(1) The medicaid agency's skilled nursing facility per diem rate, established in chapters
74.46 RCW, 388-96, and
388-97 WAC, includes any reusable and disposable medical supplies that may be required for a skilled nursing facility client, unless otherwise specified within this section.
(2) The agency pays for the following medical equipment outside of the skilled nursing facility per diem rate, subject to the limitations in this section:
(a) Manual or power-drive wheelchairs (including CRT);
(b) Speech generating devices (SGD); and
(c) Specialty beds.
(3) The agency pays for one manual or one power-drive wheelchair for clients who reside in a skilled nursing facility, with prior authorization, according to the requirements in WAC
182-543-4100,
182-543-4200, and
182-543-4300. Requests for prior authorization must:
(a) Be for the exclusive full-time use of a skilled nursing facility resident;
(b) Not be included in the skilled nursing facility's per diem rate;
(c) Include a completed General Information for Authorization form (HCA 13-835);
(d) Include a copy of the telephone order, signed by the physician, for the wheelchair assessment;
(e) Include a completed Medical Necessity for Wheelchair Purchase for Nursing Facility Clients form (HCA 13-729).
(4) The agency pays for wheelchair accessories and modifications that are specifically identified by the manufacturer as separate line item charges, with prior authorization. To receive payment, providers must submit the following to the agency:
(a) A copy of the telephone order, signed by the physician for the wheelchair accessories and modifications;
(b) A completed Medical Necessity for Wheelchair Purchase for Nursing Facility Clients form (HCA 13-729). The date on this form (HCA 13-729) must not be prior to the date on the telephone order. The agency's electronic forms are available online (see WAC
182-543-7000, Authorization);
(c) The make, model, and serial number of the wheelchair to be modified;
(d) The modification requested; and
(e) Specific information regarding the client's medical condition that necessitates modification.
(5) The agency pays for wheelchair repairs with prior authorization. To receive payment, providers must submit the following to the agency:
(a) A completed Medical Necessity for Wheelchair Purchase for Nursing Facility Clients form (HCA 13-729). The agency's electronic forms are available online (see WAC
182-543-7000, Authorization);
(b) The make, model, and serial number of the wheelchair to be repaired; and
(c) The repair requested.
(6) Prior authorization is required for the repair and modification of client-owned equipment.
(7) The skilled nursing facility must provide a house wheelchair as part of the per diem rate, when the client resides in a skilled nursing facility.
(8) When the client is eligible for both medicare and medicaid and is residing in a skilled nursing facility in lieu of hospitalization, the agency does not reimburse for medical equipment, related services, or related repairs or labor charges under fee-for-service (FFS).
(9) The agency pays for the purchase and repair of a speech generating device (SGD), with prior authorization. The agency pays for replacement batteries for SGDs in accordance with WAC
182-543-5500(3).
(10) The agency pays for the purchase or rental of a specialty bed (a heavy duty bariatric bed is not a specialty bed), with prior authorization, when:
(a) The specialty bed is intended to help the client heal; and
(b) The client's nutrition and laboratory values are within normal limits.
(11) The agency considers decubitus care products to be included in the skilled nursing facility per diem rate and does not reimburse for these separately.
(12) See WAC
182-543-9000 for reimbursement for wheelchairs and CRT.
(13) The agency pays for the following medical supplies for a client in a skilled nursing facility outside the skilled nursing facility per diem rate:
(a) Medical supplies or services that replace all or part of the function of a permanently impaired or malfunctioning internal body organ. This includes, but is not limited to, the following:
(i) Colostomy and other ostomy bags and necessary supplies (see WAC
388-97-1060(3)); and
(ii) Urinary retention catheters, tubes, and bags, excluding irrigation supplies.
(b) Supplies for intermittent catheterization programs, for the following purposes:
(i) Long term treatment of atonic bladder with a large capacity; and
(ii) Short term management for temporary bladder atony.
(c) Surgical dressings required as a result of a surgical procedure, for up to six weeks post-surgery.