(1) To be eligible for private duty nursing under the medically intensive children's program (MICP), clients must:
(a) Be age seventeen or younger;
(b) Meet financial eligibility under subsection (2) of this section;
(c) Meet medical eligibility under subsection (3) of this section;
(d) Have informal support by a person who has been trained to provide designated skilled nursing care and is able to perform the care as required;
(e) Have prior authorization from the department of social and health services/developmental disabilities administration (DSHS/DDA); and
(f) Have exhausted all other funding sources for private duty nursing, according to RCW 74.09.185
, prior to accessing these services through the medically intensive children's program (MICP).
(2) To be financially eligible for private duty nursing, clients must meet medicaid eligibility requirements under the categorically needy program, the medically needy program, or alternative benefits plan program (see WAC 182-501-0060
(3) To be medically eligible for private duty nursing under fee-for-service, clients must be assessed by a DSHS/DDA nursing care consultant and determined medically eligible for MICP.
(4) Clients must meet the following criteria to be medically eligible for MICP:
(a) Require four or more continuous hours of active skilled nursing care with consecutive tasks at a level that:
(i) Cannot be delegated at the time of the initial assessment; and
(ii) Can be provided safely outside of a hospital in a less restrictive setting.
(b) Require two or more tasks of complex skilled nursing care such as:
(i) System assessments, including multistep approaches of systems (e.g., respiratory assessment, airway assessment, vital signs, nutritional and hydration assessment, complex gastrointestinal assessment and management, seizure management requiring intervention, or level of consciousness);
(ii) Administration of treatment for complex respiratory issues related to technological dependence requiring multistep approaches on a day-to-day basis (e.g., ventilator tracheostomy);
(iii) Assessment of complex respiratory issues and interventions with use of oximetry, titration of oxygen, ventilator settings, humidification systems, fluid balance, or any other cardiopulmonary critical indicators based on medical necessity;
(iv) Skilled nursing interventions of intravenous/parenteral administration of multiple medications and nutritional substances on a continuing or intermittent basis with frequent interventions; or
(v) Skilled nursing interventions of enteral nutrition and medications requiring multistep approaches daily.