GAU MANAGED CARE BENEFITS

2009

When medically necessary, here are some of the benefits (services) covered for GAU clients enrolled in the GAU managed care program. This list is not all inclusive. For full scope of benefit coverage, please see the GAU contract. The scope of service for GAU clients is the same for those enrolled in managed care or in fee for service. Specific items may differ along with authorization requirements, billing, and reimbursement. Please note that the GAU managed care plan makes its own determination of medical necessity in accordance with the definition in Washington Administrative Code (WAC) 388-500-0005.

ADATSA=Alcohol & Drug Addiction Treatment Support Act ADSA=Aging & Disability Service Administration CD=Chemical Dependency also called Substance Abuse CHP=Community Health Plan of WA CMHC=Community Mental Health Center DBHR=Division of Behavioral Health Resources ER= Emergency Room ETP= Exception to Policy FFS=fee-for-service (Medical Assistance) HRSA= Health and Recovery Services Administration MC= managed care RSN=Regional Support Network PCP=primary care provider (managed care)

General Overview of the GAU Managed Care CoverageThe GAU Managed Care program was piloted in King and Pierce counties from 1/1/05 to 10/31/09. On 11/1/09 this managed care program will be statewide in all 39 counties in Washington. There is only one managed care plan, the Community Health Plan (CHP) of Washington, 1-800-440-1561. CHP provides primary care, referral coordination, other services and most pharmaceutical drugs. HRSA pays the bills for hospital facilities services (inpatient, outpatient & ER). Professional services are billed to CHP, except for GA-U Psychiatric In-patient. See below for handling at HRSA. See HRSA numbered memos #09-63 and #09-64 regarding GA-U Managed Care Enrollment at http://hrsa.dshs.wa.gov/download/Numberedmemos.html.

ITEM	HOW COVERED	COMMENTS/REFERENCES
Abortions, Voluntary	DSHS	See Pregnancy Terminations.
Abortions, Involuntary	CHP	See Pregnancy Terminations.
Acupuncture	Not covered for GAU
Adult Day Health	Not covered for GAU
Alcoholism		See Chemical Dependency Services, Inpatient and Outpatient.
Ambulance Services	CHP	Emergent only or transporting between facilities.
Antigen (allergy serum)	CHP
Audiology Tests	CHP
Autologous Blood	CHP	Covered are blood, blood components, human blood products & their administration.
Bariatric Surgery	DSHS	See Weight Loss Treatment.
Birthing Centers/Home Birth	Not covered for GAU	Pregnancy benefits are not covered for GAU: Women on GAU who become pregnant should contact their local CSO to be changed to the appropriate pregnancy program.
Birth Control	CHP or Family Planning Provider/Pharmacy	See Family Planning.
Blood Products	CHP	See Autologous Blood.
Bone-anchored hearing aid	CHP	When determined medically necessary by the plan, surgery includes the hearing device.
Braces (Orthopedic)	CHP	Prosthetic and orthotic devices, orthopedic appliances and braces, medical supplies.
Breast Implant Removal	CHP	When medically necessary, not for cosmetic reasons.
Breast Pumps	Not covered for GAU	Pregnancy benefits are not covered for GAU: Women on GAU who become pregnant should contact their local CSO to be changed to the appropriate pregnancy program.
Breast Reductions	CHP	When medically necessary, not for cosmetic reasons.
Chemical Dependency (CD) Services, Detox	DSHS	Alcohol, 3 days Drugs, 5 days
Chemical Dependency (CD) Services	DBHR certified Chemical Dependency agencies through: http://www.dshs.wa.gov/DASA/services/certification/Directory/Directory.shtml. Treatment Expansion is access to treatment for people who are receiving GAU. Funding from the 2005 Legislature provided for these services. Both residential and outpatient treatment are covered under these funds.
Chemotherapy	CHP	Hospital costs paid by HRSA
Childbirth Classes	Not covered for GAU	Pregnancy benefits are not covered for GAU: Women on GAU who become pregnant should contact their local CSO to be changed to the appropriate pregnancy program.
Chiropractic Care	Not covered for GAU
Cochlear Implants	CHP	Includes repairs & replacement parts such as battery packs, cables, speech processors, etc. Need Prior Authorization from CHP.
Community Services	Not covered for GAU	COPES, Personal Care Services, etc
Contraceptives		See Family Planning
Cosmetic Surgery	Not covered for GAU	EXCEPTION: Correction of congenital anomalies, trauma or mastectomy reconstruction.
Court-Ordered Services That Are Not Medically Necessary	Not covered for GAU	The exclusion applies to services requested merely for forensic or legal reasons.
Diapers, Pull-ups & Incontinence Supplies	CHP	Plan determines medical necessity.
Dental Care	DSHS	Very limited coverage. See Dental Billing Instructions, at http://hrsa.dshs.wa.gov/DentalProviders/DentalIndex.html .
Diabetic Supplies	CHP
Dialysis	DSHS
Durable Medical Equipment (DME) & Supplies	Not covered for GAU	Exception to Policy Only
Ear or body piercing, tattoos, or tattoo removal	Not covered for GAU
Eating Disorders	CHP
Emergency Room Services	DSHS	Hospital costs paid by HRSA. Note: No out- of-state care. Border counties are considered in-state care.
Emergency Contraceptive Counseling		See Family Planning.
Enteral/Parenteral Therapy	CHP
Experimental or Investigative Services	Not covered for GAU
Eye Exams & Refractions	CHP
Eyeglasses, Contact Lenses & Fittings	DSHS
Family Planning Services	CHP or Family Planning Provider/Pharmacy	Client has choice of either CHP or DSHS. All FDA-approved birth control methods covered. Emergency contraceptive counseling covered under DSHS if not by CHP. Prescription costs covered by plan.
Fertility Drugs	Not covered for GAU
Gastroplasty	DSHS	Exception To Policy only
GAU Determinations	Covered by CSO
Glucometers	CHP
Hearing Aid Devices	DSHS
Hearing Exams	CHP
Hemodialysis	CHP	Hospital costs paid for by HRSA
HIV/AIDS screening	CHP or DSHS	DSHS if done at Health Departments or Family Planning Clinics.

Home Health	CHP
Hospice	Not covered for GAU	Contact CSO to see if eligible for GAX.
Hospital Facilities, Inpatient/Outpatient	DSHS	Needs to be coordinated by CHP. Professional services are billed to CHP EXCEPT for psychiatric inpatient professional claims. These claims need "MC GAU PROF FEE" in box 19.
Humidifiers	CHP	For specific oxygen-related services only.
Immunizations/ Vaccinations	CHP or health departments	No travel immunizations. No Zostavax (shingles) immunizations.
Impotence & Sexual Dysfunction	Not covered for GAU
Incarcerated Clients Services	Provider bills the agency that has legal custody of the client.	Incarceration begins when client is arrested/put in custody.
Infertility Services	Not covered for GAU
Inpatient Admission Physicals for Oral Surgery	DSHS
Interpreters, Medical	Provided through HRSA contracted brokers for medical visits & medical fair hearings. See Interpreter Services for current list: http://hrsa.dshs.wa.gov/InterpreterServices	Note: provider arranges for interpreter. Also, the plan may use any provider for plan business.
Laboratory Services	CHP
Mammograms	CHP	When done in a free-standing imaging center.
Mammaplasty	CHP	After mastectomy only, not for cosmetic reason.
Massage Therapy	Not covered for GAU	EXCEPTION: Covered when performed by physical therapist as part of a therapeutic procedure.
Maternity & Prenatal Care	Not covered for GAU	Pregnancy benefits are not covered for GAU: Women on GAU who become pregnant should contact their local CSO to be changed to the appropriate pregnancy program.
Medical Supplies	CHP
Mental Health, Inpatient	CHP	Professional claims for these services need to have "MC GAU PROF FEE" in box 19 to be paid by DSHS
Mental Health, Outpatient	CHP	Limited service only. Not available except through CHP managed care. Contact Care Coordinator at PCP Clinic or call CHP at 1-800-440-1561.
Methadone Treatment		See Chemical Dependency Services
Naturopathy	Not covered for GAU
Nursing Facility (NF)	DSHS after ADSA 1-800-422-3263 (CHP if the plan chooses to do so in lieu of hospitalization)	Most members are exempted out of managed care if residing in a nursing facility. If an enrollee is in a NF, the NF needs to coordinate professional services with CHP. Members in a NF for a short stay due to rehabilitation services do not need to be exempted from CHP. See # Memo 09-64.
Nursing (including private duty) Services	CHP
Nutritional Counseling	CHP	For certain conditions such as diabetes, high blood pressure, anemia
Occupational Therapy	CHP
Organ Transplants	CHP	Heart, kidney, liver, bone marrow, lung, heart-lung, pancreas, kidney, kidney-pancreas, cornea, peripheral blood stem cell.
Orthotics	CHP
Ostomy Supplies	CHP
Out-of-Area Care, in-state only	CHP for non-emergent; DSHS for emergent	Only care that needs treatment prior to returning home is covered; no out-of-state care, except in border counties.
Oxygen & Respiratory Services	CHP
Pathology Services	CHP
Personal Care Services	ADSA 1-800-422-3263	In certain conditions.
Pharmaceutical Drugs & Over-the-Counter	CHP except Protease Inhibitors, these drugs are covered by DSHS.	CHP's formulary must be therapeutically equivalent to HRSA's (but not necessarily the same drugs).
Physical Medicine & Rehabilitation	CHP	Hospital care covered by HRSA - need DSHS authorization.
Physicals	CHP	Not covered for program eligibility, insurance, employment. CSO pays for GA-U eligibility exams.
Physical Therapy	CHP
Psychological Evaluations	CSO	If a psychological evaluation is needed for eligibility, contact the CSO.
Physician Services	CHP except Psych In-Patient (IP)	Psych In Patient professional claims need to have "MC GAU PROF FEE" in box 19 in order to be paid by DSHS.
Plastic Surgery	CHP	Cosmetic surgery not covered.
Pregnancy Terminations, Involuntary	CHP	Miscarriage, etc.
Pregnancy Terminations, Voluntary	DSHS	Includes care for any complications.
Private Duty Nursing	CHP	Limited
Protease Inhibitors	DSHS
Psychiatric In Patient	DSHS	Psych In Patient professional claims need to have "MC GAU PROF FEE" in box 19 in order to be paid by DSHS.
Psychological Testing & Evaluation	CSO for GAU Evaluations only; otherwise not covered
Radiology & Medical Imaging Services	CHP
Reconstructive Surgery after Mastectomy	CHP
Sexually-Transmitted Diseases Treatment	CHP and/or DSHS Health Department and Family Planning Clinic	Member can choose CHP or FFS.
Sexual Dysfunction & Sex Changes	Not covered for GAU
Skilled Nursing Facility Room & Board	DSHS after ADSA approval.	Need CHP authorization for professional fees
Smoking Cessation Drugs/Aids	CHP
Spinal Manipulations	CHP	Only those by an Osteopath, not a chiropractor. See Osteopathic Manipulations in the Physicians Billing Instructions. http://hrsa.dshs.wa.gov/download/Billing%20Instructions%20Web%20Pages/Physician-Related_Services.html
Sterilizations	CHP	Hospital costs paid by HRSA. Reversals not covered.
Supplies (nondurable)	CHP
Transplants, Organs & Tissue	CHP	Covered: heart, kidney, liver, bone marrow, lung, heart-lung, pancreas, cornea, and peripheral blood stem cell. Includes all ancillary services to make it happen (e.g. donor costs and testing). Hospital costs paid by DSHS.

Transportation, Brokered, nonemergent	DSHS http://hrsa.dshs.wa.gov/Transportation/index.html or 1-800-562-3022 for current list	Broker in each county.
Tuberculosis Screening & Follow-up	CHP & Health Departments
Vitamins & Iron Supplements	Not covered for GAU
Weight Loss Treatment (surgery)	CHP & DSHS	CHP is only responsible for the initial assessment services as described in WAC 388-531-1600. Other weight loss services and products are NOT COVERED.
Women's Health Care	CHP	Services must be obtained from only CHP's network of providers. It includes follow-up treatment for any problems discovered.

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Page modified: November 2009

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GAU MANAGED CARE BENEFITS

See Pregnancy Terminations.

See Family Planning.

See Autologous Blood.

COPES, Personal Care Services, etc

See Family Planning.