1. (1) The medicaid agency pays for health care services provided outside the state of Washington only when the service meets the provisions described in WAC 182-501-0180, 182-501-0182, 182-501-0184, and specific program WAC.
2. (2) With the exception of hospital services and nursing facilities, the agency pays the provider of service in designated bordering cities as if the care was provided within the state of Washington (see WAC 182-501-0175).
3. (3) With the exception of designated bordering cities, the agency does not pay for health care services provided to clients in medical care services (MCS) programs outside the state of Washington.

4. (4) With the exception of hospital services (see subsection (5) of this section), the agency pays for health care services provided outside the state of Washington at the lower of:

   1. (a) The billed amount; or
   2. (b) The rate established by the Washington apple health programs.
5. (5) The agency pays for hospital services provided in designated bordering cities and outside the state of Washington under WAC 182-550-3900, 182-550-4000, 182-550-4800, and 182-550-6700.

6. (6) The agency pays nursing facilities located outside the state of Washington when approved by the home and community living administration (HCLA) at the lower of the billed amount or the adjusted statewide average reimbursement rate for in-state nursing facility care, only in the following limited circumstances:

   1. (a) Emergency situations; or

   2. (b) When the client intends to return to Washington state and the out-of-state stay is for:

      1. (i) Thirty days or less; or
      2. (ii) More than 30 days if approved by HCLA.

7. (7) To receive payment from the agency, an out-of-state provider must:

   1. (a) Have a signed agreement with the agency;
   2. (b) Meet the functionally equivalent licensing requirements of the state or province in which care is rendered;
   3. (c) Meet the conditions in WAC 182-502-0100 and 182-502-0150;
   4. (d) Satisfy all medicaid conditions of participation;
   5. (e) Accept the agency's payment as payment in full according to 42 C.F.R. 447.15; and
   6. (f) If a Canadian provider, bill at the U.S. exchange rate in effect when the service was provided.

8. (8) For covered services for eligible clients, the agency reimburses other approved out-of-state providers at the lower of:

   1. (a) The billed amount; or
   2. (b) The rate paid by the Washington state Title XIX medicaid program.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-22-083, s 182-502-0120, filed 11/4/25, effective 12/5/25; WSR 15-14-039, § 182-502-0120, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0120, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-502-0120, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035. WSR 08-08-064, § 388-502-0120, filed 3/31/08, effective 5/1/08. Statutory Authority: RCW 74.08.090. WSR 01-02-076, § 388-502-0120, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.04.050 and 74.08.090. WSR 00-01-088, § 388-502-0120, filed 12/14/99, effective 1/14/00.]