title: RCW 74.09.670

text:
(1) Except as provided in subsection (2) of this section, when the authority receives information that a person enrolled in medical assistance is confined in a setting in which federal financial participation is disallowed by the state's agreements with the federal government, the authority shall suspend, rather than terminate, medical assistance benefits for these persons, including those who are: Incarcerated in a correctional facility as defined in RCW 72.09.015 and 70.48.020, confined in an institution or facility operated by the department of children, youth, and families, or committed to a state hospital or other treatment facility. A person who is not currently enrolled in medical assistance must be allowed to apply for medical assistance in suspense status during confinement, and the ability to apply may not depend upon knowledge of the release or discharge date of the person.
(2)(a) During the first 29 days of a person's incarceration or confinement in a correctional facility, as defined in RCW 72.09.015 and 70.48.020, or in an institution or facility operated by the department of children, youth, and families:
(i) A person's incarceration or confinement status may not affect the person's enrollment in medical assistance if the person was enrolled in medical assistance at the time of incarceration or confinement; and
(ii) A person not enrolled in medical assistance at the time of incarceration or confinement must have the ability to apply for medical assistance during incarceration or confinement, which may not depend on knowledge of the release date of the person. If the person is enrolled in medical assistance during the first 29 days of the person's incarceration or confinement, the person's incarceration or confinement status may not affect the person's enrollment in medical assistance.
(b) After the first 29 days of the person's incarceration or confinement, the person's medical assistance status is subject to suspension or application in suspense status under subsection (1) of this section.
[ 2025 c 12 s 2. Prior: 2021 c 243 s 2; 2021 c 166 s 2; 2016 c 154 s 2.]
Notes:
Finding—2025 c 12: "The legislature recognizes that in 2021, Engrossed Second Substitute Senate Bill 5304 was signed into law to better ensure continuity of coverage for medicaid enrollment of incarcerated youth. The legislature finds that further clarification is required to ensure local and state juvenile facilities are made aware of opportunities for continuity of coverage. The legislature therefore resolves to remove ambiguity in state statute and to direct the health care authority to document its efforts working with local providers to ensure a warm handoff upon release from detention facilities." [ 2025 c 12 s 1.]
Conflict with federal requirements—2025 c 12: "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." [ 2025 c 12 s 8.]
Findings—2021 c 243: "The legislature finds that when considering releasing persons from state and local institutions, realizing the safety of the public is the primary concern. The legislature also finds that the success of persons with behavioral health needs being released from confinement in a prison, jail, juvenile rehabilitation facility, state hospital, and other state and local institutions can be increased with access to continuity of medical assistance, supportive services, and other targeted assistance. The legislature finds that this act provides strategies to prevent interruption of medical assistance benefits and to allow for a seamless transfer between systems of care. The legislature further finds that this act removes stigmatizing language from the program created under RCW 72.09.370 and 71.24.470 and creates a work group to study how to expand the cost-effective strategies of this program to other populations and settings to enhance recovery, reduce recidivism, and improve safety." [ 2021 c 243 s 1.]
Amendments—Waivers—2021 c 166 s 2: "The health care authority is authorized to seek any necessary state plan amendments or waivers from the federal department of health and human services that are necessary to implement section 2 of this act." [ 2021 c 166 s 4.]
Findings—Intent—2021 c 166: "(1) The legislature finds that:
(a) Having access to same day and next day physical and behavioral health services is imperative to facilitate successful reentry for individuals releasing from jails;
(b) The overwhelming majority of individuals in jails are incarcerated for less than 30 days;
(c) Suspending medicaid for individuals on short-term jail stays causes significant delays in medicaid reinstatement upon release; and
(d) Delays in medicaid reinstatement impede access to physical and behavioral health appointments and prescription medications upon release.
(2) The legislature intends to facilitate successful jail reentry by not suspending medicaid for individuals who are incarcerated for less than 30 days." [ 2021 c 166 s 1.]
Conflict with federal requirements—2021 c 166: "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." [ 2021 c 166 s 5.]
Intent—2016 c 154: "Persons with mental illness and persons with substance use disorders in the custody of the criminal justice system need seamless access to community treatment networks and medical assistance upon release from custody to prevent gaps in treatment and reduce barriers to accessing care. Access to care is critical to reduce recidivism and reduce costs associated with relapse, decompensation, and crisis care. In accord with the recommendations of the adult behavioral health system task force, persons should be allowed to apply or retain their enrollment in medical assistance during periods of incarceration. The legislature intends for the Washington state health care authority and the department of social and health services to raise awareness of best clinical practices to engage persons with behavioral health disorders and other chronic conditions during periods of incarceration and confinement to highlight opportunities for good preventive care and standardize reporting and payment practices for services reimbursable by federal law that support the safe transition of the person back into the community." [ 2016 c 154 s 1.]

catchline: Medical assistance benefits—Incarcerated or committed persons—Suspension.


doc_type: statute

jurisdiction: wa

title: RCW 74.09.671

text:
The authority shall collaborate with the department, the Washington state association of counties, the Washington association of sheriffs and police chiefs, and accountable communities of health to improve population health and reduce avoidable use of intensive services and settings by requesting expenditure authority from the federal government to provide behavioral health services to persons who are incarcerated in local jails. The authority in consultation with its partners may narrow its submission to discrete programs or regions of the state as deemed advisable to effectively demonstrate the potential to achieve savings by integrating medical assistance across community and correctional settings.
[ 2016 c 154 s 4.]
Notes:
Intent—2016 c 154: See note following RCW 74.09.670.

license: public-domain-government-work

rule_set: Revised Code of Washington

catchline: Incarcerated persons—Local jails—Behavioral health services—Federal funding.

code: rcw

unit: section

court: Washington State Legislature


title: RCW 74.09.672

text:
It is the understanding of the legislature that persons participating in a work release program or other partial confinement programs at the state, county, or city level which allow regular freedom during the day to pursue rehabilitative community activities such as participation in work, treatment, or medical care should not be considered "inmates of a public institution" for the purposes of exclusion from medicaid coverage under the social security act. The authority is instructed to obtain any permissions from the federal government necessary to confirm this understanding, and report back to the governor and relevant committees of the legislature.
[ 2016 c 154 s 5.]
Notes:
Intent—2016 c 154: See note following RCW 74.09.670.

catchline: Inmates of a public institution—Exclusion from medicaid coverage—Work release and partial confinement programs.


title: RCW 74.09.675

text:
(1) In the provision of gender-affirming care services through programs under this chapter, the authority, managed care plans, and providers that administer or deliver such services may not discriminate in the delivery of a service provided through a program of the authority based on the covered person's gender identity or expression.
(2) Beginning January 1, 2022:
(a) The authority and any managed care plans delivering or administering services purchased or contracted for by the authority may not apply categorical cosmetic or blanket exclusions to gender-affirming treatment.
(b) Facial feminization surgeries and facial gender-affirming treatment, such as tracheal shaves, hair electrolysis, and other care such as mastectomies, breast reductions, breast implants, or any combination of gender-affirming procedures, including revisions to prior treatment, when prescribed as gender-affirming treatment, may not be excluded as cosmetic.
(c) The authority and managed care plans administering services purchased or contracted for by the authority may not issue an adverse benefit determination denying or limiting access to gender-affirming treatment, unless a health care provider with experience prescribing or delivering gender-affirming treatment has reviewed and confirmed the appropriateness of the adverse benefit determination.
(d) If the authority and managed care plans administering services purchased or contracted for by the authority do not have an adequate network for gender-affirming treatment, they shall ensure the delivery of timely and geographically accessible medically necessary gender-affirming treatment at no greater expense than if they had an in-network, geographically accessible provider available. This includes, but is not limited to, providing case management services to secure out-of-network gender-affirming treatment options that are available to the enrollee in a timely manner within their geographic region. The enrollee shall pay no more than the same cost sharing that the enrollee would pay for the same covered services received from an in-network provider.
(3) For the purposes of this section, "gender-affirming treatment" means a service or product that a health care provider, as defined in RCW 70.02.010, prescribes to an individual to support and affirm the individual's gender identity. Gender-affirming treatment includes, but is not limited to, treatment for gender dysphoria. Gender-affirming treatment can be prescribed to two spirit, transgender, nonbinary, and other gender diverse individuals.
(4) Nothing in this section may be construed to mandate coverage of a service that is not medically necessary.
(5) The authority shall adopt rules necessary to implement this section.
[ 2021 c 280 s 4.]
Notes:
Short title—2021 c 280: See note following RCW 49.60.178.

catchline: Gender-affirming care services—Prohibited discrimination.


title: RCW 74.09.680

text:
(1)(a) Any benefit administered by the authority through contracted entities to provide medically tailored meals to enrollees under this chapter shall, to the extent possible, prioritize the purchase of medically tailored meals produced by medically tailored meal vendors that are nonprofit organizations or small businesses that are able to provide locally sourced, fresh, whole foods or from scratch prepared meals.
(b) Medically tailored meal vendors shall comply with the enrollee's medically tailored meal nutrition care plan. The medically tailored meal vendor shall have a qualified medical professional review and approve the menus provided in response to a nutrition care plan for medically tailored meals.
(c) All medically tailored meals provided to enrollees under this chapter shall:
(i) Align with evidence-based nutritional practice guidelines for treating the specified condition;
(ii) Offer accommodations in dietary needs, allergy restrictions, and cultural preferences;
(iii) Prioritize local, whole foods or from scratch prepared meals unless otherwise required to appropriately meet the needs of an enrollee;
(iv) Provide at least 500 calories, or otherwise meet an enrollee's medically appropriate energy needs; and
(v) Provide one-third of the recommended dietary reference intakes for carbohydrates and protein as established by the food and nutrition board of the national academy of medicine, unless otherwise permitted.
(2) For the purposes of this section:
(a) "Locally sourced" means:
(i) Agricultural commodities that were grown, raised, harvested, caught, or otherwise derived fully or in part within the state of Washington; or
(ii) Fully or in part prepared, processed, assembled, cooked, or packaged within the state of Washington.
(b) "Medically tailored meal" means a fresh or frozen meal that is designed by a qualified medical professional for the treatment of one or more medical conditions of an enrollee.
(c) "Medically tailored meal vendor" means a vendor that provides medically tailored meals according to specifications from a qualified medical professional.
(d) "Qualified medical professional" means a person who holds a credential issued by a disciplining authority under RCW 18.130.040 and whose credential includes the authority to establish and tailor nutrition care plans to meet the medical needs of a referred client.
[ 2026 c 200 s 3.]
Notes:
Intent—Findings—2026 c 200: See note following RCW 74.39A.560.

catchline: Medically tailored meals.


title: RCW 74.09.700

text:
(1) To the extent of available funds and subject to any conditions placed on appropriations made for this purpose, medical care may be provided under the limited casualty program to persons not eligible for medical assistance or medical care services who are medically needy as defined in the social security Title XIX state plan and medical indigents in accordance with eligibility requirements established by the authority. The eligibility requirements may include minimum levels of incurred medical expenses. This includes residents of nursing facilities, residents of intermediate care facilities for persons with intellectual disabilities, and individuals who are otherwise eligible for section 1915(c) of the federal social security act home and community-based waiver services, administered by the department who are aged, blind, or disabled as defined in Title XVI of the federal social security act and whose income exceeds three hundred percent of the federal supplement security income benefit level.
(2) Determination of the amount, scope, and duration of medical coverage under the limited casualty program shall be the responsibility of the authority, subject to the following:
(a) Only the following services may be covered:
(i) For persons who are medically needy as defined in the social security Title XIX state plan: Inpatient and outpatient hospital services, and home and community-based waiver services;
(ii) For persons who are medically needy as defined in the social security Title XIX state plan, and for persons who are medical indigents under the eligibility requirements established by the authority: Rural health clinic services; physicians' and clinic services; prescribed drugs, dentures, prosthetic devices, and eyeglasses; nursing facility services; and intermediate care facility services for persons with intellectual disabilities; home health services; hospice services; other laboratory and X-ray services; rehabilitative services, including occupational therapy; medically necessary transportation; and other services for which funds are specifically provided in the omnibus appropriations act;
(b) Medical care services provided to the medically indigent and received no more than seven days prior to the date of application shall be retroactively certified and approved for payment on behalf of a person who was otherwise eligible at the time the medical services were furnished: PROVIDED, That eligible persons who fail to apply within the seven-day time period for medical reasons or other good cause may be retroactively certified and approved for payment.
(3) The authority shall establish standards of assistance and resource and income exemptions. All nonexempt income and resources of limited casualty program recipients shall be applied against the cost of their medical care services.
[ 2011 1st sp.s. c 15 s 42; 2010 c 94 s 25; 2001 c 269 s 1; 1993 c 57 s 2. Prior: 1991 sp.s. c 9 s 7; 1991 sp.s. c 8 s 10; 1991 c 233 s 2; 1989 c 87 s 3; 1985 c 5 s 4; 1983 1st ex.s. c 43 s 1; 1982 1st ex.s. c 19 s 1; 1981 2nd ex.s. c 10 s 6; 1981 2nd ex.s. c 3 s 6; 1981 1st ex.s. c 6 s 22.]
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.
Purpose—2010 c 94: See note following RCW 44.04.280.
Effective dates—1991 sp.s. c 9: "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 shall take effect on July 1, 1991, except sections 1 through 6 and 9 of this act which shall take effect on September 1, 1991." [ 1991 sp.s. c 9 s 11.]
Effective date—1991 sp.s. c 8: See note following RCW 18.51.050.
Effective dates—1989 c 87: See note following RCW 74.09.510.
Effective date—1983 1st ex.s. c 43: "This act is necessary for the immediate preservation of the public peace, health, and safety, the support of the state government and its existing public institutions, and shall take effect on July 1, 1983." [ 1983 1st ex.s. c 43 s 3.]
Effective date—1982 1st ex.s. c 19: See note following RCW 74.09.035.
Severability—1981 2nd ex.s. c 3: See note following RCW 74.09.510.
Effective date—Severability—1981 1st ex.s. c 6: See notes following RCW 74.04.005.

catchline: Medical care—Limited casualty program.


title: RCW 74.09.705

text:
The family medicine workforce development account is created in the state treasury. All receipts from funding available for the family medicine residency network pursuant to RCW 74.60.090 and 70.112.060 and any other funds collected for the medicaid direct payment program established in chapter 376, Laws of 2024 must be deposited into the account. Moneys in the account may be spent only after appropriation. Expenditures from the account may be used only to supplement primary care graduate medical education.
[ 2024 c 168 s 8.]
Notes:
Effective dates—2024 c 168 ss 4-13: See note following RCW 41.05.155.

catchline: Family medicine workforce development account.


title: RCW 74.09.710

text:
(1) The authority, in collaboration with the department of health and the department of social and health services, shall:
(a) Design and implement medical homes for its aged, blind, and disabled clients in conjunction with chronic care management programs to improve health outcomes, access, and cost-effectiveness. Programs must be evidence based, facilitating the use of information technology to improve quality of care, must acknowledge the role of primary care providers and include financial and other supports to enable these providers to effectively carry out their role in chronic care management, and must improve coordination of primary, acute, and long-term care for those clients with multiple chronic conditions. The authority shall consider expansion of existing medical home and chronic care management programs and build on the Washington state collaborative initiative. The authority shall use best practices in identifying those clients best served under a chronic care management model using predictive modeling through claims or other health risk information; and
(b) Evaluate the effectiveness of current chronic care management efforts in the authority and the department, comparison to best practices, and recommendations for future efforts and organizational structure to improve chronic care management.
(2) For purposes of this section:
(a) "Medical home" means a site of care that provides comprehensive preventive and coordinated care centered on the patient needs and assures high quality, accessible, and efficient care.
(b) "Chronic care management" means the authority's program that provides care management and coordination activities for medical assistance clients determined to be at risk for high medical costs. "Chronic care management" provides education and training and/or coordination that assist program participants in improving self-management skills to improve health outcomes and reduce medical costs by educating clients to better utilize services.
[ 2011 1st sp.s. c 15 s 43; 2007 c 259 s 4.]
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.
Subheadings not law—2007 c 259: See note following RCW 7.70.060.

catchline: Chronic care management programs—Medical homes—Definitions.


title: RCW 74.09.715

text:
Within funds appropriated for this purpose, the authority shall establish two dental access projects to serve seniors and other adults who are categorically needy blind or disabled. The projects shall provide:
(1) Enhanced reimbursement rates for certified dentists for specific procedures, to begin no sooner than July 1, 2009;
(2) Reimbursement for trained medical providers for preventive oral health services, to begin no sooner than July 1, 2009;
(3) Training, development, and implementation through a partnership with the University of Washington school of dentistry;
(4) Local program coordination including outreach and case management; and
(5) An evaluation that measures the change in utilization rates and cost savings.
[ 2011 1st sp.s. c 15 s 44; 2008 c 146 s 13.]
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.
Findings—Intent—Severability—2008 c 146: See notes following RCW 74.41.040.

catchline: Access to dental care.


title: RCW 74.09.717

text:
(1) It is the intent of the legislature to provide that dental health aide therapist services are eligible for medicaid funding in order to promote increased dental care access for persons served in settings operated by Indian tribes, tribal organizations, and urban Indian organizations.
(2) The health care authority is directed to coordinate with the centers for medicare and medicaid services to provide that dental health aide therapist services authorized in chapter 70.350 RCW are eligible for federal funding of up to one hundred percent.
[ 2017 c 5 s 8.]

catchline: Dental health aide therapist services—Federal funding.


title: RCW 74.09.719

text:
(1) The COFA islander dental care program is established to provide dental services to COFA citizens who meet the requirements in subsection (2) of this section. The authority shall begin administering this program by January 1, 2020.
(2) Subject to the availability of amounts appropriated for this specific purpose, the program shall provide dental services as covered under RCW 74.09.520 to an individual who is eligible for the COFA premium assistance program under RCW 43.71A.020, or:
(a) Is a resident;
(b) Is a COFA citizen;
(c) Has income that is less than one hundred thirty-three percent of the federal poverty level; and
(d) Is enrolled in medicare coverage under Title XVIII of the social security act (42 U.S.C. Sec. 1395 et seq., as amended).
(3) The authority may disqualify a participant from the program if the participant:
(a) No longer meets the eligibility criteria in subsection (2) of this section;
(b) Fails, without good cause, to comply with procedural or documentation requirements established by the authority in accordance with subsection (4) of this section;
(c) Fails, without good cause, to notify the authority of a change of address in a timely manner; or
(d) Withdraws the participant's application or requests termination of coverage.
(4) The authority shall establish:
(a) Application, enrollment, and renewal processes for the COFA islander dental care program; and
(b) Procedural requirements for continued participation in the program, including participant documentation requirements that are necessary for the authority to administer the program.
(5) For the purposes of this section, "COFA citizen" has the same meaning as in RCW 43.71A.010.
[ 2019 c 311 s 4.]
Notes:
Findings—Intent—2019 c 311: "(1) The legislature finds that:
(a) The legislature recognized the important relationship between the citizens of the compact of free association (COFA) nations and the United States by enacting the COFA premium assistance program in 2018 to pay for premiums and out-of-pocket expenses for COFA citizens who purchase qualifying health coverage;
(b) While other Washingtonians who are income-eligible for medicaid receive dental coverage through apple health, individuals enrolled in the COFA premium assistance program do not currently have affordable access to dental coverage;
(c) Affordable access to dental care, including preventative care, is critical to treating the whole body health of an individual and preventing systemic health problems such as stroke, heart attack, and diabetes. Poor oral health is also associated with a wide range of hardships including difficulty obtaining employment, work absences due to pain, and decreased productivity; and
(d) Research shows that people living in households in which the primary language spoken at home is not English, seniors, people with disabilities, and people who identify as Native Hawaiian or Pacific Islanders are disproportionately impacted by oral health inequities.
(2) The legislature therefore intends to increase access to dental services for COFA islanders residing in Washington by establishing a dental services program that provides dental coverage to income-eligible members of this population." [ 2019 c 311 s 1.]

catchline: Compact of free association islander dental care program.


title: RCW 74.09.725

text:
The authority shall provide coverage for prostate cancer screening under this chapter, provided that the screening is delivered upon the recommendation of the patient's physician, *advanced registered nurse practitioner, or physician assistant.
[ 2011 1st sp.s. c 15 s 46; 2006 c 367 s 8.]
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—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.
PDF
RCW 74.09.725
Prostate cancer screening. (Effective June 30, 2027.)
The authority shall provide coverage for prostate cancer screening under this chapter, provided that the screening is delivered upon the recommendation of the patient's physician, advanced practice registered nurse, or physician assistant.
[ 2025 c 58 s 5168; 2011 1st sp.s. c 15 s 46; 2006 c 367 s 8.]
Notes:
Effective date—2025 c 58 ss 5058-5170: See note following RCW 7.68.030.
Explanatory note—2025 c 58: See note following RCW 1.16.050.
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: Prostate cancer screening. (Effective until June 30, 2027.)


title: RCW 74.09.730

text:
(1) In establishing Title XIX payments for inpatient hospital services:
(a) To the extent funds are appropriated specifically for this purpose, and subject to any conditions placed on appropriations made for this purpose, the authority shall provide a disproportionate share hospital adjustment considering the following components:
(i) A low-income care component based on a hospital's medicaid utilization rate, its low-income utilization rate, its provision of obstetric services, and other factors authorized by federal law;
(ii) A medical indigency care component based on a hospital's services to persons who are medically indigent; and
(iii) A state-only component, to be paid from available state funds to hospitals that do not qualify for federal payments under (a)(ii) of this subsection, based on a hospital's services to persons who are medically indigent;
(b) The payment methodology for disproportionate share hospitals shall be specified by the authority in regulation.
(2) Nothing in this section shall be construed as a right or an entitlement by any hospital to any payment from the authority.
[ 2018 c 201 s 7020; 2011 1st sp.s. c 15 s 47; 2009 c 538 s 1; 1991 sp.s. c 9 s 8; 1989 c 260 s 1; 1987 1st ex.s. c 5 s 20.]
Notes:
Findings—Intent—Effective date—2018 c 201: See notes following RCW 41.05.018.
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.
Effective dates—1991 sp.s. c 9: See note following RCW 74.09.700.

catchline: Disproportionate share hospital adjustment.


title: RCW 74.09.741

text:
(1) The following persons have the right to an adjudicative proceeding:
(a) Any applicant or recipient who is aggrieved by a decision of the authority or an authorized agency of the authority; or
(b) A current or former recipient who is aggrieved by the authority's claim that he or she owes a debt for overpayment of assistance.
(2) For purposes of this section:
(a) "Applicant" means any person who has made a request, or on behalf of whom a request has been made to the authority for any medical services program established under this chapter.
(b) "Recipient" means a person who is receiving benefits from the authority for any medical services program established in this chapter.
(3) An applicant or recipient has no right to an adjudicative proceeding when the sole basis for the authority's decision is a federal or state law requiring an assistance adjustment for a class of applicants or recipients.
(4) An applicant or recipient may file an application for an adjudicative proceeding with either the authority or the department and must do so within 90 calendar days after receiving notice of the aggrieving decision unless good cause is shown, to the extent allowable under federal law. The authority shall determine which agency is responsible for representing the state of Washington in the hearing, in accordance with agreements entered pursuant to RCW 41.05.021.
(a) For the purpose of this subsection, good cause is defined as a substantive reason or legal justification for failing to meet a hearing deadline. Good cause to fail to meet a hearing deadline may include, but is not limited to: Military deployment, medical reasons, housing instability, language barriers, or domestic violence.
(b) The authority or the department shall not grant a request for a hearing for good cause if the request is filed more than one year after the aggrieving decision.
(5)(a) The adjudicative proceeding is governed by the administrative procedure act, chapter 34.05 RCW, and this subsection. The following requirements shall apply to adjudicative proceedings in which an appellant seeks review of decisions made by more than one agency. When an appellant files a single application for an adjudicative proceeding seeking review of decisions by more than one agency, this review shall be conducted initially in one adjudicative proceeding. The presiding officer may sever the proceeding into multiple proceedings on the motion of any of the parties, when:
(i) All parties consent to the severance; or
(ii) Either party requests severance without another party's consent, and the presiding officer finds there is good cause for severing the matter and that the proposed severance is not likely to prejudice the rights of an appellant who is a party to any of the severed proceedings.
(b) If there are multiple adjudicative proceedings involving common issues or parties where there is one appellant and both the authority and the department are parties, upon motion of any party or upon his or her own motion, the presiding offer may consolidate the proceedings if he or she finds that the consolidation is not likely to prejudice the rights of the appellant who is a party to any of the consolidated proceedings.
(c) The adjudicative proceeding shall be conducted at the local community services office or other location in Washington convenient to the applicant or recipient and, upon agreement by the applicant or recipient, may be conducted telephonically.
(d) The applicant or recipient, or his or her representative, has the right to inspect his or her file from the authority and, upon request, to receive copies of authority documents relevant to the proceedings free of charge.
(e) The applicant or recipient has the right to a copy of the audio recording of the adjudicative proceeding free of charge.
(f) If a final adjudicative order is issued in favor of an applicant, medical services benefits must be provided from the date of earliest eligibility, the date of denial of the application for assistance, or 45 days following the date of application, whichever is soonest. If a final adjudicative order is issued in favor of a recipient, medical services benefits must be provided from the effective date of the authority's decision.
(g) The authority is limited to recovering an overpayment arising from assistance being continued pending the adjudicative proceeding to the amount recoverable up to the 60th day after the director's receipt of the application for an adjudicative proceeding.
(6) If the director requires that a party seek administrative review of an initial order to an adjudicative proceeding governed by this section, in order for the party to exhaust administrative remedies pursuant to RCW 34.05.534, the director shall adopt and implement rules in accordance with this subsection.
(a) The director, in consultation with the secretary, shall adopt rules to create a process for parties to seek administrative review of initial orders issued pursuant to RCW 34.05.461 in adjudicative proceedings governed by this subsection when multiple agencies are parties.
(b) This process shall seek to minimize any procedural complexities imposed on appellants that result from multiple agencies being parties to the matter, without prejudicing the rights of parties who are public assistance applicants or recipients.
(c) Nothing in this subsection shall impose or modify any legal requirement that a party seek administrative review of initial orders in order to exhaust administrative remedies pursuant to RCW 34.05.534.
(7) This subsection only applies to an adjudicative proceeding in which the appellant is an applicant for or recipient of medical services programs established under this chapter and the issue is his or her eligibility or ineligibility due to the assignment or transfer of a resource. The burden is on the authority or its authorized agency to prove by a preponderance of the evidence that the person knowingly and willingly assigned or transferred the resource at less than market value for the purpose of qualifying or continuing to qualify for medical services programs established under this chapter. If the prevailing party in the adjudicative proceeding is the applicant or recipient, he or she is entitled to reasonable attorneys' fees.
(8) When an applicant or recipient files a petition for judicial review as provided in RCW 34.05.514 of an adjudicative order entered with respect to the medical services program, no filing fee may be collected from the person and no bond may be required on any appeal. In the event that the superior court, the court of appeals, or the supreme court renders a decision in favor of the applicant or recipient, the person is entitled to reasonable attorneys' fees and costs. If a decision of the court is made in favor of an applicant, assistance shall be paid from the date of earliest eligibility, the date of the denial of the application for assistance, or 45 days following the date of application, whichever is soonest. If a decision of the court is made in favor of a recipient, assistance shall be paid from the effective date of the authority's decision.
(9) The provisions of RCW 74.08.080 do not apply to adjudicative proceedings requested or conducted with respect to the medical services program pursuant to this section.
(10) The authority shall adopt any rules it deems necessary to implement this section.
[ 2022 c 163 s 2; 2011 1st sp.s. c 15 s 53.]
Notes:
Conflict with federal requirements—Effective date—2022 c 163: See notes following RCW 74.08.080.
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: Adjudicative proceedings.


title: RCW 74.09.745

text:
(1) The authority shall collaborate with the department of children, youth, and families to identify opportunities to leverage medicaid funding for home visiting services.
(2) The authority must provide a set of recommendations relevant to subsection (1) of this section to the legislature by December 1, 2018, that builds upon the research and strategies developed in the Washington state home visiting and medicaid financing strategies report submitted by the authority to the department of early learning in August 2017.
[ 2018 c 175 s 4.]
Notes:
Findings—Intent—2018 c 175: See note following RCW 74.09.495.

catchline: Medicaid funding for home visiting services—Recommendations to legislature.


title: RCW 74.09.748

text:
Upon adoption of a fully integrated managed health care system pursuant to chapter 71.24 RCW, regional service areas:
(1) Must allow reimbursement for time spent supervising persons working toward satisfying supervision requirements established for the relevant practice areas pursuant to RCW 18.225.090; and
(2) May allow reimbursement for services delivered through a partial hospitalization or intensive outpatient program as described in RCW 71.24.385.
[ 2018 c 175 s 8.]
Notes:
Findings—Intent—2018 c 175: See note following RCW 74.09.495.

catchline: Regional service areas—Certain reimbursements required or allowed upon adoption of fully integrated managed health care system.


title: RCW 74.09.758

text:
(1) The authority and the department may restructure medicaid procurement of health care services and agreements with managed care systems on a phased basis to better support integrated physical health, mental health, and substance use disorder treatment, consistent with assumptions in Second Substitute Senate Bill No. 6312, Laws of 2014, and recommendations provided by the behavioral health task force. The authority and the department may develop and utilize innovative mechanisms to promote and sustain integrated clinical models of physical and behavioral health care.
(2) The authority and the department may incorporate the following principles into future medicaid procurement efforts aimed at integrating the delivery of physical and behavioral health services:
(a) Medicaid purchasing must support delivery of integrated, person-centered care that addresses the spectrum of individuals' health needs in the context of the communities in which they live and with the availability of care continuity as their health needs change;
(b) Accountability for the client outcomes established in RCW 71.24.435 and 71.36.025 and performance measures linked to those outcomes;
(c) Medicaid benefit design must recognize that adequate preventive care, crisis intervention, and support services promote a recovery-focused approach;
(d) Evidence-based care interventions and continuous quality improvement must be enforced through contract specifications and performance measures that provide meaningful integration at the patient care level with broadly distributed accountability for results;
(e) Active purchasing and oversight of medicaid managed care contracts is a state responsibility;
(f) A deliberate and flexible system change plan with identified benchmarks to promote system stability, provide continuity of treatment for patients, and protect essential existing behavioral health system infrastructure and capacity; and
(g) Community and organizational readiness are key determinants of implementation timing; a phased approach is therefore desirable.
(3) The principles identified in subsection (2) of this section are not intended to create an individual entitlement to services.
(4) The authority shall increase the use of value-based contracting, alternative quality contracting, and other payment incentives that promote quality, efficiency, cost savings, and health improvement, for medicaid and public employee purchasing. The authority shall also implement additional chronic disease management techniques that reduce the subsequent need for hospitalization or readmissions. It is the intent of the legislature that the reforms the authority implements under this subsection are anticipated to reduce extraneous medical costs, across all medical programs, when fully phased in by fiscal year 2017 to generate budget savings identified in the omnibus appropriations act.
[ 2019 c 325 s 5029; 2014 c 223 s 7.]
Notes:
Effective date—2019 c 325: See note following RCW 71.24.011.
Finding—2014 c 223: See note following RCW 41.05.690.

catchline: Medicaid procurement of services—Value-based contracting for medicaid and public employee purchasing.


title: RCW 74.09.7585

text:
(1) The authority shall consult with the department of commerce and the department of health quarterly for all agencies to plan and prepare for new or expanded services in each regional service area, which must include, but are not limited to, incorporating regional capacity changes reported to the authority by managed care organizations, behavioral health administrative services organizations, providers including Indian health services providers, Indian health care providers, urban Indian health organizations, or provider networks. When programs or facilities including, but not limited to, those programs and facilities described in RCW 71.24.045(1)(e) are newly established or closed or existing services are expanded or reduced in a region the authority shall direct the state's medicaid contractor for actuarial services to promptly and prospectively adjust medicaid managed care rates to include a programmatic adjustment related to the new or expanded service prior to the facility opening or the service expansion, consistent with the rate-setting cycles directed by the authority. If a facility closes or services are reduced, managed care and fee-for-service rates must be adjusted accordingly in the rate-setting cycle following the facility closure.
(2) Within existing funds, the authority's preparation for the reprocurement of services to enrollees of medical assistance programs authorized under this chapter shall include the opportunity for comment by key stakeholders, to the extent allowed by applicable state and federal procurement standards, including tribes, patient groups, health care providers and facilities, counties, and behavioral health administrative services organizations. Preparation for the reprocurement of services must also include:
(a) Methodologies for measuring network access and adequacy for each provider type subject to network access and adequacy standards and tailored to the particular needs of the regional service areas, to be implemented in the reprocurement to assure access to appropriate and timely behavioral health services in each region; and
(b) Opportunities to amend managed care contract requirements to further streamline and standardize processes to reduce administrative burden for providers.
[ 2025 c 216 s 1.]

catchline: Changes in services—Adjustments to medicaid managed care rates.


title: RCW 74.09.760

text:
This act may be known and cited as the "maternity care access act of 1989."
[ 1989 1st ex.s. c 10 s 1.]

catchline: Short title—1989 1st ex.s. c 10.


title: RCW 74.09.770

text:
(1) The legislature finds that Washington state and the nation as a whole have a high rate of infant illness and death compared with other industrialized nations. This is especially true for minority and low-income populations. Premature and low weight births have been directly linked to infant illness and death. The availability of adequate maternity care throughout the course of pregnancy has been identified as a major factor in reducing infant illness and death. Further, the investment in preventive health care programs, such as maternity care, contributes to the growth of a healthy and productive society and is a sound approach to health care cost containment. The legislature further finds that access to maternity care for low-income women in the state of Washington has declined significantly in recent years and has reached a crisis level.
(2) It is the purpose of this subchapter to provide, consistent with appropriated funds, maternity care necessary to ensure healthy birth outcomes for low-income families. To this end, a maternity care access system is established based on the following principles:
(a) The family is the fundamental unit in our society and should be supported through public policy.
(b) Access to maternity care for eligible persons to ensure healthy birth outcomes should be made readily available in an expeditious manner through a single service entry point.
(c) Unnecessary barriers to maternity care for eligible persons should be removed.
(d) Access to preventive and other health care services should be available for low-income children.
(e) Each woman should be encouraged to and assisted in making her own informed decisions about her maternity care.
(f) Unnecessary barriers to the provision of maternity care by qualified health professionals should be removed.
(g) The system should be sensitive to cultural differences among eligible persons.
(h) To the extent possible, decisions about the scope, content, and delivery of services should be made at the local level involving a broad representation of community interests.
(i) The maternity care access system should be evaluated at appropriate intervals to determine effectiveness and need for modification.
(j) Maternity care services should be delivered in a cost-effective manner.
[ 2011 1st sp.s. c 15 s 48; 1989 1st ex.s. c 10 s 2.]
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: Maternity care access system established.


title: RCW 74.09.780

text:
The legislature reserves the right to amend or repeal all or any part of this subchapter at any time and there shall be no vested private right of any kind against such amendment or repeal. All rights, privileges, or immunities conferred by this subchapter or any acts done pursuant thereto shall exist subject to the power of the legislature to amend or repeal this subchapter at any time.
[ 2018 c 201 s 7021; 1989 1st ex.s. c 10 s 3.]
Notes:
Findings—Intent—Effective date—2018 c 201: See notes following RCW 41.05.018.

catchline: Reservation of legislative power.


title: RCW 74.09.790

text:
Unless the context clearly requires otherwise, the definitions in this section apply throughout RCW 74.09.760 through 74.09.820 and 74.09.510:
(1) "At-risk eligible person" means an eligible person determined by the authority to need special assistance in applying for and obtaining maternity care, including pregnant women who are substance abusers, pregnant and parenting adolescents, pregnant minority women, and other eligible persons who need special assistance in gaining access to the maternity care system.
(2) "Authority" means the Washington state health care authority.
(3) "County authority" means the board of county commissioners, county council, or county executive having the authority to participate in the maternity care access program or its designee. Two or more county authorities may enter into joint agreements to fulfill the requirements of this chapter.
(4) "Department" means the department of social and health services.
(5) "Eligible person" means a woman in need of maternity care or a child, who is eligible for medical assistance pursuant to this chapter or the prenatal care program administered by the authority.
(6) "Family planning services" means planning the number of one's children by use of contraceptive techniques.
(7) "Maternity care services" means inpatient and outpatient medical care, case management, and support services necessary during prenatal, delivery, and postpartum periods.
(8) "Support services" means, at least, public health nursing assessment and follow-up, health and childbirth education, psychological assessment and counseling, outreach services, nutritional assessment and counseling, needed vitamin and nonprescriptive drugs, transportation, family planning services, and child care. Support services may include alcohol and substance abuse treatment for pregnant women who are addicted or at risk of being addicted to alcohol or drugs to the extent funds are made available for that purpose.
[ 2011 1st sp.s. c 15 s 49; 1993 c 407 s 9; 1990 c 151 s 4; 1989 1st ex.s. c 10 s 4.]
Notes:
Reviser's note: The definitions in this section have been alphabetized pursuant to RCW 1.08.015(2)(k).
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: Definitions.


title: RCW 74.09.800

text:
The authority shall, consistent with the state budget act, develop a maternity care access program designed to ensure healthy birth outcomes as follows:
(1) Provide maternity care services to low-income pregnant women and health care services to children in poverty to the maximum extent allowable under the medical assistance program, Title XIX of the federal social security act;
(2) Provide maternity care services to low-income women who are not eligible to receive such services under the medical assistance program, Title XIX of the federal social security act;
(3) Have the following procedures in place to improve access to maternity care services and eligibility determinations for pregnant women applying for maternity care services under the medical assistance program, Title XIX of the federal social security act:
(a) Use of a shortened and simplified application form;
(b) Outstationing authority staff to make eligibility determinations;
(c) Establishing local plans at the county and regional level, coordinated by the authority; and
(d) Conducting an interview for the purpose of determining medical assistance eligibility within five working days of the date of an application by a pregnant woman and making an eligibility determination within fifteen working days of the date of application by a pregnant woman;
(4) Establish a maternity care case management system that shall assist at-risk eligible persons with obtaining medical assistance benefits and receiving maternity care services, including transportation and child care services;
(5) Within available resources, establish appropriate reimbursement levels for maternity care providers;
(6) Implement a broad-based public education program that stresses the importance of obtaining maternity care early during pregnancy;
(7) Refer persons eligible for maternity care services under the program established by this section to persons, agencies, or organizations with maternity care service practices that primarily emphasize healthy birth outcomes;
(8) Provide family planning services including information about the synthetic progestin capsule implant form of contraception, for twelve months immediately following a pregnancy to women who were eligible for medical assistance under the maternity care access program during that pregnancy or who were eligible only for emergency labor and delivery services during that pregnancy; and
(9) Within available resources, provide family planning services to women who meet the financial eligibility requirements for services under subsections (1) and (2) of this section.
[ 2011 1st sp.s. c 15 s 50; 1993 c 407 s 10; 1989 1st ex.s. c 10 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.

catchline: Maternity care access program established.


title: RCW 74.09.810

text:
(1) The authority shall establish an alternative maternity care service delivery system, if it determines that a county or a group of counties is a maternity care distressed area. A maternity care distressed area shall be defined by the authority, in rule, as a county or a group of counties where eligible women are unable to obtain adequate maternity care. The authority shall include the following factors in its determination:
(a) Higher than average percentage of eligible persons in the distressed area who receive late or no prenatal care;
(b) Higher than average percentage of eligible persons in the distressed area who go out of the area to receive maternity care;
(c) Lower than average percentage of obstetrical care providers in the distressed area who provide care to eligible persons;
(d) Higher than average percentage of infants born to eligible persons per obstetrical care provider in the distressed area; and
(e) Higher than average percentage of infants that are of low birth weight, five and one-half pounds or two thousand five hundred grams, born to eligible persons in the distressed area.
(2) If the authority determines that a maternity care distressed area exists, it shall notify the relevant county authority. The county authority shall, within one hundred twenty days, submit a brief report to the authority recommending remedial action. The report shall be prepared in consultation with the authority and with the department's local community service offices, the local public health officer, community health clinics, health care providers, hospitals, the business community, labor representatives, and low-income advocates in the distressed area. A county authority may contract with a local nonprofit entity to develop the report. If the county authority is unwilling or unable to develop the report, it shall notify the authority within thirty days, and the authority shall develop the report for the distressed area.
(3) The authority shall review the report and use it, to the extent possible, in developing strategies to improve maternity care access in the distressed area. The authority may contract with or directly employ qualified maternity care health providers to provide maternity care services, if access to such providers in the distressed area is not possible by other means. In such cases, the authority is authorized to pay that portion of the health care providers' malpractice liability insurance that represents the percentage of maternity care provided to eligible persons by that provider through increased medical assistance payments.
[ 2011 1st sp.s. c 15 s 51; 1989 1st ex.s. c 10 s 6.]
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: Alternative maternity care service delivery system established—Remedial action report.


title: RCW 74.09.820

text:
To the extent that federal matching funds are available, the authority or the department of health shall establish, in consultation with the health science programs of the state's colleges and universities, and community health clinics, a loan repayment program that will encourage maternity care providers to practice in medically underserved areas in exchange for repayment of part or all of their health education loans.
[ 2011 1st sp.s. c 15 s 52; 1989 1st ex.s. c 10 s 7.]
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.
Health professional scholarships: Chapter 28B.115 RCW.

catchline: Maternity care provider's loan repayment program.


title: RCW 74.09.825

text:
(1) The authority shall provide coverage under this chapter for medically necessary donor human milk for inpatient use when ordered by a licensed health care provider with prescriptive authority or an international board certified lactation consultant certified by the international board of lactation consultant examiners for an infant who is medically or physically unable to receive maternal human milk or participate in chest feeding or whose parent is medically or physically unable to produce maternal human milk in sufficient quantities or caloric density or participate in chest feeding, if the infant meets at least one of the following criteria:
(a) An infant birth weight of below 2,500 grams;
(b) An infant gestational age equal to or less than 34 weeks;
(c) Infant hypoglycemia;
(d) A high risk for development of necrotizing enterocolitis, bronchopulmonary dysplasia, or retinopathy of prematurity;
(e) A congenital or acquired gastrointestinal condition with long-term feeding or malabsorption complications;
(f) Congenital heart disease requiring surgery in the first year of life;
(g) An organ or bone marrow transplant;
(h) Sepsis;
(i) Congenital hypotonias associated with feeding difficulty or malabsorption;
(j) Renal disease requiring dialysis in the first year of life;
(k) Craniofacial anomalies;
(l) An immunologic deficiency;
(m) Neonatal abstinence syndrome;
(n) Any other serious congenital or acquired condition for which the use of pasteurized donor human milk and donor human milk derived products is medically necessary and supports the treatment and recovery of the child; or
(o) Any baby still inpatient within 72 hours of birth without sufficient human milk available.
(2) Donor human milk covered under this section must be obtained from a milk bank that meets minimum standards adopted by the department of health pursuant to RCW 43.70.645.
(3) The authority may require an enrollee to obtain expedited prior authorization to receive coverage for donor human milk as required under this section.
(4) In administering this program, the authority must seek any available 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.
(5) For purposes of this section:
(a) "Donor human milk" means human milk that has been contributed to a milk bank by one or more donors.
(b) "Milk bank" means an organization that engages in the procurement, processing, storage, distribution, or use of human milk contributed by donors.
[ 2022 c 236 s 4.]

catchline: Donor human milk—Standards—Federal funding.


title: RCW 74.09.830

text:
(1) The authority shall extend health care coverage from 60 days postpartum to one year postpartum for pregnant or postpartum persons who, on or after the expiration date of the federal public health emergency declaration related to COVID-19, are receiving postpartum coverage provided under this chapter.
(2) By June 1, 2022, the authority must:
(a) Provide health care coverage to postpartum persons who reside in Washington state, have countable income equal to or below 193 percent of the federal poverty level, and are not otherwise eligible under Title XIX or Title XXI of the federal social security act; and
(b) Ensure all persons approved for pregnancy or postpartum coverage at any time are continuously eligible for postpartum coverage for 12 months after the pregnancy ends regardless of whether they experience a change in income during the period of eligibility.
(3) By November 1, 2024, the income standards for a postpartum person eligible for Washington apple health pregnancy or postpartum coverage shall have countable income equal to or below 210 percent of the federal poverty level.
(4) Health care coverage under this section must be provided during the 12-month period beginning on the last day of the pregnancy.
(5) The authority shall not provide health care coverage under this section to individuals who are eligible to receive health care coverage under Title XIX or Title XXI of the federal social security act. Health care coverage for these individuals shall be provided by a program that is funded by Title XIX or Title XXI of the federal social security act. Further, the authority shall make every effort to expedite and complete eligibility determinations for individuals who are presumptively eligible to receive health care coverage under Title XIX or Title XXI of the federal social security act to ensure the state is receiving the maximum federal match. This includes, but is not limited to, working with the managed care organizations to provide continuous outreach in various modalities until the individual's eligibility determination is completed. Beginning January 1, 2022, the authority must submit quarterly reports to the caseload forecast work group on the number of individuals who are presumptively eligible to receive health care coverage under Title XIX or Title XXI of the federal social security act but are awaiting for the authority to complete eligibility determination, the number of individuals who were presumptively eligible but are now receiving health care coverage with the maximum federal match under Title XIX or Title XXI of the federal social security act, and outreach activities including the work with managed care organizations.
(6) To ensure continuity of care and maximize the efficiency of the program, the amount and scope of health care services provided to individuals under this section must be the same as that provided to pregnant and postpartum persons under medical assistance, as defined in RCW 74.09.520.
(7) In administering this program, the authority must seek any available 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. This includes, but is not limited to, ensuring the state is receiving the maximum federal match for individuals who are presumptively eligible to receive health care coverage under Title XIX or Title XXI of the federal social security act by expediting completion of the individual's eligibility determination.
(8) Working with stakeholder and community organizations and the Washington health benefit exchange, the authority must establish a comprehensive community education and outreach campaign to facilitate applications for and enrollment in the program or into a more appropriate program where the state receives maximum federal match. Subject to the availability of amounts appropriated for this specific purpose, the education and outreach campaign must provide culturally and linguistically accessible information to facilitate participation in the program, including but not limited to enrollment procedures, program services, and benefit utilization.
(9) Beginning January 1, 2022, the managed care organizations contracted with the authority to provide postpartum coverage must annually report to the legislature on their work to improve maternal health for enrollees, including but not limited to postpartum services offered to enrollees, the percentage of enrollees utilizing each postpartum service offered, outreach activities to engage enrollees in available postpartum services, and efforts to collect eligibility information for the authority to ensure the enrollee is in the most appropriate program for the state to receive the maximum federal match.
[ 2024 c 213 s 4; 2021 c 90 s 2.]
Notes:
Intent—2021 c 90: "(1) In Washington and across the country, maternal mortality rates continue to be unacceptably high. The maternal mortality rate in the United States is higher than in most developed countries. Approximately 700 people die each year in the United States due to pregnancy-related conditions. The majority of these deaths are preventable.
(2) National and state maternal mortality data reveals significant racial and ethnic disparities. Nationally, black women are two to three times more likely to die from a pregnancy-related cause than white women. In this state, data from the maternal mortality review panel reveals that American Indian and Alaska Native women are six to seven times as likely to die from a pregnancy-related cause than white women. Significant disparities in maternal mortality rates also exist for Hispanic, Asian, and multiracial women in Washington.
(3) Over 50 percent of pregnancy-related deaths in Washington state are women enrolled in medicaid. In 2019, medicaid covered almost 37,000 births which is nearly half of the total of nonmilitary births in Washington state.
(4) The centers for disease control and prevention find pregnancy-related deaths occur up to one year postpartum, and data shows that health needs continue during that entire year. In Washington, nearly one-third of all pregnancy-related deaths and the majority of suicides and accidental overdoses occurred between 43 and 365 days postpartum.
(5) The maternal mortality review panel has identified access to health care services and gaps in continuity of care, especially during the postpartum period, as factors that contribute to preventable pregnancy-related deaths. In their October 2019 report to the legislature, the panel recommended ensuring funding and access to postpartum care and support through the first year after pregnancy. The panel also recommended addressing social determinants of health, structural racism, provider biases, and other social inequities to reduce maternal mortality in priority populations.
(6) Approximately 50,000 people also experience serious complications from childbirth each year, resulting in increased medical costs, longer hospitalization stays, and long-term health effects.
(7) Postpartum medicaid coverage currently ends 60 days after pregnancy, creating an unsafe gap in coverage. Continuity of care is critical during this vulnerable time, and uninterrupted health care coverage provides birthing parents with access to stable and consistent care. Extending health care coverage through the first year postpartum is one of the best tools for increasing access to care and improving maternal and infant health. A health impact review published by the state board of health found very strong evidence that this policy would decrease inequities by race and ethnicity, immigration status, socioeconomic status, and geography.
(8) During the public health emergency, a federal maintenance of effort requirement has extended medicaid coverage beyond 60 days postpartum. This extension is critical, with pregnancy-related deaths increasing due to COVID-19. Pregnant women are more likely to be admitted to the intensive care unit and receive invasive ventilation and are at increased risk of death compared to nonpregnant women. The pandemic has also exacerbated the behavioral health challenges normally faced in the pregnancy and postpartum period. It has also highlighted and contributed to increased housing crises. Even outside of the pandemic, research shows that pregnancy can increase a woman's risk of becoming homeless, and pregnant women face significantly greater health risks while unstably housed. The legislature is committed to continuing coverage for this population beyond the maintenance of effort requirement.
(9) Pending federal legislation, the helping moms act, would provide federal matching funds to states that provide one year of postpartum coverage under medicaid and the children's health insurance program.
(10) The legislature therefore intends to extend health care coverage from 60 days to 12 months postpartum." [ 2021 c 90 s 1.]

catchline: Postpartum health care coverage.


title: RCW 74.09.835

text:
(1) By no later than January 1, 2026, the authority shall create a postdelivery and transitional care program that allows for extended postdelivery hospital care for people with a substance use disorder at the time of delivery. The authority shall:
(a) Allow for up to five additional days of hospitalization stay for the birth parent;
(b) Provide the birth parent access to integrated care and medical services including, but not limited to, access to clinical health, medication management, behavioral health, addiction medicine, specialty consultations, and psychiatric providers;
(c) Provide the birth parent access to social work support which includes coordination with the department of children, youth, and families to develop a plan for safe care;
(d) Allow dedicated time for health professionals to assist in facilitating early bonding between the birth parent and infant by helping the birth parent recognize and respond to their infant's cues; and
(e) Establish provider requirements and pay only those qualified providers for the services provided through the program.
(2) In order to provide technical assistance to participating hospitals regarding the postdelivery and transitional care program, the authority shall contract with the Washington state chapter of a national organization that provides a physician-led professional community for those who prevent, treat, and promote remission and recovery from the disease of addiction and whose comprehensive set of guidelines for determining placement, continued stay, and transfer or discharge of enrollees with substance use disorders and co-occurring disorders have been incorporated into medicaid managed care contracts.
(3) In administering the program, the authority shall seek any available 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, the federal family first prevention services act, and any other federal funding sources that are now available or may become available.
[ 2024 c 213 s 1.]

catchline: Postdelivery and transitional care program—Contracting—Funding.


title: RCW 74.09.837

text:
(1) Subject to the amounts appropriated for this specific purpose, the authority shall update the maternity support services program to address perinatal outcomes and increase equity and healthier birth outcomes. By January 1, 2026, the authority shall:
(a) Update current screening tools to be culturally relevant, include current risk factors, ensure the tools address health equity, and include questions identifying various social determinants of health that impact a healthy birth outcome and improve health equity;
(b) Ensure care coordination, including sharing screening tools with the patient's health care providers as necessary;
(c) Develop a mechanism to collect the results of the maternity support services screenings and evaluate the outcomes of the program. At minimum, the program evaluation shall:
(i) Identify gaps, strengths, and weaknesses of the program; and
(ii) Make recommendations for how the program may improve to better align with the authority's maternal and infant health initiatives; and
(d) Increase the allowable benefit and reimbursement rates with the goal of increasing utilization of services to all eligible maternity support services clients who choose to receive the services.
(2) The authority shall adopt rules to implement this section.
[ 2024 c 213 s 2.]

catchline: Maternity support services program—Updates—Rule making.


title: RCW 74.09.839

text:
By November 1, 2024, the income standards for a pregnant person eligible for Washington apple health pregnancy coverage shall have countable income equal to or below 210 percent of the federal poverty level.
[ 2024 c 213 s 3.]

catchline: Apple health pregnancy coverage.


title: RCW 74.09.840

text:
(1) Beginning January 1, 2024, the authority shall require each managed care organization to comply with the following standards related to prior authorization for health care services and prescription drugs:
(a) The managed care organization shall meet the following time frames for prior authorization determinations and notifications to a participating provider or facility that submits the prior authorization request through an electronic prior authorization process, as designated by each managed care organization:
(i) For electronic standard prior authorization requests, the managed care organization shall make a decision and notify the provider or facility of the results of the decision within three calendar days, excluding holidays, of submission of an electronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the managed care organization to make a decision, the managed care organization shall request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization request.
(ii) For electronic expedited prior authorization requests, the managed care organization shall make a decision and notify the provider or facility of the results of the decision within one calendar day of submission of an electronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the managed care organization to make a decision, the managed care organization shall request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization request.
(b) The managed care organization shall meet the following time frames for prior authorization determinations and notifications to a participating provider or facility that submits the prior authorization request through a process other than an electronic prior authorization process described in subsection (2) of this section:
(i) For nonelectronic standard prior authorization requests, the managed care organization shall make a decision and notify the provider or facility of the results of the decision within five calendar days of submission of a nonelectronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the managed care organization to make a decision, the managed care organization shall request any additional information from the provider or facility within five calendar days of submission of the nonelectronic prior authorization request.
(ii) For nonelectronic expedited prior authorization requests, the managed care organization shall make a decision and notify the provider or facility of the results of the decision within two calendar days of submission of a nonelectronic prior authorization request by the provider or facility that contains the necessary information to make a determination. If insufficient information has been provided to the managed care organization to make a decision, the managed care organization shall request any additional information from the provider or facility within one calendar day of submission of the nonelectronic prior authorization request.
(c) In any instance in which a managed care organization has determined that a provider or facility has not provided sufficient information for making a determination under (a) and (b) of this subsection, a managed care organization may establish a specific reasonable time frame for submission of the additional information. This time frame must be communicated to the provider and enrollee with a managed care organization's request for additional information.
(d) The prior authorization requirements of the managed care organization must be described in detail and written in easily understandable language. The managed care organization shall make its most current prior authorization requirements and restrictions, including the written clinical review criteria, available to providers and facilities in an electronic format upon request. The prior authorization requirements must be based on peer-reviewed clinical review criteria. The clinical review criteria must be evidence-based criteria and must accommodate new and emerging information related to the appropriateness of clinical criteria with respect to black and indigenous people, other people of color, gender, and underserved populations. The clinical review criteria must be evaluated and updated, if necessary, at least annually.
(2)(a) Each managed care organization shall establish and maintain a prior authorization application programming interface that is consistent with final rules issued by the federal centers for medicare and medicaid services and published in the federal register, and that indicates that a prior authorization denial or authorization of a service less intensive than that included in the original request is an adverse benefit determination and is subject to the managed care organization's grievance and appeal process under RCW 48.43.535.
(b) Each managed care organization shall establish and maintain an interoperable electronic process or application programming interface that automates the process for in-network providers to determine whether a prior authorization is required for a covered prescription drug. The interoperable electronic process or application programming interface must support the exchange of prior authorization requests and determinations for prescription drugs, including information on covered alternative prescription drugs, beginning January 1, 2027, and must:
(i) Allow providers to identify prior authorization information and documentation requirements;
(ii) Facilitate the exchange of prior authorization requests and determinations from its electronic health records or practice management system; and
(iii) Indicate that a prior authorization denial or authorization of a drug other than the one included in the original prior authorization request is an adverse benefit determination and is subject to the managed care organization's grievance and appeal process under RCW 48.43.535.
(c) Regardless of whether federal rules related to standards for using an application programming interface to communicate prior authorization status to providers are revoked, delayed, suspended, or not finalized after February 8, 2024, the requirements of (a) of this subsection shall be enforced beginning January 1, 2027.
(3) Nothing in this section applies to prior authorization determinations made pursuant to RCW 71.24.618 or 74.09.490.
(4) For the purposes of this section:
(a) "Expedited prior authorization request" means a request by a provider or facility for approval of a health care service or prescription drug where:
(i) The passage of time:
(A) Could seriously jeopardize the life or health of the enrollee;
(B) Could seriously jeopardize the enrollee's ability to regain maximum function; or
(C) In the opinion of a provider or facility with knowledge of the enrollee's medical condition, would subject the enrollee to severe pain that cannot be adequately managed without the health care service or prescription drug that is the subject of the request; or
(ii) The enrollee is undergoing a current course of treatment using a nonformulary drug.
(b) "Standard prior authorization request" means a request by a provider or facility for approval of a health care service or prescription drug where the request is made in advance of the enrollee obtaining a health care service or prescription drug that is not required to be expedited.
[ 2025 c 25 s 3; 2023 c 382 s 3.]

catchline: Prior authorization.


title: RCW 74.09.850

text:
If any part of this chapter is found to conflict with federal requirements which are a prescribed condition to the allocation of federal funds to the state, the conflicting part of this chapter is hereby declared to be inoperative solely to the extent of the conflict, and such finding or determination shall not affect the operation of the remainder of this chapter.
[ 1981 2nd ex.s. c 3 s 7.]
Notes:
Severability—1981 2nd ex.s. c 3: See note following RCW 74.09.510.

catchline: Conflict with federal requirements.


title: RCW 74.09.860

text:
(1) The authority shall issue a request for proposals to provide integrated managed health and behavioral health care for foster children receiving care through the medical assistance program. Behavioral health services provided under chapters 71.24 and 71.34 RCW must be integrated into the managed care organization for foster children beginning January 1, 2019. The request for proposals must address the program elements described in section 110, chapter 225, Laws of 2014, including development of a service delivery system, benefit design, reimbursement mechanisms, incorporation or coordination of services currently provided by the regional support networks, and standards for contracting with health organizations. The request for proposals must be issued and completed in time for services under the integrated managed care plan to begin on October 1, 2016.
(2) The parent or guardian of a child who is no longer a dependent child pursuant to chapter 13.34 RCW may choose to continue in the transitional foster care eligibility category for up to twelve months following reunification with the child's parents or guardian if the child:
(a) Is under eighteen years of age;
(b) Was 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 Indian tribe located within the state; and
(c) Meets income and other eligibility standards for medical assistance coverage.
[ 2023 c 51 s 52; 2018 c 27 s 1; 2015 c 283 s 1.]
Notes:
Effective date—2018 c 27: "This act takes effect July 1, 2018." [ 2018 c 27 s 2.]

catchline: Request for proposals—Foster children—Integrated managed health and behavioral health care—Continuation of health care benefits following reunification.


title: RCW 74.09.865

text:
(1) Subject to the availability of amounts appropriated for this specific purpose, the postinpatient housing program for young adults is established to provide supportive transitional housing with behavioral health support focused on securing long-term housing for young adults exiting inpatient behavioral health treatment.
(2) To be eligible for the postinpatient housing program for young adults created under this section, a person must:
(a) Be 18 through 24 years of age;
(b)(i) Be exiting inpatient behavioral health treatment; or
(ii) Have exited inpatient behavioral health treatment within the last month and be engaged in a recovery plan; and
(c) Not have secured long-term housing.
(3) Subject to the availability of amounts appropriated for this specific purpose and to fulfill the requirements of this section, the authority shall:
(a) Provide funding to a community-based organization or organizations or federally recognized tribes within Washington or tribal organizations that serve American Indians and Alaska Natives in Washington with expertise in working with young people experiencing unaccompanied homelessness, behavioral health conditions, or both, to operate a residential program or programs as described in this subsection (3)(a). The organization selected to operate a residential program or programs in this subsection (3)(a) may choose whether or not to serve individuals eligible according to the criteria established in subsection (2) of this section. The residential program or programs must be voluntary for participants and may not be a secure facility, or a facility that limits residents' ingress and egress pursuant to chapter 71.24 RCW, or a facility at which individuals may be detained pursuant to chapter 71.05 RCW. In addition, the authority shall consult with a transition support provider when soliciting and selecting a community-based organization or organizations under this subsection. The funding provided under this subsection must be used to:
(i) Establish at least two residential programs with six to 10 beds with one program on either side of the Cascade mountain range;
(ii) Establish a developmentally and culturally responsive environment that values healing and recovery;
(iii) Engage peers with behavioral health experience in the support and recovery of individuals served by the program;
(iv) Serve individuals determined eligible according to the criteria established in subsection (2) of this section for up to 90 days; and
(v) Support and strengthen the ongoing healing and learning that occurred for those served by the program during their inpatient treatment;
(b) Provide additional funding to the transition support provider for:
(i) Consultation and training services to the residential program or programs selected under (a) of this subsection;
(ii) Return-to-community planning for the individuals served by the residential programs described under (a) of this subsection; and
(iii) To the extent possible, making contact with individuals served by the residential programs described under (a) of this subsection at regular intervals after those individuals leave the residential program and reporting this information to the authority;
(c) Provide flexible funding to support individuals served by the residential programs described under (a) of this subsection. The flexible funding provided under this subsection may be provided to support the immediate needs of the individual. Uses of the flexible funding provided under this subsection may include, but are not limited to, the following:
(i) Car repair or other transportation assistance;
(ii) Rental application fees, a security deposit, or short-term rental assistance; or
(iii) Other uses that will help support the person's housing stability, education, or employment, or meet immediate basic needs; and
(d) Provide funding to contract with individuals or entities that provide behavioral health support to individuals determined eligible according to the criteria established in subsection (2) of this section, which may include, but are not limited to:
(i) On-site and community-based behavioral health supports;
(ii) Peer supports; and
(iii) Medication management.
(4) For purposes of this section, "transition support provider" means a community-based organization selected by the authority that continues to:
(a) Provide information and support services related to safe housing and support services for youth exiting inpatient behavioral health treatment; and
(b) Organize a coalition of community housing providers, federally recognized tribes within Washington or tribal organizations that serve American Indians and Alaska Natives in Washington, inpatient behavioral health discharge planners, and young people with lived experience of behavioral health conditions or unaccompanied homelessness.
[ 2024 c 175 s 2.]
Notes:
Findings—2024 c 175: "(1) The legislature has committed to and invested in ensuring that young people exiting the system of care do so with safe housing and developmentally responsive services through the enactment of Substitute Senate Bill No. 6560 (2018) and Second Substitute House Bill No. 1905 (2022).
(2) The legislature finds that young people who exit behavioral health inpatient treatment are the largest group of people who become homeless within three to 12 months of all the young people who exit any publicly funded system of care, as identified in a 2023 report produced by the research and data analysis division of the department of social and health services.
(3) The legislature has invested significant funding in the behavioral health system and finds that ensuring a person's safe return to the community postinpatient treatment is a high priority and a major opportunity to end their experience with homelessness. In addition, the legislature finds that a young person who enters treatment demonstrates the courage to engage in their personal health and creates the opportunity for family and community reunification, career development, and a full life.
(4) The legislature further finds that it often takes more time and resources than expected during a person's inpatient treatment episode to identify a return to community plan that includes long-term, safe housing and a developmentally and culturally responsive support system that includes relationships, services, and passions.
(5) For these reasons, the legislature finds that having an interim housing option that provides a safe and soft landing postinpatient treatment, located on each side of the state, that has well-trained staff and peers who have behavioral health expertise, is a sound investment in our young people and our collective goals to prevent and end homelessness." [ 2024 c 175 s 1.]

catchline: Postinpatient housing program for young adults.


title: RCW 74.09.870

text:
(1) Upon receipt of guidance for the creation of common regional service areas from the adult behavioral health system task force established in section 1, chapter 338, Laws of 2013, the authority shall establish regional service areas as provided in this section.
(2) Counties, through the Washington state association of counties, must be given the opportunity to propose the composition of regional service areas. Each service area must:
(a) Include a sufficient number of medicaid lives to support full financial risk managed care contracting for services included in contracts with the department or the authority;
(b) Include full counties that are contiguous with one another; and
(c) Reflect natural medical and behavioral health service referral patterns and shared clinical, health care service, behavioral health service, and behavioral health crisis response resources.
(3) The Washington state association of counties must submit their recommendations to the department, the authority, and the task force described in section 1, chapter 225, Laws of 2014 on or before August 1, 2014.
[ 2018 c 201 s 2006; 2014 c 225 s 2. Formerly RCW 43.20A.893.]
Notes:
Findings—Intent—Effective date—2018 c 201: See notes following RCW 41.05.018.

catchline: Regional service areas—Establishment.