(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.
(6) The agency pays nursing facilities
located outside the state of Washington when approved by the aging and
long-term support administration (ALTSA) 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 thirty days if approved by
ALTSA.
(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;
(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.
