Medicaid Benefits: Online Database

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Acute Care Services

Institutional and Clinic Services

Practitioner Services

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Physical Therapy and Other Services

Products and Devices

Transportation Services

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Long-Term Care Services

Community Based Care

Institutional Care

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Benefits by State: Washington (October 2008) Notes

Acute Care Services

Is the Benefit Covered?	Copayment Requirement	Prior Approval Requirement	Coverage Limitations	Reimbursement Methodology	Populations Covered

Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes				Fee for service	CN & MN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes				Fee for service	CN & MN
Federally Qualified Health Center Services
Yes				Prospective cost based rate/visit	CN & MN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes			LOS limited to medically necessary days per InterQual IS/SI criteria if admission not paid under DRG method, elective admissions in specified areas of state restricted to contracted hospitals	Prospective payment/discharge using DRG or per diem, cost based payment for critical access hospitals using prospective percentage of charges	CN & MN
Outpatient Hospital Services
Yes	$3/non-emergency visit in ER	Specified services		Most urban hospitals paid prospective cost based rates, rural hospitals paid prospective percentage of charge	CN & MN
Rehabilitation Services: Mental Health and Substance Abuse
Yes		Specified services	Ambulatory detox and other specified services not covered	Fee for service or percentage of charge	CN & MN
Rural Health Clinic Services
Yes				Prospective cost based rate/visit	CN & MN
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes				Fee for service	CN & MN
Chiropractor Services
No
Dental Services
Yes		Specified services	Specified restorative services, including crowns and anterior root canals, not covered for adults	Fee for service	CN & MN
Medical and Remedial Care - Other Practitioners

Medical/Surgical Services of a Dentist
Yes				Fee for service	CN & MN
Nurse Midwife Services
Yes				Fee for service	CN & MN
Nurse Practitioner Services
Yes				Fee for service, fixed rate per visit to nurse practitioner clinics	CN & MN
Optometrist Services
Yes			1 refractive exam/2 years, orthoptic therapy not covered	Fee for service	CN & MN
Physician Services
Yes		Specified surgical procedures	1 inpatient hospital visit/day unless payment is all-inclusive fee, 2 nursing facility visits/month, routine physical exams limited	Fee for service	CN & MN
Podiatrist Services
Yes			Routine foot care not covered	Fee for service	CN & MN
Psychologist Services
Yes		Yes	1 psychological evaluation/lifetime, 1 hour therapy/day up to 12 hours/year	Fee for service	CN
Prescription Drugs
Prescription Drugs
Yes		Specified drugs		AWP-14% to traditional pharmacies or AWP-19% to mail order contractors for drugs available from fewer than 5 labelers or manufacturers, AWP-50% to traditional pharmacies or AWP-15% to mail order contractors for multi-source drugs, plus a dispensing fee to traditional pharmacies dependent on Medicaid volume (low and unit dose: $5.25, med: $4.56, high: $4.24), $3.25 dispensing fee to mail order contractors	CN & MN
Physical Therapy and Other Services
Occupational Therapy Services
Yes			12 visits/year	Fee for service	CN
Physical Therapy Services
Yes		Yes	48 units of service/year	Fee for service	CN
Services for Speech, Hearing and Language Disorders
Yes		Yes	12 visits/year	Fee for service	CN
Products and Devices
Dentures
Yes		Yes	1 full upper and 1 full lower denture/10 years, 1 partial upper and 1 partial lower denture/10 years	Fee for service	CN & MN
Eyeglasses
Yes		2 pair eyeglasses rather than bifocals	1 pair eyeglasses/2 years except 1 pair eyeglasses/year for developmentally disabled	Fee for service	CN & MN
Hearing Aids
Yes		Bone conduction or binaural hearing aid	1 hearing aid/5 years	Fee for service	CN
Medical Equipment and Supplies
Yes		Specified med equipment and med supply items	Quantity and frequency limits vary by item	Fee for service	CN & MN
Prosthetic and Orthotic Devices
Yes		Specified services or items		Fee for service	CN & MN
Transportation Services
Ambulance Services
Yes				Fee for service	CN & MN
Non-Emergency Medical Transportation Services
Yes		Yes		See service-specific FN	CN & MN
Other Services
Diagnostic, Screening and Preventive Services
Yes			Limited to preventive services only	Fee for service, contracted rate for disease management services	CN & MN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women

Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes		Specified services		Fee for service	CN & MN
Targeted Case Management
Yes			Coverage parameters vary by condition and need	Fee for service, capitated rate or cost based payment	CN & MN

Long-Term Care Services


Community Based Care
Home and Community Based Services Waiver
Yes		Services for the following populations: 2, 4 & 8 - See service-specific FN	Dependent upon the services provided	CN & MN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes		2 nurse visits/day, 1 home health aide visit/day, 3 nurse visits for high-risk pregnant women/pregnancy	Fee for service using prevailing charge as limit, rates vary geographically	CN & MN
Hospice Care
Yes			Prospective rates based on Medicare methodology, rates vary geographically	CN & MN
Personal Care Services
Yes		Scope of coverage dependent upon functional needs assessment	Hourly rate or daily rate depending on setting	CN
Private Duty Nursing Services
Yes	Yes	Must meet specified medical need criteria	Fee for service	CN & MN
Program of All-Inclusive Care for the Elderly
Yes		See service-specific FN	Capitated payment	CN
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes		Hosp leave days not covered, 18 therapeutic leave days/year	Prospective cost based per diem	CN & MN
Inpatient Psychiatric Services, under age 21
Yes		48-hour weekend absences for therapeutic leave up to 14 days/year	Prospective per diem	CN & MN
Intermediate Care Facility Services for the Mentally Retarded
Yes	More than 7 consecutive therapeutic leave days	Hosp leave days not covered, 18 therapeutic leave days/year	Private facilities paid prospective cost based per diem with limits, cost based payment for public facilities	CN & MN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes		Hosp leave days not covered, 18 therapeutic leave days/year	Prospective per diem based on cost using peer groups, with efficiency incentives and assuming 85% occupancy	CN & MN
Religious Non-Medical Health Care Institution and Practitioner Services
No

Notes: This State has an approved Section 1115 waiver from CMS under which it extended Medicaid eligibility to children in families with income above the federal poverty level (FPL) who meet specified Categorically Needy eligibility criteria. The waiver provisions permit the State to impose income-based monthly premiums. The State has also added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA) in a program called Healthcare for Workers with Disabilities. These beneficiaries are allowed to continue Medicaid coverage, and receive full benefits, if their income is at or below 220 percent of the FPL and an income-based monthly premium is paid.