(1) This rule applies to nonemergency treatment situations occurring in another state or U.S. territory. Applicable situations include, but are not limited to:

(a) Health care services the medicaid agency has prior authorized for a client; and

(b) Health care services obtained by the client, independent of the agency, while traveling or visiting.

(2) Under the prior authorization process described in WAC 182-501-0165, except as specified in subsection (3) of this section, the agency pays for covered nonemergency health care services provided to an eligible Washington apple health (WAH) recipient in another state or U.S. territory to the same extent that it pays for covered nonemergency services provided within the state of Washington when the agency determines that:

(a) Services are medically necessary and the client's health will be endangered if the client must travel to the state of Washington to receive the needed care;

(b) Medically necessary services are not available in Washington state or designated bordering cities (see WAC 182-501-0175) and are more readily available in another state; or

(c) It is general practice for clients in a particular Washington state locality to use medically necessary resources in a bordering state.

(3) The agency pays for covered nonemergency health care services for an eligible WAH recipient in another state or U.S. territory, unless the out-of-state provider will not accept the agency's payment as payment in full under 42 C.F.R. 447.15. The agency does not pay when the provider refuses to accept the agency's payment as payment in full.

(4) The agency does not pay for medically necessary, nonsymptomatic treatment (i.e., preventive care) furnished outside the state of Washington unless it is furnished in a designated bordering city, which is considered the same as an in-state city for the purposes of health care coverage (see WAC 182-501-0175). Covered nonemergency services requiring prior authorization, when provided in the state of Washington, also require prior authorization, when provided in a designated bordering city (see WAC 182-501-0165 for the agency's medical necessity determination process).

(5) See WAC 182-501-0180 for additional information regarding health care services provided outside the state of Washington.

(6) The agency's director or designee reviews all exception to rule (ETR) requests.