title: RCW 74.09.325

text:
(1)(a) All managed care organizations contracted with the authority for the medicaid program shall reimburse a provider for a health care service provided to a covered person through telemedicine or store and forward technology if:
(i) The managed care organization in which the covered person is enrolled provides coverage of the health care service when provided in person by the provider;
(ii) The health care service is medically necessary;
(iii) The health care service is a service recognized as an essential health benefit under section 1302(b) of the federal patient protection and affordable care act in effect on January 1, 2015;
(iv) The health care service is determined to be safely and effectively provided through telemedicine or store and forward technology according to generally accepted health care practices and standards, and the technology used to provide the health care service meets the standards required by state and federal laws governing the privacy and security of protected health information; and
(v) Beginning January 1, 2023, for audio-only telemedicine, the covered person has an established relationship with the provider.
(b)(i) Except as provided in (b)(ii) of this subsection, a managed care organization shall reimburse a provider for a health care service provided to a covered person through telemedicine the same amount of compensation the managed care organization would pay the provider if the health care service was provided in person by the provider.
(ii) Hospitals, hospital systems, telemedicine companies, and provider groups consisting of eleven or more providers may elect to negotiate an amount of compensation for telemedicine services that differs from the amount of compensation for in-person services.
(iii) For purposes of this subsection (1)(b), the number of providers in a provider group refers to all providers within the group, regardless of a provider's location.
(iv) A rural health clinic shall be reimbursed for audio-only telemedicine at the rural health clinic encounter rate.
(2) For purposes of this section, reimbursement of store and forward technology is available only for those services specified in the negotiated agreement between the managed care organization and health care provider.
(3) An originating site for a telemedicine health care service subject to subsection (1) of this section includes a:
(a) Hospital;
(b) Rural health clinic;
(c) Federally qualified health center;
(d) Physician's or other health care provider's office;
(e) Licensed or certified behavioral health agency;
(f) Skilled nursing facility;
(g) Home or any location determined by the individual receiving the service; or
(h) Renal dialysis center, except an independent renal dialysis center.
(4) Except for subsection (3)(g) of this section, any originating site under subsection (3) of this section may charge a facility fee for infrastructure and preparation of the patient. Reimbursement for a facility fee must be subject to a negotiated agreement between the originating site and the managed care organization. A distant site, a hospital that is an originating site for audio-only telemedicine, or any other site not identified in subsection (3) of this section may not charge a facility fee.
(5) A managed care organization may not distinguish between originating sites that are rural and urban in providing the coverage required in subsection (1) of this section.
(6) A managed care organization may subject coverage of a telemedicine or store and forward technology health service under subsection (1) of this section to all terms and conditions of the plan in which the covered person is enrolled including, but not limited to, utilization review, prior authorization, deductible, copayment, or coinsurance requirements that are applicable to coverage of a comparable health care service provided in person.
(7) This section does not require a managed care organization to reimburse:
(a) An originating site for professional fees;
(b) A provider for a health care service that is not a covered benefit under the plan; or
(c) An originating site or health care provider when the site or provider is not a contracted provider under the plan.
(8)(a) If a provider intends to bill a patient or a managed care organization for an audio-only telemedicine service, the provider must obtain patient consent for the billing in advance of the service being delivered and comply with all rules created by the authority related to restrictions on billing medicaid recipients. The authority may submit information on any potential violations of this subsection to the appropriate disciplining authority, as defined in RCW 18.130.020, or take contractual actions against the provider's agreement for participation in the medicaid program, or both.
(b) If the health care authority has cause to believe that a provider has engaged in a pattern of unresolved violations of this subsection (8), the health care authority may submit information to the appropriate disciplining authority for action. Prior to submitting information to the appropriate disciplining authority, the health care authority may provide the provider with an opportunity to cure the alleged violations or explain why the actions in question did not violate this subsection (8).
(c) If the provider has engaged in a pattern of unresolved violations of this subsection (8), the appropriate disciplining authority may levy a fine or cost recovery upon the provider in an amount not to exceed the applicable statutory amount per violation and take other action as permitted under the authority of the disciplining authority. Upon completion of its review of any potential violation submitted by the health care authority or initiated directly by an enrollee, the disciplining authority shall notify the health care authority of the results of the review, including whether the violation was substantiated and any enforcement action taken as a result of a finding of a substantiated violation.
(9) For purposes of this section:
(a)(i) "Audio-only telemedicine" means the delivery of health care services through the use of audio-only technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment.
(ii) For purposes of this section only, "audio-only telemedicine" does not include:
(A) The use of facsimile or email; or
(B) The delivery of health care services that are customarily delivered by audio-only technology and customarily not billed as separate services by the provider, such as the sharing of laboratory results;
(b) "Disciplining authority" has the same meaning as in RCW 18.130.020;
(c) "Distant site" means the site at which a physician or other licensed provider, delivering a professional service, is physically located at the time the service is provided through telemedicine;
(d) "Established relationship" means the provider providing audio-only telemedicine has access to sufficient health records to ensure safe, effective, and appropriate care services and:
(i) The covered person has had, within the past three years, at least one in-person appointment, or at least one real-time interactive appointment using both audio and video technology, with the provider providing audio-only telemedicine or with a provider employed at the same medical group, at the same clinic, or by the same integrated delivery system operated by a carrier licensed under chapter 48.44 or 48.46 RCW as the provider providing audio-only telemedicine; or
(ii) The covered person was referred to the provider providing audio-only telemedicine by another provider who has had, within the past three years, at least one in-person appointment, or at least one real-time interactive appointment using both audio and video technology, with the covered person and has provided relevant medical information to the provider providing audio-only telemedicine;
(e) "Health care service" has the same meaning as in RCW 48.43.005;
(f) "Hospital" means a facility licensed under chapter 70.41, 71.12, or 72.23 RCW;
(g) "Originating site" means the physical location of a patient receiving health care services through telemedicine;
(h) "Provider" has the same meaning as in RCW 48.43.005;
(i) "Store and forward technology" means use of an asynchronous transmission of a covered person's medical information from an originating site to the health care provider at a distant site which results in medical diagnosis and management of the covered person, and does not include the use of audio-only telephone, facsimile, or email; and
(j) "Telemedicine" means the delivery of health care services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment. For purposes of this section only, "telemedicine" includes audio-only telemedicine, but does not include facsimile or email.
[ 2024 c 215 s 3. Prior: 2023 c 51 s 38; 2023 c 8 s 3; 2022 c 213 s 4; 2021 c 157 s 5; 2020 c 92 s 3; 2017 c 219 s 3; 2016 c 68 s 5; 2015 c 23 s 4.]
Notes:
Conflict with federal requirements—2022 c 213: See note following RCW 41.05.700.
Conflict with federal requirements—2021 c 157: See note following RCW 74.09.327.
Effective date—2020 c 92: See note following RCW 48.43.735.
Effective date—2017 c 219: See note following RCW 48.43.735.
Effective date—Intent—2016 c 68: See notes following RCW 48.43.735.
Effective date—Adoption of sections—2015 c 23 ss 2-4: See notes following RCW 41.05.700.
Intent—2015 c 23: See note following RCW 41.05.700.

catchline: Reimbursement of a health care service provided through telemedicine or store and forward technology—Audio-only telemedicine.


doc_type: statute

jurisdiction: wa

title: RCW 74.09.327

text:
(1) The authority shall adopt rules regarding medicaid fee-for-service reimbursement for services delivered through audio-only telemedicine. Except as provided in subsection (2) of this section, the rules must establish a manner of reimbursement for audio-only telemedicine that is consistent with RCW 74.09.325.
(2) The rules shall require rural health clinics to be reimbursed for audio-only telemedicine at the rural health clinic encounter rate.
(3)(a) For purposes of this section, "audio-only telemedicine" means the delivery of health care services through the use of audio-only technology, permitting real-time communication between a patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment.
(b) For purposes of this section only, "audio-only telemedicine" does not include:
(i) The use of facsimile or email; or
(ii) The delivery of health care services that are customarily delivered by audio-only technology and customarily not billed as separate services by the provider, such as the sharing of laboratory results.
[ 2021 c 157 s 6.]
Notes:
Conflict with federal requirements—2021 c 157: "If any part of this act is found to be in conflict with federal requirements that are a prescribed condition to the allocation of federal funds to the state, the conflicting part of this act is inoperative solely to the extent of the conflict and with respect to the agencies directly affected, and this finding does not affect the operation of the remainder of this act in its application to the agencies concerned. Rules adopted under this act must meet federal requirements that are a necessary condition to the receipt of federal funds by the state. Nothing in this act alters the requirement for the health care authority to report potential fraud to the medicaid fraud control division of the Washington attorney general's office under 42 C.F.R. 455.21." [ 2021 c 157 s 10.]

license: public-domain-government-work

rule_set: Revised Code of Washington

code: rcw

unit: section

court: Washington State Legislature


title: RCW 74.09.328

text:
(1) In order to protect patients and ensure that they benefit from seamless quality care when contracted providers are absent from their practices or when there is a temporary vacancy in a position while a hospital, rural health clinic, or rural provider is recruiting to meet patient demand, hospitals, rural health clinics, and rural providers may use substitute providers to provide services. Medicaid managed care organizations must allow for the use of substitute providers and provide payment consistent with the provisions in this section.
(2) Hospitals, rural health clinics, and rural providers that are contracted with a medicaid managed care organization may use substitute providers that are not contracted with a managed care organization when:
(a) A contracted provider is absent for a limited period of time due to vacation, illness, disability, continuing medical education, or other short-term absence; or
(b) A contracted hospital, rural health clinic, or rural provider is recruiting to fill an open position.
(3) For a substitute provider providing services under subsection (2)(a) of this section, a contracted hospital, rural health clinic, or rural provider may bill and receive payment for services at the contracted rate under its contract with the managed care organization for up to sixty days.
(4) To be eligible for reimbursement under this section for services provided on behalf of a contracted provider for greater than sixty days, a substitute provider must enroll in a medicaid managed care organization. Enrollment of a substitute provider in a medicaid managed care organization is effective on the later of:
(a) The date the substitute provider filed an enrollment application that was subsequently approved; or
(b) The date the substitute provider first began providing services at the hospital, rural health clinic, or rural provider.
(5) A substitute provider who enrolls with a medicaid managed care organization may not bill under subsection (4) of this section for any services billed to the medicaid managed care organization pursuant to subsection (3) of this section.
(6) Nothing in this section obligates a managed care organization to enroll any substitute provider who requests enrollment if they do not meet the organizations enrollment criteria.
(7) For purposes of this section:
(a) "Circumstances precluded enrollment" means that the provider has met all program requirements including state licensure during the thirty-day period before an application was submitted and no final adverse determination precluded enrollment. If a final adverse determination precluded enrollment during this thirty-day period, the contractor shall only establish an effective billing date the day after the date that the final adverse action was resolved, as long as it is not more than thirty days prior to the date on which the application was submitted.
(b) "Contracted provider" means a provider who is contracted with a medicaid managed care organization.
(c) "Hospital" means a facility licensed under chapter 70.41 or 71.12 RCW.
(d) "Rural health clinic" means a federally designated rural health clinic.
(e) "Rural provider" means physicians licensed under chapter 18.71 RCW, osteopathic physicians and surgeons licensed under chapter 18.57 RCW, podiatric physicians and surgeons licensed under chapter 18.22 RCW, physician assistants licensed under chapter 18.71A RCW, osteopathic physician assistants licensed under chapter 18.71A RCW, and *advanced registered nurse practitioners licensed under chapter 18.79 RCW, who are located in a rural county as defined in RCW 82.14.370.
(f) "Substitute provider" includes physicians licensed under chapter 18.71 RCW, osteopathic physicians and surgeons licensed under chapter 18.57 RCW, podiatric physicians and surgeons licensed under chapter 18.22 RCW, physician assistants licensed under chapter 18.71A RCW, osteopathic physician assistants licensed under chapter 18.71A RCW, and *advanced registered nurse practitioners licensed under chapter 18.79 RCW.
[ 2023 c 51 s 39; 2020 c 4 s 3.]
Notes:
*Reviser's note: The term "advanced registered nurse practitioner" was changed to "advanced practice registered nurse" by 2024 c 239 s 1, effective June 30, 2027.
Effective date—2020 c 4 s 3: "Section 3 of this act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect immediately [March 17, 2020]." [ 2020 c 4 s 4.]

catchline: Use of substitute providers—When permitted—Reimbursement requirements.


title: RCW 74.09.330

text:
The authority shall develop a reimbursement methodology for ambulance services when transporting a medical assistance enrollee to a mental health facility or chemical dependency program in accordance with the applicable alternative facility procedures adopted under RCW 70.168.100.
[ 2015 c 157 s 6.]

catchline: Reimbursement methodology for ambulance services—Transport of a medical assistance enrollee to a mental health facility or chemical dependency program.


title: RCW 74.09.335

text:
The authority shall adopt standards for the reimbursement of health care services provided to eligible clients by fire departments pursuant to a community assistance referral and education services program under RCW 35.21.930. The standards must allow payment for covered health care services provided to individuals whose medical needs do not require ambulance transport to an emergency department.
[ 2017 c 273 s 1.]

catchline: Reimbursement of health care services provided by fire departments—Adoption of standards.


title: RCW 74.09.340

text:
(1) Except as provided in RCW 72.36.160, beginning July 1, 2023, the personal needs allowance for clients being served in medical institutions and in residential settings is $100.
(2) Beginning January 1, 2024, and each year thereafter, the personal needs allowance for clients being served in medical institutions and in residential settings shall:
(a) Be adjusted for economic trends and conditions by increasing the allowance by the percentage cost-of-living adjustment for old-age, survivors, and disability social security benefits as published by the federal social security administration; and
(b) Not exceed the maximum personal needs allowance permissible under the federal social security act.
(3) Unless subject to a separate determination of a monthly maintenance needs allowance for a community spouse by authority rule, beginning July 1, 2022, the personal needs allowance for a client receiving home and community-based waiver services authorized by home and community services while living at home shall:
(a) Be adjusted to an amount that is no less than 300 percent of the federal benefit rate; and
(b) Not exceed the maximum personal needs allowance permissible under the federal social security act.
[ 2023 c 201 s 1; 2022 c 164 s 1; 2018 c 137 s 1; 2017 c 270 s 2.]
Notes:
Findings—Intent—2017 c 270: "(1) The legislature finds that through the medicaid program, state and federal government fund long-term care, mental health, and medical services for many elderly persons and people with disabilities, both in institutions and in community alternatives. The legislature also finds that a significant portion of these individuals' social security benefits is retained by the state to assist with the cost of their care. The legislature intends that these individuals retain for their own use a reasonable and modest personal needs allowance which may be used to purchase clothing, postage, barber services, travel, and other personal items not covered by their care setting, in order to promote their autonomy and personal dignity.
(2) It is the intent of the legislature to adjust the personal needs allowance annually to reflect cost-of-living adjustments to federal social security benefits for medicaid-eligible residents in institutions and community-based residential settings receiving long-term care, developmental disabilities, or mental health services." [ 2017 c 270 s 1.]
Effective date—2017 c 270: "Section 2 of this act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect July 1, 2017." [ 2017 c 270 s 3.]

catchline: Personal needs allowance, adjusted.


title: RCW 74.09.390

text:
(1) Subject to the availability of amounts appropriated for this specific purpose, the authority shall expand the access to baby and child dentistry (ABCD) program to include eligible children as clients.
(2) Once enrolled in the program, eligible children must be covered until their thirteenth birthday.
(3) Eligible children enrolled in the program shall receive all services and benefits received by program clients.
(4) The authority shall pay enhanced fees for program services provided to eligible children enrolled in the program to dentists, primary care providers, and dental hygienists certified to provide program services. To receive certification to provide program services to eligible children, a dentist, primary care provider, or dental hygienist must:
(a) Be licensed under Title 18 RCW; and
(b) Complete a course on treating eligible children as defined by the authority in rule.
(5) On or before December 15, 2020, and on or before December 15, 2021, the authority, in consultation with any organizations administering the program, shall provide a report, in compliance with RCW 43.01.036, to the health care and fiscal committees of the legislature, to include:
(a) The number of dentists, primary care providers, and dental hygienists participating in the program; and
(b) The number of eligible children who received treatment through the program.
(6) For purposes of this section:
(a) "Eligible children" means all individuals who meet clinical criteria established by the authority, who are under the age of thirteen with a disability attributable to intellectual disability, cerebral palsy, epilepsy, autism, or another neurological condition closely related to an intellectual disability or that requires treatment similar to that required for persons with intellectual disabilities, which has continued or can be expected to continue indefinitely, and which constitutes a substantial limitation to such individual, who are eligible for one of the following medical assistance programs:
(i) Categorically needy program;
(ii) Limited casualty program-medically needy program;
(iii) Children's health program; or
(iv) State children's health insurance program.
(b) "Program" means the access to baby and child dentistry program as established by WAC 182-535-1245 or successor rule.
[ 2020 c 242 s 1; 2018 c 156 s 1.]

catchline: Access to baby and child dentistry program—Coverage for eligible children—Authority's duties—Report to legislature.


title: RCW 74.09.395

text:
(1) The authority, in consultation with the office of equity, created in chapter 332, Laws of 2020, shall work with the statewide managing partner of the access to baby and child dentistry program to develop a local access to baby and child dentistry program fund allocation formula, key deliverables, and target metrics for increased outreach and provider engagement and support with the goal of reducing racial and ethnic disparities.
(2) The authority, in consultation with the office of equity, created in chapter 332, Laws of 2020, shall collaborate with stakeholders to monitor progress toward the goals articulated in subsection (1) of this section and provide support to local access to baby and child dentistry programs and providers.
[ 2020 c 293 s 2.]
Notes:
Intent—2020 c 293: "The legislature recognizes that oral disease is the most common childhood chronic disease, yet is almost entirely preventable, impacting school readiness, future employability, and overall well-being and quality of life. The access to baby and child dentistry program has made Washington a leader in oral health care access across the nation, providing greater levels of access and utilization for medicaid eligible children under six years old. The legislature further recognizes that the access to baby and child dentistry program connects children to a dental home in their communities, enabling children to get off to a healthy start. While the state has made great strides, children of color continue to experience higher rates of tooth decay than their peers and children under the age of two are not accessing care at the same rate as older children. Therefore, it is the legislature's intent to expand on the program investments the state has already made to provide additional outreach and support to eligible families and providers, increase very young children's access to care, and further reduce racial and ethnic disparities in access to care and oral health outcomes." [ 2020 c 293 s 1.]

catchline: Access to baby and child dentistry program—Outreach and engagement—Stakeholder collaboration.


title: RCW 74.09.402

text:
(1) The legislature finds that:
(a) Improving the health of children in Washington state is an investment in a productive and successful next generation. The health of children is critical to their success in school and throughout their lives;
(b) Healthy children are ready to learn. In order to provide students with the opportunity to become responsible citizens, to contribute to their own economic well-being and to that of their families and communities, and to enjoy productive and satisfying lives, the state recognizes the importance that access to appropriate health services and improved health brings to the children of Washington state. In addition, fully immunized children are themselves protected, and in turn protect others, from contracting communicable diseases;
(c) Children with health insurance coverage have better health outcomes than those who lack coverage. Children without health insurance coverage are more likely to be in poor health and more likely to delay receiving, or go without, needed health care services;
(d) Health care coverage for children in Washington state is the product of critical efforts in both the private and public sectors to help children succeed. Private health insurance coverage is complemented by public programs that meet needs of low-income children whose parents are not offered health insurance coverage through their employer or who cannot otherwise afford the costs of coverage. In 2006, thirty-five percent of children in Washington state had some form of public health coverage. Washington state is making progress in its efforts to increase the number of children with health care coverage. Yet, even with these efforts of both private and public sectors, many children in Washington state continue to lack health insurance coverage. In 2006, over seventy thousand children were uninsured. Almost two-thirds of these children are in families whose income is under two hundred fifty percent of the federal poverty level; and
(e) Improved health outcomes for the children of Washington state are the expected result of improved access to health care coverage. Linking children with a medical home that provides preventive and well child health services and referral to needed specialty services, linking children with needed behavioral health and dental services, more effectively managing childhood diseases, improving nutrition, and increasing physical activity are key to improving children's health. Care should be provided in appropriate settings by efficient providers, consistent with high quality care and at an appropriate stage, soon enough to avert the need for overly expensive treatment.
(2) It is therefore the intent of the legislature that:
(a) All children in the state of Washington have health care coverage by 2010. This should be accomplished by building upon and strengthening the successes of private health insurance coverage and publicly supported children's health insurance programs in Washington state. Access to coverage should be streamlined and efficient, with reductions in unnecessary administrative costs and mechanisms to expeditiously link children with a medical home;
(b) The state, in collaboration with parents, schools, communities, health plans, and providers, take steps to improve health outcomes for the children of Washington state by linking children with a medical home, identifying health improvement goals for children, and linking innovative purchasing strategies to those goals.
[ 2007 c 5 s 1; 2005 c 279 s 1.]

catchline: Children's health care—Findings—Intent.


title: RCW 74.09.460

text:
(1) The legislature finds that parents have a responsibility to:
(a) Enroll their children in affordable health coverage;
(b) Ensure that their children receive appropriate well-child preventive care;
(c) Link their child with a medical home; and
(d) Understand and act upon the health benefits of good nutrition and physical activity.
(2) The legislature intends that the programs and outreach and education efforts established in RCW 74.09.470(6), as well as partnerships with the public and private sectors, provide the support and information needed by parents to meet the responsibilities set forth in this section.
[ 2007 c 5 s 3.]

catchline: Children's affordable health coverage—Findings—Intent.


title: RCW 74.09.470

text:
(1) Consistent with the goals established in RCW 74.09.402, through the apple health for kids program authorized in this section, the authority shall provide affordable health care coverage to children under the age of nineteen who reside in Washington state and whose family income at the time of enrollment is not greater than 260 percent of the federal poverty level as adjusted for family size and determined annually by the federal department of health and human services, and effective January 1, 2009, and only to the extent that funds are specifically appropriated therefor, to children whose family income is not greater than 312 percent of the federal poverty level. In administering the program, the authority shall take such actions as may be necessary to ensure the receipt of federal financial participation under the medical assistance program, as codified at Title XIX of the federal social security act, the state children's health insurance program, as codified at Title XXI of the federal social security act, and any other federal funding sources that are now available or may become available in the future. The authority and the caseload forecast council shall estimate the anticipated caseload and costs of the program established in this section.
(2) The authority shall accept applications for enrollment for children's health care coverage; establish appropriate minimum-enrollment periods, as may be necessary; and determine eligibility based on current family income. The authority shall make eligibility determinations within the time frames for establishing eligibility for children on medical assistance, as defined by RCW 74.09.510. The application and annual renewal processes shall be designed to minimize administrative barriers for applicants and enrolled clients, and to minimize gaps in eligibility for families who are eligible for coverage. If a change in family income results in a change in the source of funding for coverage, the authority shall transfer the family members to the appropriate source of funding and notify the family with respect to any change in premium obligation, without a break in eligibility. The authority shall use the same eligibility redetermination and appeals procedures as those provided for children on medical assistance programs. The authority shall modify its eligibility renewal procedures to lower the percentage of children failing to annually renew. The authority shall manage its outreach, application, and renewal procedures with the goals of: (a) Achieving year by year improvements in enrollment, enrollment rates, renewals, and renewal rates; (b) maximizing the use of existing program databases to obtain information related to earned and unearned income for purposes of eligibility determination and renewals, including, but not limited to, the basic food program, the child care subsidy program, federal social security administration programs, and the employment security department wage database; (c) streamlining renewal processes to rely primarily upon data matches, online submissions, and telephone interviews; and (d) implementing any other eligibility determination and renewal processes to allow the state to receive an enhanced federal matching rate and additional federal outreach funding available through the federal children's health insurance program reauthorization act of 2009 by January 2010. The department shall advise the governor and the legislature regarding the status of these efforts by September 30, 2009. The information provided should include the status of the department's efforts, the anticipated impact of those efforts on enrollment, and the costs associated with that enrollment.
(3) To ensure continuity of care and ease of understanding for families and health care providers, and to maximize the efficiency of the program, the amount, scope, and duration of health care services provided to children under this section shall be the same as that provided to children under medical assistance, as defined in RCW 74.09.520.
(4) The primary mechanism for purchasing health care coverage under this section shall be through contracts with managed health care systems as defined in RCW 74.09.522, subject to conditions, limitations, and appropriations provided in the biennial appropriations act. However, the authority shall make every effort within available resources to purchase health care coverage for uninsured children whose families have access to dependent coverage through an employer-sponsored health plan or another source when it is cost-effective for the state to do so, and the purchase is consistent with requirements of Title XIX and Title XXI of the federal social security act. To the extent allowable under federal law, the authority shall require families to enroll in available employer-sponsored coverage, as a condition of participating in the program established under this section, when it is cost-effective for the state to do so. Families who enroll in available employer- sponsored coverage under this section shall be accounted for separately in the annual report required by RCW 74.09.053.
(5)(a) To reflect appropriate parental responsibility, the authority shall develop and implement a schedule of premiums for children's health care coverage due to the authority from families with income greater than 210 percent of the federal poverty level. For families with income greater than 260 percent of the federal poverty level, the premiums shall be established in consultation with the senate majority and minority leaders and the speaker and minority leader of the house of representatives. For children eligible for coverage under the federally funded children's health insurance program, Title XXI of the federal social security act, premiums shall be set at a reasonable level that does not pose a barrier to enrollment. The amount of the premium shall be based upon family income and shall not exceed the premium limitations in Title XXI of the federal social security act. For children who are not eligible for coverage under the federally funded children's health insurance program, premiums shall be set every two years in an amount no greater than the average state-only share of the per capita cost of coverage in the state-funded children's health program.
(b) Premiums shall not be imposed on children in households at or below 210 percent of the federal poverty level as articulated in RCW 74.09.055.
(c) The authority shall offer families whose income is greater than 312 percent of the federal poverty level the opportunity to purchase health care coverage for their children through the programs administered under this section without an explicit premium subsidy from the state. The design of the health benefit package offered to these children should provide a benefit package substantially similar to that offered in the apple health for kids program, and may differ with respect to cost-sharing, and other appropriate elements from that provided to children under subsection (3) of this section including, but not limited to, application of preexisting conditions, waiting periods, and other design changes needed to offer affordable coverage. The amount paid by the family shall be in an amount equal to the rate paid by the state to the managed health care system for coverage of the child, including any associated and administrative costs to the state of providing coverage for the child. Any pooling of the program enrollees that results in state fiscal impact must be identified and brought to the legislature for consideration.
(6) The authority shall undertake and continue a proactive, targeted outreach and education effort with the goal of enrolling children in health coverage and improving the health literacy of youth and parents. The authority shall collaborate with the department of social and health services, department of health, local public health jurisdictions, the office of the superintendent of public instruction, the department of children, youth, and families, health educators, health care providers, health carriers, community-based organizations, and parents in the design and development of this effort. The outreach and education effort shall include the following components:
(a) Broad dissemination of information about the availability of coverage, including media campaigns;
(b) Assistance with completing applications, and community-based outreach efforts to help people apply for coverage. Community-based outreach efforts should be targeted to the populations least likely to be covered;
(c) Use of existing systems, such as enrollment information from the free and reduced-price lunch program, the department of children, youth, and families child care subsidy program, the department of health's women, infants, and children program, and the early childhood education and assistance program, to identify children who may be eligible but not enrolled in coverage;
(d) Contracting with community-based organizations and government entities to support community-based outreach efforts to help families apply for coverage. These efforts should be targeted to the populations least likely to be covered. The authority shall provide informational materials for use by government entities and community-based organizations in their outreach activities, and should identify any available federal matching funds to support these efforts;
(e) Development and dissemination of materials to engage and inform parents and families statewide on issues such as: The benefits of health insurance coverage; the appropriate use of health services, including primary care provided by health care practitioners licensed under chapters 18.71, 18.57, 18.36A, and 18.79 RCW, and emergency services; the value of a medical home, well-child services and immunization, and other preventive health services with linkages to department of health child profile efforts; identifying and managing chronic conditions such as asthma and diabetes; and the value of good nutrition and physical activity;
(f) An evaluation of the outreach and education efforts, based upon clear, cost-effective outcome measures that are included in contracts with entities that undertake components of the outreach and education effort;
(g) An implementation plan to develop online application capability that is integrated with the automated client eligibility system, and to develop data linkages with the office of the superintendent of public instruction for free and reduced-price lunch enrollment information and the department of children, youth, and families for child care subsidy program enrollment information.
(7) The authority shall take action to increase the number of primary care physicians providing dental disease preventive services including oral health screenings, risk assessment, family education, the application of fluoride varnish, and referral to a dentist as needed.
(8) The department shall monitor the rates of substitution between private-sector health care coverage and the coverage provided under this section.
[ 2023 c 51 s 40; 2018 c 58 s 2; 2011 1st sp.s. c 33 s 2; 2011 1st sp.s. c 15 s 21; 2009 c 463 s 2; 2007 c 5 s 2.]
Notes:
Reviser's note: Chapter 33, Laws of 2011 1st sp.s. took effect April 1, 2011, but amended 2011 1st sp.s. c 15, which took effect July 1, 2011.
Effective date—2018 c 58: See note following RCW 28A.655.080.
Contingent effective dates—2011 1st sp.s. c 33: "(1) Section 1 of this act takes effect if section 21, chapter 15, Laws of 2011 1st sp. sess. is not enacted into law.
(2) Section 2 of this act takes effect if section 21, chapter 15, Laws of 2011 1st sp. sess. is enacted into law." [ 2011 1st sp.s. c 33 s 3.]
Effective date—2011 1st sp.s. c 33: "Subject to section 3 of this act, this act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect April 1, 2011." [ 2011 1st sp.s. c 33 s 4.]
Effective date—Findings—Intent—Report—Agency transfer—References to head of health care authority—Draft legislation—2011 1st sp.s. c 15: See notes following RCW 74.09.010.
Findings—Intent—2009 c 463: "The legislature finds that substantial progress has been made toward achieving the equally important goals set in 2007 that all children in Washington state have health care coverage by 2010 and that child health outcomes improve. The legislature also finds that continued steps are necessary to reach the goals that all children in Washington state shall have access to the health services they need to be healthy and ready to learn and that key measures of child health outcomes will show year by year improvement. The legislature further finds that reaching these goals is integral to the state's ability to weather the current economic crisis. The recent reauthorization of the federal children's health insurance program provides additional opportunities for the state to reach these goals. In view of these important objectives, the legislature intends that the apple health for kids program be managed actively across administrations in the department of social and health services, and across state and local agencies, with clear accountability for achieving the intended program outcomes. The legislature further intends that the department continue the implementation of the apple health for kids program with a commitment to fully utilizing the new program identity with appropriate materials." [ 2009 c 463 s 1.]
Short title—2009 c 463: "This act may be known and cited as the apple health for kids act." [ 2009 c 463 s 5.]

catchline: Children's affordable health coverage—Authority duties.


title: RCW 74.09.4701

text:
For apple health for kids, the department shall not count the twenty-five dollar increase paid as part of an individual's weekly benefit amount when determining family income, eligibility, and payment levels.
[ 2023 c 51 s 41; 2011 c 4 s 19.]
Notes:
Effective date—2011 c 4 ss 1-6 and 16-21: See note following RCW 50.20.120.
Conflict with federal requirements—2011 c 4: See note following RCW 50.29.021.

catchline: Apple health for kids—Unemployment compensation.


title: RCW 74.09.475

text:
(1) Effective January 1, 2018, the authority shall require that all health care facilities that provide newborn delivery services to medical assistance clients establish policies and procedures to provide:
(a) Skin-to-skin placement of the newborn on the mother's chest immediately following birth to promote the initiation of breastfeeding, except as otherwise indicated by authority guidelines; and
(b) Room-in practices in which a newborn and a mother share the same room for the duration of their postdelivery stay at the facility, except as otherwise indicated by authority guidelines.
(2) The authority shall provide guidelines for hospitals to use when establishing policies and procedures for services under subsection (1) of this section, including circumstances in which providing the services is not appropriate.
(3) The authority shall require managed care organizations to report on the frequency with which each facility they contract with is able to adhere to the policies and procedures and the most common reasons for nonadherence. The authority shall include a summary of this information in the biennial report required under RCW 74.09.480(3).
[ 2017 c 294 s 2.]
Notes:
Findings—2017 c 294: "(1) The legislature finds that the state has an interest in assuring that children are given the opportunity to have a healthy start in life. Because approximately half of all births in Washington state are funded by state resources, and over eight hundred thousand children in Washington state are enrolled in the apple health program, the state is in a unique position to make a difference in the health of children in Washington.
(2) The legislature also finds that there may be gaps in programs that could greatly benefit children. Where programs may benefit children in their early stages of development, the state must assure they receive these benefits. Where children are not receiving services because the public is unaware of the services, opportunities for outreach must be explored.
(3) The legislature additionally finds that several hospitals have begun adopting the best practices of the baby-friendly hospital initiative. The state can use its resources to encourage hospitals to adopt some of the most critical components by incorporating the standards into medicaid contracts.
(4) The legislature further finds that providing children with a healthy start also requires promoting healthy pregnancies. In one national survey, pregnant workers said they needed more frequent breaks while pregnant. Prenatal care is also critical for positive birth outcomes, and pregnant women have cited the need for flexibility in their work schedule for the purposes of attending doctor visits. Reasonable accommodations for pregnant women in the workplace can go a long way to promoting healthy pregnancies without producing an undue hardship on employers." [ 2017 c 294 s 1.]

catchline: Newborn delivery services to medical assistance clients—Policies and procedures—Reporting.


title: RCW 74.09.480

text:
(1) The authority, in collaboration with the department of health, department of social and health services, health carriers, local public health jurisdictions, children's health care providers including pediatricians, family practitioners, *advanced registered nurse practitioners, certified nurse midwives, and pediatric subspecialists, community and migrant health centers, parents, and other purchasers, shall establish a concise set of explicit performance measures that can indicate whether children enrolled in the program are receiving health care through an established and effective medical home, and whether the overall health of enrolled children is improving. Such indicators may include, but are not limited to:
(a) Childhood immunization rates;
(b) Well child care utilization rates, including the use of behavioral and oral health screening, and validated, structured developmental screens using tools, that are consistent with nationally accepted pediatric guidelines and recommended administration schedule, once funding is specifically appropriated for this purpose;
(c) Care management for children with chronic illnesses;
(d) Emergency room utilization;
(e) Visual acuity and eye health;
(f) Preventive oral health service utilization; and
(g) Children's mental health status. In defining these measures the authority shall be guided by the measures provided in RCW 71.36.025.
Performance measures and targets for each performance measure must be established and monitored each biennium, with a goal of achieving measurable, improved health outcomes for the children of Washington state each biennium.
(2) Beginning in calendar year 2009, targeted provider rate increases shall be linked to quality improvement measures established under this section. The authority, in conjunction with those groups identified in subsection (1) of this section, shall develop parameters for determining criteria for increased payment, alternative payment methodologies, or other incentives for those practices and health plans that incorporate evidence-based practice and achieve sustained improvement with respect to the measures.
(3) The department shall provide a report to the governor and the legislature related to provider performance on these measures, as well as the information collected under RCW 74.09.475, beginning in September 2010 for 2007 through 2009 and the authority shall provide the report biennially thereafter.
[ 2023 c 51 s 42; 2017 c 294 s 4; 2011 1st sp.s. c 15 s 22; 2009 c 463 s 4; 2007 c 5 s 4.]
Notes:
*Reviser's note: The term "advanced registered nurse practitioner" was changed to "advanced practice registered nurse" by 2024 c 239 s 1, effective June 30, 2027.
Findings—2017 c 294: See note following RCW 74.09.475.
Effective date—Findings—Intent—Report—Agency transfer—References to head of health care authority—Draft legislation—2011 1st sp.s. c 15: See notes following RCW 74.09.010.
Findings—Intent—Short title—2009 c 463: See notes following RCW 74.09.470.

catchline: Performance measures—Provider rate increases—Report.


title: RCW 74.09.490

text:
(1) The authority, in consultation with the evidence-based practice institute established in RCW 71.24.061, shall develop and implement policies to improve prescribing practices for treatment of emotional or behavioral disturbances in children, improve the quality of children's mental health therapy through increased use of evidence-based and research-based practices and reduced variation in practice, improve communication and care coordination between primary care and mental health providers, and prioritize care in the family home or care which integrates the family where out-of-home placement is required.
(2) The authority shall identify those children with emotional or behavioral disturbances who may be at high risk due to off-label use of prescription medication, use of multiple medications, high medication dosage, or lack of coordination among multiple prescribing providers, and establish one or more mechanisms to evaluate the appropriateness of the medication these children are using, including but not limited to obtaining second opinions from experts in child psychiatry.
(3) The authority shall review the psychotropic medications of all children under five and establish one or more mechanisms to evaluate the appropriateness of the medication these children are using, including but not limited to obtaining second opinions from experts in child psychiatry.
(4) Within existing funds, the authority shall require a second opinion review from an expert in psychiatry for all prescriptions of one or more antipsychotic medications of all children under eighteen years of age in the foster care system. Thirty days of a prescription medication may be dispensed pending the second opinion review. The second opinion feedback must include discussion of the psychosocial interventions that have been or will be offered to the child and caretaker if appropriate in order to address the behavioral issues brought to the attention of the prescribing physician.
(5) The authority shall track prescriptive practices with respect to psychotropic medications with the goal of reducing the use of medication.
(6) The authority shall promote the appropriate use of cognitive behavioral therapies and other treatments which are empirically supported or evidence-based, in addition to or in the place of prescription medication where appropriate and such interventions are available.
[ 2015 c 283 s 2; 2011 1st sp.s. c 15 s 23; 2007 c 359 s 5.]
Notes:
Effective date—Findings—Intent—Report—Agency transfer—References to head of health care authority—Draft legislation—2011 1st sp.s. c 15: See notes following RCW 74.09.010.
Captions not law—2007 c 359: See note following RCW 71.36.005.

catchline: Children's mental health—Improving medication management and care coordination.


title: RCW 74.09.495

text:
(1) To better assure and understand issues related to network adequacy and access to services, the authority shall report to the appropriate committees of the legislature by December 1, 2017, and annually thereafter, on the status of access to behavioral health services for children from birth through age seventeen using data collected pursuant to RCW 70.320.050.
(2) At a minimum, the report must include the following components broken down by age, gender, and race and ethnicity:
(a) The percentage of discharges for patients ages six through seventeen who had a visit to the emergency room with a primary diagnosis of mental health or alcohol or other drug dependence during the measuring year and who had a follow-up visit with any provider with a corresponding primary diagnosis of mental health or alcohol or other drug dependence within thirty days of discharge;
(b) The percentage of health plan members with an identified mental health need who received mental health services during the reporting period;
(c) The percentage of children served by behavioral health administrative services organizations and managed care organizations, including the types of services provided;
(d) The number of children's mental health providers available in the previous year, the languages spoken by those providers, and the overall percentage of children's mental health providers who were actively accepting new patients; and
(e) Data related to mental health and medical services for eating disorder treatment in children and youth by county, including the number of:
(i) Eating disorder diagnoses;
(ii) Patients treated in outpatient, residential, emergency, and inpatient care settings; and
(iii) Contracted providers specializing in eating disorder treatment and the overall percentage of those providers who were actively accepting new patients during the reporting period.
[ 2019 c 325 s 4002; 2018 c 175 s 3; 2017 c 226 s 6; 2017 c 202 s 3; 2016 c 96 s 3.]
Notes:
Effective date—2019 c 325: See note following RCW 71.24.011.
Findings—Intent—2018 c 175: "The legislature finds that the children's mental health work group established in chapter 96, Laws of 2016 reported recommendations in December 2016 related to increasing access to adequate, appropriate, and culturally and linguistically relevant mental health services for children and youth. The legislature further finds that legislation implementing many of the recommendations of the children's mental health work group was enacted in 2017. Despite these gains, barriers to service remain and additional work is required to assist children with securing adequate mental health treatment. The legislature further finds that by January 1, 2020, the community behavioral health program must be fully integrated in a managed care health system that provides behavioral and physical health care services to medicaid clients. Therefore, it is the intent of the legislature to reestablish the children's mental health work group through December 2020 and to implement additional recommendations from the work group in order to improve mental health care access for children and their families." [ 2018 c 175 s 1.]
Sustainable solutions for the integration of behavioral and physical health—2017 c 226: See note following RCW 74.09.497.
Findings—Intent—2017 c 202: "The legislature finds that children and their families face systemic barriers to accessing necessary mental health services. These barriers include a workforce shortage of mental health providers throughout the system of care. Of particular concern are shortages of providers in underserved rural areas of our state and a shortage of providers statewide who can deliver culturally and linguistically appropriate services. The legislature further finds that greater coordination across systems, including early learning, K-12 education, and health care, is necessary to provide children and their families with coordinated care.
The legislature further finds that until mental health and physical health services are fully integrated in the year 2020, children who are eligible for medicaid services and require mental health treatment should receive coordinated mental health and physical health services to the fullest extent possible.
The legislature further finds that in 2013, the department of social and health services and the health care authority reported that only forty percent of the children on medicaid who had mental health treatment needs were receiving services and that mental health treatment needs increase with the number of adverse childhood experiences that a child has undergone.
The legislature further finds that children with mental health service needs have higher rates of emergency room use, criminal justice system involvement, and an increased risk of homelessness, and that trauma-informed care can mitigate some of these negative outcomes.
Therefore, the legislature intends to implement recommendations from the children's mental health work group, as reported in December 2016, in order to improve mental health care access for children and their families through the early learning, K-12 education, and health care systems. The legislature further intends to encourage providers to use behavioral health therapies and other therapies that are empirically supported or evidence-based and only prescribe medications for children and youth as a last resort." [ 2017 c 202 s 1.]
Findings—Intent—2016 c 96: "(1) The legislature understands that adverse childhood experiences, such as family mental health issues, substance abuse, serious economic hardship, and domestic violence, all increase the likelihood of developmental delays and later health and mental health problems. The legislature further understands that early intervention services for children and families at high risk for adverse childhood experience help build secure parent-child attachment and bonding, which allows young children to thrive and form strong relationships in the future. The legislature finds that early identification and intervention are critical for children exhibiting aggressive or depressive behaviors indicative of early mental health problems. The legislature intends to improve access to adequate, appropriate, and culturally responsive mental health services for children and youth. The legislature further intends to encourage the use of behavioral health therapies and other therapies that are empirically supported or evidence-based and only prescribe medications for children and youth as a last resort.
(2) The legislature finds that nearly half of Washington's children are enrolled in medicaid and have a higher incidence of serious health problems compared to children who have commercial insurance. The legislature recognizes that disparities also exist in the diagnosis and initiation of treatment services for children of color, with studies demonstrating that children of color are diagnosed and begin receiving early interventions at a later age. The legislature finds that within the current system of care, families face barriers to receiving a full range of services for children experiencing behavioral health problems. The legislature intends to identify what network adequacy requirements, if strengthened, would increase access, continuity, and coordination of behavioral health services for children and families. The legislature further intends to encourage managed care plans and behavioral health organizations to contract with the same providers that serve children so families are not required to duplicate mental health screenings, and to recommend provider rates for mental health services to children and youth which will ensure an adequate network and access to quality based care.
(3) The legislature recognizes that early and accurate recognition of behavioral health issues coupled with appropriate and timely intervention enhances health outcomes while minimizing overall expenditures. The legislature intends to assure that annual depression screenings are done consistently with the highly vulnerable medicaid population and that children and families benefit from earlier access to services." [ 2016 c 96 s 1.]

catchline: Access to children's behavioral health services—Report to legislature.


title: RCW 74.09.4951

text:
(1) The children and youth behavioral health work group is established to:
(a) Identify barriers to and opportunities for accessing behavioral health services for children, youth, and young adults and their families;
(b) Strengthen and build a coordinated systemic approach to providing behavioral health care and supports that ensure that all children, youth, young adults, and their families have timely access to high quality, equitable, well-resourced behavioral health education, care, and supports across the continuum when and where they need it, including prenatal care;
(c) Advise and provide recommendations to the children and youth behavioral health leadership council established in RCW 43.06.547 regarding implementation of the Washington thriving strategic plan developed under subsection (6) of this section and the system of care that the strategic plan outlines; and
(d) Advise the legislature on statewide behavioral health services for this population.
(2) The work group shall consist of members and alternates as provided in this subsection. Members must represent the regional, racial, and cultural diversity of all children and families in the state.
(a) The president of the senate shall appoint one member and one alternate from each of the two largest caucuses in the senate.
(b) The speaker of the house of representatives shall appoint one member and one alternate from each of the two largest caucuses in the house of representatives.
(c) The governor shall appoint six members representing the following state agencies and offices: The department of children, youth, and families; the department of social and health services; the health care authority; the department of health; the office of homeless youth prevention and protection programs; and the office of the governor.
(d) Subject to the requirements under (k) of this subsection, the governor shall appoint the following members:
(i) One representative of behavioral health administrative services organizations;
(ii) One representative of community mental health agencies;
(iii) Two representatives of medicaid managed care organizations, one of which must provide managed care to children and youth receiving child welfare services;
(iv) One regional provider of co-occurring disorder services;
(v) One pediatrician or primary care provider;
(vi) One provider specializing in infant or early childhood mental health;
(vii) One representative who advocates for behavioral health issues on behalf of children and youth;
(viii) One representative of early learning and child care providers;
(ix) One representative of the evidence-based practice institute;
(x) Two parents or caregivers of children who have received behavioral health services, one of which must have a child under the age of six;
(xi) One representative of an education or teaching institution that provides training for mental health professionals;
(xii) One foster parent;
(xiii) One representative of providers of culturally and linguistically appropriate health services to traditionally underserved communities;
(xiv) One pediatrician located east of the crest of the Cascade mountains;
(xv) One child psychiatrist;
(xvi) One representative of an organization representing the interests of individuals with developmental disabilities;
(xvii) Three youth or young adult representatives who have experience with behavioral health services;
(xviii) One representative of a private insurance organization;
(xix) One representative from the statewide family youth system partner roundtable established in the T.R. v. Strange and McDermott, formerly the T.R. v. Dreyfus and Porter, settlement agreement;
(xx) One representative from educational service districts established under chapter 28A.310 RCW; and
(xxi) One substance use disorder professional.
(e) The governor shall appoint two representatives of federally recognized Indian tribes whose traditional lands and territories included parts of Washington, nominated by the governor's Indian health advisory council established in RCW 43.71B.020. The participation of these representatives supports, but does not replace, tribal consultation requirements including an agency's responsibilities under chapter 43.376 RCW.
(f) The superintendent of public instruction shall appoint one representative from the office of the superintendent of public instruction.
(g) The insurance commissioner shall appoint one representative from the office of the insurance commissioner.
(h) The work group shall choose one of the work group's cochairs from among its legislative members and the other cochair must be the representative from the health care authority. The representative from the health care authority shall convene at least two meetings of the work group each year.
(i) The cochairs may invite additional members of the house of representatives and the senate to participate in work group activities, including as leaders of advisory groups to the work group. These legislators are not required to be formally appointed members of the work group in order to participate in or lead advisory groups.
(j) The cochairs may request that the governor appoint additional members of the work group representing specific professions, organizations, or communities. The governor's office may consult with the cochairs as needed on these discretionary appointments.
(k) The terms for work group members appointed under (d) of this subsection after June 6, 2024, may not exceed three years. Work group members appointed under (d) of this subsection before June 6, 2024, may remain in their positions until January 1, 2027, but their terms may not go beyond that date.
(3) The work group shall:
(a) Monitor the implementation of enacted legislation, programs, and policies related to children and youth behavioral health, including provider payment for mood, anxiety, and substance use disorder prevention, screening, diagnosis, and treatment for children and young mothers; consultation services for child care providers caring for children with symptoms of trauma; home visiting services; and streamlining agency rules for providers of behavioral health services;
(b) Consider system strategies to improve coordination and remove barriers between the early learning, K-12 education, and health care systems;
(c) Identify opportunities to remove barriers to treatment and strengthen behavioral health service delivery for children and youth;
(d) Determine the strategies and resources needed to:
(i) Improve inpatient and outpatient access to behavioral health services;
(ii) Support the unique needs of young children prenatally through age five, including promoting health and social and emotional development in the context of children's family, community, and culture;
(iii) Develop and sustain system improvements to support the behavioral health needs of children, youth, and young adults; and
(iv) Achieve parity of private health insurance coverage for behavioral health conditions with the coverage provided for other health conditions;
(e) Consider issues and recommendations put forward by the statewide family youth system partner roundtable established in the T.R. v. Strange and McDermott, formerly the T.R. v. Dreyfus and Porter, settlement agreement; and
(f) Use the Washington thriving strategic plan developed under subsection (6) of this section to guide the priorities and efforts of the work group.
(4) At the direction of the cochairs, the work group may convene advisory groups to evaluate specific issues and report related findings and recommendations to the full work group.
(5) The work group shall convene an advisory group focused on school-based behavioral health and suicide prevention. The advisory group shall advise the full work group on creating and maintaining an integrated system of care through a tiered support framework for preschool through twelfth grade school systems defined by the office of the superintendent of public instruction and behavioral health care systems that can rapidly identify students in need of care and effectively link these students to appropriate services, provide age-appropriate education on behavioral health and other universal supports for social-emotional wellness for all students, and improve both education and behavioral health outcomes for students. The school-based behavioral health and suicide prevention advisory group shall consider the broader behavioral health issues impacting children, youth, and families, while focusing on the issues that are unique to children and families that interface with schools. The work group cochairs may invite nonwork group members to participate as advisory group members.
(6)(a) Subject to the availability of amounts appropriated for this specific purpose, the work group shall convene an advisory group for the purpose of developing a draft strategic plan that describes:
(i) The current landscape of behavioral health services available to families in the perinatal phase, children, youth transitioning into adulthood, and the caregivers of those children and youth in Washington state, including a description of:
(A) The gaps and barriers in receiving or accessing behavioral health services, including services for co-occurring behavioral health disorders or other conditions;
(B) Access to high quality, equitable care and supports in behavioral health education and promotion, prevention, intervention, treatment, recovery, and ongoing well-being supports;
(C) The current supports and services that address emerging behavioral health issues before a diagnosis and more intensive services or clinical treatment is needed; and
(D) The current behavioral health care oversight and management of services and systems;
(ii) The vision for the behavioral health service delivery system for families in the perinatal phase, children, youth transitioning into adulthood, and the caregivers of those children and youth, including:
(A) A complete continuum of services from education, promotion, prevention, early intervention through crisis response, intensive treatment, postintervention, and recovery, as well as supports that sustain wellness in the behavioral health spectrum;
(B) How access can be provided to high quality, equitable care and supports in behavioral health education, promotion, prevention, intervention, recovery, and ongoing well-being when and where needed;
(C) How the children and youth behavioral health system must successfully pair with the 988 behavioral health crisis response described under chapter 82.86 RCW;
(D) The incremental steps needed to achieve the vision for the behavioral health service delivery system based on the current gaps and barriers for accessing behavioral health services, with estimated dates for these steps; and
(E) The oversight and management needed to ensure effective behavioral health care; and
(iii) A comparison of the current behavioral health system for families in the perinatal phase, children, youth transitioning into adulthood, and the caregivers of those children and youth that is primarily based on crisis response and inadequate capacity with the behavioral health system vision created by the strategic planning process through a cost-benefit analysis.
(b) The work group cochairs shall appoint a chair for the strategic plan advisory group and may invite nonwork group members to participate as advisory group members, but the strategic plan advisory group shall include, at a minimum:
(i) Community members with lived experience including those with cultural, linguistic, and ethnic diversity, as well as those having diverse experience with behavioral health care invited by the work group cochairs;
(ii) A representative from the department of children, youth, and families;
(iii) A representative from the department;
(iv) A representative from the authority;
(v) A representative from the department of health;
(vi) A representative from the office of homeless youth prevention and protection programs;
(vii) A representative from the office of the governor;
(viii) A representative from the developmental disability administration of the department of social and health services;
(ix) A representative from the office of the superintendent of public instruction;
(x) A representative from the office of the insurance commissioner;
(xi) A tribal representative;
(xii) Two legislative members or alternates from the work group; and
(xiii) Individuals invited by the work group cochairs with relevant subject matter expertise.
(c) The health care authority shall conduct competitive procurements as necessary in accordance with chapter 39.26 RCW to select a third-party facilitator to facilitate the strategic plan advisory group.
(d) To assist the strategic plan advisory group in its work, the authority, in consultation with the cochairs of the work group, shall select an entity to conduct the activities set forth in this subsection. The health care authority may contract directly with a public agency as defined under RCW 39.34.020 through an interagency agreement. If the health care authority determines, in consultation with the cochairs of the work group, that a public agency is not appropriate for conducting these analyses, the health care authority may select another entity through competitive procurements as necessary in accordance with chapter 39.26 RCW. The activities that entities selected under this subsection must complete include:
(i) Following a statewide stakeholder engagement process, a behavioral health landscape analysis for families in the perinatal phase, children, youth transitioning into adulthood, and the caregivers of those children and youth outlining:
(A) The current service continuum including the cost of care, delivery service models, and state oversight for behavioral health services covered by medicaid and private insurance;
(B) Current gaps in the service continuum, areas without access to services, workforce demand, and capacity shortages;
(C) Barriers to accessing preventative services and necessary care including inequities in service access, affordability, cultural responsiveness, linguistic responsiveness, gender responsiveness, and developmentally appropriate service availability; and
(D) Incorporated information provided by the 988 crisis hotline crisis response improvement strategy committee;
(ii) A gap analysis estimating the prevalence of needs for Washington state behavioral health services for families in the perinatal phase, children, youth transitioning into adulthood, and the caregivers of those children and youth served by medicaid or private insurance, including:
(A) The estimated number of families in the perinatal phase, children, youth transitioning into adulthood, and the caregivers of those children and youth who need clinical behavioral health services or could benefit from preventive or early intervention services on an annual basis;
(B) The estimated number of expectant parents and caregivers in need of behavioral health services;
(C) A collection and analysis of disaggregated data to better understand regional, economic, linguistic, gender, and racial gaps in access to behavioral health services;
(D) The estimated costs of providing services that include a range of behavioral health supports that will meet the projected needs of the population; and
(E) Recommendations on the distribution of resources to deliver needed services to families in the perinatal phase, children, youth transitioning into adulthood, and the caregivers of those children and youth across multiple settings; and
(iii) An analysis of peer-reviewed publications, evidence-based practices, and other existing practices and guidelines with preferred outcomes regarding the delivery of behavioral health services to families in the perinatal phase, children, youth transitioning into adulthood, and the caregivers of those children and youth across multiple settings including:
(A) Approaches to increasing access and quality of care for underserved populations;
(B) Approaches to providing developmentally appropriate care;
(C) The integration of culturally responsive care with effective clinical care practices and guidelines;
(D) Strategies to maximize federal reinvestment and resources from any alternative funding sources; and
(E) Workforce development strategies that ensure a sustained, representative, and diverse workforce.
(e) The strategic plan advisory group shall prioritize its work as follows:
(i) Hold its first meeting by September 1, 2022;
(ii) Provide a progress report on the development of the strategic plan, including a timeline of future strategic plan development steps, to be included in the work group's 2022 annual report required under subsection (10) of this section;
(iii) Provide a progress report on the development of the strategic plan, including discussion of the work group recommendations that align with the strategic plan development thus far, to be included in the work group's 2024 annual report required under subsection (10) of this section;
(iv) Provide a draft strategic plan, along with any materials produced by entities selected under (d) of this subsection, to the work group by August 1, 2025. The draft strategic plan must be developed in coordination with the joint legislative and executive committee on behavioral health established in section 135(15), chapter 475, Laws of 2023, the department of health, and the health care authority related to the implementation of the 988 crisis hotline.
(f) The work group shall discuss the draft strategic plan and adopt a final strategic plan that must be submitted to the governor and the appropriate committees of the legislature at the same time as the work group's 2025 annual report required under subsection (10) of this section.
(7)(a) Staff support for the work group, including administration of work group meetings and preparation of full work group recommendations and reports required under this section, must be provided by the health care authority.
(b) Additional staff support for legislative members of the work group may be provided by senate committee services and the house of representatives office of program research.
(c) Subject to the availability of amounts appropriated for this specific purpose, the office of the superintendent of public instruction must provide staff support to the school-based behavioral health and suicide prevention advisory group, including administration of advisory group meetings and the preparation and delivery of advisory group recommendations to the full work group.
(8)(a) Legislative members of the work group are reimbursed for travel expenses in accordance with RCW 44.04.120. Nonlegislative members are not entitled to be reimbursed for travel expenses if they are elected officials or are participating on behalf of an employer, governmental entity, or other organization. Except as provided under (b) of this subsection, any reimbursement for other nonlegislative members is subject to chapter 43.03 RCW.
(b) Members of the children and youth behavioral health work group or an advisory group established under this section with lived experience may receive a stipend of up to $200 per day if:
(i) The member participates in the meeting virtually or in person, even if only participating for one meeting and not on an ongoing basis; and
(ii) The member does not receive compensation, including paid leave, from the member's employer or contractor for participation in the meeting.
(9) The following definitions apply to this section:
(a) "A member with lived experience" means an individual who has received behavioral health services or whose family member has received behavioral health services; and
(b) "Families in the perinatal phase" means families during the time from pregnancy through one year after birth.
(10) Beginning November 1, 2020, and annually thereafter, the work group shall provide recommendations in alignment with subsection (3) of this section to the governor and the legislature. Beginning November 1, 2026, the work group shall include in its annual report a discussion of how the work group's recommendations align with the final strategic plan described under subsection (6) of this section.
(11) This section expires December 30, 2031.
[ 2026 c 93 s 1; 2024 c 372 s 1; 2022 c 76 s 1; 2020 c 130 s 1; 2019 c 360 s 2; 2018 c 175 s 2.]
Notes:
Findings—Intent—2019 c 360: "(1) The legislature finds that the children's mental health work group established in chapter 96, Laws of 2016 reported recommendations related to increasing access to mental health services for children and youth and that many of those recommendations were adopted by the 2017 and 2018 legislatures. The legislature further finds that additional work is needed to improve mental health support for children and families and that the children's mental health work group was reestablished for this purpose in chapter 175, Laws of 2018.
(2) The legislature finds that there is a workforce shortage of behavioral health professionals and that increasing medicaid rates to a level that is equal to medicare rates will increase the number of providers who will serve children and families on medicaid. Further, the legislature finds that there is a need to increase the cultural and linguistic diversity among children's behavioral health professionals and that hiring practices, professional training, and high quality translations of accreditation and licensing exams should be implemented to incentivize this diversity in the workforce.
(3) Therefore, the legislature intends to implement the recommendations adopted by the children's mental health work group in January 2019, in order to improve mental health care access for children and their families." [ 2019 c 360 s 1.]

catchline: Children and youth behavioral health work group—Advisory groups—Report to governor and legislature. (Expires December 30, 2031.)


title: RCW 74.09.497

text:
(1) By August 1, 2017, the authority must complete a review of payment codes available to health plans and providers related to primary care and behavioral health. The review must include adjustments to payment rules if needed to facilitate bidirectional integration. The review must involve stakeholders and include consideration of the following principles to the extent allowed by federal law:
(a) Payment rules must allow professionals to operate within the full scope of their practice;
(b) Payment rules should allow medically necessary behavioral health services for covered patients to be provided in any setting;
(c) Payment rules should allow medically necessary primary care services for covered patients to be provided in any setting;
(d) Payment rules and provider communications related to payment should facilitate integration of physical and behavioral health services through multifaceted models, including primary care behavioral health, whole-person care in behavioral health, collaborative care, and other models;
(e) Payment rules should be designed liberally to encourage innovation and ease future transitions to more integrated models of payment and more integrated models of care;
(f) Payment rules should allow health and behavior codes to be reimbursed for all patients in primary care settings as provided by any licensed behavioral health professional operating within their scope of practice, including but not limited to psychiatrists, psychologists, psychiatric advanced registered nurse professionals, physician assistants working with a psychiatrist who is acting as a participating physician as defined in RCW 18.71A.010, psychiatric nurses, mental health counselors, social workers, chemical dependency professionals, chemical dependency professional trainees, marriage and family therapists, and mental health counselor associates under the supervision of a licensed clinician;
(g) Payment rules should allow health and behavior codes to be reimbursed for all patients in behavioral health settings as provided by any licensed health care provider within the provider's scope of practice;
(h) Payment rules which limit same-day billing for providers using the same provider number, require prior authorization for low-level or routine behavioral health care, or prohibit payment when the patient is not present should be implemented only when consistent with national coding conventions and consonant with accepted best practices in the field.
(2) Concurrent with the review described in subsection (1) of this section, the authority must create matrices listing the following codes available for provider payment through medical assistance programs: All behavioral health-related codes; and all physical health-related codes available for payment when provided in licensed behavioral health agencies. The authority must clearly explain applicable payment rules in order to increase awareness among providers, standardize billing practices, and reduce common and avoidable billing errors. The authority must disseminate this information in a manner calculated to maximally reach all relevant plans and providers. The authority must update the provider billing guide to maintain consistency of information.
(3) The authority must inform the governor and relevant committees of the legislature by letter of the steps taken pursuant to this section and results achieved once the work has been completed.
[ 2024 c 62 s 31; 2017 c 226 s 2.]
Notes:
Effective date—2024 c 62 ss 1-8, 10-18, 20-26, 28, and 30-32: See note following RCW 18.71A.010.
Intent—2024 c 62: See note following RCW 18.71A.020.
Contingent effective date—2017 c 226 s 2: "Section 2 of this act takes effect only if Engrossed Substitute House Bill No. 1340 (including any later amendments or substitutes) is not signed into law by the governor by July 23, 2017." [ 2017 c 226 s 10.] Engrossed Substitute House Bill No. 1340 was not signed into law by July 23, 2017.
Sustainable solutions for the integration of behavioral and physical health—2017 c 226: "Health transformation in Washington state requires a multifaceted approach to implement sustainable solutions for the integration of behavioral and physical health. Effective integration requires a holistic approach and cannot be limited to one strategy or model. Bidirectional integration of primary care and behavioral health is a foundational strategy to reduce health disparities and provide better care coordination for patients regardless of where they choose to receive care.
An important component to health care integration supported both by research and experience in Washington is primary care behavioral health, a model in which behavioral health providers, sometimes called behavioral health consultants, are fully integrated in primary care. The primary care behavioral health model originated more than two decades ago, has become standard practice nationally in patient centered medical homes, and has been endorsed as a viable integration strategy by Washington's Dr. Robert J. Bree Collaborative.
Primary care settings are a gateway for many individuals with behavioral health and primary care needs. An estimated one in four primary care patients have an identifiable behavioral health need and as many as seventy percent of primary care visits are impacted by a psychosocial component. A behavioral health consultant engages primary care patients and their caregivers on the same day as a medical visit, often in the same exam room. This warm hand-off approach fosters coordinated whole-person care, increases access to behavioral health services, and reduces stigma and cultural barriers in a cost-effective manner. Patients are provided evidence-based brief interventions and skills training, with more severe needs being effectively engaged, assessed, and referred to appropriate specialized care.
While the benefits of primary care behavioral health are not restricted to children, the primary care behavioral health model also provides a unique opportunity to engage children who have a strong relationship with primary care, identify problems early, and assure healthy development. Investment in primary care behavioral health creates opportunities for prevention and early detection that pay dividends throughout the life cycle.
The legislature also recognizes that for individuals with more complex behavioral health disorders, there are tremendous barriers to accessing primary care. Whole-person care in behavioral health is an evidence-based model for integrating primary care into behavioral health settings where these patients already receive care. Health disparities among people with behavioral health disorders have been well-documented for decades. People with serious mental illness or substance use disorders continue to experience multiple chronic health conditions and dramatically reduced life expectancy while also constituting one of the highest-cost and highest-risk populations. Two-thirds of premature deaths are due to preventable or treatable medical conditions such as cardiovascular, pulmonary, and infectious diseases, and forty-four percent of all cigarettes consumed nationally are smoked by people with serious mental illness.
The whole-person care in behavioral health model allows behavioral health providers to take responsibility for managing the full array of physical health needs, providing routine basic health screening, and ensuring integrated primary care by actively coordinating with or providing on-site primary care services.
Providers in Washington need guidance on how to effectively implement bidirectional integration models in a manner that is also financially sustainable. Payment methodologies must be scrutinized to remove nonessential restrictions and limitations that restrict the scope of practice of behavioral health professionals, impede same-day billing for behavioral health and primary care services, abet billing errors, and stymie innovation that supports wellness and health integration." [ 2017 c 226 s 1.]

catchline: Authority review of payment codes available to health plans and providers related to primary care and behavioral health—Requirements—Principles considered—Matrices—Reporting.


title: RCW 74.09.500

text:
There is hereby established a new program of federal-aid assistance to be known as medical assistance to be administered by the authority. The authority is authorized to comply with the federal requirements for the medical assistance program provided in the social security act and particularly Title XIX of Public Law (89-97), as amended, in order to secure federal matching funds for such program.
[ 2011 1st sp.s. c 15 s 24; 1979 c 141 s 343; 1967 ex.s. c 30 s 3.]
Notes:
Effective date—Findings—Intent—Report—Agency transfer—References to head of health care authority—Draft legislation—2011 1st sp.s. c 15: See notes following RCW 74.09.010.

catchline: Medical assistance—Established.


title: RCW 74.09.510

text:
Medical assistance may be provided in accordance with eligibility requirements established by the authority, as defined in the social security Title XIX state plan for mandatory categorically needy persons and:
(1) Individuals who would be eligible for cash assistance except for their institutional status;
(2) Individuals who are under twenty-one years of age, who would be eligible for medicaid, but do not qualify as dependent children and who are in (a) foster care, (b) subsidized adoption, (c) a nursing facility or an intermediate care facility for persons with intellectual disabilities, or (d) inpatient psychiatric facilities;
(3) Individuals who:
(a) Are under twenty-one years of age;
(b) On or after July 22, 2007, were in foster care under the legal responsibility of the department of social and health services, the department of children, youth, and families, or a federally recognized tribe located within the state; and
(c) On their eighteenth birthday, were in foster care under the legal responsibility of the department of children, youth, and families or a federally recognized tribe located within the state;
(4) Persons who are aged, blind, or disabled who: (a) Receive only a state supplement, or (b) would not be eligible for cash assistance if they were not institutionalized;
(5) Categorically eligible individuals who meet the income and resource requirements of the cash assistance programs;
(6) Individuals who are enrolled in managed health care systems, who have otherwise lost eligibility for medical assistance, but who have not completed a current six-month enrollment in a managed health care system, and who are eligible for federal financial participation under Title XIX of the social security act;
(7) Children and pregnant women allowed by federal statute for whom funding is appropriated;
(8) Working individuals with disabilities authorized under section 1902(a)(10)(A)(ii) of the social security act for whom funding is appropriated;
(9) Other individuals eligible for medical services under RCW 74.09.700 for whom federal financial participation is available under Title XIX of the social security act;
(10) Persons allowed by section 1931 of the social security act for whom funding is appropriated; and
(11) Women who: (a) Are under sixty-five years of age; (b) have been screened for breast and cervical cancer under the national breast and cervical cancer early detection program administered by the department of health or tribal entity and have been identified as needing treatment for breast or cervical cancer; and (c) are not otherwise covered by health insurance. Medical assistance provided under this subsection is limited to the period during which the woman requires treatment for breast or cervical cancer, and is subject to any conditions or limitations specified in the omnibus appropriations act.
[ 2017 3rd sp.s. c 6 s 337; 2013 2nd sp.s. c 10 s 6. Prior: 2011 1st sp.s. c 36 s 9; 2011 1st sp.s. c 15 s 25; 2010 c 94 s 24; 2007 c 315 s 1; prior: 2001 2nd sp.s. c 15 s 3; 2001 1st sp.s. c 4 s 1; prior: 1997 c 59 s 14; 1997 c 58 s 201; 1991 sp.s. c 8 s 8; 1989 1st ex.s. c 10 s 8; 1989 c 87 s 2; 1985 c 5 s 2; 1981 2nd ex.s. c 3 s 5; 1981 1st ex.s. c 6 s 20; 1981 c 8 s 19; 1971 ex.s. c 169 s 4; 1970 ex.s. c 60 s 1; 1967 ex.s. c 30 s 4.]
Notes:
Effective date—2017 3rd sp.s. c 6 ss 102, 104-115, 201-227, 301-337, 401-419, 501-513, 801-803, and 805-822: See note following RCW 43.216.025.
Conflict with federal requirements—2017 3rd sp.s. c 6: See RCW 43.216.908.
Effective date—2013 2nd sp.s. c 10: See note following RCW 74.62.030.
Findings—Intent—2011 1st sp.s. c 36: See RCW 74.62.005.
Effective date—2011 1st sp.s. c 36: See note following RCW 74.62.005.
Effective date—Findings—Intent—Report—Agency transfer—References to head of health care authority—Draft legislation—2011 1st sp.s. c 15: See notes following RCW 74.09.010.
Purpose—2010 c 94: See note following RCW 44.04.280.
Conflict with federal requirements—2007 c 315: "If any part of this act is found to be in conflict with federal requirements that are a prescribed condition to the allocation of federal funds to the state, the conflicting part of this act is inoperative solely to the extent of the conflict and with respect to the agencies directly affected, and this finding does not affect the operation of the remainder of this act in its application to the agencies concerned. Rules adopted under this act must meet federal requirements that are a necessary condition to the receipt of federal funds by the state." [ 2007 c 315 s 3.]
Findings—Intent—2001 2nd sp.s. c 15: See note following RCW 74.09.540.
Effective date—2001 1st sp.s. c 4: "This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect July 1, 2001." [ 2001 1st sp.s. c 4 s 2.]
Short title—Part headings, captions, table of contents not law—Exemptions and waivers from federal law—Conflict with federal requirements—Severability—1997 c 58: See RCW 74.08A.900 through 74.08A.904.
Effective date—1991 sp.s. c 8: See note following RCW 18.51.050.
Effective dates—1989 c 87: "(1) Sections 7 and 8 of this act are necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and shall take effect July 1, 1989.
(2) Sections 1 through 5 of this act shall take effect October 1, 1989." [ 1989 c 87 s 9.]
Severability—1981 2nd ex.s. c 3: "If any provision of this act or its application to any person or circumstance is held invalid, the remainder of the act or the application of the provision to other persons or circumstances is not affected." [ 1981 2nd ex.s. c 3 s 8.]
Effective date—Severability—1981 1st ex.s. c 6: See notes following RCW 74.04.005.

catchline: Medical assistance—Eligibility.