1. (1) The medicaid agency covers nonemergency transportation for a Washington apple health client to and from health care services if all of the following apply:

   1. (a) The health care services are:

      1. (i) Within the scope of coverage of the eligible client's benefit services package;
      2. (ii) Covered as defined in WAC 182-501-0050 through 182-501-0065 and the specific program rules; and
      3. (iii) Authorized, as required under specific program rules.
   2. (b) The health care service is medically necessary as defined in WAC 182-500-0070;

   3. (c) The health care service is being provided:

      1. (i) Under fee-for-service, by an agency-contracted provider;
      2. (ii) Through an agency-contracted managed care organization (MCO), by an MCO provider;
      3. (iii) Through a behavioral health organization (BHO), by a BHO contractor; or

      4. (iv) Through one of the following providers, as long as the provider is eligible for enrollment as a medicaid provider (see WAC 182-502-0012):

         1. (A) A medicare enrolled provider;
         2. (B) A provider in the network covered by the client's primary insurance where there is third-party insurance;
         3. (C) A provider performing services paid for by the Veteran's Administration, charitable program, or other voluntary program (Shriners, etc.).
   4. (d) The trip is to a local provider as defined in WAC 182-546-5100 (see WAC 182-546-5700(3) for local provider exceptions);
   5. (e) The transportation is the lowest cost available mode or alternative that is both accessible to the client and appropriate to the client's medical condition and personal capabilities;
   6. (f) The trip is authorized by the broker before a client's travel; and
   7. (g) The trip is a minimum of three-quarters of a mile from pick-up point to the drop-off point (see WAC 182-546-6200(7) for exceptions to the minimum distance requirement).
2. (2) Coverage for nonemergency medical transportation is limited to one roundtrip per day, with the exception of multiple medical appointments which cannot be accessed in one roundtrip.
3. (3) For clients age 20 and younger, see the early periodic screening, diagnosis, and treatment (EPSDT) program described in chapter 182-534 WAC.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-07-031, s 182-546-5500, filed 3/11/26, effective 4/11/26. Statutory Authority: RCW 41.05.021, 41.05.160, 2014 c 225. WSR 16-06-053, § 182-546-5500, filed 2/24/16, effective 4/1/16. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-03-050, § 182-546-5500, filed 1/14/15, effective 2/14/15. WSR 11-17-032, recodified as § 182-546-5500, filed 8/9/11, effective 8/9/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.500. WSR 11-15-029, § 388-546-5500, filed 7/12/11, effective 8/12/11. Statutory Authority: RCW 74.08.090 and 42 C.F.R. Part 440. WSR 10-05-079, § 388-546-5500, filed 2/15/10, effective 3/18/10. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. WSR 01-06-029, § 388-546-5500, filed 3/2/01, effective 4/2/01.]