Scope of Healthcare Services Table
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Note: DSHS provides funding for a wide range of medical services. The level of medical coverage for any given client depends on the Medical Program for which the client is eligible. This table lists services that may be provided under the specific services/programs if the individual meets all the criteria required to receive the service. Some services may require prior authorization from DSHS or a DSHS-contracted managed care plan. This table is provided for general information only and does not in any way guarantee that any service will actually be covered. Benefits, coverage, and interpretation of benefits and coverage may change at any time. Coverage limitations can be found in federal statutes & regulations, state statutes & regulations, state budget provisions, and DSHS billing instructions and numbered memoranda. Clients with questions regarding coverage may call the 800 number on the back of their Medical ID Card.
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Categorically Needy |
Medically Needy |
General Assistance |
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| Service/Program |
CN |
S-CHIP/CHP |
MN |
GA |
ADATSA |
FP/TC |
| Adult Day Health | Y | N | N | N | N | N |
| Ambulance (Ground/Air) | Y | Y | Y | Y | Y | Y |
| Ambulatory Surgery Center | Y | Y | Y | R1 | R1 | N1 |
| Blood/Blood Administration | Y | Y | Y | Y | Y | N |
| Childbirth Education | Y | Y | N | N | N | N |
| Chiropractic Services for Children | Y | Y | Y | N | N | N |
| Dental Services | Y | Y | Y | R2 | R2 | N |
| Crowns/Dentures | Y | Y | Y | N | N | N |
| Detoxification | Y | Y | Y | R | R | N |
| Diabetes Education | Y | Y | Y | Y | Y | N |
| Early Periodic Screening Diagnosis & Treatment (EPSDT) | Y | Y | Y | N | N | N |
| Family Planning Services | Y | Y | Y | Y | Y | Y |
| Hearing Aids & Services (Audiology and Exams) | Y | Y | N | Y | Y | N |
| HIV/AIDS Case Management | Y | Y | Y | N | N | N |
| Home Health Services | Y | Y | Y | Y | Y | N |
| Y | Y | Y | Y | Y | N | |
| Y | Y | Y | N | N | N | |
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Hospital Services - Inpatient |
Y | Y | Y | Y | Y | N1 |
| Intermediate Care Facility/Services for the Mentally Retarded (IMR) | Y | Y | Y | Y | Y | N |
| Y | Y | Y | Y | Y | N | |
| Maternity Care & Delivery Services | Y | Y | Y | N | N | N |
| Wheelchairs, Durable Medical Equipment | Y | Y | Y | Y | Y | N |
| Nondurable Medical Equipment | Y | Y | Y | Y | Y | N |
| Enteral Nutrition Services | Y | Y | Y | Y | Y | N |
| Medical Nutrition Program | Y4 | Y4 | Y | R4 | R4 | N |
| Mental Health Services | Y | Y | Y | R5 | N | N |
| Inpatient Hospital Care | Y | Y | Y | Y | Y | N |
| Outpatient Hospital Care | Y | Y | Y | R | R | N |
| Mental Health Services - Children | Y | Y | Y | N | N | N |
| Nursing Facility Services | Y | Y | Y | Y | N | N |
| Organ Transplants | Y | Y | Y | Y | Y | N |
| Out of State Services (Excludes Border Cities) | Y | Y | Y | N6 | N6 | N |
| Oxygen Respiratory Services | Y | Y | Y | Y | Y | N |
| Personal Care Services | R | R | R | N | N | N |
| Physician Related Services | Y | Y | Y | Y | Y | R |
| Prenatal Diagnosis Genetic Counseling | Y | Y | Y | N | N | N |
| Prescription Drugs* | Y | Y | Y | Y | Y | R |
| Private Duty Nursing for Children | Y | Y | Y | N | N | N |
| Prosthetic/Orthotic Devices | Y | Y | Y | Y | Y | N |
| Psychological Evaluations | Y | Y | Y | N7 | N7 | N |
| School Based Healthcare Services | Y | N | Y | N | N | N |
| Smoking Cessation | Y | Y | Y | Y | N | N |
| Y | Y | Y | Y8 | Y8 | N | |
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Therapy - |
Y | Y | N4 | Y | Y | N |
| Vision Care Services | Y | Y | Y | Y | Y | N |
| Version 10/10/2008 | ||||||
| LEGEND: Y=Yes, service is usually included; N=No, service is not included; R=Restricted with coverage limitations. | ||||||
| *Medicare recipients receive outpatient prescriptions through their Medicare Part D plan. | ||||||
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1.Services limited by parent program (e.g., Dental Program limitations, Family Planning sterilization services) 2.Covers only service codes as listed in the Dental Program billing instructions. 3.Coverage requirements are located in the Dental Program billing instructions. 4.Coverage limited to children age 20 years old and under if done through an EPSDT screening referral. 5.Restricted to GA clients enrolled in Managed Care. 6.Border cities are considered "in state" for GA coverage. 7.Services covered by the local community mental health center. 8.Service is covered directly through the Division of Alcohol and Substance Abuse (DASA).
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| Other Services | ||||||
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The Health and Recovery Services Administration (HRSA) covers services only necessary to treat the client's emergency medical condition.
HRSA Covers on the Medicare coinsurance and deductible up to the Medicare or HRSA allowed amount, whichever is less.
HRSA covers not emergency medical transportation for eligible clients to or from covered services through contracted brokers. The brokers arrange and pay for trips for qualifying DSHS/HRSA clients. Currently, eligible clients include Medicaid, S-CHIP, CHP, GA, ADATSA, and AEM.
HRSA covers the cost of interpreter service for eligible clients through contracted brokers. Requests for spoken language interpreter services must be requested by Medicaid providers or authorized DSHS staff.
HRSA covers the cost of sign language services for eligible clients. Requests for sign language interpreter services must be requested by Medicaid providers or authorized DSHS staff and provided by DSHS approved contractors.
HRSA covers voluntary psychiatric inpatient care for clients eligible under the PII program.
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| Customer Service Phone Numbers | ||||||
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DSHS clients may call 1-800-562-3022 (option 1) for more information. Providers may call 1-800-562-3022 (option 2) for more information. Locate Medical Assistance Billing Instructions at http://hrsa.dshs.wa.gov/download/bi.html
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| ACRONYMS | ||||||
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ADATSA - Alcohol and Drug Abuse Treatment and Support Act CHP - Children's Health Program CN - Categorically Needy Program FP/TC - Family Planning Only/TAKE CHARGE GA - General Assistance MN - Medically Needy Program S-CHIP - State Children's Health Insurance Program
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Page modified: November 2009
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