PLEASE NOTE: This is only a guide – Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by
PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Abortion Excluded is voluntary termination of pregnancy. Covered through Medicaid Fee- X For-Service. (Apple Health IMC Contract 16.13.5.4) Acupuncture Alcoholism Ambulance Transportation Covered is involuntary termination of pregnancy (miscarriage). Excluded - HCA does not reimburse for services performed by acupuncturists. (HCA Physician-Related Services/Healthcare Professional Services Medicaid Provider Guide page 40, WAC 182-531-0250 (2 a)) See Substance Use Disorder Covered through Medicaid Fee-For-Service. Emergent Transportation: Covered is ground ambulance transportation for emergency medical conditions. Emergency medical conditions include psychotic episodes necessitating ambulance transportation of a mentally ill member to an evaluation and treatment facility. Covered ground ambulance services include Basic and Advanced Life Support (BLS and ALS) Services, Specialty Care Transport (SCT), and other required transportation costs, such as tolls, fares and extra attendant. Includes emergency airlift transportation. (Apple Health IMC Contract 16.13.5.8, HCA Ambulance-ITA Medicaid Provider Guide page 26) Non-Emergent Transportation: Covered is when it is necessary to transport an member between facilities to receive a contracted service and when it is necessary to transport a member, who must be carried on a stretcher, or who may require medical attention en route (RCW 18.73.180) to receive a covered service. (Apple Health IMC Contract 16.13.5.7, HCA Ambulance-ITA Medicaid Provider Guide page 27) Court-ordered transportation services, including ambulance services. (Apple Health IMC Contract 16.13.5.5) X See Substance Use Disorder Covered through Medicaid FeeFor-Service. Emergent Transportation: Covered is ground ambulance transportation for emergency medical conditions. Emergency medical conditions include psychotic episodes necessitating ambulance transportation of a mentally ill member to an evaluation and treatment facility. Covered ground ambulance services include Basic and Advanced Life Support (BLS and ALS) Services, Specialty Care Transport (SCT), and other required transportation costs, such as tolls, fares and extra attendant. Includes, emergency airlift transportation. (Apple Health IMC Contract 16.13.5.8, HCA 1 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Treat and Refer: treatment with no transport when provided by eligible providers defined as fire departments pursuant to a community assistance referral and education services program (CARES) as described in RCW 35.21.930. (Apple Health IMC Contract 16.13.5.22. Qualifying providers must complete and submit Ambulance-ITA Medicaid Provider Guide page 26) Court-ordered transportation the HCA Treat & Refer Program Participation Attestation (HCA 60-0024) form to the Health Care Authority. services, including ambulance services. (Apple Health IMC Contract 16.13.5.5) Antigen (Allergy Serum) Applied Behavioral Analysis (ABA) Autism Covered are antigen allergens. (Apple Health IMC Contract 16.12.4.2.1, HCA Physician-Related Services/Healthcare, Professional Services Medicaid Provider Guide, pages 180-181) Covered is the Initial Clinical Evaluation by a Center of Excellence for children under 21 years of age with a diagnosis, or suspected diagnosis of autism spectrum disorder, or other developmental delay conditions for evaluation of the appropriateness of Applied Behavioral Analysis (ABA) as part of the child's plan of care. (Apple Health IMC Contract 16.10.9.2 and WAC 182-531A) Non-Emergent Transportation: Not covered X X A.D.D. (Attention Deficit Disorder) Autism Autologous Blood Bariatric Surgery Covered is ABA treatment services and care coordination activities for children with a diagnosis or suspected diagnosis of autism spectrum disorder, in accordance with EPSDT requirements. (Apple Health IMC Contract 16.10.9.3) Covered as a medical condition if treated by PCP, pediatrician or neurologist. Covered under mental health benefit if treated by a psychiatrist or other mental health professional. See Applied Behavioral Analysis (ABA) - Autism See Blood Products Covered are surgical procedures (bariatric surgery) for weight loss or reduction consistent with WAC 182-531-1600 and WAC 182-550-2301. (Apple Health IMC Covered under mental health benefit if treated by a psychiatrist or other mental health professional X X X 2 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Contract 16.10.37, HCA Physician-Related Services/Healthcare Professional Services Medicaid Provider Guide page 117) See Weight Loss Treatments Biofeedback Covered is bio-feedback training, when determined medically necessary. (Apple X Health IMC Contract 16.10.10.18, Apple Health IMC Member Handbook page 14) Birthing Covered are deliveries in a birthing center or at home. (Apple Health IMC X Centers/Home Births Contract 16.9.4, HCA Planned Home Births and Births in Birthing Centers Medicaid Provider Guide page 9) Birth Control Covered are: X All Food and Drug Administration (FDA) approved contraceptive drugs, devices, and supplies, including emergency contraception, all long acting reversible contraceptives, all over-the-counter (OTC) contraceptives and contraceptive methods which require administration or insertion by a health care professional in a medical setting. Coverage of contraceptive drugs, devices and supplies include: All OTC contraceptives without a prescription. This includes but is not limited to condoms, spermicides, sponges and any emergency contraceptive drug that is FDA-approved to be dispensed over the counter. There are no limits to these OTC contraceptives. OTC contraceptives must be covered without authorization or quantity limits. Contraceptives when dispensed by either a pharmacy or a Family Planning Clinic at the time of a family planning visit. Contraceptives dispensed by a Family Planning Clinic must be covered under the medical benefit. Dispensing of 12 months of contraceptives at one time without authorization requirements related to quantity or days supplied. Duration of any authorization for contraceptives for other reasons must be no less than 12 months. (Apple Health IMC Contract 16.12.4.2.5 -16.12.3.4.5.5, Apple Health IMC Member Handbook, pages 14-15, HCA Prescription Drug Program Medicaid Provider Guide pages 31, 33, 36, 47-48, 59, 62, 96-97) 3 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare See Prescriptions See Family Planning Blood Products Covered are Blood factors, VII, VIII, and IX and the anti-inhibitor provided to X members with a diagnosis of hemophilia or von Willebrand disease when the member is receiving services in an inpatient setting. Otherwise excluded- covered by Fee-For-Service. (Apple Health IMC Contract 16.12.4.2.4,Physician-Related Services/ Health Care Professional Services Medicaid Provider Guide pages 245- 249) Braces (Orthopedic) See Durable Medical Equipment, Prosthetics and Supplies X Braces (Orthodontics) Excluded are orthodontics. Covered through Medicaid Fee-For-Service (Apple X Health IMC Contract 16.13.5.10) See Dental Care Breast Implant Excluded is cosmetic treatment or surgery, except for medically necessary X reconstructive surgery to correct defects attributable to trauma, birth defect, or illness. (Apple Health IMC Contract 16.10.10.10) Covered if medically necessary. Breast Reductions Bulimia Cardiac Rehab Covered are cosmetic, reconstructive, or plastic surgery, and related services and supplies to correct physiological defects from birth, illness, or physical trauma, or for mastectomy reconstruction for post cancer treatment. (HCA PhysicianRelated Services/Healthcare Professional Services Medicaid Provider Guide pages 38, 112-113, WAC 182-531-0150) See Plastic Surgery See Mental Health Covered is outpatient cardiac rehab CPT codes 93798 or G0422 with continuous ECG monitoring only when billed with specific diagnosis codes. (HCA Physician- X See Mental Health X 4 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Related Services/Healthcare Professional Services Medicaid Provider Guide pages 184-185) Chemical Dependency See Substance Use Disorder See Substance Use Disorder Chemotherapy Covered (HCA Physician-Related Services/Healthcare Professional Services X Medicaid Provider Guide pages186-187) Childbirth Classes Covered through Medicaid Fee-For-Service. (HCA Childbirth Education Medicaid X Provider Guide page 14) Chiropractic Care Covered are chiropractic services for children age 20 years and younger when X referred as a result of an EPSDT exam. (HCA Chiropractic Services for Children Medicaid Provider Guide page 14) Circumcision of Excluded is cosmetic treatment or surgery, except for medically necessary X Newborns reconstructive surgery to correct defects attributable to trauma, birth defect, or illness. (HCA Physician-Related Services/Healthcare Professional Services Medicaid Provider Guide page 37) Covered if medically necessary. Covered are circumcisions (CPT codes 54150, 54160, and 54161) When billed with one of the following diagnosis Phimosis (N47.3-N47.8), Balanoposthitis (N47.0-N47.8, N48.1), or Balanitis Xerotica (N48.0). (HCA Physician-Related Services/Healthcare Professional Services Medicaid Provider Guide page 127) Cleft Palate Covered are cosmetic, reconstructive, or plastic surgery, and related services and X supplies to correct physiological defects from birth, illness, or physical trauma, or for mastectomy reconstruction for post cancer treatment. (Apple Health IMC Contract 16.10.10.10, HCA Physician-Related Services/Healthcare Professional Services Medicaid Provider Guide pages 37, 285-286) Colonoscopy Covered are medically necessary services relating to the prevention, diagnosis, X and treatment of health impairments. (Apple Health IMC Contract 16.1.1.1) 5 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Excluded is tomographic colonography for routine colorectal cancer screening as medically necessary. (HCA Physician-Related Services/Healthcare Professional Services Medicaid Provider Guide, page 149) Complications of Covered is medically necessary treatment for complications resulting from an X Excluded Services excluded service. (Apple Health IMC Contract 16.10.39) Counseling See Mental Health See Mental Health Court Ordered Treatment Covered Covered Covered by Fee-For-Service program is court-ordered transportation services, including ambulance services. (Apple Health IMC Contract 16.13.5.5) Covered by Fee-For-Service program is court-ordered transportation services, including ambulance services (Apple Health IMC Contract 16.13.5.5) Crisis Services Covered are crisis services administered through the selected Behavioral Health Covered are crisis services Administrative Services Organization (BH-ASO). (Apple Health IMC Contract 9.16) administered through the selected Behavioral Health Administrative Services Organization (BH-ASO) (Apple Health IMC Contract 9.16). Custodial Care See Home Health Care/Home Health Aide X Dental Care Excluded are professional services provided by a dentist, dental surgeon, dental X hygienist, denturist, dental anesthesiologist, endodontist, periodontist, or other dental specialist for care and treatment of a dental condition, including anesthesia for dental care; prescriptions written by a dentist or oral surgeon for a dental diagnosis. Dental services covered through WA Medicaid Fee-For Service for all adults and children. (Apple Health IMC Contract 16.13.5.9, HCA Dental Related Services Medicaid Provider Guide pages 23-25) Diabetes Education Covered (HCA Diabetes Education Medicaid Provider Guide) X Diabetic Supplies See Prescriptions X 6 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Dialysis Covered is hemodialysis or other appropriate procedures to treat renal failure X including equipment needed in the course of treatment. (Apple Health IMC Contract 16.10.25, HCA Physician-Related Services/Healthcare Professional Services Medicaid Provider Guide pages 37,188-189, HCA Kidney Center Services Medicaid Provider Guide pages 16-17) Diapers (Adult) See Durable Medical Equipment (DME), Prosthetics and Supplies X Durable Medical Covered are durable medical equipment and supplies including but not limited to: X Equipment (DME), wheelchairs, hospital beds, respiratory equipment; prosthetic and orthotic Prosthetics and devices; casts, splints, crutches, trusses, and braces. (WAC 182-501-0065) Supplies Covered are durable medical equipment and supplies and any applicable sales tax: including but not limited to DME; surgical appliances; orthopedic appliances and braces; prosthetic and orthotic devices; breast pumps; incontinence supplies for members over three (3) years of age and medical supplies. Incontinence supplies shall not include non-disposable diapers unless the member agrees. (Apple Health IMC Contract 16.10.21) Covered is fitting prosthetic and orthotic devices. (Apple Health IMC Contract 16.10.10.14) Some limits apply. HCA Prosthetic and Orthotic Devices Medicaid Provider Guide and Medical Equipment and Supplies Medicaid Provider Guide) Glucometer test strips are not covered through DME benefit. Test strips must be provided by member's local pharmacy. 7 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Excluded are nonmedical equipment such as ramps or other home modifications. (Apple Health IMC Handbook page 22) Eating Disorders See Oxygen See Formula (Enteral/Parenteral Nutrition) Covered if medically necessary Covered if medically necessary Emergency Room and Out of Area Care See Mental Health See Nutritional Counseling See Weight Loss Treatments Covered are emergency services: In service area The plan shall cover members for all physical and/or behavioral health medically necessary services included in the scope of services covered by the contract. (Apple Health IMC Contract 16.1.1, Behavioral Health Services Wraparound Contract 16.1.1) Out of service area Physical Health: The plan shall cover emergency, post stabilization, urgent care and services that are neither emergent nor urgent but are medically necessary and cannot wait until members return to the service area. (Apple Health IMC Contract 16.1.13.1.1- 16.1.13.1.3) Out of service area - Behavioral Health: The plan shall cover emergency, post stabilization, urgent care services associated with the presentation of behavioral health conditions that require immediate attention, but are not life threatening, services that are neither emergent nor urgent, bur are medically necessary and cannot wait until Enrollee's return to the service area. (Behavioral Health Services Wraparound Contract 16.1.6) See Mental Health Covered are emergency services: In service area- The plan shall cover members for all medically necessary behavioral health services. (Apple Health IMC Contract 16.1.1, Behavioral Health Services Wraparound Contract 16.1.1) Out of service area- Behavioral Health: the plan shall cover emergency, post stabilization, urgent care services associated with the presentation of behavioral health conditions that require immediate attention, but are not life threatening, services that are neither emergent nor urgent, bur are medically necessary and 8 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare The plan is not responsible for coverage of any services when a member is outside the US and its territories and possessions (e.g. Puerto Rico is a territory). Exception: emergent and routine care is covered in British Columbia under certain circumstances (Apple Health IMC Contract 16.13.3, WAC 182-501-0184). cannot wait until Enrollee's return to the service area. (Behavioral Health Services Wraparound Contract 16.1.6) See Crisis Services The plan is not responsible for coverage of any services when a member is outside the United States of America and its territories and possessions. (Behavioral Health Services Wraparound Contract 16.1.6.1.4). Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Covered are all EPSDT screening, diagnostic, and treatment services found to be medically necessary. (Apple Health IMC Contract 16.10.29) See Crisis Services X Pursuant to WAC 182-501-0050, review any request for a non-covered service to determine the medical necessity of the service, including evaluating the safety and effectiveness of the requested service and to establish it is not experimental. If a service is determined to be medically necessary under the EPSDT benefit, the Contractor will provide the service, whether or not it is a contracted service, unless it is specifically excluded or prohibited by Federal rules. (Apple Health IMC Contract 16.10.29.2) If any EPSDT service exceeds the "soft" limit placed on the scope, amount or duration of a service, the Contractor shall use LE procedures in accordance with WAC 182-501-0169 to determine medical necessity of the requested services and authorize the additional services as indicated. (Apple Health IMC Contract 16.10.28.2.1) 9 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Covered are screening services which include, but are not limited to: a complete health and developmental history that assess for physical and mental health, developmental disorders, autism and substance use disorder, a comprehensive, unclothed physical exam, immunizations according to age and health history, laboratory tests, including appropriate blood lead screening, health education and anticipatory guidance for both the child and caregiver, and screenings for: vision, dental, substance use conditions, mental health and hearing. (Apple Health IMC Contract 16.10.29.1.1) Covered are diagnostic and treatment services which include vision, dental and hearing services and developmental screenings for all children at 9 months, 18 months, and one between 24 to 36 months of age, autism screening for all children 18 months and 24 months of age, as well as any other services prescribed to correct or ameliorate physical, mental, psychological, medical, developmental or other health conditions discovered by and determined to be medically necessary by a qualified health care provider acting within his or her scope of practice. (Apple Health IMC Contract 16.10.29.1.3) Covered are annual depression screening for youth ages twelve (12) to eighteen (18), and up to age twenty (20) per EPSDT requirements. (Apple Health IMC Contract 16.10.10.2) Experimental Plans are to use criteria to determine whether an experimental or investigational X Treatment or Devices service is medically necessary. (Apple Health IMC Contract 11.7) Medicaid medical necessity determinations for its Fee-For-Service program described in WAC 182-501-0165. Eye Exams, Routine Covered are eye examinations and refraction and fitting services with the X Refractions following limitations: Once every 24 months for 21 years of age or older; 10 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Once every 12 months for 20 years of age or younger Covered are additional examinations and refraction services outside the limitation described above when: The provider is diagnosing or treating the member for a medical condition that has symptoms of vision problems or disease; The member is on medication that affects vision; or The service is necessary due to lost or broken eyeglasses/contacts (Apple Health IMC Contract 16.10.13, HCA Physician- Related Services/Healthcare Professional Services Medicaid Provider Guide pages 199204) Eye Glasses Excluded are eyeglass frames, lenses and fabrication services for adult's age 21 X years and over. Covered for children under age 21 through HCA's Fee-For-Service. Associated fitting and dispensing services covered for all members. (HCA Vision Hardware for Clients 20 Years of Age and Younger Medicaid Provider Guide pages 28-33) For children - Eyeglasses, Contact Lenses, & hardware fittings are covered separately under the Fee-For-Service program. (Apple Health IMC Contract 16.13.5.3) Family Planning Covered are: family planning services provided or referred by a participating X provider or practitioner. (Apple Health IMC Contract 16.10.10.6) See Birth Control 11 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Fertility Drugs Excluded is care, testing, or treatment of infertility, frigidity, or impotency. This X includes procedures for donor ovum, sperm, womb, and reversal of vasectomy or tubal ligation. (HCA Physician- Related Services/Healthcare Professional Services Medicaid Provider Guide page 42, WAC 182-531-0150) Formula Infant formula for oral feeding is covered by the Women, infants and Children X (Enteral/Parenteral (WIC) program in the Department of Health. (Apple Health IMC Contract Nutrition) 16.13.6.4) PCP should call WIC at (800) 841-1410. If not on WIC formulary, Plan responsible. Covered are enteral nutrition products and supplies for tube-feeding for all enrollees. (HCA Enteral Nutrition Medicaid Provider Guide pages 19-20, 27-28) Covered are parenteral nutritional supplements and supplies for all enrollees. (HCA Home Infusion Therapy/ Parenteral Nutrition Medicaid Provider Guide pages 17-29) Covered are Medically necessary oral enteral nutrition products, including prescribed infant formulas not covered by WIC or additional quantities beyond amounts allowed by WIC, for clients 20 years of age and under. Parenteral and enteral nutrition supplied through specialized DME providers. Apple Health IMC Contract 16.10.19 Gastroplasty See Bariatric Surgery X 12 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Genetic Services Covered are genetic services when medically necessary for diagnosis of a X medical condition. (Apple Health IMC Contract 16.10.10.19, HCA Physician- Related Services/Healthcare Professional Services Medicaid Provider Guide pages 189-192) See Prenatal Genetic Counseling Glucometers See Prescriptions X Habilitative Services Covered for Apple Health Adult IMC members only who have a congenital or X genetic condition. Children: No limitation; Adults: Twenty-four (24) units each for physical and occupational therapy and six (6) units of speech therapy, subject to limitation extensions as determined medically necessary. Habilitative services do not include: Day habilitation services designed to provide training, structured activities and specialized services to adults; Chore services to assist with basic needs; Vocational services; Custodial services; Respite care; Recreational care; Residential treatment; Social services; and Educational services. (Apple Health IMC Contract 16.10.34.3, Habilitative Services Medicaid Provider Guide, pages 17-21) Health Education Covered is member health education (Apple Health IMC Contract.10.10.16) X 13 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Covered under EPSDT. (HCA EPSDT Medicaid Provider Guide) See Diabetes Education See Nutritional Counseling Hearing Aids Covered are monaural and binaural hearing aids, including fitting, follow-up care, X batteries, and repair for children and adults. (Apple Health IMC Contract 16.10.30, HCA Hearing Hardware Medicaid Provider Guide, pages 17-18, 25-29) See Implants Hearing Exam Covered when medically necessary. X Home Birth See Birthing Centers/Home Birth X Home Health Care/ Covered are acute home health services. (Apple Health IMC Contract 16.10.20, X Private Duty Nursing HCA Home Health Services (Acute Care Services) Medicaid Provider Guide pages 19--23) Covered is medical intensive children's private duty nursing for children age seventeen (17) and younger. (Apple Health IMC Contract 16.10.10.8) Excluded is long-term private duty nursing for members 18 and over. These services are covered by DSHS, Aging and Long-Term Services Administration (Apple Health IMC Contract 16.13.5.19) Excluded are community based services (e.g. COPES, CFC and Personal Care Services) covered through the Aging and Long Term Services Administration (ALTSA). (Apple Health IMC Contract 16.13.6.1) Hospice Care Covered when a member, a physician, or an authorized representative under X RCW 7.70.065 initiates hospice care. The member's physician must provide certification that the member is terminally ill and certify that the member has a life expectancy of six months or less and is appropriate for hospice care. Hospice 14 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare care is provided skilled nursing facilities/ nursing facilities, hospitals, hospice care centers and the member's home. Hospice services include: Palliative Care and Care Coordination: Provision of skilled care services and care coordination to Enrollees with a life-limiting medical condition under a palliative care model. Services can be provided in the following settings, but not limited to, hospice care centers, hospitals, clinics, and the Enrollee's home. (Apple Health IMC Contract 16.10.23) Pediatric Concurrent Care: Treatment, including diagnostics that is related to an Enrollee's terminal condition for an Enrollee aged twenty and younger who voluntarily elects hospice care. Pediatric concurrent care preserves the Enrollee's rights to hospice care without waiving any rights to services that the Enrollee is entitled to under Title XIX Medicaid and Title XXI CHIP. (WAC 182551-1860, Apple Health IMC Contract 16.10.24.1) (Apple Health Contract 16.10.24, HCA Hospice Services Medicaid Provider Guide, pages 38-41) Hospitalization Covered are hospital inpatient services. (WAC 182-531-0100, Inpatient Hospital Services Medicaid Provider Guide) See Inpatient Behavioral Health Covered are: inpatient services provided by a Nursing Facility, Skilled Nursing Facility or other acute care setting, when services are determined medically necessary and nursing facility services are not covered by DSHS' Aging and Long Term Supports Administration, or provided when the Plan determines that nursing facility care is more appropriate than acute hospital care. (Apple Health IMC Contract 16.10.4) Inpatient services at Certified Public Expenditure (CPE) hospitals for Categorically Needy- Blind and Disabled (AHBD) identified by Health Care Authority are covered by Medicaid Fee-For-Service. (Apple Health IMC Contract 5.19.4 and 16.10.4.1) Associated professional claims are covered by MHW. 15 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare CPE Hospitals: University of Washington Medical Center Harborview Medical Center Cascade Valley Hospital Evergreen Hospital and Medical Center Kennewick General Hospital Olympic Medical Center Samaritan Hospital Moses Lake Skagit County Hospital District #2 Island Skagit Valley Hospital Valley General Hospital Monroe Valley Medical Center Renton See Inpatient Behavioral Health Immunizations See Vaccinations X Implants Covered are medically necessary services. (Apple Health IMC Contract 16.1.1) X Covered are cochlear and Bone Anchored Hearing Aids (BAHA) implants for children under age 21 and medically necessary, repair and replacement for adults 21 and older. (HCA Physician-Related Services/Healthcare Professional Services Medicaid Provider Guide pages 115-116 and WAC 182-531-0200(4) (c)) Covered are batteries for cochlear implants. (HCA Hearing Hardware Medicaid Provider Guide page 14, Apple Health IMC Contract 16.10.32) Impotence Excluded is care, testing, or treatment of infertility, frigidity, or impotency. This X includes procedures for donor ovum, sperm, womb, and reversal of vasectomy or tubal ligation. (HCA Physician-Related Services/Healthcare Professional Services Medicaid Provider Guide, page 40, WAC 182-531-0150) Incarcerated Members Excluded is any service provided to a member while incarcerated with the X (in Jail or Prison) Washington State Department of Corrections (DOC). (Apple Health IMC Contract 16.13.6.5) 16 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Infertility Inpatient Behavioral Health The Plan will provide inpatient hospital services to members who are inmates of a city or county jail facility when an inpatient admission occurs during the first month of the incarceration period and HCA has paid a premium for that month to the Plan. The contractor shall provide transitional care coordination services to inmates upon release from jail in accordance with subsection 14.22. (Apple Health IMC Contract 16.10.33) See Impotence Covered is Inpatient Withdrawal Management (Alcohol and Drug Detoxification) services required for the care and/or treatment of individuals intoxicated or incapacitated by alcohol or other drugs while the person recovers from the transitory effects of acute or chronic intoxication or withdrawal from alcohol or other drugs. Services are provided in facilities with 16 beds or less and exclude room and board (Apple Health IMC Contract 16.10.14.1). Services include: Screening and detoxification Counseling of person admitted to a program within a certified facility, regarding their illness in order to stimulate motivation to obtain further treatment, and referral of detoxified chemically dependent person to other appropriate chemical dependency service providers Covered is Inpatient/Residential Substance Abuse Treatment Services. Rehabilitative services including diagnostic evaluation and face-to-face individual or group counseling using therapeutic techniques directed toward enrollees who are harmfully affected by the use of mood-altering chemicals or have been diagnosed with a SUD. Provided in certified residential treatment facilities with 16 beds or less. Room and Board is excluded. (Apple Health IMC Contract 1.124 & 16.10.14.2) Services include: Intensive inpatient services (WAC 388-877B-2050) X Covered is Inpatient Withdrawal Management (Alcohol and Drug Detoxification) services required for the care and/or treatment of individuals intoxicated or incapacitated by alcohol or other drugs while the person recovers from the transitory effects of acute or chronic intoxication or withdrawal from alcohol or other drugs. Services are provided in facilities with 16 beds or less and exclude room and board (Apple Health IMC Contract 16.10.14.1). Services include: Screening and detoxification Counseling of person admitted to a program within a certified facility, regarding their illness in order to stimulate motivation to obtain further treatment, and referral of detoxified chemically 17 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Recovery house treatment services (WAC 388-877B- 0260) Long-term residential treatment services (WAC 388-877B-0270) Youth residential services (WAC 388-877B-0280) dependent person to other appropriate chemical dependency service providers The Contractor shall pay for the inpatient professional mental health services associated with an IMC behavioral health approved inpatient psychiatric admission. The Contractor shall also pay for the inpatient psychiatric mental health claim. Covered is court-ordered mental health Involuntary Treatment Act (ITA) commitment prior to the date the ninety (90) day court order is issued. (Apple Health IMC Contract 16.10.13.3). Covered through Medicaid Fee-For-Service ninety (90) to one hundred eighty (180) day court order, where the individual is approved for placement in a state hospital or HCA-contracted long-term mental health community hospital bed or E&T Apple Health IMC Contract 16.13.5.6). Covered is Inpatient/Residential Substance Abuse Treatment Services. Rehabilitative services including diagnostic evaluation and face-to-face individual or group counseling using therapeutic techniques directed toward enrollees who are harmfully affected by the use of moodaltering chemicals or have been diagnosed with a SUD. Provided in certified residential treatment facilities with 16 beds or less. Room and Board is excluded (Apple Health IMC Contract 16.10.14.2) Services include: Intensive inpatient services (WAC 388-877B-2050) Recovery house treatment services (WAC 388-877B- 0260) Long-term residential treatment services (WAC 388-877B-0270) Youth residential services (WAC 388-877B-0280) 18 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Covered is court-ordered mental health Involuntary Treatment Act (ITA) commitment prior to the date the ninety (90) day court order is issued. (Apple Health IMC Contract 16.10.13.3). Keratotomy/ KeratoPlasty (Refractive Lensectomy) Laboratory Tests Learning Disorders Lifetime Maximum Benefit Limit Mammogram See Plastic Surgery Covered is performing and/or reading diagnostic tests. (Apple Health IMC Contract 16.10.10.7) See Neurodevelopmental Therapy There is no life time maximum limitation on Plan payments. Covered are medically necessary services relating to the prevention, diagnosis, and treatment of Enrollee's disease, condition, and/or disorder that results in health impairments and/or disability 42 C.F.R. § 438.210(a)(5)(ii)(A). Covered through Medicaid FeeFor-Service ninety (90) to one hundred eighty (180) day court order, where the individual is approved for placement in a state hospital or HCA-contracted longterm mental health community hospital bed or E&T Apple Health IMC Contract 16.13.5.6). X X X There is no life time maximum limitation on Plan payments. X (Apple Health IMC Contract 16.1.1.1, HCA Physician Related Services/Health Care Professional Services Medicaid Provider Guide page 141) 19 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Mammaplasty See Plastic Surgery X Manipulative Therapy Covered are Osteopathic Manipulative Therapy (OMT) services only when X provided by either an osteopathic physician licensed under chapter 18.71 RCW or a naturopathic physician licensed under chapter 18.36A RCW. 10 manipulations (CPT Codes 98925-98929) are covered per calendar year. (HCA Physician- Related Services/Healthcare Professional Services Medicaid Provider Guide page 207) Massage Therapy Covered during physical therapy and occupational therapy treatment only. (HCA X Outpatient Rehabilitation Medicaid Provider Guide page 26) Maternity Care Medication Assisted Treatment Mental Health Otherwise excluded - HCA does not reimburse for services performed by massage therapists. (HCA Physician Related Services/Health Care Professional Services Medicaid Provider Guide page 28, WAC 182-531-0250 (2a)) See Prenatal Care See Substance Use Disorder X See Substance Use Disorder Covered are medically necessary behavioral health services which may include the following Outpatient Behavioral Health Services: (Apple Health IMC Contract 16.10.15) Brief Intervention: means solution-focused and outcomes-oriented cognitive and behavioral interventions intended to resolve situational disturbances. (Apple Health IMC Contract 1.28, 16.10.15.1). Day Support: means an intensive rehabilitative program which provides a range of integrated and varied life skills training (e.g., health, hygiene, nutritional issues, money management, maintaining living arrangement, symptom management) for Medicaid Enrollees to promote improved functioning or a restoration to previous higher level functioning. (Apple Health IMC Contract 1.75, 16.10.15.2). Evaluation and Treatment: means services provided in freestanding inpatient residential (non-hospital/non-Institution for Mental Disease (IMD) facilities Covered are medically necessary behavioral health services which may include the following Outpatient Behavioral Health Services: (Apple Health IMC Contract 16.10.15) Brief Intervention: means solution-focused and outcomesoriented cognitive and behavioral interventions intended to resolve situational disturbances. (Apple 20 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). licensed and certified by the Department of Health to provide medically Health IMC Contract 1.28, necessary evaluation and treatment to the Medicaid-enrolled individual who 16.10.15.1). would otherwise meet hospital admission criteria. (Apple Health IMC Contract 1.97, 16.10.15.4) Day Support: means an intensive rehabilitative program Family Treatment: means behavioral health counseling provided for the direct which provides a range of benefit of a Medicaid- enrolled individual. Service is provided with family integrated and varied life skills members and/or other relevant persons in attendance as active participants. (Apple Health IMC Contract 1.107, 16.9.15.3). training (e.g., health, hygiene, nutritional issues, money Mental Health Group Treatment Services: means services provided to Medicaid-enrolled individuals designed to assist in the attainment of goals described in the Individual Service Plan (ISP). (Apple Health IMC Contract 1.173, 16.10.15.5). High Intensity Treatment such as PACT Teams: means intensive levels of service provided to Medicaid-enrolled individuals who require a multi-disciplinary treatment team in the community that is available upon demand based on the individual's needs. Twenty-four (24) hours per day, seven (7) days per week, access is required if necessary. (Apple Health IMC Contract 1.130, 16.10.15.6). Individual Treatment Services: means a set of treatment services designed to help a Medicaid-enrolled individual attain goals as prescribed in his/her Individual Service Plan (ISP). (Apple Health IMC Contract 1.140, 16.10.15.7). Intake Evaluation: means an evaluation that is culturally and age relevant initiated prior to the provision of any other mental health services, except crisis services, stabilization services and freestanding evaluation and treatment. (Apple Health IMC Contract 1.142, 16.10.15.8). Medication Management: means the prescribing and/or administering and reviewing of medications and their side effects. (Apple Health IMC Contract 1.170, 16.10.15.9). Medication Monitoring: Means face-to-face, one-on-one cueing, observing, and encouraging a Medicaid-enrolled individual to take medications as prescribed. (Apple Health IMC Contract 1.171, 16.10.15.10). Peer Support Services: means services provided by peer counselors to Medicaid-enrolled individuals under the consultation, facilitation, or supervision of a Mental Health Professional who understands rehabilitation and recovery. (Apple Health IMC Contract 1.202, 16.10.15.11). Psychological Assessment: (Apple Health IMC Contract 16.10.15.12) Rehabilitation Case Management: means a range of activities by the outpatient CMHA's liaison conducted in or with a facility for the direct benefit of a Medicaid-enrolled individual in the public mental health system. These specialized mental health coordination activities are intended to promote discharge, maximize the benefits of the placement, minimize the risk of management, maintaining living arrangement, symptom management) for Medicaid Enrollees to promote improved functioning or a restoration to previous higher level functioning. (Apple Health IMC Contract 1.75, 16.10.15.2). Evaluation and Treatment: means services provided in freestanding inpatient residential (non-hospital/non-Institution for Mental Disease (IMD) facilities licensed and certified by the Department of Health to provide medically necessary evaluation and treatment to the Medicaidenrolled individual who would otherwise meet hospital admission criteria. (Apple Health IMC Contract 1.97, 16.10.15.4) Family Treatment: means behavioral health counseling provided for the direct benefit of a Medicaid- enrolled individual. Service is provided with family members and/or other relevant persons in attendance as active participants. (Apple Health IMC Contract 1.107, 16.10.15.3). Mental Health Group Treatment Services: means 21 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare unplanned re-admission, and to increase the community tenure for the individual. (Apple Health IMC Contract 1.235, 16.10.15.13). Residential Mental Health Services: means a specialized form of rehabilitation service (non-hospital/ non IMD) that offers sub-acute psychiatric management environment. Treatment for these individuals cannot be safely provided in a less restrictive environment and they do not meet hospital criteria. (Apple Health IMC Contract 1.239, 16.10.15.14). Stabilization Services: means services provided to Medicaid-enrolled individuals who are experiencing a mental health crisis. (Apple Health IMC Contract 1.253, 16.10.15.15). Special Population Evaluation: means an evaluation by a child, geriatric, disabled, or ethnic minority specialist that considers age and cultural variables specific to the individual being evaluated and other culturally and age competent evaluation methods. (Apple Health IMC Contract 1.251, 16.10.15.16). Therapeutic Psychoeducation: (Apple Health IMC Contract 16.10.15.17) Chemical Dependency Case Management: Chemical Dependency case management services assist clients in gaining access to needed medical, social, education, and other services. (Apple Health IMC Contract 16.10.15.18). Chemical Dependency Outpatient Services: means rehabilitative services including diagnostic evaluation and face-to-face individual or group counseling using therapeutic techniques directed toward enrollees who are harmfully affected by the use of mode-altering chemicals or have been diagnosed with a SUD. (Apple Health IMC Contract 16.10.15.19). Opioid Treatment Program (OTP): means evaluation designated program that dispenses approved medication as specified in 21 C.F.R Part 291, for opioid treatment programs in accordance with WAC 246-341-1000. (Apple Health IMC Contract 16.10.15.20). services provided to Medicaidenrolled individuals designed to assist in the attainment of goals described in the Individual Service Plan (ISP). (Apple Health IMC Contract 1.173, 16.10.15.5). High Intensity Treatment such as PACT Teams: means intensive levels of service provided to Medicaid-enrolled individuals who require a multidisciplinary treatment team in the community that is available upon demand based on the individual's needs. Twenty-four (24) hours per day, seven (7) days per week, access is required if necessary. (Apple Health IMC Contract 1.130, 16.10.14.6). Individual Treatment Services: means a set of treatment services designed to help a Medicaid-enrolled individual attain goals as prescribed in his/her Individual Service Plan (ISP). (Apple Health IMC Contract 1.140, 16.10.15.7). See Prescriptions Intake Evaluation: means an evaluation that is culturally and 22 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare age relevant initiated prior to the provision of any other mental health services, except crisis services, stabilization services and freestanding evaluation and treatment. (Apple Health IMC Contract 1.142, 16.10.15.8). Medication Management: means the prescribing and/or administering and reviewing of medications and their side effects. (Apple Health IMC Contract 1.170, 16.10.15.9). Medication Monitoring: Means face-to-face, one-on-one cueing, observing, and encouraging a Medicaid-enrolled individual to take medications as prescribed. (Apple Health IMC Contract 1.171, 16.10.15.10). Peer Support Services: means services provided by peer counselors to Medicaid-enrolled individuals under the consultation, facilitation, or supervision of a Mental Health Professional who understands rehabilitation and recovery. 23 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). (Apple Health IMC Contract 1.202, 16.10.15.11). Psychological Assessment: (Apple Health IMC Contract 16.10.15.12) Rehabilitation Case Management: means a range of activities by the outpatient CMHA's liaison conducted in or with a facility for the direct benefit of a Medicaid-enrolled individual in the public mental health system. These specialized mental health coordination activities are intended to promote discharge, maximize the benefits of the placement, minimize the risk of unplanned re-admission, and to increase the community tenure for the individual. (Apple Health IMC Contract 1.235, 16.10.15.13). Residential Mental Health Services: means a specialized form of rehabilitation service (non-hospital/ non IMD) that offers sub-acute psychiatric management environment. Treatment for these individuals cannot be safely provided in a less restrictive environment and they do not meet hospital criteria. (Apple Health IMC Contract 1. 239, 16.10.15.14). Stabilization Services: means services provided to Medicaidenrolled individuals who are experiencing a mental health crisis. (Apple Health IMC Contract 1.253, 16.10.15.15). 24 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Special Population Evaluation: means an evaluation by a child, geriatric, disabled, or ethnic minority specialist that considers age and cultural variables specific to the individual being evaluated and other culturally and age competent evaluation methods. (Apple Health IMC Contract 1. 251, 16.10.15.16). Therapeutic Psychoeducation: (Apple Health IMC Contract 16.15.17) Chemical Dependency Case Management: Chemical Dependency case management services assist clients in gaining access to needed medical, social, education, and other services. (Apple Health IMC Contract 16.10.15.18). Chemical Dependency Outpatient Services: means rehabilitative services including diagnostic evaluation and faceto-face individual or group counseling using therapeutic techniques directed toward enrollees who are harmfully 25 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare affected by the use of modealtering chemicals or have been diagnosed with a SUD. (Apple Health IMC Contract 16.1. 15.19). Opioid Treatment Program (OTP): means evaluation designated program that dispenses approved medication as specified in 21 C.F.R Part 291, for opioid treatment programs in accordance with WAC 246-341-1000. (Apple Health IMC Contract 16.10. 15.20). See Prescriptions Military Coverage (VA For members who have primary insurance, the plan shall coordinate benefits in Benefits) accordance with the 42 U.S.C § 1396a(a)(25) and other applicable law. (Apple X Health IMC Contract 17.2.3) Naturopathy Covered (HCA Physician-Related Services/Healthcare Professional Services X Medicaid Provider Guide page 25-26, WAC 182-531-0250 (1g)) Neurodevelopmental Covered are neurodevelopmental services, occupational therapy, speech therapy, X Therapy and physical therapy: services for the restoration or maintenance of a function Long Term PT, OT affected by a member's illness, disability, condition or injury, or for the and Speech amelioration of the effects of a developmental disability. (Apple Health IMC Contract 16.10.17) 26 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Nicorette Gum See Smoking Cessation X Norplant- See Birth Control X Implantable Contraceptives Nursing Homes See Skilled Nursing Facilities X Nutritional Covered is nutritional counseling by a certified registered dietician for specific X Counseling/Therapy conditions such as failure to thrive, feeding problems, cystic fibrosis, diabetes, high blood pressure, and anemia who are 20 years of age and younger with an EPSDT referral. (Apple Health IMC Contract 16.10.10.17 and Medical Nutrition Therapy Medicaid Provider Guide) CPT: 97802 97804 covered for children only per Molina Healthcare decision See Weight Loss Treatments Obesity Treatments See Nutritional Counseling X See Weight Loss Treatments Occupational Therapy See Physical Therapy X Oral surgery See Dental Care X Organ/Tissue Covered are tissue and organ transplants: Heart, kidney, liver, bone marrow, X Transplants lung, heart-lung, pancreas, kidney-pancreas, cornea, small bowel, and peripheral blood stem cell. (Apple Health IMC Contract 16.10.11) The transplant procedures must be performed in a hospital designated by HCA as a "center of excellence" for transplant procedures. Covered are skin grafts and corneal transplants at any hospital when medically necessary. Covered are organ procurement fees and donor searches. (HCA Physician-Related 27 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Services/Healthcare Professional Services Medicaid Provider Guide pages 250251) Orthotics Out of Area Care Outpatient Behavioral Health Outpatient Surgery Per MHW Medical Director transplant coverage decisions are complex. Providers must contact Plan to obtain specific information. Some transplants are well proven by medical research. Others are not and may not work for a member's situation. The provider needs to contact the Plan about each situation. See Durable Medical Equipment, Prosthetics and Supplies See Emergency Room and Out of Area Care See Mental Health Covered are Outpatient Hospital Services provided by acute care hospitals; including surgeries, labs, diagnostics and emergency room (licensed under Chapter 70.41 RCW). (Apple Health IMC Contract 16.10.5) X See Emergency Room and Out of Area Care See Mental Health X Covered are services provided at ambulatory centers. (Apple Health IMC Contract 16.10.8) Over-Age Dependents Covered are facility costs of surgical procedures that can be performed safely on an ambulatory basis in an Ambulatory Surgery Center. (HCA Ambulatory Surgery Centers Medicaid Provider Guide page 7). Not applicable, WA Medicaid determines eligibility. Oxygen Pain Clinics Covered is respiratory equipment, services and supplies. (Apple Health IMC Contract 16.10.22, HCA Respiratory Care Medicaid Provider Guide pages 39-44) Covered is one inpatient hospital stay, up to 21 consecutive days, once per lifetime. The plan may cover plan-contracted facilities. (WAC 182-550-2400) Not applicable, WA Medicaid determines eligibility. X X 28 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Physical Exams See Preventive Care X Physical Therapy Covered are neurodevelopmental services, occupational therapy, speech therapy, X and physical therapy. (Apple Health IMC Contract 16.10.17) (HCA Outpatient Rehabilitation Medicaid Provider Guide pages 16-21) Plastic & Excluded is cosmetic treatment or surgery, except for medically necessary X Reconstructive reconstructive surgery to correct defects attributable to trauma, birth defect, or Surgery illness. Covered are cosmetic, reconstructive, or plastic surgery, and related services and supplies to correct physiological defects from birth, illness, or physical trauma, or for mastectomy reconstruction for post cancer treatment. (HCA Physician-Related Services/Healthcare Professional Services Medicaid Provider Guide page 37, Apple Health IMC Contract 16.10.10.10, WAC 182-531-0150) Podiatry Covered are services for children under age 21 when medically necessary. X Excluded is foot care for adults age 21 and older to treat chronic acquired conditions of the foot such as, but not limited to: Removal of warts, corns, or calluses; Trimming of nails and other regular hygiene care Treatment of flat feet; Treatment of high arches Bunions and tailor's bunion Adult acquired flatfoot Covered is treatment 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 member that causes pain resulting in inability to perform activities of daily living, 29 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare acute disability, or threatens to cause the loss of life or limb, unless otherwise specified. (HCA Physician-Related Services/Healthcare Professional Services Medicaid Provider Guide pages 38, 41, 294) Pre-existing The plan is responsible for covering medically necessary services. (Apple Health X Conditions IMC Contract 16.1.1) Prenatal Care Covered are maternity care, delivery, and newborn care services. (Apple Health X IMC Contract 16.9.1, WAC 182-531-0100, HCA Physician-Related Services/Healthcare Professional Services Medicaid Provider Guide pages 217- 232) Excluded are early, elective inductions (before 39 weeks) that do not meet medically necessary indicators set by the Joint Commission (Apple Health IMC Contract 16.10.38) Prenatal Genetic Excluded is prenatal diagnosis genetic counseling provided to members to allow X Counseling members and their PCPs to make informed decisions regarding current genetic practices and testing. Covered by HCA Fee-For-Service. (Apple Health IMC Contract 16.13.5.15, Physician-Related Services/Health Care Professional Services Billing Guide pages 192-193) See Genetic Services Prescriptions Covered are prescription and over-the-counter drug products according to the X Preferred Drug List (PDL) and HCA approved formulary from participating rebate eligible manufacturers The Plan's formulary shall include all therapeutic classes in the Health Care Authority's Fee-For-Service drug file and a sufficient variety of drugs in each therapeutic class to meet member's medically necessary health care needs. (Apple Health IMC Contract 16.12.2) 30 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Covered are Psychotropic medications according to the Plan's approved formulary when prescribed by a medical or mental health professional, when he or she is prescribing medications within his or her scope of practice with appropriate authorization. (Apple Health IMC Contract 16.12.4.2.3) Covered are birth control methods/contraceptive drugs authorized in one-year supply dispensed at one time unless a member requests a smaller supply or the prescribing physician instructs that the patient must receive a smaller supply. The Plan shall authorize on-site dispensing of the prescribed birth control methods\contraceptive drugs at family planning clinics. Contraceptives dispensed by a Family Planning Clinic must be covered under the medical benefit. (Apple Health IMC Contract 16.12.4.2.5) Covered drug products shall include family planning drugs, devices, and drugrelated supplies, prescription vitamins and mineral products, drug-related devices and drug-related supplies as an outpatient pharmacy benefit, preservatives, flavoring and/or coloring agents, only when used as a suspending agent in a compound, over-the-counter and prescription drugs to promote smoking cessation. (HCA Prescription Drug Program Medicaid Provider Guide pages 23035) Glucometers are covered under MHW policy that provides True Result glucometer. Requests for other glucometers require prior authorization through Pharmacy on Pharmacy Request Form to demonstrate why member must use other meter. Glucometer test strips are only covered under the prescription benefit and must be provided by member's local pharmacy. See Birth Control 31 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Preventive Care Covered is preventive care. X Covered are medical examinations, including wellness exams for adults and EPSDT for children, immunizations. (Apple Health IMC Contract 16.10.10.1) Prosthetic Limbs See Durable Medical Equipment, Prosthetics and Supplies X Pulmonary Rehab Psychiatric Disorders Radial Keratotomy Radiology Excluded HCPCS code G0424 (Pulmonary rehab w/ exer.) is not covered (CNC in Physician's fee schedule and Coverage Indicator 0 in the Outpatient fee schedule) See Mental Health See Plastic Surgery Covered are radiology, and other medical imaging services, screening and diagnostic services and radiation therapy (Apple Health IMC Contract 16.10.12). X See Mental Health X X Reconstructive Surgery Screening, Brief Intervention and Referral to Treatment (SBIRT) Covered are radiology services such as but not limited to CT scans, PET scans, MRI, ultrasound, mammograms, heart catheterizations and nuclear medicine. (HCA Physician Related Services/Healthcare Professional Services Medicaid Provider Guide pages 140-148) See Plastic Surgery Covered are Screening, Brief Intervention and Referral to Treatment (SBIRT) services for adolescents and adults known to have or at high risk for substance abuse, to include alcohol and drugs with or without anxiety or depression. (Apple Health IMC Contract 16.10.35, Physician Related Services/Health Care Professional Services Medicaid Provider Guide pages 234-238). X Covered are Screening, Brief Intervention and Referral to Treatment (SBIRT) services for adolescents and adults known to have or at high risk for substance abuse, to include alcohol and drugs with or without anxiety or depression. (Apple Health IMC Contract 16.10.35, Physician 32 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Related Services/Health Care Professional Services Medicaid Provider Guide pages 234-238). Second Opinions The Plan must authorize a second opinion regarding the member's health care from a qualified health care professional within the plan's network, or provide X authorization for the member to obtain a second opinion outside the plan's network, if the plan's network is unable to provide for a qualified health care professional. (Apple Health IMC Contract 16.2) Skilled Nursing Covered are: inpatient services provided by a Nursing Facility, Skilled Nursing X Facilities Facility or other acute care setting, when services are determined medically necessary and nursing facility services are not covered by DSHS' Aging and Long Term Supports Administration, or provided when the Plan determines that nursing facility care is more appropriate than acute hospital care. (Apple Health IMC Contract 16.10.4.2) The Plan shall coordinate with the SNF or NF to provide care coordination and transitional care and shall ensure coverage of all medically necessary services, prescriptions and equipment not included in the negotiated SNF daily rate. This includes but is not limited to: prescription medications, durable medical equipment, therapies, intravenous medications, and any other medically necessary service or product. (Apple Health IMC Contract 14.19.3) Excluded is care that is determined to not be medically necessary for rehabilitation. If the member continues in the SNF, Aging and Long-Term Services Administration (ALTSA) Home and Community Services (HCS) will cover the stay from the date of the Plan denial letter. (Apple Health IMC Contract 16.13.6.2) Sleep Disorders Covered as a medical condition. X 33 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Smoking Cessation Covered are smoking cessation services including but not limited to: X Telephone counseling and follow-up support calls through the quit line; Nicotine patches or gum through the quit line, if appropriate; Prescription medications recommended by the quit line. The member will then be referred back to their provider for a prescription, if appropriate. (HCA Physician Related Services/Healthcare Professional Services Medicaid Provider Guide pages 54-59) MHW policy - Covers all Molina members 18 and over. Members can re-enroll two times a year for up to three year re-enroll lifetime maximum. Speech Therapy Covered are neurodevelopmental services, occupational therapy, speech therapy, X and physical therapy. (Apple Health IMC Contract 16.10.17) (HCA Outpatient Rehabilitation Medicaid Provider Guide pages 17-20) Spinal Manipulations See Chiropractic Care and Manipulative Therapy X 34 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Sterilization (Tubal Covered for members over age 21. The plan shall assure all sterilizations and X Ligation, hysterectomies performed under the contract are in compliance with 42 CFR 441 Salpingectomy and Subpart F and that the federal consent form HHS-687. A hysterectomy requires Vasectomy) the Hysterectomy Consent and Patient Information form (HCA 13-365). (Apple Health IMC Contract 16.3, HCA Physician Related Services/ Healthcare Professional Services Medicaid Provider Guide 126-127, Sterilization Supplemental Medicaid Provider Guide, pages 17-31) Excluded are sterilizations for members under age 21 or those that do not meet other federal requirements (42 CFR 441 Subpart F). (Apple Health IMC Contract 16.13.5.12). Covered through Medicaid Fee-For-Service - HCA sterilization consent form must be completed see above. Substance Use Disorder Excluded is reversal of vasectomy or tubal ligation. (HCA Physician Related Services/Healthcare Professional Services Medicaid Provider Guide page 41) Covered are medically necessary behavioral health services to enrollees. Covered are clinically appropriate Medicaid Services in the event that the plan does not have available resources to provide GFS services. Within available resources services are covered related to (Behavioral Health Services Wraparound Contract 16.1.1): Prevention, intervention and after-care of behavioral health conditions Achievement of age-appropriate growth and development Attainment, maintenance or regaining of functional capacity Covered are medically necessary behavioral health services which may include the following Therapeutic Psychoeducation: (Apple Health IMC Contract 16.10.15.17) Chemical Dependency Case Management: Chemical Dependency case management services assist clients in gaining access to needed medical, social, education, and other services. (Apple Health IMC Contract 16.10.15.18) Covered are medically necessary behavioral health services to enrollees. Covered are clinically appropriate Medicaid Services in the event that the plan does not have available resources to provide GFS services. Within available resources services are covered related to (Behavioral Health Services Wraparound Contract 16.1.1): Prevention, intervention and after-care of behavioral health conditions 35 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Chemical Dependency Outpatient Services: means rehabilitative services including diagnostic evaluation and face-to-face individual or group counseling using therapeutic techniques directed toward enrollees who are harmfully affected by the use of mode-altering chemicals or have been diagnosed with a SUD. (Apple Health IMC Contract, 16.10.15.19) Opiate Substitution Treatment: means treatment and rehabilitative services for opiate dependent individuals. Services include: methadone treatment, detoxification (up to 180 days), individual and group counseling, HIV education and testing, drug screen urinalysis, and medical evaluation. (Apple Health IMC Contract 16.10.15.20) Apple Health IMC Member Handbook page 15 Covered are all drugs FDA labeled or prescribed as Medication Assisted Treatment (MAT) or maintenance therapy for substance use disorders, with the exception of methadone dispensed directly by opiate substitution treatment programs. The Contractor will cover all MAT according to guidelines and requirements determined by HCA. (Apple Health IMC Contract 16.12.4.2.6) See Wraparound Services Ability to achieve ageappropriate growth and development Ability to maintain or regain of functional capacity Covered are medically necessary behavioral health services which may include the following Therapeutic Psychoeducation: (Apple Health IMC Contract 16.10.15.17) Chemical Dependency Case Management: Chemical Dependency case management services assist clients in gaining access to needed medical, social, education, and other services. (Apple Health IMC Contract 16.10.15.18) Chemical Dependency Outpatient Services: means rehabilitative services including diagnostic evaluation and faceto-face individual or group counseling using therapeutic techniques directed toward enrollees who are harmfully affected by the use of mode- 36 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare altering chemicals or have been diagnosed with a SUD. (Apple Health IMC Contract 16.10.15.19) Opiate Substitution Treatment: means treatment and rehabilitative services for opiate dependent individuals. Services include: methadone treatment, detoxification (up to 180 days), individual and group counseling, HIV education and testing, drug screen urinalysis, and medical evaluation. (Apple Health IMC Contract 16.10.15.20) Apple Health IMC Member Handbook page 15 Supplies (NonDurable) TMJ Transgender Health Services See Durable Medical Equipment, Prosthetics and Supplies See Wraparound Services X Covered is medically necessary services. (Apple Health IMC Contract 16.1.1) Covered is medical care including hormone therapy for any transgender enrollees and puberty-blocking treatment for transgender adolescents and mental health services to treat gender dysphoria. (Apple Health IMC Contract 16.10.10.21) X Covered are mental health services to treat gender dysphoria. Covered through Fee For Service (FFS) is surgical procedures related to gender reassignment surgery and electrolysis and postoperative complications. 37 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Excluded is cosmetic procedures and services, voice modification surgery, voice therapy. (HCA Physician Related Services/Healthcare Professional Services Medicaid Provider Guide pages 292-299) Transplants See Organ Transplants X Travel Immunizations See Vaccinations X Urgent Care Covered are urgent care services associated with the presentation of medical signs that require immediate attention but are not life threatening. (Apple Health IMC Contract 16.1.13.1.2) See Crisis Services Covered are urgent care services associated with the presentation of behavioral health conditions that require immediate attention, but are not life threatening. (Apple Health IMC Contract 16.1.13.1.2, Behavioral Health Services Wraparound Contract 16.1.6.1.2) Vaccinations (Immunizations) Covered are immunizations. (HCA Physician-Related Services/ Healthcare Professional Services Medicaid Provider Guide pages 214-216) See Crisis Services X Covered is shingles vaccine for members over age 60 years and over. Additional requirements for members under 60 years of age. (Apple Health IMC Contract 16.10.10.4) Covered is Human Papillomavirus (HPV) Ages 9-18 #90649 SL (SL shows received through DOH program for kids.) Ages 19-6 #90649 no SL modifier & #90471 for administration. (HCA Prescription Drug Program Medicaid Provider Guide page 54, 57) Vasectomy See Sterilization X 38 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Vitamins Covered are therapeutic vitamins and iron prescribed for prenatal and postnatal X care. (Apple Health IMC Contract 16.12.4.2.2) Covered are prescription vitamins and mineral products, when prescribed for clinically documented deficiencies, prenatal vitamins and fluoride varnish for children under the early and periodic screening, diagnosis and treatment (EPSDT) program. (HCA Prescription Drug Program Medicaid Provider Guide page 31) Vision Therapy Covered is vision therapy. (HCA Physician-Related Services/ Healthcare X Professional Services Medicaid Provider Guide page 198) Vocational Long term in-depth vocational rehabilitation is covered through DSHS Fee-For- X Rehabilitation Service under the Division of Vocational Rehabilitation (http://www.dshs.wa.gov/dvr/). Weight Loss Drugs Excluded are drugs prescribed for weight loss or gain. (HCA Prescription Drug X Program Medicaid Provider Guide page 19) See Weight Loss Treatments Weight Loss Covered are surgical procedures for weight loss or reduction consistent with WAC X Treatments 182-531-1600 (Apple Health IMC Contract 16.10.37) Excluded except as provided in WAC 182-531-1600, is 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. (WAC 182-531-0150, HCA Physician-Related/Healthcare Professional Services Medicaid Provider Guide page 42) See Bariatric Surgery See Nutritional Counseling 39 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare Wraparound Services for Substance Use Disorder and Mental Health Services *** Note: services are not exhaustive and are subject to fund availability*** Covered based on availability of resources are: Room and Board Urinalysis Testing Therapeutic Interventions for Children High Intensity Treatment (PACT) Sobering Services Expanded Community Services Interim Services Opiate Dependency/HIV Services Outreach Childcare Services Rehabilitation Case Management Recovery Support Services Outreach and Engagement Transportation Family Hardship Continuing Education Alcohol /Drug Information School PPW Housing Support Services Supported Employment Jail Transition Services *** Note: services are not exhaustive and are subject to fund availability*** Covered based on availability of resources are: Room and Board Urinalysis Testing Therapeutic Interventions for Children High Intensity Treatment (PACT) Sobering Services Expanded Community Services Interim Services Opiate Dependency/HIV Services Outreach Childcare Services Rehabilitation Case Management Recovery Support Services Outreach and Engagement Transportation (Behavioral Health Services Wraparound Around Contract Section 16.2) Family Hardship Continuing Education Alcohol /Drug Information School PPW Housing Support Services Supported Employment Jail Transition Services 40 July 2019 PLEASE NOTE: This is only a guide Benefits, coverage and interpretation of benefits and coverage may change. Please use the contract or HCA Medicaid Provider Guides in determining coverage issues. All excluded or non-covered services are subject to appeal by the member or provider (with written consent by the member). Molina Healthcare of Washington (MHW) Benefits Index All covered services must be MEDICALLY NECESSARY and are SUBJECT TO PREAUTHORIZATION REQUIREMENTS. Reference or page numbers refer to the contract, HCA Medicaid Provider Guides, schedule of benefits or WAC. 2019 Apple Health Integrated Managed Care (IMC) Apple Health State Children's Health Insurance Program (SCHIP), Apple Health IMC Family/Pregnancy Medical (IMC-AHFAM), Apple Health Adult IMC (IMC-AHA), Apple Health Blind Disabled IMC (IMC-AHBD) Behavioral Health Services Only (BHSO) X = Not covered, part of the Medicaid physical health benefit covered through Fee-For-Service or Medicare (Behavioral Health Services Wraparound Around Contract Section 16.2) 41 July 2019Microsoft Word 2013