WSR 12-01-097

PERMANENT RULES

HEALTH CARE AUTHORITY


(Medicaid Program)

[ Filed December 20, 2011, 4:01 p.m. , effective January 20, 2012 ]


Effective Date of Rule: Thirty-one days after filing.

Purpose: The health care authority (HCA) is revising chapter 182-533 WAC pursuant to ESHB 1086, which reduces funding for maternity support services and mandates HCA to prioritize evidence-based practices for delivery of maternity support services and to target funding for maternity support services by leveraging local public funding for those services. In addition, upon order of the governor, HCA must reduce its budget expenditures for the current fiscal year ending June 30, 2011, by 6.3 percent.

While WAC 182-533-0390 is not part of this budget reduction, HCA has reorganized the section and rewritten it to make it clearer. No policy was changed.

Citation of Existing Rules Affected by this Order: Amending WAC 182-533-0300, 182-533-0320, 182-533-0325, 182-533-0370, 182-533-0380, and 182-533-0390.

Statutory Authority for Adoption: RCW 41.05.021.

Other Authority: Chapter 5, Laws of 2011, ESHB 1086.

Adopted under notice filed as WSR 11-22-085 on November 1, 2011.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 6, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 6, Repealed 0.

Date Adopted: December 20, 2011.

Kevin M. Sullivan

Rules Coordinator

OTS-4402.2


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-533-0300   Services under First Steps.   (1) Under the 1989 Maternity Care Access Act, and RCW 74.09.760 through 74.09.910, the ((department)) agency established First Steps to provide access to services for eligible women and their infants.

(2) The rules for the:

(a) Maternity support services (MSS) component of First Steps are found in WAC ((388-533-0310)) 182-533-0310 through ((388-533-0345)) 182-533-0345.

(b) Infant case management (ICM) component of First Steps are found in WAC ((388-533-0360)) 182-533-0360 through ((388-533-0386)) 182-533-0386.

(c) Childbirth education (CBE) component of First Steps are found in WAC ((388-533-0390)) 182-533-0390.

(3) Other services under First Steps include:

(a) Medical services, including full medical coverage, prenatal care, delivery, post-pregnancy follow-up, ((dental, vision,)) and twelve months family planning services post-pregnancy;

(b) Ancillary services, including but not limited to, expedited medical eligibility determination((, case finding and outreach)); and

(c) Alcohol and drug assessment and treatment services for pregnant women available statewide and administered by the division of behavioral health and recovery (see WAC ((388-533-0701)) 182-533-0701).

[11-14-075, recodified as 182-533-0300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 1109. 10-12-011, 388-533-0300, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, 388-533-0300, filed 6/10/04, effective 7/11/04. Statutory Authority: RCW 74.08.090, 74.09.770, and 74.09.800. 00-14-068, 388-533-0300, filed 7/5/00, effective 8/5/00.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-533-0320   Maternity support services -- Client eligibility.   (1) To receive maternity support services (MSS), a client must:

(a) Be covered under one of the following medical assistance programs:

(i) Categorically needy ((program (CNP))) (CN);

(ii) ((CNP -- Children's health insurance program)) Children's health care as described in WAC 388-505-0210;

(iii) Medically needy program (MNP); or

(iv) A pregnancy medical program as described in WAC 388-462-0015.

(b) Be within the eligibility period of a maternity cycle as defined in WAC ((388-533-0315)) 182-533-0315; and

(c) Meet any other eligibility criteria as determined by the ((department)) agency and published in the ((department's)) agency's current billing instructions and/or numbered memoranda.

(2) Clients who meet the eligibility criteria in this section may receive:

(a) An in-person screening by a provider who meets the criteria established in WAC ((388-533-0325)) 182-533-0325. Clients are screened for risk factors related to issues that may impact their birth outcomes.

(b) Up to the maximum number of MSS units of service allowed per client as determined by the ((department)) agency and published in the ((department's)) agency's current billing instructions and/or numbered memoranda. The ((department)) agency may determine the maximum number of units allowed per client when directed by the legislature to achieve targeted expenditure levels for payment of maternity support services for any specific biennium.

(3) Clients meeting the eligibility criteria in this section who are enrolled in ((a department-contracted)) an agency-contracted managed care ((plan)) organization (MCO), are eligible for MSS outside their plan.

(4) See chapter ((388-534)) 182-534 WAC for clients eligible for coverage under the early periodic screening, diagnosis and treatment (EPSDT) program.

(5) Clients receiving MSS before ((July 1, 2009)) March 1, 2011, are subject to the transition plan as determined and published by the ((department)) agency in numbered memoranda.

(6) Clients who do not agree with ((a department)) an agency decision regarding eligibility for MSS have a right to a fair hearing under chapter 388-02 WAC.

[11-14-075, recodified as 182-533-0320, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 1109. 10-12-011, 388-533-0320, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, 388-533-0320, filed 6/10/04, effective 7/11/04.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-533-0325   Maternity support services -- Provider requirements.   (1) To be paid for providing maternity support services (MSS) and infant case management (ICM) services to eligible clients, an agency or entity must:

(a) Be currently approved as an MSS/ICM provider by the ((department of health (DOH))) medicaid agency;

(b) Be enrolled as an eligible provider with the ((department of social and health services' (department's) health and recovery services administration (HRSA))) medicaid agency (see WAC ((388-502-0010)) 182-502-0010);

(c) Ensure that staff providing services meet the minimum regulatory and educational qualifications for the scope of services provided; and

(d) Meet the requirements in this chapter, chapter ((388-502)) 182-502 WAC and the ((department's)) medicaid agency's current published billing instructions and numbered memoranda.

(2) An individual or service organization that has a written agreement with an agency or entity that meets the requirements in subsection (1) of this section may also provide MSS and ICM services to eligible clients.

(a) The ((department)) medicaid agency requires the agency or entity to:

(i) Keep a copy of the written agreement on file;

(ii) Ensure that an individual or service organization staff member providing MSS/ICM services meets the minimum regulatory and educational qualifications required of an MSS/ICM provider;

(iii) Assure that the individual or service organization provides MSS/ICM services under the requirements of this chapter; and

(iv) Maintain professional, financial, and administrative responsibility for the individual or service organization.

(b) The agency or entity is responsible to:

(i) Bill for services using the agency's or entity's assigned provider number; and

(ii) Reimburse the individual or service organization for MSS/ICM services provided under the written agreement.

[11-14-075, recodified as 182-533-0325, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 1109. 10-12-011, 388-533-0325, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, 388-533-0325, filed 6/10/04, effective 7/11/04.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-533-0370   Infant case management -- Eligibility.   (1) To receive infant case management (ICM), an infant must:

(a) Be covered under one of the medical assistance programs listed in WAC ((388-533-0320)) 182-533-0320(1);

(b) Meet the age requirement for ICM which is the day after the maternity cycle (defined in WAC ((388-533-0315)) 182-533-0315) ends, through the last day of the month of the infant's first birthday;

(c) Reside with at least one parent (see WAC ((388-533-0315)) 182-533-0315 for definition of parent);

(d) Have a parent(s) who needs assistance in accessing medical, social, educational and/or other services to meet the infant's basic health and safety needs; and

(e) Not be receiving any case management services funded through Title XIX medicaid that duplicate ICM services.

(2) Infants who meet the eligibility criteria in subsection (1) of this section, and the infant's parent(s), are eligible to receive:

(a) An in-person screening by a provider who meets the criteria established in WAC ((388-533-0375)) 182-533-0375. Infants and their parent(s) are screened for risk factors related to issues that may impact the infant's welfare, health, and/or safety.

(b) Up to the maximum number of ICM units of service allowed per client as determined by the ((department)) agency and published in the ((department's)) agency's current billing instructions and/or numbered memoranda. The ((department)) agency may determine the maximum number of units allowed per client when directed by the legislature to achieve targeted expenditure levels for payment in any specific biennium.

(3) Clients meeting the eligibility criteria in subsection (1) of this section who are enrolled in ((a department-contracted)) an agency-contracted managed care ((plan)) organization (MCO) are eligible for ICM services outside their plan.

(4) See chapter ((388-534)) 182-534 WAC for clients eligible for coverage under the early periodic screening, diagnosis and treatment (EPSDT) program.

(5) Clients receiving ICM before ((July 1, 2009)) March 1, 2011, are subject to the transition plan as determined and published by the ((department)) agency in numbered memoranda.

(6) Clients who do not agree with ((a department)) an agency decision regarding eligibility for ICM have a right to a fair hearing under chapter 388-02 WAC.

[11-14-075, recodified as 182-533-0370, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 1109. 10-12-010, 388-533-0370, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, 388-533-0370, filed 6/10/04, effective 7/11/04.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-533-0380   Infant case management -- Covered services.   (1) The ((department)) agency covers infant case management (ICM) services subject to the restrictions and limitations in this section and other applicable WAC.

(2) Covered services include:

(a) An initial in-person screening for ICM services which includes an assessment of risk factors, and the development of an individualized care plan;

(b) Case management services and care coordination;

(c) Linking and referring the infant and parent(s) to other services or resources;

(d) Advocating for the infant and parent(s);

(e) Follow-up contact(s) with the parent(s) to ensure the care plan continues to meet the needs of the infant and parent(s); and

(f) Additional services as determined and published in the maternity support services/infant case management (MSS/ICM) billing instructions.

(3) The ((department)) agency pays for covered ICM services according to WAC ((388-533-0386)) 182-533-0386.

[11-14-075, recodified as 182-533-0380, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 1109. 10-12-010, 388-533-0380, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, 388-533-0380, filed 6/10/04, effective 7/11/04.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-533-0390   Childbirth education (CBE) classes (((CBE))).   (1) Purpose. The purpose of childbirth education ((services described in this section are intended to)) (CBE) classes is to help prepare the ((pregnant)) client and her support person(s):

(a) For ((labor and delivery)) the physiological, emotional, and psychological changes experienced during and after pregnancy;

(b) To develop self-advocacy skills;

(c) To increase knowledge about and access to local community resources;

(d) To improve parenting skills; and

(e) To improve the likelihood of positive birth outcomes.

(2) Definitions. The ((following)) definitions ((apply to)) in chapter 182-500 WAC, medial assistance definitions, and WAC ((388-533-0390:

(a) Approved instructor -- A childbirth instructor meeting specific criteria set by the Washington department of health (DOH) maternal and infant health section and approved by the DOH health education consultant to provide childbirth education to pregnant clients.

(b) Childbirth education classes (CBE) -- A series of educational sessions offered in a group setting; with a minimum of eight hours of instruction and led by an approved instructor to prepare a pregnant woman and her support person for an upcoming childbirth.

(c) Social services payment systems (SSPS) -- The payment method used by the department of social and health services (DSHS) for certain social services and independent providers)) 182-533-0315, maternity support services definitions, also apply to this section.

(3) Client eligibility. ((Childbirth education)) To be eligible for CBE classes ((under WAC 388-533-0390 are available to women who are)), a client must be:

(a) Pregnant; and

(b) Covered under one of the ((following)) medical assistance ((administration (MAA))) programs((:

(i) Categorically needy program (CNP);

(ii) Categorically needy program -- Children's health insurance program; (CNP-Children's health insurance program); or

(iii) Categorically needy program emergency medical only (CNP-Emergency medical only))) described in WAC 182-533-0320 (1)(a)(i) and (iv).

(4) Provider requirements. ((A childbirth educator providing services under WAC 388-533-0390)) To be paid for providing CBE classes to eligible clients, an approved instructor must:

(a) ((Be an approved CBE provider (individual or agency) with an assigned SSPS/CBE billing number, and a signed program assurances document on file with MAA;

(b))) Have a core provider agreement on file with the health care authority (the agency);

(b) Ensure that individuals providing CBE classes have credentials and/or certification as outlined in the agency's current published billing instructions;

(c) Deliver CBE ((services)) classes in a series of group sessions; (((c) Bill the medical assistance administration (MAA):

(i) Using the assigned SSPS/CBE billing number; and

(ii) According to the form and instruction requirements in MAA's CBE billing instructions; and

(d) Accept the MAA fee as final and complete payment for a client.

(5) Covered services. MAA covers childbirth education when the instruction is:

(a) Provided to clients eligible under WAC 388-533-0390(3);

(b) Delivered in group sessions with a minimum of eight hours of instruction; and

(c) Delivered according to a curriculum approved by the MAA/DOH program managers.

(6) Noncovered services. The following are considered noncovered services under childbirth education:

(a) Any services beyond the scope of CBE; and

(b) Any education about childbirth that is provided during a one-to-one home or office visit. (CBE provided in a one-to-one home or office visit must be billed according to WAC 388-533-0340 and 388-533-0345, Maternity support services rules.))) and

(d) Provide curriculum containing topics outlined in the agency's CBE curriculum checklist found in the agency's current published billing instructions. Topics include, but are not limited to:

(i) Pregnancy;

(ii) Labor and birth;

(iii) Newborns; and

(iv) Family adjustment.

(5) Documentation. Providers must:

(a) Follow the health care record requirements found in WAC 182-502-0020; and

(b) Maintain the following additional documentation:

(i) An original signed copy of each client's Freedom of Choice/Consent for Services form;

(ii) A client sign-in sheet for each class; and

(iii) Names and ProviderOne Client ID numbers of eligible clients attending CBE classes and the date(s) they participated in each CBE class.

(6) Coverage.

(a) The agency covers one CBE class series per client, per pregnancy. The client must attend at least one CBE session for the provider to be paid.

(b) CBE classes must include a minimum of eight hours of instruction and are subject to the restrictions and limitations in this section and other applicable WAC.

(7) ((Reimbursement)) Payment. ((MAA reimburses)) The agency pays for the CBE ((services subject to the following terms and limitations)) classes described in subsection (6) of this section on a fee-for-service basis subject to the following:

(a) ((Reimbursement)) CBE must:

(i) ((Is limited to one series per client, per pregnancy;

(ii) Must be for the clients specifically enrolled in the session; and

(iii))) Include((s)) all classes, core materials, publications, and educational materials provided throughout the class series. (((MAA)) Clients must receive the same materials as are offered to other attendees((.))); and

(ii) Be billed according to the agency's current published billing instructions.

(b) ((A client must attend at least one CBE session in order for the provider to be reimbursed for the CBE services to the client.)) The provider must accept the agency's fee as payment in full for classes provided to a client in accordance with 42 CFR 447.15.

[11-14-075, recodified as 182-533-0390, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, 388-533-0390, filed 6/10/04, effective 7/11/04.]

Washington State Code Reviser's Office