21, effective 6/12/21.*

## **Chapter 182-558** Premium payment program. {#struct-chapter-182-558}

##### **Wash. Admin. Code § 182-558-0010** Premium payment program (PPP). {#sec-182-558-0010 omnilex-key=us-wa-regs-official--title-182--182-558-0010}

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.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-11-129, § 182-558-0010, filed 5/22/19, effective 6/22/19*
- *WSR 17-03-014, § 182-558-0010, filed 1/5/17, effective 3/1/17.*

##### **Wash. Admin. Code § 182-558-0020** Definitions. {#sec-182-558-0020 omnilex-key=us-wa-regs-official--title-182--182-558-0020}

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.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-02-019, § 182-558-0020, filed 12/21/23, effective 3/1/24*
- *WSR 19-11-129, § 182-558-0020, filed 5/22/19, effective 6/22/19*
- *WSR 17-03-014, § 182-558-0020, filed 1/5/17, effective 3/1/17.*

##### **Wash. Admin. Code § 182-558-0030** Overview of eligibility. {#sec-182-558-0030 omnilex-key=us-wa-regs-official--title-182--182-558-0030}

(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.

(b) The client must provide the medicaid agency with proof of:

(i) Enrollment in a comprehensive individual or comprehensive employer-sponsored health insurance plan;

(ii) A Social Security Number or tax identification number for the policy holder; and

(iii) Premium expenditures.

(c) A client enrolled in a qualified individual health insurance plan purchased through the Washington health benefit exchange must complete an eligibility telephone consultation with the medicaid agency within 30 calendar days of submitting a completed application.

(i) The telephone consultation must occur between the agency and the client, or the client's legal representative, or both.

(A) Within seven business days of receipt of the client's completed application, the agency attempts to schedule the consultation with the client by telephone. If the client is not reached within two business days from the first attempt, the agency attempts to reach the client in the manner in which the application was received (i.e., mail or email).

(B) The client must schedule their telephone consultation by responding to the agency by telephone or email within 10 business days of the agency's outreach.

(C) Upon completion of the telephone consultation, premium payment enrollment begins as outlined in subsection (7) of this section.

(ii) The agency may deny the client's application if the client fails to timely complete their telephone consultation.

(d) If the agency suspects that a client has been encouraged by any entity into enrollment in the premium payment program for the purpose of maximizing the revenue of a provider or a health plan, the agency immediately informs the client of their right to disenroll from the program. The agency may take other legal actions, as appropriate, which could result in the exclusion of a provider from the medicaid program under chapter 182-502 WAC.

(2) Comprehensive health insurance plans. A comprehensive health insurance plan includes:

(a) An individual health insurance plan purchased from the Washington health benefit exchange, also known as a qualified health plan (QHP);

(b) An employer-sponsored group health insurance plan; or

(c) A qualified employer-sponsored group health insurance plan.

(3) Comprehensive health insurance plan exclusions. A comprehensive health insurance plan does not include:

(a) A health savings account, flexible health spending arrangement, or other surcharge deductions (i.e., tobacco and spousal deductions);

(b) A high-deductible plan;

(c) A high-risk plan, including a Washington state health insurance pool (WSHIP) plan;

(d) A medicare advantage or supplemental plan, including medicare Part C;

(e) A QHP purchased through the Washington health benefit exchange with a premium tax credit;

(f) A plan that is the legal obligation of a noncustodial parent, or any other liable party under RCW 74.09.185; or

(g) Any individual health insurance plan that was not purchased through the Washington health benefit exchange.

(4) Exceptions to comprehensive health insurance plan requirement:

(a) The agency allows an exception to the comprehensive health insurance requirement for clients enrolled in the PPP based on a plan as described in subsection (3) (d) and (e) of this section when the client:

(i) Has been enrolled in the same plan continuously since January 1, 2012;

(ii) Was approved for and continuously enrolled in the PPP since January 1, 2012; and

(iii) Remained eligible for a medicaid program identified in subsection (1)(a) of this section continuously since January 1, 2012.

(b) If a client's medicaid eligibility for a program identified in subsection (1)(a) of this section or their enrollment in their health plan changes or terminates, the exception to the comprehensive health insurance requirement terminates.

(5) Cost-effective comprehensive health insurance plan. A comprehensive health insurance plan must be cost-effective as defined in WAC 182-558-0020.

(6) Comprehensive health insurance premium above average cost.

(a) If the agency determines that a client's comprehensive health insurance premium is more than the average cost per user, the agency pays a greater amount for a medicaid client on the health insurance plan if the following criteria are met:

(i) The client must provide the following completed information to the agency:

(A) A written request that the agency pay a greater amount than the average cost per user for a medicaid client on the health insurance plan.

(I) The client must currently have a medical condition or conditions requiring ongoing medical care.

(II) The request must include the cost of the premium for each member on the comprehensive health insurance.

(B) Written documentation from the client's provider of a medical condition or conditions that require ongoing medical care. (For example, a client's providers could submit treatment plans, medication or durable medical equipment lists, or other documentation.)

(ii) The agency reviews the submitted documentation and determines that the cost of the greater premium is less than the cost of covering the client under medicaid.

(A) The agency's clinical staff reviews the written documentation from the client's providers to determine if the client has a medical condition or conditions requiring ongoing medical care.

(B) The agency notifies the client within 60 days of the initial request if additional documentation is required.

(b) The agency notifies the client in writing of the approval or denial of the client's request within 90 calendar days from the date the agency received:

(i) All requested information from the client; or

(ii) The client's written request.

(c) The agency may deny the request if the client fails to submit all requested information in (a)(i) of this subsection within 90 calendar days of the client's request or fails to participate in consultation as required in subsection (1)(c) of this section.

(d) The agency determines the updated premium amount based on the client's portion of the total premium using the information submitted by the client under (a)(i) of this subsection.

(e) If approved, the effective date of the increased premium amount is the date the client submitted the written request to the agency.

(7) Premium limit. The agency pays no more than one premium per client, per month. PPP enrollment begins no sooner than the date on which:

(a) A client is approved for a medicaid program identified in subsection (1)(a) of this section;

(b) The agency receives and accepts the completed Application for HCA Premium Payment Program (HCA 13-705) form;

(c) A client's apple health managed care enrollment, if applicable, ends; and

(d) A client completes the telephone eligibility phone consultation, if applicable under subsection (1)(c) of this section.

(8) Integrated managed care exemption. A client enrolled in the PPP is exempt from integrated managed care under chapter 182-538 WAC.

(9) Premium assistance subsidy. The agency's premium assistance subsidy may not exceed the minimum amount required to maintain comprehensive health insurance for the medicaid-eligible client.

(10) Proof of premium expenditures. Proof of premium expenditures must be submitted to the agency by the client or the client's representative no later than the end of the third month following the last month of coverage.

(11) Cost-sharing benefit limitations. The agency's cost-sharing benefit for copays, coinsurance, and deductibles is limited to services covered under the medicaid state plan.

(12) Proof of cost-sharing required. Proof of cost-sharing must be submitted to the agency no later than the end of the sixth month following the date of service.

(13) Client eligibility review.

(a) The agency reviews a client's eligibility annually for the PPP or when the client's:

(i) Health insurance plan has an annual open enrollment;

(ii) Medicaid eligibility for a program identified in subsection (1)(a) of this section changes or ends;

(iii) Medical assistance unit changes;

(iv) Premium changes; or

(v) Private health insurance coverage changes or ends.

(b) If the agency finds that the client's premiums or medicaid eligibility have changed, the agency may adjust the premium reimbursement or terminate eligibility for the PPP. The agency notifies the client of any changes in PPP eligibility under this subsection.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-02-019, § 182-558-0030, filed 12/21/23, effective 3/1/24*
- *WSR 19-11-129, § 182-558-0030, filed 5/22/19, effective 6/22/19*
- *WSR 17-03-014, § 182-558-0030, filed 1/5/17, effective 3/1/17.*

##### **Wash. Admin. Code § 182-558-0040** PPP for a client with an individual health insurance plan. {#sec-182-558-0040 omnilex-key=us-wa-regs-official--title-182--182-558-0040}

(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.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-11-129, § 182-558-0040, filed 5/22/19, effective 6/22/19*
- *WSR 17-03-014, § 182-558-0040, filed 1/5/17, effective 3/1/17.*

##### **Wash. Admin. Code § 182-558-0050** PPP for a client with an employer-sponsored group health insurance plan. {#sec-182-558-0050 omnilex-key=us-wa-regs-official--title-182--182-558-0050}

(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.

(2) Eligible persons. An eligible person is any client who:

(a) Has a comprehensive employer-sponsored group health insurance plan, which may be a Consolidated Omnibus Budget Reconciliation Act (COBRA) health insurance plan as described in 26 C.F.R. 54.4980; and

(b) Is receiving categorically needy, medically needy, or the alternative benefit plan scope of coverage.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-11-129, § 182-558-0050, filed 5/22/19, effective 6/22/19*
- *WSR 17-03-014, § 182-558-0050, filed 1/5/17, effective 3/1/17.*

##### **Wash. Admin. Code § 182-558-0060** PPP for a client with a qualified employer-sponsored group health insurance plan. {#sec-182-558-0060 omnilex-key=us-wa-regs-official--title-182--182-558-0060}

(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.

(b) The parent of the client in (a) of this subsection, if:

(i) Enrollment in the health plan depends on a parent's enrollment; and

(ii) The client is a dependent of the parents.

(3) Cost-sharing benefit. The premium payment program (PPP) may provide cost-sharing reimbursement to nonmedicaid-eligible parents for medicaid-covered services under this section.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-02-019, § 182-558-0060, filed 12/21/23, effective 3/1/24*
- *WSR 19-11-129, § 182-558-0060, filed 5/22/19, effective 6/22/19*
- *WSR 17-03-014, § 182-558-0060, filed 1/5/17, effective 3/1/17.*

##### **Wash. Admin. Code § 182-558-0070** Program monitoring. {#sec-182-558-0070 omnilex-key=us-wa-regs-official--title-182--182-558-0070}

(1) The agency monitors payments under the premium payment program.

(2) Under RCW 41.05A.110, the agency may recover any overpayment 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.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-02-019, § 182-558-0070, filed 12/21/23, effective 3/1/24*
- *WSR 17-03-014, § 182-558-0070, filed 1/5/17, effective 3/1/17.*

##### **Wash. Admin. Code § 182-558-0080** Administrative hearings. {#sec-182-558-0080 omnilex-key=us-wa-regs-official--title-182--182-558-0080}

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.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-02-019, § 182-558-0080, filed 12/21/23, effective 3/1/24*
- *WSR 17-03-014, § 182-558-0080, filed 1/5/17, effective 3/1/17.*

## **Chapter 182-559** Foundational community supports program. {#struct-chapter-182-559}

##### **Wash. Admin. Code § 182-559-100** General. {#sec-182-559-100 omnilex-key=us-wa-regs-official--title-182--182-559-100}

(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.

(2) Community support services include:

(a) Pretenancy supports:

(i) Conducting a functional needs assessment to:

(A) Identify the participant's preferences related to housing (type, location, living alone or with someone else, identifying a roommate, accommodations needed, or other important preferences); and

(B) Identify the participant's needs for support to maintain community integration. This includes what type of setting works best for the client, assistance in budgeting for housing/living expenses, assistance in connecting the client with social services to assist with filling out applications and submitting appropriate documentation to obtain sources of income necessary for community living and establishing credit, and in understanding and meeting obligations of tenancy.

(ii) Assisting clients to connect with social services to help with finding and applying for housing necessary to support the clients in meeting their medical care needs;

(iii) Developing an individualized community integration plan based upon the assessment as part of the overall person-centered plan;

(iv) Identifying and establishing short and long-term measurable goal(s), and establishing how goals will be achieved and how concerns will be addressed;

(v) Participating in person-centered plan meetings at redetermination and revision plan meetings, as needed;

(vi) Providing supports and interventions according to the person-centered plan.

(b) Tenancy-sustaining services:

(i) Service planning support and participating in person-centered plan meetings at redetermination and revision plan meetings as needed;

(ii) Coordinating and linking the client to services including:

(A) Primary care and health homes;

(B) Substance use disorder treatment providers;

(C) Mental health providers;

(D) Medical, vision, nutritional and dental providers;

(E) Vocational, education, employment and volunteer supports;

(F) Hospitals and emergency rooms;

(G) Probation and parole;

(H) Crisis services;

(I) End of life planning; and

(J) Other support groups and natural supports.

(iii) Entitlement assistance including assisting clients in obtaining documentation, navigating and monitoring application process and coordinating with the entitlement agency;

(iv) Assistance in accessing supports to preserve the most independent living, including skills coaching, financing counseling, anger management, individual and family counseling, support groups, and natural supports;

(v) Providing supports to assist the client in communicating with the landlord and/or property manager regarding the participant's disability (if authorized and appropriate), detailing accommodations needed, and addressing components of emergency procedures involving the landlord and/or property manager;

(vi) Coordinating with the client to review, update and modify their housing support and crisis plan on a regular basis to reflect current needs and address existing or recurring housing retention barriers; and

(vii) Connecting the client to training and resources that will assist the client in being a good tenant and lease compliance, including ongoing support with activities related to household management.

(c) The community support services benefit does not include:

(i) Payment of rent or other room and board costs;

(ii) Capital costs related to the development or modification of housing;

(iii) Expenses for utilities or other regular occurring bills;

(iv) Goods or services intended for leisure or recreation;

(v) Duplicative services from other state or federal programs; and

(vi) Services to clients in a correctional institution.

(d) Community support services must be provided:

(i) In an integrated setting of the client's choice; and

(ii) In a manner that ensures the client's individual right of privacy, dignity, respect, and freedom from coercion and restraint;

(iii) Post tenancy, in settings consistent with home and community-based services, as defined in 42 C.F.R. Sec. 441.530, such as those that:

(A) Do not have the qualities of an institution;

(B) Are not located in a building that is also a publicly or privately operated facility providing inpatient institutional treatment;

(C) Are not on the grounds of, or immediately adjacent to a public institution;

(D) Do not have the effect of isolating the client from community members who are not receiving medicaid services; and

(E) Are not a licensed residential care facility such as an adult family home or assisted living facility.

(3) Supported employment, such as individual placement and support (IPS) services, is individualized and includes one or more of the following services:

(a) Preemployment services:

(i) Prevocational/job-related discovery or assessment;

(ii) Person-centered employment planning;

(iii) Individualized job development and placement;

(iv) Job carving;

(v) Benefits education and planning; or

(vi) Transportation (only in conjunction with the delivery of an authorized service).

(b) Employment sustaining services:

(i) Career advancement services;

(ii) Negotiation with employers;

(iii) Job analysis;

(iv) Job coaching;

(v) Benefits education and planning;

(vi) Transportation (only in conjunction with the delivery of an authorized service);

(vii) Asset development; or

(viii) Follow-along supports.

(c) The IPS benefit does not include:

(i) Generalized employer contacts that are not connected to a specific enrolled individual or an authorized service;

(ii) Employment support for individuals in subminimum wage, or sheltered workshop settings; and

(iii) Facility-based habilitation or personal care services.

(d) Supported employment services must be provided in settings consistent with settings defined in 42 C.F.R. 441.530 (a)(1)(i) through (v) and (a)(2).

(4) Clients who meet the eligibility criteria for both community support services and supported employment services may receive both services concurrently. See WAC 182-559-300 for community support services eligibility criteria and WAC 182-559-350 for supported employment eligibility criteria.

(5) In order to ensure the demand for services remains within available funds, the agency may impose enrollment waitlists for services. The waitlist for foundational community supports services is considered on a first-come first-serve basis using the date the client requests community support services.

(6) Services described in this chapter must be approved under the explicit authority of the medicaid transformation project.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-23-052, § 182-559-100, filed 11/10/21, effective 12/11/21*
- *WSR 18-15-007, § 182-559-100, filed 7/6/18, effective 8/6/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2014 c 225 § 9 (1)(i) and 2016 1st sp.s c 36 § 213 (1)(f) and (g). WSR 17-11-136, § 182-559-100, filed 5/24/17, effective 7/1/17.*

##### **Wash. Admin. Code § 182-559-150** Definitions. {#sec-182-559-150 omnilex-key=us-wa-regs-official--title-182--182-559-150}

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.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-15-007, § 182-559-150, filed 7/6/18, effective 8/6/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2014 c 225 § 9 (1)(i) and 2016 1st sp.s c 36 § 213 (1)(f) and (g). WSR 17-11-136, § 182-559-150, filed 5/24/17, effective 7/1/17.*

##### **Wash. Admin. Code § 182-559-200** Eligible providers. {#sec-182-559-200 omnilex-key=us-wa-regs-official--title-182--182-559-200}

(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.

(2) Providers of community support services or supported employment services must:

(a) Obtain a core provider agreement in accordance with WAC 182-502-0005;

(b) Enroll with the medicaid agency as a nonbilling provider in accordance with WAC 182-502-0006; or

(c) Be qualified to bill for home and community living administration services to provide community support services or supported employment services.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-559-200, filed 11/4/25, effective 12/5/25*
- *WSR 21-23-052, § 182-559-200, filed 11/10/21, effective 12/11/21*
- *WSR 18-15-007, § 182-559-200, filed 7/6/18, effective 8/6/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2014 c 225 § 9 (1)(i) and 2016 1st sp.s c 36 § 213 (1)(f) and (g). WSR 17-11-136, § 182-559-200, filed 5/24/17, effective 7/1/17.*

##### **Wash. Admin. Code § 182-559-300** Eligibility for community support services. {#sec-182-559-300 omnilex-key=us-wa-regs-official--title-182--182-559-300}

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 multi-dimensional assessment approach for determining a client's need for SUD treatment.

(b) Clients assessed via a CARE assessment, per WAC 388-106-0050, to have a need for assistance demonstrated by:

(i) The need for assistance with at least three activities of daily living (ADLs) defined in WAC 388-106-0010, one of which may be body care; or

(ii) The need for hands-on assistance with at least one ADL which may include body care.

(c) Clients assessed to be a homeless person with a disability, according to 24 C.F.R. 578.3, which is defined as a long continuing or indefinite physical condition requiring improvement, stabilization, or prevention of deterioration of functioning (including ability to live independently without support).

(4) Exhibit at least one of the following risk factors:

(a) Homeless clients who:

(i) Have been homeless for at least 12 months; or

(ii) Have been homeless on at least four separate occasions in the last three years, as long as the combined occasions equal at least 12 months.

Homeless is defined as living in a safe haven, an emergency shelter, or a place not meant for human habitation. See 24 C.F.R. 578.3.

(b) A history of frequent or lengthy institutional contact.

(i) Institutional care facilities include jails, substance use disorder or mental health treatment facilities, hospitals, or other similar facilities, as defined in 24 C.F.R. 578.3, or skilled nursing facilities as defined in WAC 388-97-0001.

(ii) Frequent means more than one contact in the past 12 months.

(iii) Lengthy means 90 or more consecutive days within an institutional setting in the past 12 months.

(c) A history of frequent stays at adult residential care facilities as defined by WAC 388-110-020 or residential treatment facilities as defined by WAC 246-337-005. Frequent means more than one contact in the past 12 months.

(d) Have frequent turnover of in-home caregivers as defined by WAC 388-106-0040, where within the last 12 months the client utilized three or more different in-home caregiver providers and the current placement is not appropriate for the client.

(e) Have a predictive risk score of 1.5 or above. See WAC 182-557-0225.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-24-012, § 182-559-300, filed 11/27/23, effective 12/28/23*
- *WSR 21-23-052, § 182-559-300, filed 11/10/21, effective 12/11/21*
- *WSR 18-15-007, § 182-559-300, filed 7/6/18, effective 8/6/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2014 c 225 § 9 (1)(i) and 2016 1st sp.s c 36 § 213 (1)(f) and (g). WSR 17-11-136, § 182-559-300, filed 5/24/17, effective 7/1/17.*

##### **Wash. Admin. Code § 182-559-350** Eligibility for supported employment services. {#sec-182-559-350 omnilex-key=us-wa-regs-official--title-182--182-559-350}

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.

(b) Clients assessed via a CARE assessment, per WAC 388-106-0050, to have a need for assistance demonstrated by:

(i) The need for assistance with at least three activities of daily living (ADLs) defined in WAC 388-106-0010, one of which may be body care; or

(ii) The need for hands-on assistance with at least one ADL which may include body care.

(c) There is objective evidence, as defined by the sequential evaluation process in chapter 388-449 WAC or the progressive evaluation process in chapter 388-447 WAC, of physical or mental impairments because of which the client needs assistance with basic work-related activities, including one or more of the following: Sitting, standing, walking, lifting, carrying, handling, manipulative or postural functions (pushing, pulling, reaching, handling, stooping or crouching), seeing, hearing, communicating, remembering, understanding and following instructions, responding appropriately to supervisors and coworkers, tolerating the pressures of a work setting, maintaining appropriate behavior, using judgment, and adapting to changes in a routine work setting.

(5) Exhibit at least one of the following risk factors:

(a) Unable to be gainfully employed for at least ninety consecutive days due to a mental or physical impairment, as demonstrated by eligibility for the aged, blind, or disabled program as defined in WAC 388-449-0001, or the housing and essential needs program as defined in WAC 388-447-0001;

(b) More than one instance of treatment for a substance use disorder within the past two years;

(c) At risk of deterioration of mental illness and substance use disorder, or both, including one or more of the following:

(i) Persistent or chronic risk factors such as social isolation due to a lack of family or social supports, poverty, criminal justice involvement, or homelessness;

(ii) Care for mental illness and substance use disorder, or both, requires multiple provider types, including behavioral health, primary care, long-term services and supports, or other supportive services; or

(iii) Past psychiatric history, with no significant functional improvement that can be maintained without treatment and/or supports.

(d) Dysfunction in role performance due to a behavioral health condition, including one or more of the following:

(i) Behaviors that disrupt employment or schooling, or put employment at risk of termination or schooling suspension;

(ii) A history of multiple terminations from work or suspensions/expulsions from school;

(iii) Cannot succeed in a structured work or school setting without additional support or accommodations; or

(iv) Performance significantly below expectations for cognitive/developmental level.

(e) An inability to obtain or maintain employment resulting from age, physical disability, or traumatic brain injury.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-23-052, § 182-559-350, filed 11/10/21, effective 12/11/21*
- *WSR 18-15-007, § 182-559-350, filed 7/6/18, effective 8/6/18.*

##### **Wash. Admin. Code § 182-559-400** Payment. {#sec-182-559-400 omnilex-key=us-wa-regs-official--title-182--182-559-400}

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.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-15-007, § 182-559-400, filed 7/6/18, effective 8/6/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2014 c 225 § 9 (1)(i) and 2016 1st sp.s c 36 § 213 (1)(f) and (g). WSR 17-11-136, § 182-559-400, filed 5/24/17, effective 7/1/17.*

##### **Wash. Admin. Code § 182-559-500** Foundational community supports program—Limitation of scope of benefits. {#sec-182-559-500 omnilex-key=us-wa-regs-official--title-182--182-559-500}

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.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, 2014 c 225 § 9 (1)(i) and 2016 1st sp.s c 36 § 213 (1)(f) and (g). WSR 17-11-136, § 182-559-500, filed 5/24/17, effective 7/1/17.*

##### **Wash. Admin. Code § 182-559-600** Grievance and appeals system. {#sec-182-559-600 omnilex-key=us-wa-regs-official--title-182--182-559-600}

(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.

(2) TPA grievance and appeal system. The TPA grievance and appeal system includes:

(a) A grievance process for addressing complaints about any matter that is not an adverse benefit determination;

(b) A TPA appeals process to address a client's request for review of a TPA adverse benefit determination;

(c) Access to the agency's administrative hearing process for review of a TPA's resolution of an appeal; and

(d) Allowing clients and the client's authorized representatives to file grievances and appeals orally or in writing. The TPA cannot require clients to provide written follow up for a grievance or an appeal that the TPA received orally.

(3) Notice requirements. The TPA must follow notice and timeline requirements under chapter 182-518 WAC. The TPA sends written notice when they:

(a) Approve the client's foundational community supports eligibility and authorize the delivery of services;

(b) Deny the client's foundational community supports eligibility; and

(c) Approve the client's foundational community supports eligibility without authorization of services due to necessary funding being unavailable. Clients must be notified of placement on a waitlist until funding becomes available.

(4) The TPA grievance process.

(a) A client or client's authorized representative may file a grievance with the TPA. A provider may not file a grievance on behalf of a client without the client's written consent.

(b) Clients do not have a right to an agency administrative hearing regarding the resolution of a grievance.

(c) The TPA must acknowledge receipt of each grievance either orally or in writing within two business days.

(d) The TPA must notify clients of the resolution of grievances within five business days of determination.

(5) The TPA appeals process.

(a) A client, the client's authorized representative, or a provider acting on behalf of the client with the client's written consent may appeal a TPA adverse benefit determination.

(b) The TPA treats oral inquiries about appealing an adverse benefit determination as an appeal to establish the earliest possible filing date for the appeal. The TPA confirms the oral appeal in writing.

(c) The TPA must acknowledge in writing the receipt of each appeal to both the client and the requesting provider within five calendar days of receiving the appeal request. The appeal acknowledgment letter sent by the TPA serves as written confirmation of an appeal filed orally by a client.

(d) The client must file an appeal of a TPA action within sixty calendar days of the date on the TPA's notice of adverse benefit determination.

(e) The TPA must continue services pending the results of an appeal or subsequent agency administrative hearing.

(f) The TPA internal appeal process:

(i) Provides the client a reasonable opportunity to present evidence and allegations of fact or law, both in person and in writing;

(ii) Provides the client and the client's representative the client's case file, other documents and records, and any new or additional evidence considered, relied upon, or generated by the TPA (or at the direction of the TPA) in connection with the action. This information must be provided free of charge in advance of the resolution time frame for appeals as specified in this section; and

(iii) Includes as parties to the appeal:

(A) The client and the client's authorized representative; and

(B) The legal representative of the deceased client's estate.

(g) The TPA ensures that the people making decisions on appeals were not involved in any previous level of review or decision making.

(h) Time frames for resolution of appeals.

(i) The TPA resolves each appeal and provides notice as expeditiously as the client's health condition requires and no longer than three calendar days after the day the TPA receives the appeal.

(ii) The TPA may extend the time frame by an additional fourteen calendar days if it is necessary in order to complete the appeal.

(i) Notice of resolution of appeal. The notice of the resolution of the appeal must:

(i) Be in writing and be sent to the client and the requesting provider;

(ii) Include the results of the resolution of the appeal process and the date it was completed; and

(iii) Include information on the client's right to request an agency administrative hearing and how to do so as provided in the agency hearing rules under WAC 182-526-0095, if the appeal is not resolved wholly in favor of the client.

(j) Deemed completion of the TPA appeal process. If the TPA fails to adhere to the notice and timing requirements for appeals, the client is deemed to have completed the TPA's appeals process and may request an agency administrative hearing under WAC 182-526-0095.

(6) Agency administrative hearing.

(a) Only a client or the client's authorized representative may request an agency administrative hearing. A provider may not request a hearing on behalf of a client.

(b) If the client does not agree with the TPA's resolution of an appeal at the completion of the TPA appeal process, the client may file a request for an agency administrative hearing based on the rules in this section and the agency hearing rules in chapter 182-526 WAC. The client must request an agency administrative hearing within ninety calendar days of the notice of resolution of appeal.

(c) The TPA is an independent party and responsible for its own representation in any administrative hearing, appeal to the board of appeals, and any subsequent judicial proceedings.

(7) Effect of reversed resolutions of appeals. If the TPA or a final order as defined in chapter 182-526 WAC reverses a decision to deny or limit services, the TPA must authorize or provide the disputed services promptly and as expeditiously as the client's health condition requires.

(8) Funding unavailable. When a client receives approval for services and funding is unavailable, the client may appeal the determination that funding is unavailable.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-15-007, § 182-559-600, filed 7/6/18, effective 8/6/18.*

## **Chapter 182-560** Achieving a Better Life Experience (ABLE) Act. {#struct-chapter-182-560}

##### **Wash. Admin. Code § 182-560-100** Achieving a Better Life Experience (ABLE) Act. {#sec-182-560-100 omnilex-key=us-wa-regs-official--title-182--182-560-100}

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.

(2) This section applies to ABLE account beneficiaries who:

(a) Are entitled to benefits based on blindness or disability under Title II or XVI of the Social Security Act; or

(b) Meet the blindness or disability requirements under WAC 182-512-0050 (1)(b) and (c).

(3) The disability or blindness described in subsection (2)(a) or (b) of this section must have occurred before age 46.

(4) This section does not apply if the total combined annual contributions to an ABLE account exceed the limit under 26 U.S.C. Sec. 529A.

(5) When determining countable income for apple health programs for the account's designated beneficiary, the medicaid agency or the agency's designee does not:

(a) Count contributions made by a person other than the designated beneficiary to the ABLE account;

(b) Count funds distributed from the account;

(c) Count earnings generated by the account, such as accrued interest or dividends; or

(d) Reduce income used to determine eligibility by the amount of contributions made to the account, including any funds the designated beneficiary may contribute to it.

(6) When determining eligibility for apple health programs, the agency or the agency's designee excludes as resources:

(a) The value of an ABLE account, including any earnings generated by the account; and

(b) Subject to subsection (8) of this section, distributions from the account for qualified disability expenses as long as the beneficiary:

(i) Maintains an ABLE account;

(ii) Contributes to an ABLE account; or

(iii) Receives distributions from such ABLE account.

(7) "Qualified disability expense (QDE)" means any expense related to the beneficiary's blindness or disability that is made for the benefit of the beneficiary, including the following expenses:

(a) Education;

(b) Housing;

(c) Transportation;

(d) Employment training and support;

(e) Assistive technology and personal support services;

(f) Health;

(g) Prevention and wellness;

(h) Financial management;

(i) Legal fees;

(j) Expenses for oversight and monitoring; and

(k) Funeral and burial expenses.

(8) Distributions under subsection (6)(b) of this section, which are retained into a subsequent calendar month:

(a) Remain excluded as resources as long as the distributions are identifiable and the beneficiary still intends to use the distribution for a QDE;

(b) Are available resources on the first day of a subsequent calendar month if the intent of the beneficiary changes such that the beneficiary will not use the distribution for a QDE; and

(c) Are available resources on the first day of any subsequent month when the distribution is actually used for a non-QDE.

(9) The agency or the agency's designee counts as a resource on the first day of the following month any funds distributed for purposes other than paying a QDE expense described in subsection (7) of this section.

(10) If the beneficiary has multiple ABLE accounts, the agency or the agency's designee applies this section to the first ABLE account established.

(11) Funds remaining in the ABLE account when the beneficiary dies are subject to estate recovery under chapter 182-527 WAC, less any:

(a) Outstanding QDE debts; and

(b) Premium payments made from the ABLE account on behalf of the beneficiary to obtain coverage under the apple health care for workers with disabilities described in WAC 182-511-1000.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 26 U.S.C. Sec. 529A(e). WSR 26-08-048, s 182-560-100, filed 3/26/26, effective 4/26/26. Statutory Authority: RCW 41.05.021, 41.05.160*
- *26 U.S.C. Sec. 529A. WSR 18-17-049, § 182-560-100, filed 8/8/18, effective 9/8/18. Statutory Authority: RCW 41.05.021, 41.05.160 and 2016 c 39*
- *SSB 6210, and H.R. 647. WSR 17-11-135, § 182-560-100, filed 5/24/17, effective 7/1/17.*

## **Chapter 182-561** Community behavioral health support services benefit. {#struct-chapter-182-561}

##### **Wash. Admin. Code § 182-561-0100** General. {#sec-182-561-0100 omnilex-key=us-wa-regs-official--title-182--182-561-0100}

(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.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-10-081, § 182-561-0100, filed 4/30/24, effective 7/1/24.*

##### **Wash. Admin. Code § 182-561-0200** Definitions. {#sec-182-561-0200 omnilex-key=us-wa-regs-official--title-182--182-561-0200}

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.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-10-081, § 182-561-0200, filed 4/30/24, effective 7/1/24.*

##### **Wash. Admin. Code § 182-561-0300** Eligibility. {#sec-182-561-0300 omnilex-key=us-wa-regs-official--title-182--182-561-0300}

To be eligible for the community behavioral health support services (CBHS) benefit, a person must meet all requirements and criteria in this section.

(1) General requirements. A person must:

(a) Be eligible for apple health under categorically needy or alternate benefit plan scope of care;

(b) Receive at least one of the following home and community services at home or in a community residential setting:

(i) Medicaid personal care (MPC), as described in WAC 388-106-0015(1);

(ii) Community options program entry system (COPES), as described in WAC 388-106-0015(2);

(iii) Community first choice (CFC), as described in WAC 388-106-0015(3);

(iv) New freedom consumer directed services (NFCDS), as described in WAC 388-106-0015(16); or

(v) Residential support, as described in WAC 388-106-0015(17).

(c) Have countable income at or below 150 percent of the federal poverty level (FPL);

(d) Be age 18 or older; and

(e) Have an eligible diagnosis, as identified in WAC 182-561-0700.

(2) Needs-based criteria. A person must be assessed by home and community services (HCS) or an HCS designee and found to have a demonstrated need for:

(a) Assistance with three or more activities of daily living (ADL), or assistance with body care, or both, as defined in WAC 388-106-0010; or

(b) Hands-on assistance with one or more ADLs.

(3) Risk-based criteria. A person must have:

(a) A behavioral or clinical complexity that requires the level of supplementary or specialized services and staffing available only under the CBHS benefit. This determination is based on the person exhibiting one or more of the following behaviors within the last 12 months and can be prevented only with a high level of staffing, or skilled staff intervention, or both:

(i) Multiple assaults related to a behavioral health condition during inpatient or long-term care;

(ii) Self-endangering behaviors related to a behavioral health condition that would result in bodily harm;

(iii) Intrusiveness related to a behavioral health condition (e.g., rummaging, unawareness of personal boundaries) that places the person at risk of assault by others;

(iv) Chronic psychiatric symptoms that cause distress to and escalate the person or other residents to crisis if not monitored or redirected by staff;

(v) Sexual inappropriateness related to a behavioral health condition that may compromise the safety of the person and other vulnerable adults; or

(b) A history of any of the above behaviors, which are currently only prevented by additional skilled staff intervention.

(4) Other criteria. A person must have:

(a) A history of being unsuccessful in community living settings, as evidenced by at least one or more of the following:

(i) A history of multiple failed stays in residential settings within the past two years;

(ii) Be in imminent danger of losing a current community living setting due to behaviors related to a behavioral health condition or conditions;

(iii) Frequent caregiver turnover due to behaviors related to a behavioral health condition or conditions within the past two years; or

(iv) Be at imminent risk of losing a long-term care living setting without currently receiving the CBHS benefit.

(b) A past psychiatric history, where significant functional improvement has not been effectively maintained due to the lack of the CBHS benefit, as evidenced by one or more of the following:

(i) Two or more inpatient psychiatric hospitalizations in the last 12 months;

(ii) An inpatient stay in a community hospital (acute or psychiatric) or a free-standing evaluation and treatment facility for 30 days or more in the last 12 months, with barriers to discharge related to a behavioral health condition or conditions;

(iii) Discharge from a state psychiatric hospital or a long-term 90/180-day inpatient psychiatric setting in the last 12 months; or

(iv) Be at imminent risk of requiring inpatient level of care without currently receiving the CBHS benefit.

(5) Service eligibility. Covered services may begin on the date the client meets all CBHS benefit criteria described in subsections (1) through (4) of this section. The agency approves one year of continuous eligibility for the CBHS benefit, unless the client:

(a) Moves out-of-state;

(b) Is admitted to an institution, as defined in WAC 182-500-0050, and is likely to reside there for 30 days or longer;

(c) No longer receives any of the home and community services as described in WAC 388-106-0015 (1), (2), (3), (16), or (17), at home or in a community residential setting;

(d) Dies;

(e) Has countable income over 150 percent federal poverty level (FPL); or

(f) Otherwise loses eligibility for medicaid.

(6) Service eligibility denial or termination. The agency provides a written explanation for denials as described in chapter 182-518 WAC.

(a) A change that results in termination takes effect the first of the month following the change as described in WAC 182-504-0120.

(b) A change that results in a decreased scope of care takes effect the first of the month following the advance notice period, as described in WAC 182-504-0120.

(c) A person who does not agree with an agency decision regarding CBHS services, including a denial of eligibility, may request an administrative hearing as described in chapter 182-526 WAC.

(7) Redetermination. The agency reviews client eligibility for CBHS services at least once every 12 months.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-10-081, § 182-561-0300, filed 4/30/24, effective 7/1/24.*

##### **Wash. Admin. Code § 182-561-0400** Covered services. {#sec-182-561-0400 omnilex-key=us-wa-regs-official--title-182--182-561-0400}

The community behavioral health support services (CBHS) benefit covers supportive supervision and oversight services that:

(1) Include direct monitoring, redirection, diversion, and cueing to prevent at-risk behavior that may result in harm to the client or to others.

(2) Assist with building skills and resiliency to support stabilized living and integration.

(3) Must be coordinated with other behavioral health services or incorporated into any existing crisis plans.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-10-081, § 182-561-0400, filed 4/30/24, effective 7/1/24.*

##### **Wash. Admin. Code § 182-561-0500** Service tiers. {#sec-182-561-0500 omnilex-key=us-wa-regs-official--title-182--182-561-0500}

(1) The agency has established tiers for community behavioral health support services using the needs-based criteria and risk criteria in WAC 182-561-0300.

(2) At a minimum, a person determined eligible for supportive supervision qualifies to receive Tier 1 services for an average of two hours per day.

(3) The agency determines tiers based on medical appropriateness and clinical acuity, using the following tier structure:

| Tier Level | Eligibility Criteria | Renewal or Reassessment Criteria |
| --- | --- | --- |
| Tier 1 Services | A person is eligible for Tier 1 services (0.5 - 2.0 hours per day) if they: • Demonstrate a qualifying behavior that requires daily intermittent monitoring, redirection, and cueing to promote community stability and to ensure the safety of the person and other residents; or • Have a significant history of behaviors that are well-managed in a highly structured setting but are at risk of recurring in a community setting if not met with the appropriate level of supportive supervision. | For renewal or assessment, the person has a history of behaviors meeting the guidelines for Tier 1, which are currently prevented only by additional skilled staff intervention. |
| Tier 2 Services | A person is eligible for Tier 2 services if they: • Demonstrate current qualifying behaviors at a frequency that requires an average of 2.1 to 6.0 hours per day of dedicated staff to redirect, deescalate, and cue to promote community stability and to ensure the safety of the person and the other residents; or • Have demonstrated multiple qualifying behaviors requiring an average of 2.1 to 6.0 hours per day of one-on-one staffing within the past month. Behaviors may be well-managed in a highly structured setting but are at risk of recurring in a community setting if not met with the appropriate level of supportive supervision. | For renewal or reassessment, the person has a history of behavior or behaviors meeting the guidelines for Tier 2, which are currently prevented only by additional skilled staff intervention at this tier level. |
| Tier 3 Services | A person is eligible for Tier 3 services if they: • Demonstrate multiple qualifying behaviors at a frequency and intensity that requires an average of 6.1 to 10.0 hours per day of one-on-one staffing to redirect, engage, deescalate, and cue to promote community stability and to ensure the safety of the person and other residents; or • Have demonstrated multiple qualifying behaviors requiring an average of 6.1 to 10.0 hours per day of one-on-one staffing within the past month. Behaviors may be well-managed in a highly structured setting but are at risk of recurring or increasing in frequency or severity in a community setting if not met with the appropriate level of supportive supervision. | For renewal or reassessment, the person has a history of behaviors meeting the guidelines for Tier 3, which are currently preventable only by additional skilled staff intervention at this tier level. |
| Tier 4 Services | A person is eligible for Tier 4 services if they: • Demonstrate multiple qualifying behaviors at a frequency and intensity that requires an average of 10.1 to 15.0 hours per day of one-on-one staffing to redirect, engage, deescalate, and cue to promote community stability and to ensure the safety of the person and other residents; or • Have demonstrated multiple qualifying behaviors requiring an average of 10.1 to 15.0 hours per day of one-on-one staffing within the past month. Behavior requires at least one-on-one intervention, even in a structured setting, but the behavior may be at risk of increasing in frequency, or severity, or both, in a community setting if not met with the appropriate level of supportive supervision. | For renewal or reassessment, the person has a history of behavior meeting the guidelines for Tier 4, which are currently prevented only by additional skilled staff interventions at this tier level. |
| Tier 5 Services | A person is eligible for Tier 5 services when: • The person demonstrates multiple behaviors at a frequency and intensity that requires an average of 15.1 to 20.0 hours per day of one-on-one staffing to redirect, engage, deescalate, and cue to promote community stability and to ensure the safety of the person and other residents; or • The person's behavior requires daily one-on-one intervention even in the context of a structured setting, and there would be an imminent risk of harm if the person does not receive an average of 15.1 to 20.0 hours per day of at least one-on-one staffing in a community setting. | For renewal or reassessment, the person has a history of behavior meeting the guidelines for Tier 5, which are currently prevented only by additional skilled staff intervention at this tier level. |
| Tier 6 Services | A person is eligible for Tier 6 services when: • The person demonstrates multiple qualifying behaviors at a frequency and intensity that requires an average of 20.1 to 24 hours per day of one-on-one staffing or has regular episodes that require multiple staff to redirect, engage, deescalate, and cue to promote community stability and to ensure the safety of the person and other residents; or • The person's behavior requires constant one-on-one monitoring and intervention, even in the context of a structured setting, and there would be an imminent risk of harm if the person does not receive an average of 20.1 to 24 hours per day of at least one-on-one staffing in a community setting. | For renewals or reassessment, the person has a history of behavior meeting the guidelines for Tier 6, which are currently prevented only by additional skilled staff intervention at this tier level. |

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-09-161, s 182-561-0500, filed 4/23/25, effective 5/24/25*
- *WSR 24-10-081, § 182-561-0500, filed 4/30/24, effective 7/1/24.*

##### **Wash. Admin. Code § 182-561-0600** Providers. {#sec-182-561-0600 omnilex-key=us-wa-regs-official--title-182--182-561-0600}

(1) Supportive supervision and oversight services providers. The services described in WAC 182-561-0400(1) must be provided by the following medicaid agency-contracted providers:

(a) Adult family homes, as defined in RCW 70.128.010, which are licensed under chapter 388-76 WAC;

(b) Adult residential care facilities (ARC), which are assisted living facilities with a contract to provide ARC services and are licensed under chapters 18.20 RCW and 388-78A WAC;

(c) Enhanced adult residential care (EARC) facilities, which are assisted living facilities with a contract to provide EARC services and are licensed under chapters 18.20 RCW and 388-78A WAC;

(d) Assisted living facilities, which are licensed under chapters 70.97 RCW and 388-78A and 388-110 WAC; or

(e) Enhanced services facilities, which are licensed under chapters 70.97 RCW and 388-107 WAC.

(2) Provider requirements. For the purposes of community behavioral health support services, WAC 182-502-0020 is not applicable. Providers must follow the record requirements outlined in the billing guides.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-10-081, § 182-561-0600, filed 4/30/24, effective 7/1/24.*

##### **Wash. Admin. Code § 182-561-0700** Eligible diagnoses. {#sec-182-561-0700 omnilex-key=us-wa-regs-official--title-182--182-561-0700}

For purposes of this chapter, eligible diagnoses include only the following:

• Psychotic disorder with hallucinations due to known physiological condition

• Psychotic disorder with delusions due to known physiological condition

• Mood disorder due to known physiological condition, unspecified

• Mood disorder due to known physiological condition with depressive features

• Mood disorder due to known physiological condition with major depressive-like episode

• Mood disorder due to known physiological condition with manic features

• Mood disorder due to known physiological condition with mixed features

• Anxiety disorder due to known physiological condition

• Personality change due to known physiological condition

• Diffuse traumatic brain injury with loss of consciousness sequela

• Paranoid schizophrenia

• Disorganized schizophrenia

• Catatonic schizophrenia

• Undifferentiated schizophrenia

• Residual schizophrenia

• Schizophreniform disorder

• Other schizophrenia

• Schizophrenia, unspecified

• Schizotypal disorder

• Delusional disorders

• Brief psychotic disorder

• Shared psychotic disorder

• Schizoaffective disorder, bipolar type

• Schizoaffective disorder, depressive type

• Other schizoaffective disorders

• Schizoaffective disorder, unspecified

• Other psychotic disorder not due to a substance or known physiological condition

• Unspecified psychosis not due to a substance or known physiological condition

• Manic episode without psychotic symptoms, unspecified

• Manic episode without psychotic symptoms, mild

• Manic episode without psychotic symptoms, moderate

• Manic episode, severe, without psychotic symptoms

• Manic episode, severe with psychotic symptoms

• Manic episode in partial remission

• Manic episode in full remission

• Other manic episodes

• Manic episode, unspecified

• Bipolar disorder, current episode hypomanic

• Bipolar disorder, current episode manic without psychotic features, unspecified

• Bipolar disorder, current episode manic without psychotic features, mild

• Bipolar disorder, current episode manic without psychotic features, moderate

• Bipolar disorder, current episode manic without psychotic features, severe

• Bipolar disorder, current episode manic severe with psychotic features

• Bipolar disorder, current episode depressed, mild or moderate severity, unspecified

• Bipolar disorder, current episode depressed, mild

• Bipolar disorder, current episode depressed, moderate

• Bipolar disorder, current episode depressed, severe, without psychotic features

• Bipolar disorder, current episode depressed, severe, with psychotic features

• Bipolar disorder, current episode mixed, unspecified

• Bipolar disorder, current episode mixed, mild

• Bipolar disorder, current episode mixed, moderate

• Bipolar disorder, current episode mixed, severe, without psychotic features

• Bipolar disorder, current episode mixed, severe, with psychotic features

• Bipolar disorder, currently in remission, most recent episode unspecified

• Bipolar disorder, in partial remission, most recent episodic hypomanic

• Bipolar disorder, in full remission, most recent episode hypomanic

• Bipolar disorder, in partial remission, most recent episode manic

• Bipolar disorder, in full remission, most recent episode manic

• Bipolar disorder, in partial remission, most recent episode depressed

• Bipolar disorder, in full remission, most recent episode depressed

• Bipolar disorder, in partial remission, most recent episode mixed

• Bipolar disorder, in full remission, most recent episode mixed

• Bipolar II disorder

• Other bipolar disorder

• Bipolar disorder, unspecified

• Major depressive disorder, single episode, mild

• Major depressive disorder, single episode, moderate

• Major depressive disorder, single episode, severe without psychotic features

• Major depressive disorder, single episode, severe with psychotic features

• Major depressive disorder, single episode, in partial remission

• Major depressive disorder, single episode, in full remission

• Other depressive episodes

• Premenstrual dysphoric disorder

• Other specified depressive episodes

• Major depressive disorder, single episode, unspecified

• Depression, unspecified

• Major depressive disorder, recurrent, mild

• Major depressive disorder, recurrent, moderate

• Major depressive disorder, recurrent severe without psychotic features

• Major depressive disorder, recurrent, severe with psychotic symptoms

• Major depressive disorder, recurrent, in remission, unspecified

• Major depressive disorder, recurrent, in partial remission

• Major depressive disorder, recurrent, in full remission

• Other recurrent depressive disorders

• Major depressive disorder, recurrent, unspecified

• Cyclothymic disorder

• Dysthymic disorder

• Other persistent mood (affective) disorders

• Disruptive mood dysregulation disorder

• Other specified persistent mood disorders

• Persistent mood (affective) disorder, unspecified

• Unspecified mood (affective) disorder

• Agoraphobia, unspecified

• Agoraphobia with panic disorder

• Agoraphobia without panic disorder

• Social phobia, unspecified

• Social phobia, generalized

• Claustrophobia

• Other phobic anxiety disorders

• Panic disorder (episodic paroxysmal anxiety)

• Generalized anxiety disorder

• Obsessive-compulsive disorder

• Mixed obsessional thoughts and acts

• Hoarding disorder

• Excoriation (skin-picking) disorder

• Other obsessive-compulsive disorder

• Obsessive-compulsive disorder, unspecified

• Post-traumatic stress disorder, unspecified

• Post-traumatic stress disorder, acute

• Post-traumatic stress disorder, chronic

• Dissociative amnesia

• Dissociative fugue

• Dissociative stupor

• Conversion disorder with motor symptom or deficit

• Conversion disorder with seizures or convulsions

• Conversion disorder with sensory symptom or deficit

• Conversion disorder with mixed symptom presentation

• Dissociative identity disorder

• Other dissociative and conversion disorders

• Dissociative and conversion disorder, unspecified

• Somatization disorder

• Undifferentiated somatoform disorder

• Hypochondriacal disorder, unspecified

• Hypochondriasis

• Body dysmorphic disorder

• Other hypochondriacal disorders

• Pain disorder exclusively related to psychological factors

• Pain disorder with related psychological factors

• Other somatoform disorders

• Somatoform disorder, unspecified

• Depersonalization-derealization syndrome

• Nonpsychotic mental disorder, unspecified

• Borderline personality disorder

• Trichotillomania

• Intermittent explosive disorder

• Other impulse disorders

• Impulse disorder, unspecified

• Factitious disorder imposed on self, unspecified

• Factitious disorder imposed on self, with predominantly physical signs and symptoms

• Factitious disorder imposed on self, with combined psychological and physical signs and symptoms

• Other specified disorders of adult personality and behavior

• Conduct disorder confined to family context

• Conduct disorder, childhood-onset type

• Conduct disorder, adolescent-onset type

• Other conduct disorders

• Conduct disorder, unspecified

• Separation anxiety disorder of childhood

• Other childhood emotional disorders

• Childhood emotional disorder, unspecified

• Selective mutism

• Reactive attachment disorder of childhood

• Disinhibited attachment disorder of childhood

• Other childhood disorders of social functioning

• Childhood disorder of social functioning, unspecified

• Traumatic brain injury-related diagnoses

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-10-081, § 182-561-0700, filed 4/30/24, effective 7/1/24.*

##### **Wash. Admin. Code § 182-561-0800** Appeal process. {#sec-182-561-0800 omnilex-key=us-wa-regs-official--title-182--182-561-0800}

(1) The medicaid agency gives the client written notice of an action under chapter 182-518 WAC.

(2) The client has the right to appeal the agency's adverse action according to chapter 182-526 WAC.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-10-081, § 182-561-0800, filed 4/30/24, effective 7/1/24.*

## **Chapter 182-562** Community health worker services. {#struct-chapter-182-562}

##### **Wash. Admin. Code § 182-562-0050** Purpose. {#sec-182-562-0050 omnilex-key=us-wa-regs-official--title-182--182-562-0050}

This chapter contains rules regarding community health worker (CHW) services.

(1) For the purpose of this chapter, CHWs are frontline public health workers who are trusted members, or have a close understanding, or both, of the community served. This trusting relationship enables CHWs to serve as liaisons, links, or intermediaries between health or social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.

(2) CHWs may provide preventive services at any of the following three levels:

(a) Primary prevention. This level focuses on preventing the onset of disease or injury before it occurs by reducing risk factors and promoting healthy behaviors;

(b) Secondary prevention. This level focuses on early detection and prompt intervention to halt the progress of a disease, injury, or event during its initial phase. This includes conducting appropriate screenings and assessments for conditions; or

(c) Tertiary prevention. This level focuses on reducing the impact of an ongoing disease or injury and on managing and improving the quality of life for individuals with established diseases or conditions.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2024 c 376 s 211(43). WSR 25-06-056, s 182-562-0050, filed 2/28/25, effective 7/1/25.*

##### **Wash. Admin. Code § 182-562-0100** Definitions. {#sec-182-562-0100 omnilex-key=us-wa-regs-official--title-182--182-562-0100}

The following definitions and those found in chapter 182-500 WAC apply to community health worker (CHW) services.

"Agency" - See WAC 182-500-0010.

"Care coordination and health system navigation" - Helping clients to:

(a) Identify providers to receive services;

(b) Make appointments for services, arrange transportation to health care appointments, and attend appointments with clients for health care services; and

(c) Find other relevant community resources such as support groups.

"Client" - 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 health representative (CHR)" - Community health representatives (CHRs) are well-trained, medically guided, tribal and Native community people, who provide a variety of health services within American Indian and Alaska Native communities. CHRs are recognized as CHWs for the purposes of CHW services.

"Community health worker" or "CHW" - A frontline public health worker who is a trusted member, or has a close understanding, or both, of the community served. This trusting relationship enables the CHW to provide direct services as well as serve as a liaison, link, or intermediary between health or social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.

"Community health worker services" - A type of preventive health services that:

(a) Helps prevent disease, disability, and other health conditions or their progression; prolongs life; and promotes physical and mental health and efficiency;

(b) Provides tailored support and system navigation to help address unmet health-related social needs that significantly limit a practitioner's ability to carry out a medically necessary treatment plan; and

(c) Provides navigation in the treatment of a serious, high-risk condition or illness. These services help guide the client through their course of care including addressing any unmet social needs that significantly limit the client's ability to engage and follow their plan of care.

"General supervision" - The medicaid-enrolled, licensed practitioner supervising the CHW is responsible for providing guidance, support, and oversight to ensure that CHWs and CHRs are effectively performing their roles, monitoring the course of care, and delivering quality services to the community.

"Health education and promotion" - Helping clients to:

(a) Contextualize health education provided by the client's treatment team with the client's individual needs, goals, and preferences, in the context of the principal illness and/or SDOH need(s) and educating the client on how to best participate in medical decision making; and

(b) Build client self-advocacy skills, so that the client can interact with members of the health care team and related community-based services addressing the principal illness and SDOH need(s), in ways that are more likely to promote personalized and effective diagnosis or treatment.

"Health-related social needs (HRSN)" - Health-related social needs (HRSN) are an individual's unmet, adverse social conditions (e.g., housing instability, homelessness, nutrition insecurity) that contribute to poor health and are a result of underlying social determinants of health (conditions in which people are born, grow, work, and age).

"Lived experience" - Having first-hand knowledge and insight gained from navigating challenges similar to those faced by the people in the community. This can include shared experiences like cultural backgrounds, socioeconomic status, health conditions, or barriers accessing the health and social service systems.

"Medicaid agency" - See WAC 182-500-0070.

"Person-centered assessment" - Conducting a person-centered assessment to understand the client's life story, strengths, needs, goals, preferences, and desired outcomes including understanding cultural and linguistic factors and including unmet SDOH needs to establish a plan of care.

"Preventive services" - Services that help prevent disease, disability, and other health conditions or their progression; prolong life; and promote physical and mental health efficiency.

"Supervision" - Key aspects of supervision include, but are not limited to:

(a) Training and professional development;

(b) Performance monitoring;

(c) Support and mentorship; and

(d) Problem-solving and conflict resolution.

"Washington apple health" - See WAC 182-500-0120.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2024 c 376 s 211(43). WSR 25-06-056, s 182-562-0100, filed 2/28/25, effective 7/1/25.*

##### **Wash. Admin. Code § 182-562-0150** Appeal process. {#sec-182-562-0150 omnilex-key=us-wa-regs-official--title-182--182-562-0150}

(1) The medicaid agency gives the client written notice of an action under chapter 182-518 WAC.

(2) The client has the right to appeal the agency's adverse action according to chapter 182-526 WAC.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2024 c 376 s 211(43). WSR 25-06-056, s 182-562-0150, filed 2/28/25, effective 7/1/25.*

##### **Wash. Admin. Code § 182-562-0200** Client eligibility. {#sec-182-562-0200 omnilex-key=us-wa-regs-official--title-182--182-562-0200}

To receive community health worker (CHW) services, a person must:

(1) Be eligible for one of the Washington apple health programs listed in the table in WAC 182-501-0060, except for the medical care services (MCS) programs; and

(2) Be recommended by a physician or other licensed practitioner of the healing arts, as specified in 42 C.F.R. 440.130, following an initiating visit with one of the following criteria:

(a) An unmet health-related social need (HRSN) that limits the ability to engage in health care services;

(b) A positive adverse childhood experiences (ACEs) screening;

(c) One serious, high-risk condition that places the client at risk of any of the following:

(i) Hospitalization;

(ii) Institutionalization/out-of-home placement;

(iii) Acute exacerbation or decompensation; or

(iv) Functional health decline or death;

(d) Two or more missed health care appointments within the previous six months;

(e) The client, client's spouse, or client's family member expressed a need for support in health system navigation or resource coordination services;

(f) A need for recommended preventive services; or

(g) A condition that requires monitoring or revision of a disease-specific care plan and may require frequent adjustment of the medication or treatment regimen or substantial assistance from a caregiver.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2024 c 376 s 211(43). WSR 25-06-056, s 182-562-0200, filed 2/28/25, effective 7/1/25.*

##### **Wash. Admin. Code § 182-562-0300** Initiation and recommendation. {#sec-182-562-0300 omnilex-key=us-wa-regs-official--title-182--182-562-0300}

(1) Community health worker (CHW) services must be initiated and recommended by a physician or other licensed practitioner of the healing arts, as specified in 42 C.F.R. 440.130.

(2) During the initiating visit, the health care professional:

(a) Identifies that the client exhibits one of the criteria found in WAC 182-562-0200(2);

(b) Establishes a care plan; and

(c) Provides a written recommendation for the client to see a CHW or community health representative (CHR). A written recommendation for services may be provided in physical or electronic form including, but not limited to, electronic health records (EHRs), secure digital forms, or other compliant electronic documentations.

(3) The initiating visit must be personally performed by the licensed practitioner of the healing arts, as specified in 42 C.F.R. 440.130.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2024 c 376 s 211(43). WSR 25-06-056, s 182-562-0300, filed 2/28/25, effective 7/1/25.*

##### **Wash. Admin. Code § 182-562-0400** Community health workers—Provider requirements. {#sec-182-562-0400 omnilex-key=us-wa-regs-official--title-182--182-562-0400}

(1) To be paid for providing community health worker (CHW) services to Washington apple health clients, a CHW must:

(a) Deliver the CHW services under the general supervision of a medicaid-enrolled, licensed practitioner within the scope of their licensure as described in state law;

(b) Have lived experience that aligns with and provides a connection between the CHW and the community being served;

(c) Have 2,000 supervised hours working as a CHW in paid or volunteer positions within the previous three years and demonstrated skills and practical training in the areas listed in this section;

(d) Possess the following skills or core competencies:

(i) Communication;

(ii) Interpersonal and relationship-building;

(iii) Service coordination and navigation;

(iv) Advocacy;

(v) Capacity building;

(vi) Professional conduct;

(vii) Outreach;

(viii) Individual and community assessment;

(ix) Knowledge base in public health principles and social determinants of health (SDOH);

(x) Education and facilitation; and

(xi) Evaluation and research; and

(e) Demonstrate minimum qualifications through one of the following:

(i) CHW/CHR certificate. A certificate of completion including, but not limited to, any certificate issued by the Washington state department of health, or its designee, or Indian health services of a curricula that attests to demonstrated skills or competencies, or both, listed in (d) of this subsection; or

(ii) Supervisor attestation. Medicaid-enrolled, licensed supervisors may demonstrate the CHW's skills and competencies by conducting a CHW assessment and attesting to the CHW's skills and competencies. The supervising provider must maintain documentation of the CHW assessment. Trainings may also include health-specific topics including, but not limited to:

(A) Health coaching and motivational interviewing;

(B) Immunization across the lifespan;

(C) Family planning and wellness;

(D) Cardiovascular health and heart disease;

(E) Understanding disparities and social determinants;

(F) Behavioral health care;

(G) Cancer screening and prevention;

(H) Conducting food insecurity screening;

(I) Child development/early relational health;

(J) Mental health first aid; and

(K) Substance use.

(2) CHWs that do not meet any of the identified skills or practical training areas listed in this section must obtain the necessary training within 18 months of employment during which CHW services may still be billed. Once the 18 months have been completed, if the CHW does not meet the necessary training requirements, the agency will no longer pay for services billed until the training requirements are met.

(3) CHWs must complete a minimum of six hours of additional training annually. The supervising provider must maintain documentation of the CHW's completion of continuing education requirements.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2024 c 376 s 211(43). WSR 25-06-056, s 182-562-0400, filed 2/28/25, effective 7/1/25.*

##### **Wash. Admin. Code § 182-562-0500** Community health workers—Documentation requirements. {#sec-182-562-0500 omnilex-key=us-wa-regs-official--title-182--182-562-0500}

Community health workers must fulfill the documentation requirements in the medicaid agency's community health worker (CHW) services billing guide including, but not limited to, documenting in the client's health record:

(1) Advance client consent. Consent must be obtained by the licensed, qualified health care professional or CHW before rendering services and billing for CHW/CHR services. Consent may be verbal or in writing;

(2) The date and time/duration spent with the client and the nature of the activities;

(3) The location of services;

(4) The services performed, specifying the following:

(a) Whether they were provided to an individual or a group; and

(b) If they were provided to a group, the number of clients in the group;

(5) All identified needs of the client served including, but not limited to, health-related social needs that services are addressing (e.g., the client's diagnosis as defined by the current revision of the International Statistical Classification of Diseases and Related Health Problems); and

(6) The name of the CHW or CHR rendering the services.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2024 c 376 s 211(43). WSR 25-06-056, s 182-562-0500, filed 2/28/25, effective 7/1/25.*

##### **Wash. Admin. Code § 182-562-0600** Community health workers—Covered services. {#sec-182-562-0600 omnilex-key=us-wa-regs-official--title-182--182-562-0600}

The medicaid agency covers the following services when performed by a community health worker (CHW):

(1) Conducting person-centered assessments within their focus to:

(a) Identify personal health goals and preferences;

(b) Assess for physical, mental, behavioral, and social challenges; and

(c) Collaborate with the client to establish health goals;

(2) Care coordination and health system navigation including the following:

(a) Coordinating additional supports or specialty services;

(b) Managing the client's care plan; and

(c) Assisting the client in identifying and accessing resources;

(3) Facilitating behavior change and client self-advocacy including the following:

(a) Promoting client motivation to participate in care and reach person-centered diagnosis or treatment goals;

(b) Teaching techniques for self-monitoring and self-advocacy; and

(4) Health education and promotion including the following:

(a) Helping clients to contextualize health education provided by the client's treatment team with the client's individual needs, goals, and preferences, in the context of the principal illness and/or SDOH need(s) and educating the client on how to best participate in medical decision making; and

(b) Building client self-advocacy skills, so that the client can interact with members of the health care team and related community-based services addressing the principal illness and SDOH need(s), in ways that are more likely to promote personalized and effective diagnosis or treatment.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2024 c 376 s 211(43). WSR 25-06-056, s 182-562-0600, filed 2/28/25, effective 7/1/25.*

##### **Wash. Admin. Code § 182-562-0700** Noncovered services. {#sec-182-562-0700 omnilex-key=us-wa-regs-official--title-182--182-562-0700}

Under this chapter, the medicaid agency does not cover the following services when provided by community health workers (CHW):

(1) Clinical care management services that require a state credential;

(2) Child care;

(3) Chore services, including shopping and cooking;

(4) Companion services;

(5) Employment services;

(6) Enrollment assistance for government programs or insurance not related to improving health;

(7) Delivery of medication, medical equipment, or medical supplies;

(8) Respite care;

(9) Services that duplicate another medicaid-covered service;

(10) Socialization; and

(11) Transportation.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2024 c 376 s 211(43). WSR 25-06-056, s 182-562-0700, filed 2/28/25, effective 7/1/25.*

##### **Wash. Admin. Code § 182-562-0800** Supervising providers—Provider requirements. {#sec-182-562-0800 omnilex-key=us-wa-regs-official--title-182--182-562-0800}

(1) Under this chapter, a supervising provider must:

(a) Be enrolled as a provider with the medicaid agency;

(b) Be one of the following licensed practitioners:

(i) Health care professional;

(ii) Health care entity;

(iii) Supplier; or

(iv) Contractor of service; and

(c) Meet the requirements under chapter 182-502 WAC.

(2) A supervising provider must also:

(a) Understand the specific roles, responsibilities, and scope of practice for CHWs;

(b) Provide or facilitate training and professional development for CHWs; and

(c) Maintain accurate and thorough records related to supervision, performance, and compliance.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2024 c 376 s 211(43). WSR 25-06-056, s 182-562-0800, filed 2/28/25, effective 7/1/25.*

##### **Wash. Admin. Code § 182-562-0900** Supervising providers—Documentation requirements. {#sec-182-562-0900 omnilex-key=us-wa-regs-official--title-182--182-562-0900}

In addition to the requirements in WAC 182-502-0020, supervising providers must document the following:

(1) Required supervision records for community health workers;

(2) Continued education verification and renewal of credentials for professional staff; and

(3) Consent forms and documentation for screening, assessments, care plans, case conferences, case management, care coordination, and health system navigation for each client.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2024 c 376 s 211(43). WSR 25-06-056, s 182-562-0900, filed 2/28/25, effective 7/1/25.*

##### **Wash. Admin. Code § 182-562-1000** Supervising providers—Payment and billing. {#sec-182-562-1000 omnilex-key=us-wa-regs-official--title-182--182-562-1000}

(1) The medicaid agency pays for the covered community health worker (CHW) services described in this chapter when they are:

(a) Initiated and recommended by a physician or other licensed practitioner of the healing arts, as specified in 42 C.F.R. 440.130;

(b) Provided and billed according to the agency's community health worker (CHW) services billing guide; and

(c) Documented in the client's record or chart per WAC 182-562-0900.

(2) The agency pays providers for covered services provided to eligible clients using the agency's published fee schedule.

(3) The agency uses the appropriate payment methodology found in WAC 182-531-1850 for community health worker services.

(4) For children age 20 and younger, providers must follow the rules for the early periodic screening, diagnosis, and treatment (EPSDT) program. See chapter 182-534 WAC. EPSDT is defined under WAC 182-500-0030.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2024 c 376 s 211(43). WSR 25-06-056, s 182-562-1000, filed 2/28/25, effective 7/1/25.*

## **Chapter 182-563** Reentry services. {#struct-chapter-182-563}

##### **Wash. Admin. Code § 182-563-050** General. {#sec-182-563-050 omnilex-key=us-wa-regs-official--title-182--182-563-050}

This chapter contains rules regarding reentry services.

(1) The medicaid agency covers reentry services under the following authorities:

(a) Under the authority of the reentry demonstration initiative, which is part of the agency's section 1115 medicaid demonstration waiver known as the medicaid transformation project 2.0 (MTP 2.0). Subject to the availability of amounts appropriated for this specific purpose, the agency covers a limited set of services for incarcerated individuals who are eligible for medicaid or children's health insurance program (CHIP) benefits for up to 90 days before their release from carceral facilities within Washington state; and

(b) Under sections 5121 and 5122 of the Consolidated Appropriations Act (CAA), 2023, a federal bill that created exceptions to the inmate exclusion policy and requires states to provide certain services while an eligible juvenile is incarcerated in a public institution.

(2) Reentry benefits are based on carceral facilities' eligibility to participate and successful completion of an agency-specific readiness assessment.

(3) Reentry benefits available under CAA vary based upon whether the eligible juvenile is preadjudication or postadjudication.

(a) Preadjudication benefits (section 5122 of CAA, 2023) include the following for eligible juveniles that are incarcerated in public institutions pending disposition:

(i) Medicaid and CHIP benefits; and

(ii) Reentry targeted case management (RTCM) if the individual is expected to be released in less than 90 days; and

(b) Postadjudication benefits (section 5121 of CAA, 2023), which include:

(i) Clinical assessment and evaluation for eligible juveniles (diagnostic services and medical, behavioral, and dental screenings) provided within 30 days prerelease or no later than one week postrelease; and

(ii) Thirty days of RTCM prerelease and for at least 30 days postrelease.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.715. WSR 25-11-005, s 182-563-050, filed 5/8/25, effective 7/1/25.*

##### **Wash. Admin. Code § 182-563-100** Definitions. {#sec-182-563-100 omnilex-key=us-wa-regs-official--title-182--182-563-100}

The following definitions and those found in chapter 182-500 WAC apply to this chapter.

"Adjudication" - A legal process that involves reviewing evidence and arguments to reach a decision. The decision is based on applying a standard set of guidelines to an individual's specific circumstances.

"Carceral facility" - A place of confinement or detention, such as a prison, jail, or correctional institution, where individuals are held because of legal convictions, awaiting trial, or serving sentences for criminal offences.

"Consolidated Appropriations Act (CAA), 2023" - Enacted as P.L. 117-328, section 5121 requires postadjudication services and section 5122 allows preadjudication services for eligible juveniles within a public institution.

"Eligible juvenile" - An incarcerated individual who is either:

(a) An apple health client covered under medicaid or the children's health insurance program (CHIP) who is 20 years of age or younger; or

(b) An individual between the ages of 18 and 26 who is eligible under the mandatory former foster care children group.

"Lived experience" - Having first-hand knowledge and insight gained from navigating challenges similar to those faced by the people in the community. This can include shared experiences like cultural backgrounds, socioeconomic status, health conditions, or barriers accessing the health and social service systems.

"Medicaid transformation project 2.0 (MTP 2.0)" - Washington's section 1115 medicaid demonstration waiver between the medicaid agency and the centers for medicare and medicaid services (CMS). Under MTP 2.0, the agency's goals are to:

(a) Expand coverage and access to care;

(b) Advance whole-person primary, preventive, and home-based and community-based care; and

(c) Accelerate care delivery and payment innovation focused on health-related social needs.

"Preadjudication" - The period before a court has entered the disposition of a juvenile's case.

"Postadjudication" - The status of a case after a juvenile has been found guilty of an offense.

"Reentry demonstration initiative" - Part of MTP 2.0, Washington state's section 1115 medicaid demonstration waiver, this initiative allows payment for targeted reentry services in situations where medicaid law would typically prohibit such payment.

"Reentry services" - A targeted set of apple health services provided before an individual's estimated release from a carceral facility.

"Reentry targeted case management (RTCM)" - A person-centered, recovery-focused approach to address the health of justice-involved apple health clients. RTCM is a mandatory service for carceral facilities.

"Warm handoff" - A process in which one professional or service provider personally introduces a client or patient to another professional or service provider, ensuring a smooth transition of care or services. A warm handoff involves an active exchange of information, often face-to-face or through a direct, personal communication (e.g., phone call or video conference), to ensure continuity, clarity, and a more seamless experience for the client or patient. This approach is intended to help build trust, minimize gaps in care, and ensure that the client is supported throughout the process.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.715. WSR 25-11-005, s 182-563-100, filed 5/8/25, effective 7/1/25.*

##### **Wash. Admin. Code § 182-563-200** Provider eligibility requirements. {#sec-182-563-200 omnilex-key=us-wa-regs-official--title-182--182-563-200}

Under this chapter, to provide reentry services, providers must:

(1) Be enrolled as a provider with the medicaid agency; and

(2) Meet the requirements for an enrolled provider under chapter 182-502 WAC.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.715. WSR 25-11-005, s 182-563-200, filed 5/8/25, effective 7/1/25.*

##### **Wash. Admin. Code § 182-563-300** Carceral facility requirements. {#sec-182-563-300 omnilex-key=us-wa-regs-official--title-182--182-563-300}

(1) The following carceral facilities may provide reentry services when they meet the requirements in this chapter:

(a) State prisons operated by the department of corrections (DOC);

(b) City, county, and regionally operated adult jails;

(c) Tribal jails; and

(d) The following youth correctional facilities:

(i) Juvenile rehabilitation centers operated by the department of children, youth, and families (DCYF); and

(ii) City, county, and regionally operated youth correctional facilities; juvenile detention centers; and other penal/correctional settings.

(2) Carceral facilities who are either serving eligible juveniles or are participating in MTP 2.0 are required to:

(a) Ensure access to mandatory reentry services when medically necessary;

(b) Conduct apple health eligibility screening within 24 hours of intake, or at the earliest practicable opportunity thereafter, and within 90 days of prerelease and assist an individual in applying, if appropriate;

(c) Conduct a reentry health screening upon intake and within 90 days prerelease (30 days for eligible juveniles); and

(d) Follow the processes, procedures, and operational requirements found in the agency's reentry policy and operations guide, which is located on the agency's website.

(3) Reentry health screenings may be completed by nonclinical staff and must address the following components:

(a) Medical, mental health, and substance use disorder (SUD); and

(b) If a health care need is identified, the client's interest in engaging in reentry targeted case management (RTCM).

(4) Carceral facilities are required to arrange for access to RTCM services by one of the following delivery systems:

(a) By the carceral facility, if the facility is a qualified medicaid provider according to this chapter; or

(b) By a qualified medicaid provider in the community; or

(c) If neither of the options in (a) and (b) in this subsection are selected by the carceral facility to the agency with 90 days' notice:

(i) By the agency's reentry third-party administrator for fee-for-services clients; or

(ii) By the managed care organization (MCO) for clients enrolled in an agency-contracted MCO.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.715. WSR 25-11-005, s 182-563-300, filed 5/8/25, effective 7/1/25.*

##### **Wash. Admin. Code § 182-563-400** Covered services. {#sec-182-563-400 omnilex-key=us-wa-regs-official--title-182--182-563-400}

(1) The following reentry benefits available under CAA vary based upon whether the eligible juvenile is preadjudication or postadjudication:

(a) Preadjudication benefits (section 5122 of CAA, 2023) include the following for eligible juveniles that are incarcerated in public institutions pending disposition:

(i) Medicaid and CHIP benefits; and

(ii) Reentry targeted case management (RTCM) if the individual is expected to be released in less than 90 days.

(b) Postadjudication benefits (section 5121 of CAA, 2023) include:

(i) Clinical assessment and evaluation for eligible juveniles (diagnostic services and medical, behavioral, and dental screenings) provided within 30 days prerelease or no later than one week postrelease; and

(ii) Thirty days of RTCM prerelease and for at least 30 days postrelease.

(2) Reentry services outlined in this section are identified as either mandatory or optional. Clients may choose whether to receive reentry services. Reentry services include:

(a) Mandatory services. Carceral facilities must provide the following:

(i) RTCM;

(ii) Reentry substance use disorder (SUD) treatment, including clinical assessment and evaluation to screen, assess, evaluate, and diagnose SUD and medications for SUD; and

(iii) Reentry pharmacy services at release, which include:

(A) Vaccines and vaccine administration;

(B) Provider-administered drugs and administration; and

(C) A 30-day supply of prescriptions and over-the-counter drugs covered within the apple health preferred drug list and pharmacy-supplied medical supplies, or a shorter supply:

(I) When required by applicable law, regulation, or agency policy; or

(II) As prescribed by a treating provider;

(iv) Preadjudication services for eligible juveniles, which include services available under the client's program benefit package, as defined in WAC 182-501-0060, when appropriate to provide in a carceral setting; and

(v) Postadjudication services for eligible juveniles, which include clinical assessment and evaluation to screen, assess, evaluate, and diagnose health conditions in addition to the other mandatory services listed in this section; and

(b) Optional services. Carceral facilities may choose to provide the following reentry services:

(i) Ninety days prerelease pharmacy services, which include vaccines and vaccine administration, provider-administered drugs and administration, and prescriptions and over-the-counter drugs covered within the apple health preferred drug list and pharmacy-supplied medical supplies;

(ii) Laboratory services;

(iii) Radiology services;

(iv) Services by providers with lived experience;

(v) Clinical assessment and evaluation to screen, assess, evaluate, and diagnose health conditions for clients age 21 and older who are not CAA eligible; and

(vi) Medical equipment and supplies not covered by the mandatory reentry services.

(3) For the purposes of this chapter, services not listed in this section are not covered and are not eligible for approval under exception to rule under WAC 182-501-0160(2).

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.715. WSR 25-11-005, s 182-563-400, filed 5/8/25, effective 7/1/25.*

##### **Wash. Admin. Code § 182-563-500** Documentation requirements. {#sec-182-563-500 omnilex-key=us-wa-regs-official--title-182--182-563-500}

Providers must fulfill the documentation requirements found in:

(1) WAC 182-502-0020; and

(2) Applicable medicaid agency billing guides.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.715. WSR 25-11-005, s 182-563-500, filed 5/8/25, effective 7/1/25.*

##### **Wash. Admin. Code § 182-563-600** Payment and billing. {#sec-182-563-600 omnilex-key=us-wa-regs-official--title-182--182-563-600}

(1) The medicaid agency pays for the reentry services described in this chapter when they are:

(a) Provided and billed according to the agency's rules, reentry policy and operations guide, and applicable agency billing guides; and

(b) Documented in the client's record or chart per WAC 182-563-500.

(2) The agency pays providers for covered services provided to eligible clients using the agency's published fee schedules.

(3) Payment for covered reentry services described in this chapter are based on existing applicable payment methodologies described in Title 182 WAC.

(4) Providers must meet the billing requirements found in:

(a) Chapter 182-502 WAC; and

(b) Applicable medicaid agency billing guides.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.715. WSR 25-11-005, s 182-563-600, filed 5/8/25, effective 7/1/25.*

##### **Wash. Admin. Code § 182-563-700** Grievance, hearings, and appeal. {#sec-182-563-700 omnilex-key=us-wa-regs-official--title-182--182-563-700}

(1) The medicaid agency gives fee-for-service (FFS) clients written notice of an agency action under chapter 182-518 WAC.

(2) FFS clients have the right to appeal the agency's adverse action according to chapter 182-526 WAC.

(3) Refer to WAC 182-538-110 for information about the grievance and appeal system and the right to an agency administrative hearing for clients enrolled in one of the agency's managed care organizations.

(4) Any appeals, independent rereview, or agency administrative hearing process related to a request to authorize or pay for a service will terminate when the available funding for the reentry demonstration initiative is exhausted since services cannot be authorized or paid for without funding, regardless of medical necessity.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.715. WSR 25-11-005, s 182-563-700, filed 5/8/25, effective 7/1/25.*

##### **Wash. Admin. Code § 182-563-800** Reentry targeted case management (RTCM). {#sec-182-563-800 omnilex-key=us-wa-regs-official--title-182--182-563-800}

(1) The medicaid agency pays for reentry targeted case management (RTCM):

(a) As part of a limited set of services under:

(i) CAA reentry preadjudication (section 5122 of CAA, 2023) for eligible juveniles that are incarcerated in public institutions pending disposition; and

(ii) CAA reentry postadjudication (section 5121 of CAA, 2023) 30 days prerelease and for at least 30 days postrelease; and

(b) As part of the mandatory services required under the initiative that carceral facilities must provide.

(2) RTCM must include:

(a) A reentry health assessment;

(b) A reentry care plan;

(c) Reentry coordination; and

(d) A warm handoff when the care manager changes.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 71.24.715. WSR 25-11-005, s 182-563-800, filed 5/8/25, effective 7/1/25.*

## **Chapter 182-564** Diabetes education. {#struct-chapter-182-564}

##### **Wash. Admin. Code § 182-564-0100** Outpatient diabetes education. {#sec-182-564-0100 omnilex-key=us-wa-regs-official--title-182--182-564-0100}

(1) The medicaid agency pays for outpatient diabetes education for an eligible client when:

(a) The department of health (DOH) has approved the billing facility to provide diabetes education services; and

(b) The client is referred by a licensed health care provider.

(2) The agency requires the diabetes education teaching curriculum to have measurable, behaviorally stated educational objectives. The diabetes education teaching curriculum must include all the following core modules:

(a) An overview of diabetes management and prevention of complications;

(b) Healthy coping, including identification of participants' challenges and barriers related to living with diabetes and utilization of problem solving and motivational skills to increase success in managing diabetes;

(c) Healthy eating, including individualized meal planning;

(d) Being active, including a structured approach to physical activity;

(e) Reducing risk of acute complications, such as hypoglycemia and hyperglycemia, and sick day management;

(f) Prevention of other chronic complications, such as retinopathy, nephropathy, neuropathy, cardiovascular disease, and foot and skin problems;

(g) Monitoring, including immediate and long-term diabetes control through monitoring of glucose, ketones, and glycosylated hemoglobin, and the use of continuous glucose monitoring when applicable;

(h) Medication administration, including oral and/or injected diabetes medication and use of insulin pumps; and

(i) Problem solving skills to set up specific, measurable, achievable, relevant, and time-bound (SMART) goals and support diabetes self-care behaviors.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-06-040, s 182-564-0100, filed 2/27/25, effective 4/1/25.*

## **Chapter 182-565** Health-related social needs (HRSN) program. {#struct-chapter-182-565}

##### **Wash. Admin. Code § 182-565-0100** Purpose. {#sec-182-565-0100 omnilex-key=us-wa-regs-official--title-182--182-565-0100}

(1) The Washington state health-related social needs (HRSN) program allows qualifying Washington apple health clients to receive limited, evidence-based, nonmedical services to address a client's unmet, adverse social conditions that contribute to poor health.

(2) Subject to available funds, allowable expenditures are covered up to the medicaid agency's financial limit.

(3) Housing transition navigation services are designed to remove barriers to affordable housing. Services include transition costs and housing deposits to assist with identifying, coordinating, securing, or funding one-time services and modifications necessary to help a client establish a basic household.

(4) The agency may contract with third parties to administer funds for the HRSN program.

(5) This subchapter applies to the portion of HRSN services administered by the medicaid agency.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0100, filed 6/11/25, effective 7/12/25.*

##### **Wash. Admin. Code § 182-565-0110** Definitions. {#sec-182-565-0110 omnilex-key=us-wa-regs-official--title-182--182-565-0110}

The following definitions and those found in chapter 182-500 WAC apply to this chapter:

(1) "Activities of daily living" has the same meaning as defined in 24 C.F.R. § 700.105 and WAC 388-106-0010.

(2) "Adverse benefit determination" means one or more of the following:

(a) The denial or limited authorization of a requested health-related social needs service, 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 182-565-0170 for standard resolution of grievances and appeals.

(3) "At risk of homelessness" has the same meaning as defined in 24 C.F.R. § 91.5.

(4) "Behavioral health need" means:

(a) A mental health need, where there is 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

(b) A substance use need, where an assessment using the American Society of Addiction Medicine (ASAM) criteria indicates that the person meets at least ASAM level 1.0, indicating the need for outpatient substance use disorder treatment.

(5) "Complex physical need" means a long continuing or indefinite physical condition requiring improvement, stabilization, or prevention of deterioration of functioning (including the ability to live independently without support).

(6) "Demonstration period" means the period starting July 1, 2023, and ending on June 30, 2028.

(7) "Homeless" has the same meaning as defined in 24 C.F.R. § 91.5.

(8) "Rent" means an eligible client's monthly housing payment and includes past due or forward rent payments as allowed under the health-related social needs program.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0110, filed 6/11/25, effective 7/12/25.*

##### **Wash. Admin. Code § 182-565-0120** Eligibility for housing transition navigation services or rental services. {#sec-182-565-0120 omnilex-key=us-wa-regs-official--title-182--182-565-0120}

(1) To be eligible for housing transition navigation services, a person must be:

(a) Enrolled in foundational community supports as described in WAC 182-559-100;

(b) Determined by the third-party administrator as having met at least one of the following health needs-based criteria upon program enrollment:

(i) A behavioral health need;

(ii) A need for hands-on assistance with one or more activities of daily living;

(iii) A need for assistance with three or more activities of daily living; or

(iv) A complex physical health need; and

(c) Homeless or at risk of homelessness, with the exception of the annual income requirement in 24 C.F.R. § 91.5 (1)(i).

(2) To be eligible for the pantry stocking service, a person must:

(a) Meet the requirements in subsection (1) of this section; and

(b) Be experiencing low food security or very low food security, as those terms are defined by the United States Department of Agriculture.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0120, filed 6/11/25, effective 7/12/25.*

##### **Wash. Admin. Code § 182-565-0130** Duration of services. {#sec-182-565-0130 omnilex-key=us-wa-regs-official--title-182--182-565-0130}

(1) The services described in WAC 182-565-0140 are short term and limited to a maximum of six months.

(2) The medicaid agency authorizes payment for approved housing transition navigation services for as long as it has funding through the health-related social needs program.

(3) Housing transition navigation services are subject to available funds for each service category in WAC 182-565-0100.

(4) Payments made for services described in WAC 182-565-0100(1) must not exceed six months in total during the demonstration period, to include both retrospective and prospective payments.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0130, filed 6/11/25, effective 7/12/25.*

##### **Wash. Admin. Code § 182-565-0140** Housing transition navigation covered services. {#sec-182-565-0140 omnilex-key=us-wa-regs-official--title-182--182-565-0140}

Subject to the limitations in WAC 182-565-0130, the medicaid agency pays for short-term housing transition and moving costs necessary to establish a client's basic household, to include:

(1) Security deposits;

(2) Application fees;

(3) Background checks;

(4) The first month's rent as required by the landlord for occupancy;

(5) Utility set-up fees, deposits, first month payments and up to six months of arrears, if necessary, to set up services in a new residence;

(6) Relocation expenses;

(7) A 30-day supply of groceries once per calendar year at the time of move in.

(a) The grocery supply must not exceed 200 percent of the U.S. Department of Agriculture (USDA) SNAP allowance for one month.

(b) This service must be provided in conjunction with the dietary guidelines for Americans and related resources; and

(8) Basic household goods and furniture.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0140, filed 6/11/25, effective 7/12/25.*

##### **Wash. Admin. Code § 182-565-0150** Service provider qualifications. {#sec-182-565-0150 omnilex-key=us-wa-regs-official--title-182--182-565-0150}

A service provider must be contracted with the foundational community supports (FCS) third-party administrator(s) specifically for FCS services, including payment of transition assistance funds, and meet the requirements of WAC 182-559-200. Other contracted models may be considered within other contracting structures as negotiated by the medicaid agency.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0150, filed 6/11/25, effective 7/12/25.*

##### **Wash. Admin. Code § 182-565-0160** Limitation of scope of benefits. {#sec-182-565-0160 omnilex-key=us-wa-regs-official--title-182--182-565-0160}

(1) Nothing in this chapter is intended to provide a legal right to any person to any service referenced in this chapter.

(2) The services provided under this chapter are strictly limited to the authority granted to the medicaid agency under the medicaid transformation project and available funds, as determined solely by the agency.

(3) The services described in this chapter must be approved under the explicit authority of the medicaid transformation project.

(4) Nothing in this section limits a person's right to request an administrative hearing under applicable law.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0160, filed 6/11/25, effective 7/12/25.*

##### **Wash. Admin. Code § 182-565-0170** Grievance and appeals process. {#sec-182-565-0170 omnilex-key=us-wa-regs-official--title-182--182-565-0170}

(1) General requirements. This section contains information about the third-party administrator (TPA) grievance and appeal process and the medicaid agency's administrative hearing process for clients relating to housing transition navigation services.

(a) The TPA must have a grievance and appeal process 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 182-565-0110.

(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) The TPA's policies and procedures regarding the grievance process must be approved by the agency.

(d) The TPA must maintain records of grievances and appeals.

(2) TPA grievance and appeal process. The TPA grievance and appeal process must include:

(a) A grievance process for addressing complaints about any matter that is not an adverse benefit determination;

(b) A TPA appeals process to address a client's request for review of a TPA adverse benefit determination;

(c) Access to the agency's administrative hearing process for review of a TPA's resolution of an appeal; and

(d) Allowing the client and the client's authorized representative to file grievances and appeals orally or in writing. The TPA cannot require clients to provide written follow up for a grievance or an appeal that the TPA received orally.

(3) Notice requirements.

(a) The TPA must send written notice when it:

(i) Approves the client's health-related social needs services (HRSN) eligibility and authorizes the delivery of services; or

(ii) Denies the client's HRSN eligibility.

(b) The TPA must follow the notice and timeline requirements under chapter 182-518 WAC for these notices.

(4) The TPA grievance process.

(a) A client or client's authorized representative may file a grievance with the TPA. A provider may not file a grievance on behalf of a client without the client's written consent.

(b) Clients do not have a right to an agency administrative hearing regarding the resolution of a grievance.

(c) The TPA must acknowledge receipt of each grievance either orally or in writing within two business days.

(d) The TPA must notify clients of the resolution of grievances within five business days of determination.

(5) The TPA appeals process.

(a) A client, the client's authorized representative, or a provider acting on behalf of the client with the client's written consent may appeal a TPA adverse benefit determination.

(b) The TPA must treat oral inquiries about appealing an adverse benefit determination as an appeal to establish the earliest possible filing date for the appeal. The TPA must confirm the oral appeal in writing.

(c) The TPA must acknowledge in writing the receipt of each appeal to both the client and the requesting provider within five calendar days of receiving the appeal request. The appeal acknowledgment letter sent by the TPA serves as written confirmation of an appeal filed orally by a client.

(d) The client must file an appeal of a TPA action within 60 calendar days of the date on the TPA's notice of adverse benefit determination.

(e) The TPA must continue services pending the results of an appeal or subsequent agency administrative hearing.

(f) The TPA internal appeal process must:

(i) Provide the client a reasonable opportunity to present evidence and allegations of fact or law, both in person and in writing;

(ii) Provide the client and the client's representative the client's case file, other documents and records, and any new or additional evidence considered, relied upon, or generated by the TPA (or at the direction of the TPA) in connection with the action. This information must be provided free of charge in advance of the resolution time frame for appeals as specified in this section; and

(iii) Include as parties to the appeal:

(A) The client and the client's authorized representative; and

(B) The legal representative of the deceased client's estate.

(g) The TPA must ensure that the people making decisions on appeals were not involved in any previous level of review or decision making.

(h) Time frames for resolution of appeals. The TPA:

(i) Must resolve each appeal and provide notice as expeditiously as the client's health condition requires and no longer than three calendar days after the day the TPA receives the appeal.

(ii) May extend the time frame by an additional 14 calendar days if it is necessary in order to complete the appeal.

(i) Notice of resolution of appeal. The notice of the resolution of the appeal must:

(i) Be in writing and be sent to the client and the requesting provider;

(ii) Include the results of the resolution of the appeal process and the date it was completed; and

(iii) Include information on the client's right to request an agency administrative hearing and how to do so as provided in the agency hearing rules under WAC 182-526-0095, if the appeal is not resolved wholly in favor of the client.

(j) Deemed completion of the TPA appeal process. If the TPA fails to adhere to the notice and timing requirements for appeals, the client is deemed to have completed the TPA's appeals process and may request an agency administrative hearing under WAC 182-526-0095.

(6) Agency administrative hearing.

(a) Only a client or the client's authorized representative may request an agency administrative hearing. A provider may not request a hearing on behalf of a client.

(b) If the client does not agree with the TPA's resolution of an appeal at the completion of the TPA appeal process, the client may file a request for an agency administrative hearing based on the rules in this section and the agency hearing rules in chapter 182-526 WAC. The client must request an agency administrative hearing within 90 calendar days of the notice of resolution of appeal.

(c) The TPA is an independent party and responsible for its own representation in any administrative hearing, appeal to the board of appeals, and any subsequent judicial proceedings.

(7) Effect of reversed resolutions of appeals. If the TPA or a final order as defined in chapter 182-526 WAC reverses a decision to deny or limit services, the TPA must authorize or provide the disputed services promptly and as expeditiously as the client's circumstances require.

(8) Funding unavailable. When available resources are exhausted, any appeals process or agency administrative hearing process related to a request to authorize a service will be terminated, since services cannot be authorized without funding regardless of medical necessity.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0170, filed 6/11/25, effective 7/12/25.*

##### **Wash. Admin. Code § 182-565-0200** Purpose. {#sec-182-565-0200 omnilex-key=us-wa-regs-official--title-182--182-565-0200}

(1) Rent and temporary housing payments provide stable independent living situations for clients in housing transitions who are homeless or at risk of homelessness. The payments may cover rent for up to six months per demonstration period.

(2) Subject to available funds, allowable expenditures are covered up to the medicaid agency's financial limit.

(3) The agency may contract with third parties to administer funds for the HRSN program.

(4) This subchapter applies to the portion of health-related social needs services administered by the medicaid agency.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0200, filed 6/11/25, effective 7/12/25.*

##### **Wash. Admin. Code § 182-565-0210** Definitions. {#sec-182-565-0210 omnilex-key=us-wa-regs-official--title-182--182-565-0210}

The definitions in WAC 182-565-0110 and those found in chapter 182-500 WAC apply to this chapter.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0210, filed 6/11/25, effective 7/12/25.*

##### **Wash. Admin. Code § 182-565-0220** Eligibility. {#sec-182-565-0220 omnilex-key=us-wa-regs-official--title-182--182-565-0220}

To be eligible for rental services, a person must meet the requirements identified in WAC 182-565-0120.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0220, filed 6/11/25, effective 7/12/25.*

##### **Wash. Admin. Code § 182-565-0230** Duration of services. {#sec-182-565-0230 omnilex-key=us-wa-regs-official--title-182--182-565-0230}

(1) The services described in WAC 182-565-0240 are short term and limited to a maximum of six months.

(2) The medicaid agency reimburses rental payments only for residences that meet housing habitability standards for safety, sanitation, and habitability.

(3) Rental services are subject to available funds for each service category in WAC 182-565-0240.

(4) Payments made for services described in WAC 182-565-0240 must not exceed six months in total during the demonstration period, to include both retrospective and prospective payments.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0230, filed 6/11/25, effective 7/12/25.*

##### **Wash. Admin. Code § 182-565-0240** Covered rental services. {#sec-182-565-0240 omnilex-key=us-wa-regs-official--title-182--182-565-0240}

Subject to the limitations in WAC 182-565-0230, the medicaid agency may pay for past-due or future rent payments.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0240, filed 6/11/25, effective 7/12/25.*

##### **Wash. Admin. Code § 182-565-0250** Service locations. {#sec-182-565-0250 omnilex-key=us-wa-regs-official--title-182--182-565-0250}

(1) The rental payments identified in WAC 182-565-0240 must be used only for independent living situations, such as in-home and interim housing settings that meet the housing habitability standards found on the agency's website.

(2) The medicaid agency does not reimburse for facilities:

(a) That have been temporarily converted to shelters (e.g., gymnasiums or convention centers); or

(b) Without private sleeping spaces available to residents 24 hours a day.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0250, filed 6/11/25, effective 7/12/25.*

##### **Wash. Admin. Code § 182-565-0260** Service provider qualifications. {#sec-182-565-0260 omnilex-key=us-wa-regs-official--title-182--182-565-0260}

Rental service providers must meet the requirements in WAC 182-565-0150.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0260, filed 6/11/25, effective 7/12/25.*

##### **Wash. Admin. Code § 182-565-0270** Limitation of scope of benefits. {#sec-182-565-0270 omnilex-key=us-wa-regs-official--title-182--182-565-0270}

Rental services are subject to the limitation of scope of benefits described in WAC 182-565-0160.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0270, filed 6/11/25, effective 7/12/25.*

##### **Wash. Admin. Code § 182-565-0280** Grievance and appeals. {#sec-182-565-0280 omnilex-key=us-wa-regs-official--title-182--182-565-0280}

Grievances and appeals related to rental services follow the process described in WAC 182-565-0170.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-049, s 182-565-0280, filed 6/11/25, effective 7/12/25.*

##### **Wash. Admin. Code § 182-565-0300** General. {#sec-182-565-0300 omnilex-key=us-wa-regs-official--title-182--182-565-0300}

Medical respite programs offer a lower-intensity care setting for patients who are homeless or at risk of homelessness and who would otherwise require a hospital stay or lack a safe option for discharge and recovery. Medical respite programs must meet the minimum operating standards and meet the required medical respite standards of the facility through the national institute for medical respite care (NIMRC), offer required services, meet local codes and ordinances for licensing, safety, and occupancy.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2023 c 475 s 215(64). WSR 25-19-039, s 182-565-0300, filed 9/9/25, effective 10/10/25.*

##### **Wash. Admin. Code § 182-565-0310** Definitions. {#sec-182-565-0310 omnilex-key=us-wa-regs-official--title-182--182-565-0310}

The following definitions and those found in chapter 182-500 WAC apply to this chapter:

"Behavioral health need" - See WAC 182-565-0110.

"Demonstration period" - See WAC 182-565-0110.

"Facility" - The physical location where the medical respite program provides medical respite care services to clients.

"Homelessness" or "at risk of homelessness" - See WAC 182-565-0110.

"Medical respite care services" - Temporary, short-term room and board, health care services and supports.

"Medical respite program (a.k.a., recuperative care)" - A not-for-profit organization that serves clients whose medical and behavioral health need medical respite care services.

"Rolling 12-month period" - Calculation of eligibility based on the 12 months immediately preceding any new request for services. The rolling 12-month period moves forward with each new episode of care ensuring a consistent limit on total days used, capped at 180 days within that rolling year.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-12-046, s 182-565-0310, filed 5/29/26, effective 6/29/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 2023 c 475 s 215(64). WSR 25-19-039, s 182-565-0310, filed 9/9/25, effective 10/10/25.*

##### **Wash. Admin. Code § 182-565-0320** Eligibility. {#sec-182-565-0320 omnilex-key=us-wa-regs-official--title-182--182-565-0320}

(1) A person must have or be eligible for apple health coverage before entering a medical respite program. If a person does not have coverage and wants to participate in the medical respite program, the program can help them register for coverage.

(2) To receive medical respite care services, a client must have a qualifying acute medical condition that requires treatment and/or care, does not require a hospital inpatient stay, and is too ill or frail to recover from a physical illness or injury while living on the street and is at risk of being homeless or experiencing homelessness.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2023 c 475 s 215(64). WSR 25-19-039, s 182-565-0320, filed 9/9/25, effective 10/10/25.*

##### **Wash. Admin. Code § 182-565-0330** Admission. {#sec-182-565-0330 omnilex-key=us-wa-regs-official--title-182--182-565-0330}

A client is eligible for admission to a medical respite program when the client:

(1) Is experiencing homelessness or is at risk of becoming homeless;

(2) Is experiencing medical and behavioral health needs and meets one of the following:

(a) Has recently been discharged from a hospital setting including emergency room visits; or

(b) Is referred from a medical clinic (e.g., a primary care clinic, federally qualified health center, urgent care facility, mobile medical clinic, street medicine) and both of the following are true:

(i) The client has an acute medical condition that can be safely managed in a sheltered outpatient setting; and

(ii) Medical respite care is appropriate to provide the conditions to support recovery from the acute medical condition;

(3) Can perform activities of daily living (ADLs) with minimal or no assistance; and

(4) Has signed an admission agreement.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2023 c 475 s 215(64). WSR 25-19-039, s 182-565-0330, filed 9/9/25, effective 10/10/25.*

##### **Wash. Admin. Code § 182-565-0340** Discharge. {#sec-182-565-0340 omnilex-key=us-wa-regs-official--title-182--182-565-0340}

(1) The medical respite program will discharge the client when the client meets one of the following:

(a) No longer benefits from medical respite care services;

(b) Reaches the 90-day utilization limit for their current admission or the six-month utilization limit during the rolling 12-month period; or

(c) An appropriate alternative service becomes available.

(2) The six-month utilization period limit is shared amongst other housing support services including, but not limited to, housing transition navigation services, and rent/temporary housing.

(3) The medical respite program must begin discharge planning upon the client's admission and maintain discharge planning throughout the client's stay at the facility.

(4) To discharge a client, the program must provide a referral tailored to client needs, to include:

(a) Potential housing options;

(b) Referrals to appropriate health care providers;

(c) Supportive services; and

(d) Provide advance and written notice of discharge to the client, and as applicable, the client's health care provider, managed care organization, and caregivers.

(5) Upon admission and discharge, the program must provide an admission or discharge summary to the client, the health care provider, the managed care organization if applicable, and other persons or entities requested by the client. The admission or discharge summary must include the following:

(a) Written medication list and medication refill information;

(b) Admitting primary diagnosis following discharge from the hospital or referral from a medical clinic;

(c) Estimated or documented length of stay in the medical respite program;

(d) Ongoing medical needs or conditions;

(e) Instructions for accessing relevant resources within the community including shelters or other housing options;

(f) A list of follow-up appointments and contact information for treating providers;

(g) Special medical instructions (e.g., weight-bearing limitations, dietary precautions, allergies, wound orders);

(h) Pain management plan; and

(i) A point of contact for the client.

(6) The medical respite program must ensure adequate protocols are in place for the transfer of client information and access to electronic records to appropriate providers and, if applicable, the client's managed care organization.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-12-046, s 182-565-0340, filed 5/29/26, effective 6/29/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 2023 c 475 s 215(64). WSR 25-19-039, s 182-565-0340, filed 9/9/25, effective 10/10/25.*

##### **Wash. Admin. Code § 182-565-0350** Program requirements. {#sec-182-565-0350 omnilex-key=us-wa-regs-official--title-182--182-565-0350}

(1) Medical respite programs must provide or arrange for the provision of the following services:

(a) Room and board which must include, at a minimum:

(i) A dedicated bed that is available to the client 24 hours a day, seven days a week;

(ii) Three meals a day in accordance with medical respite standards;

(iii) Laundry services;

(iv) Secured storage for personal belongings and medications;

(v) Compliance with standards set by NIMRC; and

(vi) Compliance with local codes and ordinances for licensing, safety, and occupancy.

(b) The medical respite provider must notify the agency if they no longer meet the requirements to provide medical respite care.

(2) The agency may conduct a post pay review to ensure medical respite care requirements are met. If requirements are not met at the time services are provided, the agency may recoup payment.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2023 c 475 s 215(64). WSR 25-19-039, s 182-565-0350, filed 9/9/25, effective 10/10/25.*

##### **Wash. Admin. Code § 182-565-0360** Coordination and services. {#sec-182-565-0360 omnilex-key=us-wa-regs-official--title-182--182-565-0360}

The medical respite program must provide coordination such that the client can access the following services:

(1) Clinical assessments;

(2) Behavioral health screenings for psychosocial needs;

(3) Medical case management;

(4) Case management support in accessing benefits and housing;

(5) Twenty-four hour wellness checks;

(6) Medical oversight to include:

(a) Medication monitoring; and

(b) Ongoing assessments to determine effectiveness of care plan and/or treatments;

(7) Minor clinical interventions (e.g., wound care, infection control, nonpharmacological pain management);

(8) Arrangement for transportation for the client to and from appointments that are not covered by nonemergency transportation as defined in WAC 182-546-5500; and

(9) Access to equipment for telehealth services and communication related to medical needs or care.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2023 c 475 s 215(64). WSR 25-19-039, s 182-565-0360, filed 9/9/25, effective 10/10/25.*

##### **Wash. Admin. Code § 182-565-0370** Duration of services. {#sec-182-565-0370 omnilex-key=us-wa-regs-official--title-182--182-565-0370}

Medical respite care services are short-term. For medical respite care, short-term is defined as up to 90 days per instance, and up to six months cumulative utilization per rolling 12-month period with the limitation that the six-month utilization limit is shared amongst other housing support services. The other housing support services that share the six-month utilization limit with medical respite care include, but are not limited to, housing transition navigation services and rent/temporary housing. See WAC 182-565-0340.

**History**
- *Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-12-046, s 182-565-0370, filed 5/29/26, effective 6/29/26. Statutory Authority: RCW 41.05.021, 41.05.160, and 2023 c 475 s 215(64). WSR 25-19-039, s 182-565-0370, filed 9/9/25, effective 10/10/25.*

##### **Wash. Admin. Code § 182-565-0380** Provider requirements. {#sec-182-565-0380 omnilex-key=us-wa-regs-official--title-182--182-565-0380}

A medical respite program may provide medical respite care services when the medical respite program:

(1) Is enrolled as a Washington apple health medicaid provider for claims to be paid and be able to provide documentation of proof of service;

(2) Meets the standards for medical respite care programs set by NIMRC;

(3) Completes all necessary agency forms and attestation and receives agency approval; and

(4) Meets local codes and ordinances for licensing, safety, and occupancy.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2023 c 475 s 215(64). WSR 25-19-039, s 182-565-0380, filed 9/9/25, effective 10/10/25.*

##### **Wash. Admin. Code § 182-565-0390** Grievance and appeals. {#sec-182-565-0390 omnilex-key=us-wa-regs-official--title-182--182-565-0390}

Grievance and appeals related to medical respite care services follow the process described in chapter 182-526 WAC.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 2023 c 475 s 215(64). WSR 25-19-039, s 182-565-0390, filed 9/9/25, effective 10/10/25.*

##### **Wash. Admin. Code § 182-565-0400** General. {#sec-182-565-0400 omnilex-key=us-wa-regs-official--title-182--182-565-0400}

(1) Washington state has nine accountable communities of health (ACHs), as defined in RCW 82.04.43395, each of which operates a regional community care hub. In addition, the federally recognized tribes in Washington operate a statewide native hub to support the delivery of whole-person care coordination.

(2) An eligible person may access any community care hub in the state of Washington. The community care hubs also work closely with managed care organizations, providers, and community partners to identify and engage apple health clients who are likely to have multiple health and social needs.

(3) Community care hubs provide case management, outreach, and education services to qualifying Washington apple health clients across Washington state.

(4) Subject to available funds, allowable expenditures are covered up to the medicaid agency's financial limit, as determined by the agency.

(5) This subchapter applies to the portion of health-related social needs (HRSN) services the agency administers through community care hubs.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.021 (1)(m)(iv). WSR 26-04-117, s 182-565-0400, filed 2/3/26, effective 3/6/26.*

##### **Wash. Admin. Code § 182-565-0410** Definitions. {#sec-182-565-0410 omnilex-key=us-wa-regs-official--title-182--182-565-0410}

"Clinical-risk factor" means physiological conditions that increase the likelihood of poor health outcomes.

"Community care hub (CCH)" means one of the nine regional centers managed and operated by one of the nine accountable communities of health (ACH). Each CCH organizes and supports a regional network of community-based organizations providing community-based care coordination and services to address health-related social (HRSN) needs. The medicaid agency contracts with the ACHs to provide the HRSN screening and referral service.

"Health-related social needs (HRSN)" means unmet, adverse social conditions (e.g., housing instability, homelessness, nutrition insecurity) that contribute to a person's poor health and result from underlying social determinants of health (conditions in which people are born, grow, work, and age).

"Social risk factor" means a social condition that negatively impacts a person's health and contributes to poor health outcomes and health inequities.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.021 (1)(m)(iv). WSR 26-04-117, s 182-565-0410, filed 2/3/26, effective 3/6/26.*

##### **Wash. Admin. Code § 182-565-0420** Eligibility. {#sec-182-565-0420 omnilex-key=us-wa-regs-official--title-182--182-565-0420}

To be eligible to receive covered services through community care hubs, a person must be enrolled in Washington apple health and:

(1) Meet one or more of the following social risk factors:

(a) Be homeless or at risk of homelessness, as defined by 24 C.F.R. § 91.5, except for the annual income requirement in 24 C.F.R. § 91.5 (1)(i);

(b) Meet the U.S. Department of Agriculture's (USDA) definition of low food security or very low food security;

(c) Be experiencing poverty or near poverty, as defined by income below 200 percent of the federal poverty level (FPL); or

(d) Screen positive for a health-related social need; and

(2) Have at least one of the following clinical risk factors:

(a) Complex behavioral health needs;

(b) Developmental disability needs;

(c) Assessed as having a complex physical health need;

(d) Experienced interpersonal violence;

(e) Repeated emergency department use and crisis encounters;

(f) Be pregnant or up to 12 months postpartum; or

(g) Be a child age six or younger who currently has at least one of the following conditions:

(i) Malnutrition, risk of developmental or growth delay, or impairment because of insufficient nutrition as a clinical risk factor for case management related to nutrition services only;

(ii) Child maltreatment, as defined by the Centers for Disease Control and Prevention. (See https://www.cdc.gov/violence-prevention/?CDC_AAref_Val=https://www.cdc.gov/violenceprevention/pdf/%2520CM_Surveillancea.pdf);

(iii) Is a child with a special health care need (CYSHCN) as defined by the Health Resources and Services Administration. (See https://mchb.hrsa.gov/programs-impact/focus-areas/children-youth-special-health-care-needs-cyshcn);

(iv) Low birth weight;

(v) A mental health condition; or

(vi) Health conditions, including behavioral health and developmental syndromes, stemming from trauma, child abuse, and neglect; or

(h) Be an adult age 65 or older who currently has at least one of the following:

(i) Two or more chronic conditions as defined in RCW 74.09.010;

(ii) Social isolation, which may place the person at risk for early death, neurocognitive disorders, sleep disruption, cardiovascular disease, or elder abuse;

(iii) Malnutrition as a clinical risk factor for case management related to nutrition services only;

(iv) Health conditions, including behavioral health and developmental syndromes, stemming from trauma, child abuse, and neglect; or

(v) Requires assistance with activities of daily living as defined in WAC 182-565-0110 or instrumental activities of daily living as defined in WAC 388-106-0010; or

(i) Be eligible under one of the following programs:

(i) Medicaid personal care (MPC) as described in WAC 388-106-0210;

(ii) Nursing facility care services as described in WAC 388-106-0355; or

(iii) Long-term care services as described in WAC 388-106-0045.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.021 (1)(m)(iv). WSR 26-04-117, s 182-565-0420, filed 2/3/26, effective 3/6/26.*

##### **Wash. Admin. Code § 182-565-0430** Covered services. {#sec-182-565-0430 omnilex-key=us-wa-regs-official--title-182--182-565-0430}

Community care hubs provide the following covered services:

(1) Screen clients for health needs and health-related social needs (HRSN);

(2) Check clients' eligibility to receive the case management, outreach, and education service;

(3) Refer clients to providers, community partners, or organizations that will address their HRSNs;

(4) Follow up to ensure clients' connection to services and completion of interventions;

(5) Track client outcomes;

(6) Provide technical assistance and capacity support to community partners or community-based organizations (CBOs); and

(7) Provide navigation assistance for benefit applications or referrals to HRSN services or other federal, state, and local community programs.

**History**
- *Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.021 (1)(m)(iv). WSR 26-04-117, s 182-565-0430, filed 2/3/26, effective 3/6/26.*

## **Chapter 182-600** WA cares fund program. {#struct-chapter-182-600}

##### **Wash. Admin. Code § 182-600-0100** Purpose and scope. {#sec-182-600-0100 omnilex-key=us-wa-regs-official--title-182--182-600-0100}

(1) This chapter establishes the responsibilities of the health care authority in the long-term services and supports program known as WA cares fund program as identified in RCW 50B.04.020(2).

(2) Department of social and health services program rules can be found under chapter 388-116 WAC.

(3) Employment security department program rules can be found under Title 192 WAC.

**History**
- *Statutory Authority: RCW 50B.04.020 (2)(e), 41.05.021, and 41.05.160. WSR 26-07-035, s 182-600-0100, filed 3/11/26, effective 4/11/26.*

##### **Wash. Admin. Code § 182-600-0200** Definitions. {#sec-182-600-0200 omnilex-key=us-wa-regs-official--title-182--182-600-0200}

The definitions in this section apply throughout this chapter.

Approved services has the same meaning as defined in WAC 388-116-1010.

Benefit unit has the same meaning as defined in RCW 50B.04.010.

Eligible beneficiary has the same meaning as defined in RCW 50B.04.010.

Long-term services and supports (LTSS) provider has the same meaning as defined in RCW 50B.04.010.

Preauthorization means the process and product of verifying and granting permission to the LTSS provider to provide an approved service to the eligible beneficiary at a rate or amount agreed upon between the LTSS provider and eligible beneficiary. The preauthorization is a service agreement between the beneficiary and the LTSS provider.

Program has the same meaning as defined in RCW 50B.04.010.

**History**
- *Statutory Authority: RCW 50B.04.020 (2)(e), 41.05.021, and 41.05.160. WSR 26-07-035, s 182-600-0200, filed 3/11/26, effective 4/11/26.*

##### **Wash. Admin. Code § 182-600-0300** WA cares fund program payments. {#sec-182-600-0300 omnilex-key=us-wa-regs-official--title-182--182-600-0300}

(1) The health care authority (HCA) tracks and ensures that payments for LTSS services do not exceed an eligible beneficiary's total available program benefit units.

(2) HCA pays a claim for approved services that have been preauthorized by the eligible beneficiary, when the LTSS provider:

(a) Meets the applicable requirements in chapter 388-116 WAC;

(b) Submits the claim through HCA's payment system; and

(c) Submits the original claim and any subsequent claims adjustments:

(i) No more than 60 days after the latest end-date of the preauthorization; and

(ii) After the service has been provided.

**History**
- *Statutory Authority: RCW 50B.04.020 (2)(e), 41.05.021, and 41.05.160. WSR 26-07-035, s 182-600-0300, filed 3/11/26, effective 4/11/26.*

##### **Wash. Admin. Code § 182-600-0400** Coordination of benefits. {#sec-182-600-0400 omnilex-key=us-wa-regs-official--title-182--182-600-0400}

If an eligible beneficiary is also an apple health (medicaid) client, the provider must first seek timely payment from the beneficiary's WA cares benefit units before billing apple health (medicaid) for approved services.

**History**
- *Statutory Authority: RCW 50B.04.020 (2)(e), 41.05.021, and 41.05.160. WSR 26-07-035, s 182-600-0400, filed 3/11/26, effective 4/11/26.*

##### **Wash. Admin. Code § 182-600-0500** Program integrity—Activities. {#sec-182-600-0500 omnilex-key=us-wa-regs-official--title-182--182-600-0500}

(1) The health care authority (HCA) ensures preauthorized LTSS services are provided through service verification and audits and recoups any inappropriate payments and refers potential fraud to law enforcement.

(2) Methods. Program integrity activity methods include, but are not limited to:

(a) Service verifications;

(b) Audits of records and review of other documentation to determine compliance with laws, regulations, and billing guides; and

(c) Interviews with providers, eligible beneficiaries, and witnesses.

(3) Audit period. HCA may conduct program integrity activities involving claims submitted for payment to HCA anytime up to six years after the date of service.

(4) Scope and focus. HCA determines the scope and focus of any program integrity activity.

(5) Selecting claims and information to be evaluated. HCA may evaluate records or other information relevant to validating whether the LTSS provider received inappropriate payment.

(6) Cooperation.

(a) An LTSS provider must cooperate with an audit.

(b) An LTSS provider must provide information and submit records requested by HCA by the due date in the request.

(c) An LTSS provider must submit records electronically unless otherwise requested, or granted permission by HCA to submit a hard copy, and must follow the instructions for records submission included in the request.

(d) If sent electronically, records must be sent using a secure method uploaded through HCA's managed file transfer (MFT) site.

(e) If the LTSS provider does not comply with the audit, HCA may issue a final notice of findings and assess an overpayment.

(7) HCA does not reimburse any costs an LTSS provider incurs complying with program integrity activities.

**History**
- *Statutory Authority: RCW 50B.04.020 (2)(e), 41.05.021, and 41.05.160. WSR 26-07-035, s 182-600-0500, filed 3/11/26, effective 4/11/26.*

##### **Wash. Admin. Code § 182-600-0600** Program integrity—Outcomes. {#sec-182-600-0600 omnilex-key=us-wa-regs-official--title-182--182-600-0600}

(1) When the health care authority (HCA) completes the review under WAC 182-600-0500, HCA may do any of the following:

(a) Deny and recover improperly paid claims;

(b) Instruct the LTSS provider to submit additional information or submit a new claim;

(c) Issue a final notice assessing an overpayment which the LTSS provider may appeal under WAC 182-600-0700;

(d) Refer an overpayment to the department of social and health services office of financial recovery for collection;

(e) Refer suspected fraud to law enforcement.

(2) LTSS providers must keep documentation to prove the services billed were delivered and payment was appropriate. Providers must retain all records supporting claims for a minimum of six years from the date of service, or longer if the law requires or an audit or investigation is in progress. Failure to keep this documentation may result in recoupment of the payment.

**History**
- *Statutory Authority: RCW 50B.04.020 (2)(e), 41.05.021, and 41.05.160. WSR 26-07-035, s 182-600-0600, filed 3/11/26, effective 4/11/26.*

##### **Wash. Admin. Code § 182-600-0700** Administrative hearing. {#sec-182-600-0700 omnilex-key=us-wa-regs-official--title-182--182-600-0700}

(1) The administrative hearing process is governed by chapters 34.05 RCW and 182-526 WAC.

(2) An LTSS provider who disagrees with the health care authority's (HCA) action to recoup inappropriate payments under RCW 50B.04.020 (2)(b) may request an administrative hearing under chapter 182-526 WAC.

(3) An LTSS provider does not have an administrative hearing right for the denial of payment of a claim.

(4) HCA does not recoup overpayments until an order is final.

(5) Throughout the administrative hearings process, the LTSS provider bears the burden of proving by a preponderance of the evidence that it has complied with applicable laws, rules, regulations, and agreements.

**History**
- *Statutory Authority: RCW 50B.04.020 (2)(e), 41.05.021, and 41.05.160. WSR 26-07-035, s 182-600-0700, filed 3/11/26, effective 4/11/26.*