Chapter 246-130 WAC

Last Update: 11/17/05

EARLY INTERVENTION PROGRAM

WAC Sections

246-130-001What is the early intervention program?
246-130-010What definitions does the early intervention program use?
246-130-020What early intervention program services are available?
246-130-030How does the early intervention program pay a provider or benefits manager?
246-130-040How do persons with HIV become eligible?
246-130-045Does an early intervention program client need to notify the department of any changes in their eligibility?
246-130-060Is information kept confidential?
246-130-080What do clients do if they disagree with the department's decision about their eligibility or coverage?
246-130-090How do I contact the department?
DISPOSITION OF SECTIONS FORMERLY CODIFIED IN THIS TITLE
246-130-028What services are not available? [Statutory Authority: RCW 43.70.040 and 43.70.120. WSR 00-19-117, § 246-130-028, filed 9/20/00, effective 10/21/00.] Repealed by WSR 05-23-100, filed 11/17/05, effective 12/18/05. Statutory Authority: RCW 43.70.670.
246-130-050Transfer of resources without adequate consideration. [Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-130-050, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. WSR 90-17-087 (Order 071), § 248-168-050, filed 8/17/90, effective 9/17/90. Statutory Authority: RCW 43.20A.550. WSR 87-22-012 (Order 2549), § 248-168-050, filed 10/26/87.] Repealed by WSR 95-23-018, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.040 and 43.70.120.
246-130-070Participation. [Statutory Authority: RCW 43.70.040 and 43.70.120. WSR 95-23-018, § 246-130-070, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-130-070, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. WSR 90-17-087 (Order 071), § 248-168-070, filed 8/17/90, effective 9/17/90.] Repealed by WSR 00-19-117, filed 9/20/00, effective 10/21/00. Statutory Authority: RCW 43.70.040. and 43.70.120.


246-130-001
What is the early intervention program?

The early intervention program of HIV client services' mission is to reduce the transmission and medical consequences of HIV by assuring that persons eligible for the early intervention program in Washington have access to available health care and supportive services.
The early intervention program provides treatment of HIV infection to eligible clients based on available funds. The department provides these early intervention services to improve public health by treating people living with HIV, its complications, and side effects of HIV treatment, and in order to decrease the risk of clients with HIV infecting others. Information on how to contact this program is in WAC 246-130-090.
[Statutory Authority: RCW 43.70.670. WSR 05-23-100, § 246-130-001, filed 11/17/05, effective 12/18/05. Statutory Authority: RCW 43.70.040 and 43.70.120. WSR 00-19-117, § 246-130-001, filed 9/20/00, effective 10/21/00; WSR 95-23-018, § 246-130-001, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-130-001, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. WSR 90-17-087 (Order 071), § 248-168-010, filed 8/17/90, effective 9/17/90. Statutory Authority: RCW 43.20A.550. WSR 87-22-012 (Order 2549), § 248-168-010, filed 10/26/87.]



246-130-010
What definitions does the early intervention program use?

The following words and phrases have the following meaning in chapter 246-130 WAC:
(1) "AIDS" means acquired immunodeficiency syndrome.
(2) "Applicant" means a person applying for early intervention program services.
(3) "Benefits manager" means:
(a) The pharmacy benefits manager contracted with the department to provide prescription drug claim processing and formulary management services; or
(b) The insurance benefits manager contracted with the department to provide insurance premium assistance through the HIV insurance program and the medicare premium assistance program.
(4) "Client" means a person who the department determines is currently eligible for early intervention program services.
(5) "Department" means the Washington state department of health.
(6) "Early intervention program services" means medically necessary treatment and services that reduce the rate of progression of HIV infection and HIV transmission. This includes behavioral risk reduction interventions. See WAC 246-130-020 for details.
(7) "Federal poverty level" means the official income level for poverty released by the federal government each year in February.
(8) "Formulary" means the list of prescription drugs that the early intervention program will pay for. To obtain a copy of that list, see WAC 246-130-090.
(9) "HIV" means human immunodeficiency virus as defined in RCW 70.24.017(7).
(10) "HIV insurance program" means the program that provides health insurance coverage for individuals with HIV who are not eligible for medical assistance programs from the department of social and health services. Medical assistance program is defined in RCW 74.9.010(8). Individuals must meet the eligibility requirements established by the department.
(11) "Medicare premium assistance" means the program that pays premiums, copayments and deductibles for department clients receiving medicare and enrolled in the prescription drug program.
(12) "Provider" means a health care professional contracted by the department to supply medical, dental, or laboratory services to a client.
(13) "Schedule of services" means the department's list of medical, dental, and laboratory services covered by its early intervention program. To obtain a copy of that list, see WAC 246-130-090.
(14) "Standard of care" means treatment for HIV that is commonly accepted by the local medical community.
(15) "Steering committee" means the department's early intervention steering committee. This advisory committee serves at the pleasure of the department secretary in accordance with RCW 43.70.040(2). The committee consists of Washington state residents living with HIV, HIV medical experts, and representatives from community organizations. The steering committee advises the department on its early intervention program.
[Statutory Authority: RCW 43.70.670. WSR 05-23-100, § 246-130-010, filed 11/17/05, effective 12/18/05. Statutory Authority: RCW 43.70.040 and 43.70.120. WSR 00-19-117, § 246-130-010, filed 9/20/00, effective 10/21/00; WSR 95-23-018, § 246-130-010, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.120. WSR 92-02-018 (Order 224), § 246-130-010, filed 12/23/91, effective 1/23/92. Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-130-010, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. WSR 90-17-087 (Order 071), § 248-168-015, filed 8/17/90, effective 9/17/90.]



246-130-020
What early intervention program services are available?

Services to treat HIV are available from the department, based on available funding, to eligible clients as described in this section.
(1) The department decides what specific medical, laboratory, dental, prescription medication and insurance services to cover after actively consulting with its steering committee and considering:
(a) Support of the steering committee;
(b) FDA approval for prescription medications;
(c) Standard of care recognized by the medical community;
(d) Effectiveness in treatment for HIV, complications of HIV, side effects of current treatments for HIV or support for HIV treatment adherence; and
(e) Relative cost of services.
(2) The early intervention program services described in this section are available to all clients, unless they receive those services from other sources. Specific services of this section are available for a client only when medically necessary to treat HIV and associated diseases, complications of treating HIV, or support for HIV treatment adherence.
(3) Specific covered medical, laboratory, and dental services are listed in the department's "schedule of services."
(4) Prescription drugs covered are listed in the department's "early intervention drug formulary."
(5) HIV insurance program includes:
(a) Premium payment or assistance as authorized in RCW 43.70.670;
(b) Deductible payment up to a limit determined by the early intervention program within a twelve-month period; and
(c) Co-pay payment for third-party insurance as follows:
(i) The percentage of prescription medication costs covered by the department and not covered by third-party insurers; and
(ii) Fixed dollar co-pay required by a client's third-party insurance plan for prescription medication covered by the early intervention program.
(6) Medicare premium assistance will pay premiums, copayment and deductibles for early intervention program clients on medicare who request assistance for the prescription drug program.
(7) The department may also coordinate other services to treat HIV and AIDS. These are available as funding and contracting permit. For example, as of July 1, 2000, the department may pay toward the spend-down for medically needy (MN) clients who are also early intervention program clients.
(8) The early intervention program will provide written notification to clients, providers, and the steering committee at least thirty days in advance of any reduction in service or payments.
(9) You may contact the department per WAC 246-130-090 to make comments on service coverage or to receive information.
[Statutory Authority: RCW 43.70.670. WSR 05-23-100, § 246-130-020, filed 11/17/05, effective 12/18/05. Statutory Authority: RCW 43.70.040 and 43.70.120. WSR 00-19-117, § 246-130-020, filed 9/20/00, effective 10/21/00; WSR 95-23-018, § 246-130-020, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-130-020, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. WSR 90-17-087 (Order 071), § 248-168-020, filed 8/17/90, effective 9/17/90. Statutory Authority: RCW 43.20A.550. WSR 87-22-012 (Order 2549), § 248-168-020, filed 10/26/87.]



246-130-030
How does the early intervention program pay a provider or benefits manager?

The department pays a provider or benefits manager for covered services delivered to clients, as limited by this section.
(1) The department pays a provider or benefits manager who contracts with the department for services described in WAC 246-130-020.
(a) The department will only pay for services delivered by a contracted provider or benefits manager.
(b) A provider or benefits manager must bill the department according to the procedure and terms of the contract.
(c) The department only pays for covered, medically necessary early intervention program services delivered to clients who are eligible under WAC 246-130-040.
(2) Payment of services depends on availability of federal and state funds. The department will not deny payment of any individual claim for funding availability unless the department denies an entire class of claims, or an entire program.
(3) A provider or benefits manager who disputes a payment may do so through the contracts process specified in WAC 246-130-080(3).
(4) The department is payer of last resort.
(a) A provider or benefits manager must bill all other third-party sources prior to billing the department for covered services; and
(b) A provider or benefits manager must reimburse the department for any funds paid by the department, which were actually reimbursed by other sources.
[Statutory Authority: RCW 43.70.670. WSR 05-23-100, § 246-130-030, filed 11/17/05, effective 12/18/05. Statutory Authority: RCW 43.70.040 and 43.70.120. WSR 00-19-117, § 246-130-030, filed 9/20/00, effective 10/21/00; WSR 95-23-018, § 246-130-030, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.120. WSR 92-02-018 (Order 224), § 246-130-030, filed 12/23/91, effective 1/23/92. Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-130-030, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. WSR 90-17-087 (Order 071), § 248-168-030, filed 8/17/90, effective 9/17/90. Statutory Authority: RCW 43.20A.550. WSR 87-22-012 (Order 2549), § 248-168-030, filed 10/26/87.]



246-130-040
How do persons with HIV become eligible?

(1) The department establishes the criteria for determining client eligibility for the early intervention program by consulting with the early intervention steering committee and other interested parties. The department reviews each client's application against the criteria set out in this section.
(2) An applicant is eligible for twelve months of early intervention program services beginning the first of the month that the applicant's completed application was postmarked.
(3) The department requires the following documentation:
(a) A medical diagnosis of HIV;
(b) A Washington state address;
(c) Verification of income, that is equal to or less than the limit set by the early intervention program. Income includes:
(i) Wages, salary, overtime, tips, and bonuses;
(ii) Social Security, trust funds for disability, or other disability insurance payments;
(iii) Unemployment benefits;
(iv) Veteran's Administration benefits;
(v) Lump sum payments of gifts, cash inheritance, property, lottery winnings, worker's compensation for lost income, or severance pay;
(vi) Private pensions, annuities, or royalties; and
(vii) Investment dividends.
(4) The department also considers the following when determining client eligibility:
(a) Client resources: A client must have current resources of less than or equal to the limit set by the early intervention program. Resources include trust funds, and any other financial resources available to the applicant. The department does not count the following as resources:
(i) One home, defined as real property owned by the client as his or her principal place of residence in Washington state, together with surrounding property not to exceed five acres;
(ii) Commercial property, or property used for producing income, up to the first twenty thousand dollars of value;
(iii) Household furnishings;
(iv) One automobile; or
(v) Pensions and other Internal Revenue Service designated retirement accounts; or
(vi) Burial plots or prepaid funeral arrangements.
(b) Client ineligibility for medical benefits through the department of social and health services. If a client is eligible for medical benefits through the department of social and health services, he or she may not qualify for the early intervention program, except when the department is coordinating other services as specified in WAC 246-130-020(6).
(5) Individuals transitioning from any correctional institute are eligible for service that will assist them to access medication once they are released from the facility.
(6) Refer to the HIV client services web page through DOH WEB (A-Z) at www.doh.wa.gov.
[Statutory Authority: RCW 43.70.670. WSR 05-23-100, § 246-130-040, filed 11/17/05, effective 12/18/05. Statutory Authority: RCW 43.70.040 and 43.70.120. WSR 00-19-117, § 246-130-040, filed 9/20/00, effective 10/21/00; WSR 95-23-018, § 246-130-040, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.120. WSR 92-02-018 (Order 224), § 246-130-040, filed 12/23/91, effective 1/23/92. Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-130-040, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. WSR 90-17-087 (Order 071), § 248-168-040, filed 8/17/90, effective 9/17/90. Statutory Authority: RCW 43.20A.550. WSR 87-22-012 (Order 2549), § 248-168-040, filed 10/26/87.]



246-130-045
Does an early intervention program client need to notify the department of any changes in their eligibility?

(1) Clients must notify the department of any changes that affect their eligibility within twenty days of the change.
(2) Clients who do not notify the department of changes may be disenrolled and required to repay the funds spent on their services.
(3) Clients may be disenrolled from the program if they provide false information.
[Statutory Authority: RCW 43.70.670. WSR 05-23-100, § 246-130-045, filed 11/17/05, effective 12/18/05.]



246-130-060
Is information kept confidential?

Applicant and client information supplied to the early intervention program is confidential. The early intervention program follows all applicable state and federal laws regarding the exchange of medical information.
[Statutory Authority: RCW 43.70.670. WSR 05-23-100, § 246-130-060, filed 11/17/05, effective 12/18/05. Statutory Authority: RCW 43.70.040 and 43.70.120. WSR 00-19-117, § 246-130-060, filed 9/20/00, effective 10/21/00; WSR 95-23-018, § 246-130-060, filed 11/7/95, effective 12/8/95. Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-130-060, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.70.120. WSR 90-17-087 (Order 071), § 248-168-060, filed 8/17/90, effective 9/17/90. Statutory Authority: RCW 43.20A.550. WSR 87-22-012 (Order 2549), § 248-168-060, filed 10/26/87.]



246-130-080
What do clients do if they disagree with the department's decision about their eligibility or coverage?

Applicants and clients may appeal any decision by the department about their early intervention program eligibility or coverage.
(1) Chapter 246-10 WAC details the adjudication process for matters involving receipt of benefits. The department will provide information on the cause for denied benefits, how a proceeding may be requested, the forms necessary to request a proceeding and information on required time frames.
(2) Applicants and clients may not appeal the department's denial or limitations when the department discontinues or limits an early intervention program service to either funding availability or federal or state law or rule changes. See WAC 246-130-030(3) for more details.
(3) Rate and payment disputes between a provider or benefits manager and the department are handled by contract.
(4) Clients of any other public agency must use that agency's process to resolve eligibility or other disputes regarding that agency.
[Statutory Authority: RCW 43.70.670. WSR 05-23-100, § 246-130-080, filed 11/17/05, effective 12/18/05. Statutory Authority: RCW 43.70.040 and 43.70.120. WSR 00-19-117, § 246-130-080, filed 9/20/00, effective 10/21/00.]



246-130-090
How do I contact the department?

For information or application, contact:
Department of Health
Client Services
P.O. Box 47841
Olympia, WA 98504-7841
Telephone 1-877-376-9316 Option 2
Or, visit the web site at www.doh.wa.gov. Locate HIV client services through the "DOH WEB (A-Z)" at www.doh.wa.gov.
[Statutory Authority: RCW 43.70.670. WSR 05-23-100, § 246-130-090, filed 11/17/05, effective 12/18/05. Statutory Authority: RCW 43.70.040 and 43.70.120. WSR 00-19-117, § 246-130-090, filed 9/20/00, effective 10/21/00.]