WSR 98-20-107

PROPOSED RULES

DEPARTMENT OF HEALTH

[Filed October 7, 1998, 11:59 a.m.]



Original Notice.

Preproposal statement of inquiry was filed as WSR 97-22-088.

Title of Rule: Children with special health care needs.

Purpose: Existing rules for the children with special health care needs program include obsolete provisions. Program operations have changed since current rules were adopted. The proposed changes would bring rules into compliance with current program operations.

Statutory Authority for Adoption: RCW 43.20.140.

Statute Being Implemented: RCW 43.70.080.

Summary: Changes in proposed rules include simplification of language, deletion of obsolete content, updated declaration of program purpose, changes in definitions, updated provisions on client financial eligibility and service payment authorization, qualifications of providers, and references to fees and payment schedules.

Reasons Supporting Proposal: This proposal is consistent with the Department of Health regulatory improvement plan.

Name of Agency Personnel Responsible for Drafting, Implementation, and Enforcement: Jan Fleming, CSHCN Program Manager, Olympia, (360) 236-3521.

Name of Proponent: Washington State Department of Health, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: This rule concerns the operation of the children with special health care needs program, including role of local CSHCN agencies, management of diagnostic and treatment funds, qualifications of providers, and related elements.

Proposal Changes the Following Existing Rules: The rules are updated to reflect current operations and language is simplified. Obsolete provisions are deleted. The declaration of program purpose is updated and definitions are updated. Provisions are updated for client financial eligibility and service payment authorization, qualifications of providers, and fees and payment schedules.

No small business economic impact statement has been prepared under chapter 19.85 RCW. Small businesses are not parties to, nor affected by, these rules or the children with special health care needs program. There is no economic impact on small business.

RCW 34.05.328 does not apply to this rule adoption. This rule does not subject a person to a penalty or sanction; does not establish, alter or revoke a qualification for professional licensure; and does not make a significant amendment to a policy or regulatory program. Proposed changes are intended to bring rules into conformance with program operations.

Hearing Location: Hilton Hotel, 17620 Pacific Highway South, Seattle, WA 98188, on November 12, 1998, at 11:30 a.m.

Assistance for Persons with Disabilities: Contact Frank Chestnut by November 3, 1998, TDD (800) 833-6388, or (360) 236-3574.

Submit Written Comments to: Jan Fleming, Department of Health, FAX (360) 586-7868, by November 5, 1998.

Date of Intended Adoption: November 12, 1998.

October 7, 1998

Sylvia Beck

Executive Director

State Board of Health

OTS-2357.2

AMENDATORY SECTION (Amending Order 124B, filed 12/27/90, effective 1/31/91)



WAC 246-710-001  Declaration of purpose. The following rules ((are adopted pursuant to)) implement RCW 43.20.140 ((wherein)) and chapter 43.70 RCW. The state board of health ((is empowered to promulgate)) may develop rules ((and regulations as shall be)) that are necessary to ((carry out the purposes of)) implement RCW 43.20A.635 ((empowering)) authorizing the secretary of the department of ((social and)) health ((services)) to ((establish and)) administer a program of services for ((crippled)) children with special health care needs. ((It is)) The purpose of the ((crippled children's services)) CSHCN program is to develop, extend, and improve services and service systems for locating, diagnosing, and treating children ((who are crippled or who are suffering from physical conditions leading to crippling)) with special health care needs within available resources.

((In accordance with RCW 43.20A.635 and these rules, the crippled children's services (CCS) program shall limit services in such manner and degree as will assure, in the judgment of the physician-director, provision of optimum services to crippled children with the greatest needs, commensurate with the fixed funding available to CCS.

It is the declared purpose of the department of social and health services and the state board of health that the CCS program shall be administered strictly within the limits of funds available for CCS purposes and that CCS may not authorize provision of services beyond those limits.))



[Statutory Authority: RCW 43.20.050. 91-02-051 (Order 124B), recodified as 246-710-001, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.20.140 and 43.20.050. 83-01-002 (Order 247), 248-105-010, filed 12/2/82.]



AMENDATORY SECTION (Amending Order 124B, filed 12/27/90, effective 1/31/91)



WAC 246-710-010  Definitions. (1) "Client" means an individual ((whose application for crippled children's services program funds has been approved)) with special health care needs, seventeen years of age or younger, who is being served by a local CSHCN agency.

(2) (("Crippled child")) "Children with special health care needs" means ((an individual below the age of eighteen years having an organic disease, defect or condition substantially interfering with normal growth and development)) children with disabilities or handicapping conditions; chronic illnesses or conditions; health related educational or behavioral problems; or children at risk of developing such disabilities, conditions, illnesses or problems.

(3) (("CCS")) "CSHCN" means ((crippled children's services)) the children with special health care needs program.

(4) (("DSHS")) "Department" means department of ((social and)) health ((services)).

(5) (("Limited intervention" means treatment given during a limited period of time designed to move a client's status from a lower to a substantially higher level of functioning.

(6))) "Local ((CCS)) CSHCN agency" means the local health ((department and/or district)) jurisdiction or other agency locally administering the ((CCS)) CSHCN program for the county where the ((CCS applicant or)) client resides in the state of Washington.

(((7) "Physician-director" means a medical doctor or osteopath employed by the department of social and health services having the following qualifications:

(a) Doctorate of medicine from a school of medicine accredited by the liaison committee on medical education; and

(b) Licensed to practice medicine in the state of Washington; and

(c) Certified (or eligible for certification) by an appropriate medical specialty board.

(8))) (6) "Service systems" means community-based systems of services such as primary and specialty medical services, early intervention, special education, and social and family support services for children with special health care needs and their families.

(7) "Services" means health-related interventions, including early identification, care coordination, medical, surgical and rehabilitation care, and equipment ((and appliances)) provided in hospitals, clinics, offices, and homes by ((approved)) local CSHCN agencies, physicians and other ((approved)) health care providers.



[Statutory Authority: RCW 43.20.050. 91-02-051 (Order 124B), recodified as 246-710-010, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.20.140 and 43.20.050. 83-01-002 (Order 247), 248-105-020, filed 12/2/82.]



AMENDATORY SECTION (Amending Order 124B, filed 12/27/90, effective 1/31/91)



WAC 246-710-030  Program limitations. (1) ((Reductions in)) The department may reduce the scope of ((the program shall be made by the department when required to limit program expenditures for services according to program funding available)) CSHCN services and impose or revise funding limitations on certain services when required for budgetary reasons to accommodate available funding.

(2) ((CCS may, for budgetary reasons, upon the advice and authority of the physician-director, impose or revise funding limitations on certain CCS programs.)) Financial eligibility for a client must be determined annually when health-related services and equipment are paid for with CSHCN funds. Financial eligibility will be determined according to national standards of living for low-income families such as federal poverty levels or state median income adjusted for family size. Financial eligibility is not entitlement to CSHCN services.



[Statutory Authority: RCW 43.20.050. 91-02-051 (Order 124B), recodified as 246-710-030, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.20.140 and 43.20.050. 83-01-002 (Order 247), 248-105-040, filed 12/2/82.]



AMENDATORY SECTION (Amending Order 124B, filed 12/27/90, effective 1/31/91)



WAC 246-710-050  Authorization of services. Authorization for services ((shall)) paid for with CSHCN funds will be accomplished in ((the form and manner described by crippled children's services, in)) accordance with the following:

(1) ((Using forms approved by CCS, the local CCS agency secures financial resource information from the family and the medical documentation of the crippling condition from the provider, prepares a request for authorization, and forwards all three to the state CCS office.

(2) Medical eligibility, under the supervision of the CCS physician-director, and financial eligibility shall be determined by the state CCS staff.

(3) If the child is accepted on the program, each requested service is reviewed for appropriateness to)) Financial eligibility for a client has been determined.

(2) A request for services to be paid for with CSHCN funds has been reviewed for consistency with program ((policies and guidelines, and quality assurance criteria)) directions. Services must be ((of a nature and state of development as to be a)) recognized as an acceptable form of treatment by a significant portion of the professional community.

(((4) If all criteria are met and funding is available, an authorization document is prepared by state CCS staff and sent directly to the provider of service and local CCS agencies.

(5) Written notification of a child's acceptance or nonacceptance to the program shall be mailed to the family.

(6))) (3) No services will be authorized for out-of-state providers if an equivalent service is available within the state of Washington. ((This does not preclude utilization)) However, use of resources in ((contiguous)) bordering states will be authorized when appropriate.

(((7) In cases of emergencies, and on the basis of information available, the CCS physician-director shall have the authority to approve requested services in advance of a written application and service request being received.))



[Statutory Authority: RCW 43.20.050. 91-02-051 (Order 124B), recodified as 246-710-050, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.20.140 and 43.20.050. 83-01-002 (Order 247), 248-105-060, filed 12/2/82.]



AMENDATORY SECTION (Amending Order 124B, filed 12/27/90, effective 1/31/91)



WAC 246-710-060  Qualifications ((and assurances)) of hospitals and providers. Providers of services paid for with CSHCN funds must meet the following minimum qualifications.

(1) Hospitals ((authorized by CCS to provide services must be accredited by the joint commission of accreditation of hospitals and licensed by the state of location)) will be:

(a) Accredited by the joint commission on the accreditation of health care organizations; and

(b) Licensed in the state where the hospital is located.

(2) Physicians ((and other health care providers authorized by CCS to provide services must meet all requirements and assurances set forth in the crippled children's services provider agreement form)) will be:

(a) Licensed to practice medicine in Washington, or other state where they practice; and

(b) Board-certified or board-eligible by the appropriate specialty board.

(3) Providers other than physicians will be:

(a) Licensed or certified in Washington or in the state where they practice; or

(b) Accredited by the appropriate national professional organization when there is no state licensure or certification process.



[Statutory Authority: RCW 43.20.050. 91-02-051 (Order 124B), recodified as 246-710-060, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.20.140 and 43.20.050. 83-01-002 (Order 247), 248-105-070, filed 12/2/82.]



AMENDATORY SECTION (Amending Order 124B, filed 12/27/90, effective 1/31/91)



WAC 246-710-070  Fees and payments. (1) Payments to providers of services ((shall)) using CSHCN funds will be made ((in accordance with the DSHS schedule of maximum allowances and the crippled children's services)) using the current CSHCN standards and payment schedules, including the Washington state department of social and health services medical assistance administration fee schedule and the CSHCN supplemental fee schedule.

(2) A provider will accept the fees paid under this section as full payment for services rendered.



[Statutory Authority: RCW 43.20.050. 91-02-051 (Order 124B), recodified as 246-710-070, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.20.140 and 43.20.050. 83-01-002 (Order 247), 248-105-080, filed 12/2/82.]



AMENDATORY SECTION (Amending Order 124B, filed 12/27/90, effective 1/31/91)



WAC 246-710-080  Third-party resources. ((CCS)) CSHCN is a secondary payer to all private and other public funded health programs. ((Such sources of funding must be utilized before CCS payment is made. These sources include, but are not limited to, insurance, Medicaid, Medicare, CHAMPUS (Civilians Health and Medical Program of the Uniformed Services) including provisions for basic benefits and benefits under the program for the handicapped, and other special programs with liability for health care, such as prisons, group or foster homes, and state mental hospitals and facilities. No payment will be made where trust funds or other protected assets are available.)) The department may pay for services with CSHCN funds only after payment by all entitlement programs and by all other private and public funding resources, except where prohibited by federal law.



[Statutory Authority: RCW 43.20.050. 91-02-051 (Order 124B), recodified as 246-710-080, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.20.140 and 43.20.050. 83-01-002 (Order 247), 248-105-090, filed 12/2/82.]



AMENDATORY SECTION (Amending Order 124B, filed 12/27/90, effective 1/31/91)



WAC 246-710-090  Repayment. Repayment to the department from the provider, family or other source is required should insurance benefits, trusts, court-awarded damages or like funds become available, and where payments have been made to the family or provider for services paid for by ((CCS)) CSHCN.



[Statutory Authority: RCW 43.20.050. 91-02-051 (Order 124B), recodified as 246-710-090, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.20.140 and 43.20.050. 83-01-002 (Order 247), 248-105-100, filed 12/2/82.]



REPEALER



The following section of the Washington Administrative Code is repealed:



WAC 246-710-020 Program eligibility.

Legislature Code Reviser

Register

Washington State Code Reviser's Office