PERMANENT RULES
SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Purpose: In accordance with the Maternity Care Access Act of 1989, the Medical Assistance Administration (MAA) is redesigning its maternity services and First Steps program to improve quality of services offered and to contain expenditure growth.
Citation of Existing Rules Affected by this Order: Repealing WAC 388-533-0350; and amending WAC 388-533-0300.
Statutory Authority for Adoption: RCW 74.08.090.
Other Authority: RCW 74.09.760 through 74.09.910 (Maternity Care Access Act of 1989).
Adopted under notice filed as WSR 04-05-083 on February 17, 2004.
Changes Other than Editing from Proposed to Adopted Version: The following changes, other than editing changes,
have been made to the rules as proposed (additions indicated
by underlined text, deletions indicated by strikethrough
text):
AMENDED SECTIONS:
WAC 388-533-0345 Maternity support services -- Reimbursement.
In an effort to compensate providers for the added tobacco cessation measure requirement, MAA will include reimbursement for the service. The following line has been added to the rule.
(3)(d) A one-time-only fee per client, per pregnancy for the tobacco cessation performance measure.
WAC 388-533-0370(1) Infant case management -- Eligibility.
In response to several public hearing testimonies, the department has reconsidered the ICM eligibility criteria and (1) expanded the criteria as requested; and (2) included the eligibility criteria into this section as requested. The text below is the revised version:
(1) To be eligible for infant case management (ICM):
(a) The infant must be covered under one of the medical programs listed in WAC 388-533-0320 (1)(a) of this section;
(b) The parent(s) must need assistance in accessing or providing care for the infant; and
(c) The parent or infant must meets At least one of the
following criteria exists: described in the department of
social and health services (DSHS) ICM intake form (DSHS
13-658.:
i. The parent(s) are unable to care for infant specifically due to at least one of the following:
A. Incarceration of the mother within the last year;
B. Low functioning ability (e.g., needs repeated instructions, not attuned to infant cues, leaves infant with inappropriate caregivers, parent has the equivalent of less than an eighth grade education).
C. Unstable mental health issue (regardless of whether the mental health issue is being treated or not).
D. Physical impairment.
E. Infant's mother is experiencing postpregnancy depression or mood disorder or has a history of depression/mood disorder.
F. Infant's parent(s) are unable to access resources due to age (nineteen years of age or younger).
G. Social isolation (e.g., family is new to the community, parent(s) do not have a support system, family moves frequently, lack of supportive living environment).
H. Inability to access resources due to language or cultural barrier.
ii. The infant's safety is a concern specifically due to at least one of the following:
A. Domestic or family violence in present or past relationship that keeps the parent(s) feeling unsafe.
B. Substance abuse by the infant's mother and/or father that is impacting ability to parent.
C. Secondhand smoke exposure to the infant.
D. Child Protective Service involvement within the last year or mother/father had parental rights terminated in the past.
E. Unstable living situation (e.g., homelessness, couch surfing, unsafe conditions, no cooking facilities, heat, or water).
iii. The infant's health is a concern specifically due to at least one of the following:
A. Low birth weight - less than five and one half pounds.
B. Premature birth - less than thirty-seven weeks gestation.
C. Failure to thrive (e.g., baby is not gaining weight, significant feeding difficulty, no eye contact, or baby is listless).
D. Multiple births (twins, triplets, etc.).
E. Excessive fussiness or infant has irregular sleeping patterns (e.g., parent(s)' sleep deprivation, exhaustion and/or need for respite child care).
F. Infant has an identified medical problem or disability.
A final cost-benefit analysis is available by contacting Wendy Boedigheimer, MAA, P.O. Box 45533, Olympia, WA 98504-5533, phone (360) 725-1306, fax (360) 586-9727, e-mail boediwl@dshs.wa.gov.
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 0, 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 15, Amended 1, Repealed 1.
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 15, Amended 1, Repealed 1.
Date Adopted: June 10, 2004.
Brian H. Lindgren, Manager
Rules and Policies Assistance Unit
3349.8(1) Refer to WAC 388-462-0015 for client eligibility requirements.
(2) MAA requires providers to have specific MAA approval prior to becoming an approved maternity support services (MSS) provider. MSS services must be provided by professionals from all of the following fields:
(a) Community health nursing;
(b) Nutrition; and
(c) Social work.
(3) MAA allows paraprofessional community health workers to provide MSS services to eligible clients when both of the following are met:
(a) The services are provided under the supervision of one of the qualified professionals described in subsection (2) of this section; and
(b) The services provided are limited to basic health education.
(4) A client may choose to receive MSS services from any MAA-approved MSS provider.
(5) In addition to the client's standard scope of care, MAA covers the following enhanced benefits (MSS) for eligible women during and after their pregnancy:
(a) One childbirth education course per pregnancy (see subsection (9) in this section);
(b) Assessment, counseling, education, and interventions by those qualified professionals described in subsections (2) and (3) of this section; and
(c) Child care for the client's children (see subsection (7) of this section).
(6) MSS providers refer a client who may need chemical dependency assessment to a provider who is contracted with the division of alcohol and substance abuse (DASA)(see chapter 440-22 WAC). Enhanced benefits for eligible pregnant women through DASA include:
(a) Assessment for alcohol/drug use;
(b) Parenting education; and
(c) Treatment for alcohol/drug use.
(7) MAA requires the MSS provider to do the following for child care under this section:
(a) Screen for the eligible woman's need for child care;
(b) Discuss and encourage a safe and healthy child care plan; and
(c) Authorize the child care. The MSS provider may authorize child care for any of the following reasons:
(i) Health care appointments for the client;
(ii) The maternity services medical provider ordered bed rest for the client; or
(iii) Other circumstances that the MSS provider considers necessary and are specifically approved by MAA.
(8) MAA covers up to ten MSS visits. If it is determined that a client is at high-risk for a poor birth outcome (see the maternity case management program), MAA may cover up to twenty visits. The MSS provider must maintain documentation of the high-risk circumstances in the client's file.
(9) MAA allows a provider to bill only once per client per pregnancy for childbirth education. The provider must document that the client attended at least one childbirth education session in order for MAA to reimburse for the service.
(10) MAA publishes MSS program billing instructions that contain specific process requirements for the MSS program)). The enhanced services include:
(1) Maternity support services (see WAC 388-533-0310 through 388-533-0345;
(2) Infant case management services (see WAC 388-533-0360 through 388-533-0386);
(3) Alcohol and drug assessment and treatment services (see WAC 388-533-0701);
(4) Childbirth education classes (see WAC 388-533-0390); and
(5) Childcare services (see WAC 388-533-1000).
[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.]
MATERNITY SUPPORT SERVICES
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"Advocacy" - For the purposes of the MSS program, means actions taken to support the parent(s) in accessing needed services or goods and helping the parent(s) to develop skills to access services.
"Assurances document" - A signed agreement documenting that the provider understands and agrees to maintain certain required program elements; and to work toward integrating other specifically recommended practices. Also referred to as the MSS/ICM assurances document.
"Basic health messages" - For the purposes of the MSS program, means the preventative health education messages designed to promote healthy pregnancies, healthy newborns and healthy parenting during the first year of life.
"Case management" - For the purposes of the MSS program, means services to assist individuals who are eligible under the Medicaid state plan, to gain access to needed medical, social, educational, and other services.
"Childbirth education classes (CBE)" - A series of educational sessions offered in a group setting and led by an approved instructor to prepare a pregnant woman and her support person for an upcoming childbirth.
"Childcare"
"DASA (division of alcohol and substance abuse)" - Childcare for women attending DASA-funded outpatient alcohol or drug treatment services that may be provided through the treatment facility.
"First Steps" - Childcare funded through the First Steps Program for the care of children of pregnant or postpregnant women who are attending appointments for Medicaid-covered services, pregnant women on physician ordered bed rest, and for visits to the Neonatal Intensive Care Unit (NICU) after delivery.
"Community and family health (CFH)" - Refers to the division within the state department of health whose mission is to improve the health and well-being of Washington residents with a special focus on infants, children, youth, pregnant woman, and prospective parents.
"Consultation" - For the purposes of the MSS program, means the practice of conferring with other professionals to share knowledge and problem solve with the intent of providing the best possible care to clients.
"Core services" - For the purposes of the MSS program, means the services that provide the framework for interdisciplinary, client-centered maternity support services and infant case management. These services include: client screening, basic health messages, basic linkages, and minimum interventions.
"Department of health (DOH)" - The agency whose mission is to protect and improve the health of people in Washington state.
"Department of social and health services (DSHS)" - The state agency that administers social and health services programs for the state of Washington.
"First Steps" - The 1989 Maternity Care Access Act, known as First Steps. This program provides enhanced maternity care for pregnant and postpregnant women, and health care for infants. The program is managed collaboratively by DSHS and DOH. First Steps maternity care consists of obstetrical care, maternity support services, childbirth education classes, and infant case management.
"First Steps Childcare" - See Childcare.
"Home visit" - For the purposes of the MSS program, means services delivered in the client's place of residence or other setting as described in the medical assistance administration's published MSS/ICM billing instructions.
"Infant case management (ICM)" - A program that provides case management services to eligible high-risk infants and their families. Eligibility for ICM may be established at the end of the maternity cycle and up to the infant's first birthday.
"Interagency agreement" - A written letter of agreement between two agencies for the exchange of referrals or service provision (e.g., a written agreement in letter format that agrees to an exchange of referrals or services for MSS/ICM clients).
"Interdisciplinary team" - Members from different professions and occupations that work closely together and communicate frequently to optimize care for the client (pregnant woman and infant). Each team member contributes specialized knowledge, skills and experience to support and augment the contributions of the other team members.
"Linkages" - Networking and/or collaboration between agencies in order to assure proper referral of clients and avoid duplication of services.
"Maternal and infant health (MIH)" - A section within the state department of health. MIH works collaboratively with DSHS to provide clinical consultation, oversight and monitoring of the MSS/ICM programs.
"Maternity cycle" - An eligibility period for maternity support services that begins during pregnancy and continues to the end of the month in which the sixtieth-day postpregnancy occurs.
"Maternity support services (MSS)" - Preventive health services for pregnant/postpregnant women including: professional observation, assessment, education, intervention and counseling. MSS services are provided by an interdisciplinary team consisting of at minimum, a community health nurse, a nutritionist, and a behavioral health specialist. Additional MSS services may be provided by community health workers.
"Medical assistance administration (MAA)" - The administration within DSHS authorized to administer medical assistance programs.
"Minimum interventions" - Defined levels of client assessment, education, intervention and outcome evaluation for specific risk factors found in client screening for MSS/ICM services, or identified during ongoing services.
"Performance measure" - An indicator used to measure the results of a focused intervention or initiative.
"Risk factors" - The biopsychosocial factors that could lead to negative pregnancy or parenting outcomes. The MSS/ICM program design identifies specific risk factors and corresponding minimum interventions.
"Service plan" - The written plan of care that must be developed and maintained throughout the eligibility period for each client in the MSS/ICM programs.
"Staff" - For the purposes of the MSS program, means the personnel employed by providers.
"Unit of service" - Fifteen minutes of one-to-one service delivered face-to-face.
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(a) Covered under one of the following medical assistance administration 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); and
(b) Pregnant or still within the maternity cycle.
(2) Clients meeting the eligibility criteria in WAC 388-533-0320(1) who are enrolled in an MAA managed care plan, are eligible for MSS services outside their plan. MSS services delivered outside the managed care plan are reimbursed on a fee-for-service basis and subject to the same program rules as apply to nonmanaged care clients.
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(a) Services are to be delivered in area of geographic need as determined by MAA/DOH; and
(b) Providers must:
(i) Deliver both MSS and ICM services;
(ii) Provide services in both office and home visit settings; and
(iii) Assure maintenance of staffing requirements and delivery of core services according to program design.
(2) To participate in the MSS program, a provider must:
(a) Comply with the clinical supervision/clinical consultation guidelines as required in the assurances document;
(b) Notify the appropriate state discipline-specific consultant when a staff person joins or leaves a designated position;
(c) Ensure that all newly hired staff receive an orientation to First Steps as soon as possible, but no later than sixty days from the hire date;
(d) Refer clients who may need chemical dependency assessment and/or treatment to a provider contracted with the division of alcohol and substance abuse (DASA) (see chapter 440-22 WAC);
(e) Authorize First Steps childcare for the MSS client as appropriate to facilitate MSS and First Step objectives (see WAC 388-533-1000 for rules governing First Steps childcare);
(f) Complete and document case conferencing activities.
(3) To be reimbursed by MAA for MSS, providers must:
(a) Meet the requirements in chapter 388-502 WAC, Administration of medical programs--Providers rules;
(b) Have a completed, approved MSS/ICM assurance document, signed by an officer or employee qualified to sign on behalf of the provider, on file with MAA;
(c) Meet the DOH/MAA requirements for a qualified MSS interdisciplinary team as prescribed in the assurances document;
(d) Ensure that staff meet the minimum qualifications for the MSS rules they perform; and
(e) Submit billings as instructed in MAA's published MSS/ICM billing instructions.
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(2) Covered services include:
(a) Community health nursing visits;
(b) Nutrition visits;
(c) Behavioral health visits; and
(d) Community health worker visits under the direction of a professional member of the team.
(3) The services listed in WAC 388-533-0330(2) are covered under this program only when the services are:
(a) Documented in the client's record;
(b) Provided on an individual basis in a face-to-face encounter;
(c) Delivered by a qualified staff person acting within her/his area of expertise; and
(d) Used for the purposes of the MSS program to provide:
(i) Risk screening;
(ii) Education that relates to improving pregnancy and parenting outcomes;
(iii) Brief counseling;
(iv) Interventions for identified risk factors;
(v) Basic health messages;
(vi) Referral and linkages to other services; or
(vii) Family planning screening.
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(a) Not within the scope of the program;
(b) Not listed in WAC 388-533-0330; or
(c) Any service provided by staff not qualified to deliver the service.
(2) MAA evaluates requests for services listed as noncovered under the provisions of WAC 388-501-0165.
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(1) MAA reimburses under this program only for services billed using approved procedure codes and modifiers as identified in MAA's published MSS/ICM billing instructions;
(2) MAA reimburses MSS services in units of time with one unit being equal to fifteen minutes of service;
(3) MAA reimburses a maximum of:
(a) Six units per client, per day for any combination of office or home visits;
(b) Sixty total units per client, from all disciplines, over the maternity cycle;
(c) A one-time-only fee per client for the family planning performance measure; and
(d) A one-time-only fee per client per pregnancy for the tobacco cessation performance measure.
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INFANT CASE MANAGEMENT SERVICES
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"Infant case management (ICM)" - The program that provides case management services to eligible high-risk infants and their families. Eligibility for ICM may be established at the end of the maternity cycle up to the end of the month of the baby's first birthday.
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(a) The infant must be covered under one of the medical programs listed in WAC 388-533-0320 (1)(a) of this chapter;
(b) The parent(s) must need assistance in accessing or providing care for the infant; and
(c) At least one or more of the following criteria exists:
(i) The parent(s) are unable to care for infant specifically due to at least one of the following:
(A) Incarceration of the mother within the last year;
(B) Low functioning ability (e.g., needs repeated instructions, not attuned to infant cues, leaves infant with inappropriate caregivers, parent has the equivalent of less than an eighth grade education);
(C) Unstable mental health issue (regardless of whether the mental health issue is being treated or not);
(D) Physical impairment;
(E) Infant's mother is experiencing postpregnancy depression or mood disorder or has a history of depression/mood disorder;
(F) Infant's parent(s) are unable to access resources due to age (nineteen years of age or younger);
(G) Social isolation (e.g., family is new to the community, parent(s) do not have a support system, family moves frequently, lack of supportive living environment);
(H) Inability to access resources due to language or cultural barrier.
(ii) The infant's safety is a concern specifically due to at least one of the following:
(A) Domestic or family violence in present or past relationship that keeps the parent(s) feeling unsafe;
(B) Substance abuse by the infant's mother and/or father that is impacting ability to parent;
(C) Secondhand smoke exposure to the infant;
(D) Child protective service involvement within the last year or mother/father had parental rights terminated in the past;
(E) Unstable living situation (e.g., homelessness, couch surfing, unsafe conditions, no cooking facilities, heat, or water).
(iii) The infant's health is a concern specifically due to at least one of the following:
(A) Low birth weight - less than five and one half pounds;
(B) Premature birth - less than thirty-seven weeks gestation;
(C) Failure to thrive (e.g., baby is not gaining weight, significant feeding difficulty, no eye contact, or baby is listless);
(D) Multiple births (twins, triplets. etc.);
(E) Excessive fussiness or infant has irregular sleeping patterns (e.g., parent(s)' sleep deprivation, exhaustion and/or need for respite childcare);
(F) Infant has an identified medical problem or disability.
(2) Clients meeting the eligibility criteria in WAC 388-533-0370(1) who are enrolled in an MAA managed care plan are eligible for ICM services outside their plan. ICM services delivered outside the managed care plan are reimbursed on a fee-for-service basis and subject to the same program rules as apply to nonmanaged care clients.
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(a) Services are to be delivered in area of geographic need as determined by MAA/DOH; and
(b) Provider must:
(i) Deliver both MSS and ICM services;
(ii) Provide services in both office and home visit settings; and
(iii) Assure maintenance of staffing requirements and delivery of service according to program design.
(2) To participate in the ICM program, a provider must:
(a) Comply with the clinical supervision/clinical guidelines as prescribed in the assurances document;
(b) Notify the MAA program manager when there is a staff change in a designated position;
(c) Ensure that all newly hired staff receive an orientation to First Steps services as soon as possible, but not later than sixty days from the hire date; and
(d) Submit billings as instructed in MAA's published MSS/ICM billing instructions.
(3) To be reimbursed by MAA for ICM, a provider must:
(a) Meet the requirements in chapter 388-502 WAC, Administration of medical programs -- Providers rules;
(b) Have a completed, approved MSS/ICM assurances document, signed by an officer or employee qualified to sign on behalf of the provider, on file with MAA; and
(c) Ensure that staff meet the minimum qualifications for the ICM roles they perform.
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(2) The ICM program reimburses approved providers for case management including:
(a) Assessing risk and need;
(b) Reviewing and updating the infant and parent(s) service plan;
(c) Referring and linking the client to other agencies; and
(d) Advocating for the client with other agencies.
(3) The case management activities listed in WAC 388-533-0380(2) are covered under the ICM program only when:
(a) Documented in the client's record;
(b) Provided on an individual basis in a face-to-face encounter;
(c) Performed by a qualified staff person acting within her/his area of expertise; and
(d) Provided according to program design as described in the MSS/ICM assurances document.
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(a) Any direct delivery of services other than case management activities listed in WAC 388-533-0380(2); and
(b) Any service provided by staff not qualified to deliver the service.
(2) MAA evaluates requests for services listed as noncovered under the provisions of WAC 388-501-0165.
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(1) ICM is reimbursed in units of service with one unit being equal to fifteen minutes of service;
(2) MAA reimburses:
(a) No more than six ICM units per month, per client; and
(b) No more than forty ICM units total per client through the end of the month of the baby's first birthday; and
(c) Only for services billed using the approved ICM procedure code and modifier identified in MAA's published MSS/ICM billing instructions.
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(2) Definitions. The following definitions apply to 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.
(3) Client eligibility. Childbirth education classes under WAC 388-533-0390 are available to women who are:
(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).
(4) Provider requirements. A childbirth educator providing services under WAC 388-533-0390 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) Deliver CBE services in 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.)
(7) Reimbursement. MAA reimburses CBE services subject to the following terms and limitations:
(a) Reimbursement:
(i) Is limited to one series per client, per pregnancy;
(ii) Must be for the clients specifically enrolled in the session; and
(iii) Includes 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.)
(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.
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The following section of the Washington Administrative Code is repealed:
| WAC 388-533-0350 | Maternity case management. |