Pediatric care rates

AN ACT Relating to preventing reductions in access to pediatric 1
primary care and behavioral health services; and amending RCW 2
74.09.520. 3
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:4
Sec. 1. RCW 74.09.520 and 2025 c 367 s 1 are each amended to 5
read as follows: 6
(1) The term "medical assistance" may include the following care 7
and services subject to rules adopted by the authority or department: 8
(a) Inpatient hospital services; (b) outpatient hospital services; 9
(c) other laboratory and X-ray services; (d) nursing facility 10
services; (e) physicians' services, which shall include prescribed 11
medication and instruction on birth control devices; (f) medical 12
care, or any other type of remedial care as may be established by the 13
secretary or director; (g) home health care services; (h) private 14
duty nursing services; (i) dental services; (j) physical and 15
occupational therapy and related services; (k) prescribed drugs, 16
dentures, and prosthetic devices; and eyeglasses prescribed by a 17
physician skilled in diseases of the eye or by an optometrist, 18
whichever the individual may select; (l) personal care services, as 19
provided in this section; (m) hospice services; (n) other diagnostic, 20
screening, preventive, and rehabilitative services; and (o) like 21
H-2695.2
HOUSE BILL 2331
State of Washington 69th Legislature 2026 Regular Session
By Representatives Penner and Graham
Prefiled 01/08/26. Read first time 01/12/26. Referred to Committee
on Appropriations.
p. 1 HB 2331
services when furnished to a child by a school district in a manner 1
consistent with the requirements of this chapter. For the purposes of 2
this section, neither the authority nor the department may cut off 3
any prescription medications, oxygen supplies, respiratory services, 4
or other life-sustaining medical services or supplies.5
"Medical assistance," notwithstanding any other provision of law, 6
shall not include routine foot care, or dental services delivered by 7
any health care provider, that are not mandated by Title XIX of the 8
social security act unless there is a specific appropriation for 9
these services. 10
(2) The department shall adopt, amend, or rescind such 11
administrative rules as are necessary to ensure that Title XIX 12
personal care services are provided to eligible persons in 13
conformance with federal regulations. 14
(a) These administrative rules shall include financial 15
eligibility indexed according to the requirements of the social 16
security act providing for medicaid eligibility. 17
(b) The rules shall require clients be assessed as having a 18
medical condition requiring assistance with personal care tasks. 19
Plans of care for clients requiring health-related consultation for 20
assessment and service planning may be reviewed by a nurse.21
(c) The department shall determine by rule which clients have a 22
health-related assessment or service planning need requiring 23
registered nurse consultation or review. This definition may include 24
clients that meet indicators or protocols for review, consultation, 25
or visit. 26
(3) The department shall design and implement a means to assess 27
the level of functional disability of persons eligible for personal 28
care services under this section. The personal care services benefit 29
shall be provided to the extent funding is available according to the 30
assessed level of functional disability. Any reductions in services 31
made necessary for funding reasons should be accomplished in a manner 32
that assures that priority for maintaining services is given to 33
persons with the greatest need as determined by the assessment of 34
functional disability. 35
(4) Effective July 1, 1989, the authority shall offer hospice 36
services in accordance with available funds. 37
(5) For Title XIX personal care services administered by the 38
department, the department shall contract with area agencies on aging 39
p. 2 HB 2331
or may contract with a federally recognized Indian tribe under RCW 1
74.39A.090(3): 2
(a) To provide case management services to individuals receiving 3
Title XIX personal care services in their own home; and4
(b) To reassess and reauthorize Title XIX personal care services 5
or other home and community services as defined in RCW 74.39A.009 in 6
home or in other settings for individuals consistent with the intent 7
of this section: 8
(i) Who have been initially authorized by the department to 9
receive Title XIX personal care services or other home and community 10
services as defined in RCW 74.39A.009; and 11
(ii) Who, at the time of reassessment and reauthorization, are 12
receiving such services in their own home. 13
(6) In the event that an area agency on aging or federally 14
recognized Indian tribe is unwilling to enter into or satisfactorily 15
fulfill a contract or an individual consumer's need for case 16
management services will be met through an alternative delivery 17
system, the department is authorized to: 18
(a) Obtain the services through competitive bid; and19
(b) Provide the services directly until a qualified contractor 20
can be found. 21
(7) Subject to the availability of amounts appropriated for this 22
specific purpose, the authority may offer medicare part D 23
prescription drug copayment coverage to full benefit dual eligible 24
beneficiaries. 25
(8) Effective January 1, 2016, the authority shall require 26
universal screening and provider payment for autism and developmental 27
delays as recommended by the bright futures guidelines of the 28
American academy of pediatrics, as they existed on August 27, 2015. 29
This requirement is subject to the availability of funds.30
(9) Subject to the availability of amounts appropriated for this 31
specific purpose, effective January 1, 2018, the authority shall 32
require provider payment for annual depression screening for youth 33
ages twelve through eighteen as recommended by the bright futures 34
guidelines of the American academy of pediatrics, as they existed on 35
January 1, 2017. Providers may include, but are not limited to, 36
primary care providers, public health nurses, and other providers in 37
a clinical setting. This requirement is subject to the availability 38
of funds appropriated for this specific purpose. 39
p. 3 HB 2331
(10) Subject to the availability of amounts appropriated for this 1
specific purpose, effective January 1, 2018, the authority shall 2
require provider payment for maternal depression screening for 3
mothers of children ages birth to six months. This requirement is 4
subject to the availability of funds appropriated for this specific 5
purpose. 6
(11) Subject to the availability of amounts appropriated for this 7
specific purpose, the authority shall: 8
(a) Allow otherwise eligible reimbursement for the following 9
related to mental health assessment and diagnosis of children from 10
birth through five years of age: 11
(i) Up to five sessions for purposes of intake and assessment, if 12
necessary; 13
(ii) Assessments in home or community settings, including 14
reimbursement for provider travel; and 15
(b) Require providers to use the current version of the DC:0-5 16
diagnostic classification system for mental health assessment and 17
diagnosis of children from birth through five years of age.18
(12) Effective January 1, 2024, the authority shall require 19
coverage for noninvasive preventive colorectal cancer screening tests 20
assigned either a grade of A or grade of B by the United States 21
preventive services task force and shall require coverage for 22
colonoscopies performed as a result of a positive result from such a 23
test. 24
(13)(a) The authority shall require or provide payment to the 25
hospital for any day of a hospital stay in which an adult or child 26
patient enrolled in medical assistance, including home and community 27
services or with a medicaid managed care organization, under this 28
chapter: 29
(i) Does not meet the criteria for acute inpatient level of care 30
as defined by the authority; 31
(ii) Meets the criteria for discharge, as defined by the 32
authority or department, to any appropriate placement including, but 33
not limited to: 34
(A) A nursing home licensed under chapter 18.51 RCW;35
(B) An assisted living facility licensed under chapter 18.20 RCW;36
(C) An adult family home licensed under chapter 70.128 RCW; or37
(D) A setting in which residential services are provided or 38
funded by the developmental disabilities administration of the 39
p. 4 HB 2331
department, including supported living as defined in RCW 71A.10.020; 1
and 2
(iii) Is not discharged from the hospital because placement in 3
the appropriate location described in (a)(ii) of this subsection is 4
not available. 5
(b) Pharmacy services and pharmaceuticals shall be billed by and 6
paid to the hospital separately. 7
(c) The requirements of this subsection do not alter requirements 8
for billing or payment for inpatient care. 9
(d) The authority shall adopt, amend, or rescind such 10
administrative rules as necessary to facilitate calculation and 11
payment of the amounts described in this subsection, including for 12
clients of medicaid managed care organizations. 13
(e) The authority shall adopt rules requiring medicaid managed 14
care organizations to establish specific and uniform administrative 15
and review processes for payment under this subsection.16
(f) For patients meeting the criteria in (a)(ii)(A) of this 17
subsection, hospitals must utilize swing beds or skilled nursing beds 18
to the extent the services are available within their facility and 19
the associated reimbursement methodology prior to the billing under 20
the methodology in (a) of this subsection, if the hospital determines 21
that such swing bed or skilled nursing bed placement is appropriate 22
for the patient's care needs, the patient is appropriate for the 23
existing patient mix, and appropriate staffing is available.24
(14) The authority shall adopt rules that establish a 25
standardized definition and reporting mechanism for wait times for 26
pediatric primary care and applied behavior analysis service codes by 27
December 31, 2026.28
(15) Beginning with the fiscal year that starts July 1, 2027, the 29
authority may not reduce medical assistance reimbursement rates for 30
any pediatric primary care or applied behavior analysis service code 31
if the average statewide waitlist for that service exceeds 30 days.32
(16) Beginning with the fiscal year that starts July 1, 2027, if 33
the agency-wide appropriation authority is less than the agency's 34
appropriation authority for the previous fiscal year, reductions must 35
be made in the following order:36
(a) First, to administrative costs including but not limited to 37
new contracts, goods, travel, and vacancies;38
(b) Second, to nonbargained executive management salaries and 39
wages; and40
p. 5 HB 2331
(c) Lastly, to reimbursement rates affecting benefit and client 1
services.2
(17) Beginning with the fiscal year that starts July 1, 2027, if 3
the legislature provides a rate increase for pediatric primary care 4
or applied behavior analysis service codes in the omnibus operating 5
budget, it must be applied as a distinct layer in addition to the 6
base rate.7
--- END ---
p. 6 HB 2331