PDFWAC 182-534-0100
Standard for coverage.
(1) People age 20 and younger who are enrolled in medicaid are eligible for coverage through the early periodic screening, diagnosis, and treatment (EPSDT) program. See WAC 182-501-0060, Health care coverage—Program benefit packages—Scope of service categories.
(2) Under the EPSDT program, the medicaid agency pays for health care services that fall under any of the categories listed in 42 C.F.R. Part 441, Subpart B, when they are:
(a) Medically necessary, as defined in WAC 182-500-0070;
(b) Safe and effective; and
(c) Not experimental.
(3) Services under the EPSDT program are exempt from specific coverage or service limitations, including amount, duration, and scope of services applicable to the Washington apple health categorically needy and medically needy programs.
(a) The agency may establish utilization controls to safeguard against unnecessary use of care and services. These limits may be exceeded through a process in which the agency reviews medical necessity in a manner consistent with federal EPSDT requirements.
(b) The agency conducts reviews of prior authorization requests on a case-by-case basis, evaluating each client's needs individually, so that delivery of needed treatment services is not delayed. The agency evaluates these requests using the process described in WAC 182-501-0165.
(c) Services not otherwise covered under the medicaid program, including optional services under 42 U.S.C. § 1396d, are available to children through EPSDT when the agency determines the services are medically necessary.
(4) Under the EPSDT program, the agency evaluates requests for noncovered services, as defined by WAC 182-500-0020 and 182-500-0075, under WAC 182-501-0165.
(5) Providers must document all EPSDT services furnished to each client as required by WAC 182-502-0020.
(6) To ensure clients have transportation to medically necessary services, the agency covers various modes of transportation under chapter 182-546 WAC.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-13-048, s 182-534-0100, filed 6/11/25, effective 7/12/25. Statutory Authority: RCW 41.05.021, 41.05.160, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-019, § 182-534-0100, filed 7/24/14, effective 8/24/14. Statutory Authority: RCW 41.05.021 and section 1115 (a)(2) of the Social Security Act. WSR 12-22-046, § 182-534-0100, filed 11/2/12, effective 12/3/12. WSR 11-14-075, recodified as § 182-534-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090, 42 C.F.R., Part 441, Subpart B. WSR 02-07-016, § 388-534-0100, filed 3/8/02, effective 4/8/02. Statutory Authority: RCW 74.08.090. WSR 01-02-076, § 388-534-0100, filed 12/29/00, effective 1/29/01. WSR 00-11-183, recodified as § 388-534-0100, filed 5/24/00, effective 5/24/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. WSR 98-16-044, § 388-86-027, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090. WSR 90-12-061 (Order 3019), § 388-86-027, filed 5/31/90, effective 7/1/90; WSR 82-01-001 (Order 1725), § 388-86-027, filed 12/3/81; WSR 81-10-015 (Order 1647), § 388-86-027, filed 4/27/81; WSR 80-15-034 (Order 1554), § 388-86-027, filed 10/9/80; WSR 79-12-047 (Order 1457), § 388-86-027, filed 11/26/79; Order 1112, § 388-86-027, filed 4/15/76; Order 738, § 388-86-027, filed 11/22/72.]