wa-26-17-042: Health Care Authority — WSR 26-17-042

WSR 26-17-042 (26-17)WSR 26-17-042PROPOSED RULESHEALTH CARE AUTHORITY[Filed August 12, 2026, 9:55 a.m.]Original Notice.Preproposal statement of inquiry was filed as WSR 26-05-031.Title of Rule and Other Identifying Information: WAC 182-543-2000 Eligible providers and provider requirements, 182-543-5500 Medical supplies and related services, new 182-543-6100 Urological and incontinent supplies, new 182-543-6200 Urinary and incontinent supplies under the mail order incontinence and urinary supplies and services contract, and 182-543-9000 General reimbursement.Hearing Location(s): On September 22, 2026, at 10:00 a.m., via Microsoft Teams webinar. To attend, you must register in advance at https://events.gcc.teams.microsoft.com/event/69803d74-295c-4581-a5b9-323091969802@11d0e217-264e-400a-8ba0-57dcc127d72d. After registering, you will receive a confirmation email containing information about joining the public hearing. You will be able to join the public hearing through most standard internet browsers; you do not need to install Microsoft Teams.Date of Intended Adoption: Not sooner than September 23, 2026.Submit Written Comments to: Health Care Authority (HCA) Rules Coordinator, P.O. Box 42716, Olympia, WA 98504-2716, email arc@hca.wa.gov, fax 360-586-9727, beginning August 13, 2026, 8:00 a.m., by September 22, 2026, 11:59 p.m.Assistance for Persons with Disabilities: Contact Jessica Nguyen, phone 360-725-1174, fax 360-586-9727, telecommunication relay service 711, email arc@hca.wa.gov, by September 4, 2026.Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: HCA is proposing amendments to the following sections of chapter 182-543 WAC, Medical equipment, supplies, and appliances: WAC 182-543-2000, 182-543-5500, and 182-543-9000, and new WAC 182-543-6100 and 182-543-6200.These revisions support HCA's plan to offer incontinence and urinary supplies and services provided to eligible apple health (medicaid) clients by mail order through contract. HCA will reimburse only the provider who holds the mail order incontinence and urinary supplies and services contract for urinary and incontinence supplies. The requirement applies only when medicaid fee-for-service is the primary payor. This does not apply to clients enrolled in an HCA-contracted managed care organization.Reasons Supporting Proposal: See purpose.Statutory Authority for Adoption: RCW 41.05.021 and 41.05.160.Statute Being Implemented: RCW 41.05.021 and 41.05.160.Rule is not necessitated by federal law, federal or state court decision.Name of Proponent: HCA, governmental.Name of Agency Personnel Responsible for Drafting: Valerie Freudenstein, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-5128; Implementation and Enforcement: Andrea Allen, P.O. Box 45530, Olympia, WA 98504-5530, 360-725-9805.A school district fiscal impact statement is not required under RCW 28A.305.135.A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to HCA rules unless requested by the joint administrative rules review committee or applied voluntarily.Scope of exemption for rule proposal from Regulatory Fairness Act requirements:Is not exempt.The proposed rule does not impose more-than-minor costs on businesses. Following is a summary of the agency's analysis showing how costs were calculated. The rule proposal is a change to payment methodology; therefore, does not impose more-than-minor costs on small businesses. August 12, 2026Wendy BarcusRules CoordinatorRDS-7283.2AMENDATORY SECTION(Amending WSR 25-07-045, filed 3/12/25, effective 5/1/25)WAC 182-543-2000Eligible providers and provider requirements.(1) The medicaid agency pays, on a fee-for-service basis, providers (including providers who supply medical equipment and supplies in an outpatient clinical setting), pharmacies, and suppliers, for medical equipment, medical supplies, complex rehabilitation technology (CRT), and related repair services.(a) Providers, pharmacies, and suppliers (including out-of-state providers, pharmacies, and suppliers) must:(i) Be enrolled with medicare as a pharmacy, supplier of medical equipment, medical supplies, and related repair services, or as a CRT supplier (CRT suppliers must also comply with the requirements in WAC 182-543-4400); and(ii) Possess a national provider identifier (NPI) for a pharmacy, supplier of medical equipment, medical supplies, and related repair services, or CRT supplier.(b) Prosthetics and orthotics providers, and occupational therapists providing orthotics, must meet the licensing regulations of the state in which they practice.(2) Providers and suppliers of medical equipment and supplies must:(a) Meet the general provider requirements in chapter 182-502 WAC, except when the client is dual-eligible, medicare is the primary payer, and the agency is being billed only for one or more of the copay, coinsurance, or deductible;(b) Have the proper business license and be certified, licensed and bonded if required, to perform the services billed to the agency;(c) Have a valid prescription, which is referred to as a standard written order (SWO), for the medical equipment or supplies. A SWO is a written order communicated by the treating provider to the supplier that: (i) Is written by an authorized practitioner as defined in WAC 182-551-2010 and meets the face-to-face encounter requirements described in WAC 182-551-2040;(ii) Includes the following information:(A) Client's full name;(B) Order date, which is the date the order was written or electronically signed by the treating practitioner;(C) General item description, which may be either a general description (for example, wheelchair or hospital bed), a HCPCS code, a HCPCS code narrative, or a brand name or model number;(I) For equipment, in addition to the base item description, the SWO may include all concurrently ordered options, accessories, or additional features that are separately billed or require an upgraded code (list each separately);(II) For supplies, in addition to the base item description, the order/prescription may include all concurrently ordered supplies that are separately billed (list each separately);(D) If applicable, the quantity to be provided and the frequency of use;(E) If applicable, the length of time the item is required; and(F) The name, NPI, and signature of the treating practitioner, practitioner credentials, and the signature date.(d) Provide instructions for use of equipment;(e) Provide only new equipment to clients, which include full manufacturer and dealer warranties. See WAC 182-543-2250(3);(f) Provide documentation of proof of delivery, upon agency request (see WAC 182-543-2200); and(g) Bill the agency using only the allowed procedure codes that are listed in the agency's published billing guides.(3) For the urological and incontinent supplies identified in WAC 182-543-6200 and covered under the contract, the agency limits who may bill for these supplies. (Also see WAC 182-543-9000.)AMENDATORY SECTION(Amending WSR 18-24-021, filed 11/27/18, effective 1/1/19)WAC 182-543-5500Medical supplies and related services.The medicaid agency pays for the following medical supplies and related services without prior authorization unless otherwise specified:(1) Antiseptics and germicides:(a) Alcohol (isopropyl) or peroxide (hydrogen) - One pint per month;(b) Alcohol wipes (box of ((two hundred))200) - One box per month;(c) Betadine or pHisoHex solution - One pint per month;(d) Betadine or iodine swabs/wipes (box of ((one hundred))100) - One box per month;(2) Bandages, dressings, and tapes;(3) Batteries - Replacement batteries:(a) The agency pays for the purchase of replacement batteries for wheelchairs with prior authorization.(b) The agency does not pay for wheelchair replacement batteries that are used for speech generating devices (SGDs) or ventilators.(4) Blood monitoring/testing supplies:(a) Replacement battery of any type, used with a client-owned, medically necessary or specialized blood glucose monitor - One in a three-month period;(b) Spring-powered device for lancet - One in a six-month period;(c) Diabetic test strips as follows:(i) For clients age ((twenty))20 and younger, as follows:(A) Insulin dependent, ((three hundred))300 test strips and ((three hundred))300 lancets per client, per month.(B) For noninsulin dependent, ((one hundred))100 test strips and ((one hundred))100 lancets per client, per month.(ii) For clients age ((twenty-one))21 and older:(A) Insulin dependent, ((one hundred))100 test strips and ((one hundred))100 lancets per client, per month.(B) For noninsulin dependent, ((one hundred))100 test strips and ((one hundred))100 lancets per client, every three months.(iii) For pregnant people with gestational diabetes, the agency pays for the quantity necessary to support testing as directed by the client's physician, up to ((sixty))60 days postpartum.(d) See ((WAC 182-543-5500(12)))subsection (11) of this section for blood glucose monitors.(5) Braces, belts, and supportive devices:(a) Knee brace (neoprene, nylon, elastic, or with a hinged bar) - Two per ((twelve))12-month period;(b) Ankle, elbow, or wrist brace - Two per ((twelve))12-month period;(c) Lumbosacral brace, rib belt, or hernia belt - One per ((twelve))12-month period;(d) Cervical head harness/halter, cervical pillow, pelvic belt/harness/boot, or extremity belt/harness - One per ((twelve))12-month period.(6) Decubitus care products:(a) Cushion (gel, sacroiliac, or accuback) and cushion cover (any size) - One per ((twelve))12-month period;(b) Synthetic or lamb's wool sheepskin pad - One per ((twelve))12-month period;(c) Heel or elbow protectors - Four per ((twelve))12-month period.(7) Ostomy supplies:(a) Adhesive for ostomy or catheter: Cement; powder; liquid (e.g., spray or brush); or paste (any composition, e.g., silicone or latex) - Four total ounces per month.(b) Adhesive or nonadhesive disc or foam pad for ostomy pouches - ((Ten))10 per month.(c) Adhesive remover or solvent - Three ounces per month.(d) Adhesive remover wipes, ((fifty))50 per box - One box per month.(e) Closed pouch, with or without attached barrier, with a one- or two-piece flange, or for use on a faceplate - ((Sixty))60 per month.(f) Closed ostomy pouch with attached standard wear barrier, with built-in one-piece convexity - ((Ten))10 per month.(g) Continent plug for continent stoma - ((Thirty))30 per month.(h) Continent device for continent stoma - One per month.(i) Drainable ostomy pouch, with or without attached barrier, or with one- or two-piece flange - ((Twenty))20 per month.(j) Drainable ostomy pouch with attached standard or extended wear barrier, with or without built-in one-piece convexity - ((Twenty))20 per month.(k) Drainable ostomy pouch for use on a plastic or rubber faceplate (only one type of faceplate allowed) - ((Ten))10 per month.(l) Drainable urinary pouch for use on a plastic, heavy plastic, or rubber faceplate (only one type of faceplate allowed) - ((Ten))10 per month.(m) Irrigation bag - Two every six months.(n) Irrigation cone and catheter, including brush - Two every six months.(o) Irrigation supply, sleeve - One per month.(p) Ostomy belt (adjustable) for appliance - Two every six months.(q) Ostomy convex insert - ((Ten))10 per month.(r) Ostomy ring - ((Ten))10 per month.(s) Stoma cap - ((Thirty))30 per month.(t) Ostomy faceplate - ((Ten))10 per month. The agency does not pay for either of the following when billed in combination with an ostomy faceplate:(i) Drainable pouches with plastic face plate attached; or(ii) Drainable pouches with rubber face plate.(8) Syringes and needles;(9) ((Urological supplies - Diapers and related supplies: (a) The standards and specifications in this subsection apply to all disposable incontinent products (e.g., briefs, diapers, pull-up pants, underpads for beds, liners, shields, guards, pads, and undergarments). See subsections (b), (c), (d), and (e) of this section for additional standards for specific products. All of the following apply to all disposable incontinent products:(i) All materials used in the construction of the product must be safe for the client's skin and harmless if ingested;(ii) Adhesives and glues used in the construction of the product must not be water-soluble and must form continuous seals at the edges of the absorbent core to minimize leakage;(iii) The padding must provide uniform protection;(iv) The product must be hypoallergenic;(v) The product must meet the flammability requirements of both federal law and industry standards; and(vi) All products are covered for client personal use only.(b) In addition to the standards in subsection (a) of this section, diapers must meet all the following specifications. They must:(i) Be hourglass shaped with formed leg contours;(ii) Have an absorbent filler core that is at least one-half inch from the elastic leg gathers;(iii) Have leg gathers that consist of at least three strands of elasticized materials;(iv) Have an absorbent core that consists of cellulose fibers mixed with absorbent gelling materials;(v) Have a back sheet that is moisture impervious and is at least 1.00 mm thick, designed to protect clothing and linens;(vi) Have a top sheet that resists moisture returning to the skin;(vii) Have an inner lining that is made of soft, absorbent material; and(viii) Have either a continuous waistband, or side panels with a tear-away feature, or refastenable tapes, as follows:(A) For child diapers, at least two tapes, one on each side.(B) The tape adhesive must release from the back sheet without tearing it, and permit a minimum of three fastening/unfastening cycles.(c) In addition to the standards in subsection (a) of this section, pull-up pants and briefs must meet the following specifications. They must:(i) Be made like regular underwear with an elastic waist or have at least four tapes, two on each side or two large tapes, one on each side;(ii) Have an absorbent core filler that is at least one-half inch from the elastic leg gathers;(iii) Have an absorbent core that consists of cellulose fibers mixed with absorbent gelling;(iv) Have leg gathers that consist of at least three strands of elasticized materials;(v) Have a back sheet that is moisture impervious, is at least 1.00 mm thick, and is designed to protect clothing and linens;(vi) Have an inner lining made of soft, absorbent material; and(vii) Have a top sheet that resists moisture returning to the skin.(d) In addition to the standards in subsection (a) of this section, underpads are covered only for incontinent purposes in a client's bed and must meet the following specifications:(i) Have an absorbent layer that is at least one and one-half inches from the edge of the underpad;(ii) Be manufactured with a waterproof backing material;(iii) Be able to withstand temperatures not to exceed one hundred-forty degrees Fahrenheit;(iv) Have a covering or facing sheet that is made of nonwoven, porous materials that have a high degree of permeability, allowing fluids to pass through and into the absorbent filler. The patient contact surface must be soft and durable;(v) Have filler material that is highly absorbent. It must be heavy weight fluff filler or the equivalent; and(vi) Have four-ply, nonwoven facing, sealed on all four sides.(e) In addition to the standards in subsection (a) of this section, liners, shields, guards, pads, and undergarments are covered for incontinence only and must meet the following specifications:(i) Have channels to direct fluid throughout the absorbent area, and leg gathers to assist in controlling leakage, and/or be contoured to permit a more comfortable fit;(ii) Have a waterproof backing designed to protect clothing and linens;(iii) Have an inner liner that resists moisture returning to the skin;(iv) Have an absorbent core that consists of cellulose fibers mixed with absorbent gelling materials;(v) Have pressure-sensitive tapes on the reverse side to fasten to underwear; and(vi) For undergarments only, be contoured for good fit, have at least three elastic leg gathers, and may be belted or unbelted.(f) The agency pays for urological products when they are used alone. The following are examples of products the agency does not pay for when used in combination with each other:(i) Disposable diapers;(ii) Disposable pull-up pants and briefs;(iii) Disposable liners, shields, guards, pads, and undergarments;(iv) Rented reusable diapers (e.g., from a diaper service); and(v) Rented reusable briefs (e.g., from a diaper service), or pull-up pants. (g) The agency approves a client's use of a combination of products only when the client uses different products for daytime and nighttime use. Example: pull-up pants for daytime use and disposable diapers for nighttime use. The total quantity of all products in this section used in combination cannot exceed the monthly limitation for the product with the highest limit.(h) Purchased disposable diapers (any size) are limited to two hundred per month for clients age three and older.(i) Reusable cloth diapers (any size) are limited to:(i) Purchased - Thirty-six per year; and(ii) Rented - Two hundred per month.(j) Disposable briefs and pull-up pants (any size) are limited to:(i) Two hundred per month for a client age three through age eighteen; and(ii) One hundred fifty per month for a client age nineteen and older.(k) Reusable briefs, washable protective underwear, or pull-up pants (any size) are limited to:(i) Purchased - Four per year.(ii) Rented - One hundred fifty per month.(l) Disposable pant liners, shields, guards, pads, and undergarments are limited to two hundred per month.(m) Underpads for beds are limited to:(i) Disposable (any size) - One hundred eighty per month.(ii) Purchased, reusable (large) - Forty-two per year.(iii) Rented, reusable (large) - Ninety per month.(10) Urological supplies - Urinary retention:(a) Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube - Two per month. The agency does not pay for these when billed in combination with any of the following:(i) With extension drainage tubing for use with urinary leg bag or urostomy pouch (any type, any length), with connector/adapter; and/or(ii) With an insertion tray with drainage bag, and with or without catheter.(b) Bedside drainage bottle, with or without tubing - Two per six month period.(c) Extension drainage tubing (any type, any length), with connector/adapter, for use with urinary leg bag or urostomy pouch. The agency does not pay for these when billed in combination with a vinyl urinary leg bag, with or without tube.(d) External urethral clamp or compression device (not be used for catheter clamp) - Two per twelve-month period.(e) Indwelling catheters (any type) - Three per month.(f) Insertion trays:(i) Without drainage bag and catheter - One hundred and twenty per month. The agency does not pay for these when billed in combination with other insertion trays that include drainage bag, catheters, and/or individual lubricant packets.(ii) With indwelling catheters - Three per month. The agency does not pay for these when billed in combination with other insertion trays without drainage bag and/or indwelling catheter, individual indwelling catheters, and/or individual lubricant packets.(g) Intermittent urinary catheter - One hundred twenty per month. The agency does not pay for these when billed in combination with an insertion tray with or without drainage bag and catheter, or other individual intermittent urinary catheters.(h) Irrigation syringe (bulb or piston). The agency does not pay for these when billed in combination with irrigation tray or tubing.(i) Irrigation tray with syringe (bulb or piston) - Thirty per month. The agency does not pay for these when billed in combination with irrigation syringe (bulb or piston), or irrigation tubing set.(j) Irrigation tubing set - Thirty per month. The agency does not pay for these when billed in combination with an irrigation tray or irrigation syringe (bulb or piston).(k) Leg straps (latex foam and fabric), replacement only.(l) Male external catheter, specialty type, or with adhesive coating or adhesive strip - Sixty per month.(m) Urinary suspensory with leg bag, with or without tube - Two per month. The agency does not pay for these when billed in combination with a latex urinary leg bag, urinary suspensory without leg bag, extension drainage tubing, or a leg strap.(n) Urinary suspensory without leg bag, with or without tube - Two per month.(o) Urinary leg bag, vinyl, with or without tube - Two per month. The agency does not pay for these when billed in combination with drainage bag and without catheter.(p) Urinary leg bag, latex - One per month. The agency does not pay for these when billed in combination with or without catheter.(11)))See WAC 182-543-6100 for urological and incontinent supplies.(10) Miscellaneous supplies:(a) Bilirubin light therapy supplies when provided with a bilirubin light which the agency prior authorized - Five days supply.(b) Continuous passive motion (CPM) softgoods kit - One, with rental of CPM machine.(c) Eye patch with elastic, tied band, or adhesive, to be attached to an eyeglass lens - One box of ((twenty))20.(d) Eye patch (adhesive wound cover) - One box of ((twenty))20.(e) Nontoxic gel (e.g., LiceOff TM) for use with lice combs - One bottle per ((twelve))12-month period.(f) Nonsterile gloves - ((Two hundred))200, per client, per month.(i) For clients residing in an assisted living facility, the agency pays, with prior authorization, for additional nonsterile gloves up to the quantity necessary as directed by the client's physician, not to exceed a total of ((four hundred))400 per client, per month.(ii) Prior authorization requests must include a completed:(A) General Information for Authorization form (HCA 13-835). The agency's electronic forms are available online (see WAC 182-543-7000 Authorization); and(B) Limitation Extension Request Incontinent Supplies and Gloves form (HCA 13-870).(g) Sterile gloves - ((Thirty))30 pair, per client, per month.(((12)))(11) Miscellaneous medical equipment:(a) Bilirubin light or light pad - Five days rental per ((twelve))12-month period for at-home newborns with jaundice.(b) Blood glucose monitor - One in a three-year period. See ((WAC 182-543-5500(4)))subsection (4) of this section for blood monitoring/testing supplies. The agency does not pay for continuous glucose monitoring systems including related equipment and supplies under the durable medical equipment benefit. See WAC 182-553-500 home infusion therapy/parenteral nutrition program.(c) Continuous passive motion (CPM) machine - Up to ((ten))10 days rental and requires prior authorization.(d) Lightweight protective helmet/soft shell (including adjustable chin/mouth strap) - Two per ((twelve))12-month period.(e) Lightweight ventilated hard-shell helmet (including unbreakable face bar, woven chin strap with adjustable buckle and snap fastener, and one set of cushion pads for adjusting fit to head circumference) - Two per ((twelve))12-month period.(f) Pneumatic compressor - One in a five-year period.(g) Positioning car seat - One in a five-year period.NEW SECTIONWAC 182-543-6100Urological and incontinent supplies.(1) The agency pays for urological and incontinent supplies for eligible clients based on agency rules. Prior authorization (PA) may be required. See subsections (8) and (9) of this section for quantity limits. To exceed quantity limits, providers must request a limitation extension (LE). See WAC 182-543-7200 and 182-501-0169 for LE information.(2) Automatic refills (renewals) by a qualified supplier are not allowed. Prior to refilling an order for urological and incontinent supplies, a qualified supplier must have confirmation from the client or the client's representative that the refill requested is needed. The confirmation must be documented in the client's record.(3) The agency does not pay for urological and incontinent supplies when intended and used for the same purpose, except as allowed in subsection (4) of this section. The following are examples of products the agency does not pay for when used in combination with each other:(a) Disposable diapers;(b) Disposable pull-up pants and briefs;(c) Disposable liners, shields, guards, pads, and undergarments;(d) Rented reusable diapers (e.g., from a diaper service); and(e) Rented reusable briefs (e.g., from a diaper service), or pull-up pants.(4) The agency may approve a client's use of a combination of products only when the client uses different products for daytime and nighttime use. Example: Pull-up pants for daytime use and disposable diapers for nighttime use.(5) When the client uses different products for daytime and nighttime use, the total quantity of urological and incontinent supplies used cannot exceed the monthly limitation for the product with the highest limit.(6) For clients residing in a nursing facility, the agency pays for urological and incontinent supplies only if the supplies are not included in the facility per diem rate.(7) All urological and incontinent supplies must be for client personal use only.(8) Urological supplies:*Billing provisions are limited to a one-month supply. One month equals 30 days unless otherwise specified.CategoryProduct Type/DescriptionQuantity LimitCathetersIntermittent urinary catheter; straight or coudé tip, with or without coating (e.g., hydrophilic, teflon, or silicone), with or without insertion supplies180 per month Male external catheter, with or without adhesive, disposable35 per month Female external urinary collection device; pouch – does not include suction pump31 per month Male external catheter with integral collection chamber30 per month Indwelling catheter; Foley (two-way or three-way) or specialty type (coudé, mushroom, wing), in silicone, polyurethane, or coated latex (teflon, silicone elastomer, hydrophilic)2 per month Female external urinary collection device; metal cup2 per month Rectal catheter with or without balloonPA RequiredTrays & TubingIrrigation tray with bulb or piston30 per month Irrigation tubing set for continuous bladder irrigation (through three-way foley)4 per month Insertion tray; with or without drainage bag, with or without catheter (accessories only, two-way coated latex/all-silicone, or three-way irrigation foley)2 per month Extension drainage tubing, any type2 per monthBags & BottlesBedside drainage bag, day or night2 per month Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps2 per month Urinary suspensory with leg bag, with or without tube2 per month Bedside drainage bottle with or without tubing, rigid or expandable2 per 180 days Urinary drainage bag, leg or abdomen, latex, with or without tube, with strap1 per monthStrap & Clamp AnchorsUrinary catheter anchoring device, adhesive skin attachment12 per month Disposable external urethral clamp or compression device, with pad and/or pouch2 per month External urethral clamp or compression device1 per month Urinary catheter anchoring device, leg strap (or latex/fabric replacement)1 per monthOstomy & Fecal BagsOstomy pouch, drainable, with extended wear barrier & filter (with or without built in convexity)40 per month Perianal fecal collection pouch with adhesivePA RequiredOintments & WipesLubricant, individual sterile packet200 per month Adhesive remover wipes, per wipe50 wipes per month Skin barrier wipes, 50 in box (antiseptic), per wipe50 wipes per month Lubricant per ounce8 per monthSpecialized IrrigationEnema tube, with or without adapter, any type, replacement onlyPA Required Manual transanal irrigation systemPA RequiredMisc.Urethral insertPA Required(9) Incontinent supplies:*Billing provisions are limited to a one-month supply. One month equals 30 days unless otherwise specified.CategoryYouth/Pediatric Limits (Age 3 through 20 unless otherwise indicated)Adult Limits (Ages 21+)Pediatric Briefs/Pull-OnsSizes: Small/Medium, Large200 per monthPA requiredYouth Briefs/Pull-OnsAny size200 per Month(Ages 6 through 20)PA requiredAdult Briefs or Protective BriefsAny sizeRequires PA200 per monthAdult Protective Underwear/Pull-OnsAny size200 per month(Ages 6 through 20)150 per monthDiaper ServiceReusable rental200 per month200 per monthReusable Incontinence BriefAny size36 per month36 per monthDisposable Liners/Shields/PadsFor daytime use onlyExcludes diaper doublers200 per month200 per monthDiaper doubler90 per month(PA required)90 per month(PA required)Disposable UnderpadsLargeFor client's bed onlyMin. 810 square inches180 per month180 per monthReusable UnderpadsBed size42 per year for purchase or 90 per month for rental42 per year for purchase or 90 per month for rentalReusable Protective UnderwearAll sizes4 per year for purchase or 150 per month for rental4 per year for purchase or 150 per month for rental(10) Incontinence products specifications:FeatureBriefs (Adult & Youth) or Pull-On BriefsUnderpadsLiners, Shields, Guards, Pads & UndergarmentsForm, Fit & Gathers• Hourglass with formed leg contours.• Patient contact surface must be soft and durable.• Contoured fit and/or channels to direct fluid. • Soft, absorbent material inner lining. • Soft, durable patient contact surface. • At least 3 strands of elasticized material. • Elastic leg gathers to control leakage (at least 3 for undergarments).Absorbent Core & Border• Cellulose fibers mixed with gelling materials.• Heavyweight fluff filler or equivalent.• Cellulose fibers mixed with gelling materials.• Core filler at least 0.5 inches from elastic leg gathers.• Absorbent layer at least 1.5 inches from outer edge.• Core border is not applicable.Sheet Construction• Back Sheet: Moisture impervious; at least 1.00 mm thick.• Back Sheet: Waterproof backing; sealed on all 4 sides.• Back Sheet: Waterproof backing designed to protect clothing and linens. • Top Sheet:Resists moisture returning to skin.• Top Sheet: 4-ply, nonwoven, highly porous, permeable material.• Inner Liner: Resists moisture returning to skin.Fasteners & Performance• Continuous waistband, OR side panels with tear-away, OR refastenable tapes (at least 2 for children).• Withstands temperatures not to exceed 140 degrees Fahrenheit.• Pressure-sensitive tape on reverse side to fasten to underwear. • Tape adhesive must permit at least 3 fastening cycles without tearing back sheet. • Undergarments only may be belted or unbelted.   • Thermal limits are not applicable.(11) For urinary and incontinent supplies under the mail order incontinence and urinary supplies and services contract. See WAC 182-543-6200.(12) If the supply is not listed, prior authorization can be requested. See WAC 182-543-0500.NEW SECTIONWAC 182-543-6200Urinary and incontinent supplies under the mail order incontinence and urinary supplies and services contract.(1) This section applies when medicaid fee-for-service is the primary payer. This section does not apply to clients enrolled in an agency-contracted managed care organization.(2) The agency reimburses only the provider who holds the mail order incontinence and urinary supplies and services contract for the urinary and incontinent supplies listed in subsection (4) of this section.(3) Clients must request the urinary and incontinent supplies through this contracted provider for the agency to reimburse the provider for the supplies.(4) The urinary and incontinent supplies reimbursed under the contract and addressed in this section include:(a) Bedside drainage bag;(b) Brief adult size, small, medium, large, x-large;(c) Brief pediatric size, small, medium, large;(d) Brief youth size;(e) Brief, adult size, bariatric;(f) Diaper doublers;(g) Brief/incontinent pant reuseable/washable;(h) Extension drainage tubing;(i) Female external urinary collection device;(j) Indwelling catheter;(k) Insertion tray;(l) Intermittent urinary catheter;(m) Irrigation tray;(n) Irrigation syringe;(o) Liner, disposable;(p) Lubricant;(q) Male external catheter;(r) Miscellaneous supplies when required for application of other supplies under the contract;(s) Perianal fecal collection pouch;(t) Pull-on adult size, small, medium, large, x-large;(u) Pull-on pediatric size, small, medium, large;(v) Pull-on, youth size;(w) Pull-on, adult size, bariatric;(x) Reusable washable underwear;(y) Skin barrier wipes;(z) Underpads, disposable;(aa) Urinary catheter anchoring device;(bb) Urinary leg bag.AMENDATORY SECTION(Amending WSR 26-01-207, filed 12/24/25, effective 1/24/26)WAC 182-543-9000General reimbursement.(1) The medicaid agency pays ((qualified providers who meet all conditions in WAC 182-502-0100 for))enrolled providers who are qualified to deliver medical equipment, repairs, and related services ((provided)) on a fee-for-service (FFS) basis ((as follows:(a) To agency-enrolled medical equipment providers, qualified complex rehabilitation technology (CRT) suppliers, pharmacies, and home health agencies under their national provider identifier (NPI) numbers, subject to the limitations of this chapter, and according to the procedures and codes in the agency's current medical equipment billing guide;(b))), based on agency rules. (Also see WAC 182-543-2000.)(2) Providers must:(a) Bill in accordance with the health care common procedure coding system (HCPCS) guidelines for product classification and code assignation; and(((c) Providers must))(b) Code the specific brand and model of wheelchair or complex rehabilitation technology (CRT) products dispensed according to the centers for medicare and medicaid services' (CMS) pricing, data analysis, and coding (PDAC) website.(((2)))(3) The agency sets, evaluates, and updates the maximum allowable fees for medical equipment and related services at least once yearly, unless otherwise directed by the legislature or determined necessary by the agency.(((3)))(4) The agency sets the rates for medical equipment codes subject to the federal financial participation (FFP) limitation at the lesser of medicare's prevailing payment rates in the Durable Medical Equipment Prosthetics/Orthotics, and Supplies (DMEPOS) Fee Schedule or Competitive Bid Area (CBA) rate. For all other procedure codes, the agency sets rates using one of the following:(a) Medicare fee schedules;(b) Legislative direction;(c) Input from stakeholders or relevant sources that the agency determines to be reliable and appropriate;(d) Pricing clusters; ((or))(e) A by-report (BR) basis; or(f) Contracted services.(((4)))(5) The medicaid agency evaluates a by-report (BR) item, procedure, or service for its medical necessity, appropriateness and reimbursement value on a case-by-case basis. The agency's reimbursement rate is a percentage of the manufacturer's list or manufacturer's suggested retail price (MSRP), or a percentage of the wholesale acquisition cost (AC). The MSRP or invoice must be dated within 12 months prior to the date of service and must substantiate the specific supply being billed. The agency uses the following percentages:(a) For basic standard wheelchairs, 65 percent of MSRP or 140 percent of AC;(b) For wheelchair parts and add-on CRT accessories and parts, 84 percent of MSRP or 140 percent of AC;(c) For wheelchair seat and back cushions, CRT manual wheelchair base, and up-charge modifications and seating systems, 80 percent of MSRP or 140 percent of AC;(d) For CRT power-drive wheelchair base, 85 percent of MSRP or 140 percent of AC;(e) For prosthetics and orthotics and medical supplies and related services, 85 percent of MSRP or 125 percent of AC;(f) For other medical equipment, 80 percent of MSRP or 125 percent of AC;(g) For medical supplies, 85 percent of MSRP or 125 percent of AC.(((5)))(6) When establishing reimbursement rates for medical equipment based on pricing clusters for a specific HCPCS code, the maximum allowable fee is the median or average amount of all items in the cluster. The pricing cluster is comprised of all the brands/models for which the agency obtains pricing information. However, the agency may limit the number of brands/models included in the pricing cluster due to:(a) A client's medical needs;(b) Product quality;(c) Introduction, substitution or discontinuation of certain brands/models; and/or(d) Cost.(((6)))(7) When there is only a rental rate on the DMEPOS fee schedule, the agency sets the maximum allowable purchase rate at either the DMEPOS rate divided by 0.15 or multiplied by 10. The agency sets the maximum allowable fee for daily rental at one-three-hundredth of the new purchase price or one-thirtieth of the monthly rental rate on the DMEPOS fee schedule;(((7)))(8) The agency may adopt policies, procedure codes, and/or rates that are inconsistent with those set by medicare if the agency determines that such actions are necessary to:(a) Assure that payments are sufficient to enlist providers and maintain access to care and services; or(b) Comply with legislative budget directives.(((8)))(9) The agency's maximum payment for medical equipment and related services is the lesser of either the:(a) Providers' usual and customary charges; or(b) Established rates, except as provided in WAC 182-543-8200.(((9)))(10) The agency is the payor of last resort for clients with medicare or third-party insurance.(((10)))(11) The agency's reimbursement for a prosthetic or orthotic includes the cost of any necessary molds, fitting, shipping, handling or any other administrative expenses related to provision of the prosthetic or orthotic to the client.(((11)))(12) The agency's reimbursement rate for purchased or rented covered medical equipment and related services includes all of the following:(a) Any adjustments or modifications to the medical equipment required within three months of the date of delivery or covered under the manufacturer's warranty. This does not apply to adjustments required because of changes in the client's medical condition;(b) Any pick-up or delivery fees or associated costs (e.g., mileage, travel time, gas, etc.);(c) Telephone calls;(d) Shipping, handling, and/or postage;(e) Routine maintenance that includes testing, cleaning, regulating, and assessing the client's equipment;(f) Fitting and set-up; and(g) Instruction to the client or client's caregiver in the appropriate use of the medical equipment.(((12)))(13) Medical equipment and related services supplied to eligible clients under the following reimbursement methodologies are included in those methodologies and are not reimbursed under fee-for-service:(a) Hospice providers' per diem reimbursement;(b) Hospitals' diagnosis-related group (DRG) reimbursement;(c) Managed care plans' capitation rate;(d) Skilled nursing facilities' per diem rate; and(e) Professional services' resource-based relative value system reimbursement (RBRVS) rate.(((13)))(14) The agency may enter into a contract for the delivery of medical supplies when fee-for-service is the primary payer, consistent with agency rules.(a) The agency reimburses the contracted provider for medical supplies based on the contracted amount.(b) When medicaid is not the primary payer, the agency reimburses providers according to program rules. (See also WAC 182-502-0100 and 182-501-0200.)(15) The provider must make warranty information, including date of purchase, applicable serial number, model number or other unique identifier of the equipment, and warranty period, available to the agency upon request.(((14)))(16) The dispensing provider who furnishes the medical equipment to a client is responsible for any costs incurred to have a different provider repair the equipment when:(a) Any medical equipment the agency considers purchased requires repair during the applicable warranty period;(b) The provider refuses or is unable to fulfill the warranty; and(c) The equipment continues to be medically necessary.(((15)))(17) If the rental medical equipment must be replaced during the warranty period, the agency recoups 50 percent of the total amount previously paid toward rental and eventual purchase of the medical equipment delivered to the client if:(a) The provider is unwilling or unable to fulfill the warranty; and(b) The equipment continues to be medically necessary.(((16)))(18) The agency does not reimburse for medical equipment, related services, and related repairs and labor charges under fee-for-service when the client is:(a) An inpatient hospital client;(b) Eligible for both medicare and medicaid, and is staying in a skilled nursing facility in lieu of hospitalization;(c) Terminally ill and receiving hospice care; or(d) Enrolled in a risk-based managed care plan that includes coverage for such items and/or services.(((17)))(19) The agency rescinds any purchase order for a prescribed item if the equipment was not delivered to the client before the client:(a) Dies;(b) Loses medical eligibility;(c) Becomes covered by a hospice agency; or(d) Becomes covered by a managed care organization.(((18)))(20) A provider may incur extra costs for customized equipment that may not be easily resold. In these cases, for purchase orders rescinded in subsection (((7)))(19) of this section, the agency may pay the provider an amount it considers appropriate to help defray these extra costs. The agency requires the provider to submit justification sufficient to support such a claim.(((19)))(21) For clients residing in skilled nursing facilities, see WAC 182-543-5700.