Original Notice.

     Preproposal statement of inquiry was filed as WSR 04-14-098.

     Title of Rule and Other Identifying Information: WAC 388-533-0400 Maternity care and newborn delivery, 388-533-0500 Planned home births -- Pilot project; and 388-533-0600 Births in birthing centers.

     Hearing Location(s): Blake Office Park East (behind Goodyear Courtesy Tire), Rose Room, 4500 10th Avenue S.E., Lacey, WA, on November 23, 2004, at 10:00 a.m.

     Date of Intended Adoption: November 24, 2004.

     Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, delivery 4500 10th Avenue S.E., Lacey, WA, e-mail fernaax@dshs.wa.gov, fax (360) 664-6185, by 5:00 p.m., November 23, 2004.

     Assistance for Persons with Disabilities: Contact Fred Swenson, DSHS Rules Consultant, by November 19, 2004, TTY (360) 664-6178 or (360) 664-6097.

     Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The Medical Assistance Administration (MAA) is proposing to amend WAC 388-533-0400 Maternity care and newborn delivery, 388-533-0500 Planned home births -- Pilot project; and 388-533-0600 Births in birthing centers. The existing planned home births pilot project is nearing the end of the authorized five-year timeframe. MAA has evaluated the effectiveness of the pilot project and will be retaining the program permanently. As a result, a revision of the aforementioned three sections of chapter 388-533 WAC is necessary to establish the planned home births program permanently. These changes meet the requirements in the Maternity Care Access Act of 1989 that requires MAA to evaluate the maternity care access system to determine effectiveness and need for modification and to prevent unnecessary barriers to maternity care for eligible persons.

     The proposed changes:

     •     Remove references to the medically indigent program;

     •     Remove references to "pilot project" preceding planned home births and establish planned home births as an accepted program;

     •     Combine births in birthing centers and planned home births into one section;

     •     Eliminate language no longer applicable as a result of HIPAA;

     •     Eliminate reimbursement of prenatal assessment fee; and

     •     Clarify language around antepartum care.

     Statutory Authority for Adoption: RCW 74.08.090, 74.09.760, and 74.09.770.

     Statute Being Implemented: RCW 74.09.770.

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

     Name of Proponent: Department of Social and Health Services, governmental.

     Name of Agency Personnel Responsible for Drafting: Wendy L. Boedigheimer, P.O. Box 45533, Olympia, WA 98504-5533, (360) 725-1306; Implementation and Enforcement: Bev Atteridge, P.O. Box 45506, Olympia, WA 98504-5506, (360) 725-1575.

     No small business economic impact statement has been prepared under chapter 19.85 RCW. Businesses that must comply with these rules are planned home births and births in birthing centers providers who have core provider agreements on file with the MAA. The MAA has analyzed the proposed rule and concludes that the rule change does not impose additional costs or administrative burdens on these providers and will not place a more than minor impact on small businesses.

     A cost-benefit analysis is not required under RCW 34.05.328. The proposed rule changes do not meet the definition of a "significant rule" according to RCW 34.05.328 (5)(c)(iii). Therefore, no cost-benefit analysis is required.

October 15, 2004

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

     (a) "Birthing center" means a specialized facility licensed as a childbirth center by the department of health (DOH) under chapter 246-349 WAC.

     (b) "Bundled services" means ((those services that are integral to a major procedure that may be bundled with the major procedure for the purposes of reimbursement)) services integral to the major procedure that are included in the fee for the major procedure. Under this chapter, certain ((bundled)) services which are customarily bundled must be billed separately (unbundled) when the services are provided by different providers.

     (c) "Facility fee" means ((that)) the portion of MAA's ((reimbursement that covers)) payment for the hospital or birthing center charges. This does not include MAA's ((reimbursement)) payment for the professional fee defined below.

     (d) "Global fee" means the fee MAA pays for total obstetrical care. Total obstetrical care includes all bundled antepartum care, delivery services and postpartum care.

     (e) "High-risk" pregnancy means any pregnancy that poses a significant risk of a poor birth outcome.

     (f) "Professional fee" means ((that)) the portion of MAA's ((reimbursement that covers the)) payment for services that rely on the provider's professional skill or training, or the part of the reimbursement that recognizes the provider's cognitive skill. (See WAC 388-531-1850 for reimbursement methodology.)

     (2) MAA covers full scope medical maternity care and newborn delivery services to ((its)) fee-for-service clients who qualify for categorically needy (CN) or medically needy (MN) scope of care (see WAC 388-462-0015 for client eligibility). Clients enrolled in an MAA managed care plan must receive all medical maternity care and newborn delivery services through the plan. See subsection (((21))) (20) of this section for client eligibility limitations for smoking cessation counseling provided as part of antepartum care services.

     (3) ((MAA does not provide full scope maternity care and delivery services to its clients who qualify for medically indigent (MI) scope of care (see WAC 388-462-0015 for client eligibility). Clients who qualify for MI scope of care have hospital delivery coverage only.

     (4))) MAA does not provide maternity care and delivery services to its clients who are eligible for:

     (a) Family planning only (a pregnant client under this program should be referred to the local community services office for eligibility review); or

     (b) Any other program not listed in this section.

     (((5))) (4) MAA requires providers of maternity care and newborn delivery services to meet all of the following. Providers must:

     (a) Be currently licensed by the state of Washington's department of health (DOH) and/or department of licensing;

     (b) Have signed core provider agreements with MAA;

     (c) Be practicing within the scope of their licensure; and

     (d) Have valid certifications from the appropriate federal or state agency, if such is required to provide these services (e.g., federally qualified health centers (FQHCs), laboratories certified through the Clinical Laboratory Improvement Amendment (CLIA), etc.).

     (((6))) (5) MAA covers total obstetrical care services (((reimbursed)) paid under a global fee). Total obstetrical care includes all of the following:

     (a) Routine antepartum care that begins in any trimester of a pregnancy;

     (b) Delivery (intrapartum care/birth) services; and

     (c) Postpartum care. This includes family planning counseling.

     (((7))) (6) When an eligible client receives all the services listed in subsection (((6))) (5) of this section from one provider, MAA ((reimburses)) pays that provider ((in one of the following ways:

     (a) Through a global obstetrical fee; or

     (b) Through separate fees in any combination:

     (i) First trimester antepartum care;

     (ii) Second trimester antepartum care;

     (iii) Third trimester antepartum care;

     (iv) Delivery services (intrapartum care); and

     (v) Postpartum care)) a global obstetrical fee.

     (((8))) (7) When an eligible client receives services from more than one provider, MAA ((reimburses)) pays each provider for the services furnished. The separate services that MAA ((reimburses)) pays appear in subsection (((7)(b))) (5) of this section.

     (((9) MAA reimburses))

     (8) MAA pays for antepartum care services in one of the following two ways:

     (a) Under a global fee (((for total obstetrical care))); or

     (b) Under ((separate trimester)) antepartum care fees.

     (((10))) (9) MAA's fees for antepartum care include all of the following:

     (a) Completing an initial and any subsequent patient history;

     (b) Completing all physical examinations;

     (c) Recording and tracking the client's weight and blood pressure;

     (d) Recording fetal heart tones;

     (e) Performing a routine chemical urinalysis (including all urine dipstick tests); and

     (f) Providing maternity counseling.

     (((11))) (10) MAA covers certain antepartum services in addition to the bundled services listed in subsection (((10))) (9) of this section. MAA ((reimburses)) pays separately for any of the following:

     (a) ((A prenatal assessment fee for a pregnant client (limited to one prenatal assessment fee per pregnancy per provider);

     (b))) An enhanced prenatal management fee (a ((monthly)) fee for medically necessary increased prenatal monitoring). MAA provides a list of diagnoses and/or conditions that MAA identifies as justifying more frequent monitoring visits. MAA ((reimburses)) pays for either (a) or (b) ((or (c))) of this subsection, but not both;

     (((c))) (b) A prenatal management fee for "high-risk" maternity clients. This ((monthly)) fee is payable to either a physician or a certified nurse midwife. MAA ((reimburses)) pays for either (a) or (b) ((or (c))) of this subsection, but not both;

     (((d))) (c) Necessary prenatal laboratory tests except routine chemical urinalysis, including all urine dipstick tests, as described in subsection (((10))) (9)(e) of this section; and/or

     (((e))) (d) Treatment of medical problems that are not related to the pregnancy. MAA pays these fees to physicians or advanced registered nurse practitioners (ARNP).

     (((12))) (11) MAA covers high-risk pregnancies. MAA considers a pregnant client to have a high-risk pregnancy when the client:

     (a) Has any high-risk medical condition (whether or not it is related to the pregnancy); or

     (b) Has a diagnosis of multiple births.

     (((13))) (12) MAA covers delivery services for clients with high-risk pregnancies, described in subsection (((12))) (11) of this section, when the delivery services are provided in a hospital.

     (((14))) (13) MAA ((covers the)) pays a facility fee for delivery services in the following settings:

     (a) Inpatient hospital; or

     (b) Birthing centers.

     (((15))) (14) MAA ((covers the)) pays a professional fee for delivery services in the following settings:

     (a) Hospitals, to a provider who meets the criteria in subsection (((5))) (4) of this section and who has privileges in the hospital;

     (b) Planned home ((birth settings for providers who are participating in MAA's home birth pilot project; or

     (c) Birthing centers, as described in WAC 388-533-0600.

     (16))) births and birthing centers.

     (15) MAA covers hospital delivery services for an eligible client as defined in ((subsections (2), (3), and (4)(b))) subsection (2) of this section. MAA's bundled ((reimbursement)) payment for the professional fee for hospital delivery services include:

     (a) The admissions history and physical examination; and

     (b) The management of uncomplicated labor (intrapartum care); and

     (c) The vaginal delivery of the newborn (with or without episiotomy or forceps); ((and)) or

     (d) Cesarean delivery of the newborn.

     (((17))) (16) MAA pays only a labor management fee to a provider who begins intrapartum care and unanticipated medical complications prevent that provider from following through with the birthing services.

     (((18))) (17) In addition to ((the MAA reimbursement)) MAA's payment for professional services in subsection (((16))) (15) of this section, MAA may ((reimburse)) pay separately for services provided by any of the following professional staff:

     (a) A stand-by physician in cases of high risk delivery and/or newborn resuscitation;

     (b) A physician assistant or registered nurse "first assist" when delivery is by cesarean section;

     (c) ((A registered nurse - "first assist" when delivery is by cesarean section;

     (d))) A physician, ((advanced registered nurse practitioner)) (ARNP), or licensed midwife for newborn examination as the delivery setting allows; and/or

     (((e))) (d) An obstetrician/gynecologist specialist for external cephalic version and consultation.

     (((19))) (18) In addition to the professional delivery services fee in subsection (((16))) (15) or the global/total fees (i.e., those that include the hospital delivery services) in subsections (5) and (6) ((and (7))) of this section, MAA allows additional fees for any of the following:

     (a) High-risk vaginal delivery;

     (b) Multiple vaginal births. MAA's typical ((reimbursement)) payment covers delivery of the first child. For each subsequent child, MAA ((reimburses)) pays at fifty percent of the provider's usual and customary charge, up to MAA's maximum allowable fee; or

     (c) High-risk cesarean section delivery.

     (((20))) (19) MAA does not ((reimburse)) pay separately for any of the following:

     (a) More than one child delivered by cesarean section during a surgery. MAA's cesarean section surgery fee covers one or multiple surgical births;

     (b) Postoperative care for cesarean section births. This is included in the surgical fee. Postoperative care is not the same as or part of postpartum care.

     (((21))) (20) In addition to the services listed in subsection (((11))) (10) of this section, MAA covers counseling for tobacco dependency for eligible pregnant women through two months postpregnancy. This service is commonly referred to as smoking cessation education or counseling.

     (a) MAA covers smoking cessation counseling for only those fee-for-service clients who are eligible for categorically needy (CN) scope of care. See (f) of this subsection for limitations on prescribing pharmacotherapy for eligible CN clients. Clients enrolled in managed care may participate in a smoking cessation program through their plan.

     (b) MAA pays a fee to certain providers who include smoking cessation counseling as part of an antepartum care visit or a postpregnancy office visit (which must take place within two months following live birth, miscarriage, fetal death, or pregnancy termination). MAA ((reimburses)) pays only the following providers for smoking cessation counseling:

     (i) Physicians;

     (ii) Physician assistants (PA) working under the guidance and billing under the provider number of a physician;

     (iii) ((Advanced registered nurse practitioners (ARNP))) ARNPs, including certified nurse midwives (CNM); and

     (iv) Licensed midwives (LM).

     (c) MAA covers one smoking cessation counseling session per client, per day, up to ten sessions per client, per pregnancy. The provider must keep written documentation in the client's file for each session. The documentation must reflect the information in (e) of this subsection.

     (d) MAA covers two levels of counseling. Counseling levels are:

     (i) Basic counseling (fifteen minutes), which includes (e)(i), (ii), and (iii) of this subsection; and

     (ii) Intensive counseling (thirty minutes), which includes the entirety of (e) of this subsection.

     (e) Smoking cessation counseling consists of providing information and assistance to help the client stop smoking. Smoking cessation counseling includes the following steps (refer to MAA's physician-related services (((RBRVS))) billing instructions and births and birthing centers billing instructions for specific counseling suggestions and billing requirements):

     (i) Asking the client about her smoking status;

     (ii) Advising the client to stop smoking;

     (iii) Assessing the client's willingness to set a quit date;

     (iv) Assisting the client to stop smoking, which includes developing a written quit plan with a quit date. If the provider considers it appropriate for the client, the "assisting" step may also include prescribing smoking cessation pharmacotherapy as needed (see (f) of this subsection); and

     (v) Arranging to track the progress of the client's attempt to stop smoking.

     (f) A provider may prescribe pharmacotherapy for smoking cessation for a client when the provider considers the treatment is appropriate for the client. MAA covers certain pharmacotherapy for smoking cessation as follows:

     (i) MAA covers Zyban™ only;

     (ii) The product must meet the rebate requirements described in WAC 388-530-1125;

     (iii) The product must be prescribed by a physician, ARNP, or physician assistant;

     (iv) The client for whom the product is prescribed must be eighteen years of age or older;

     (v) The pharmacy provider must obtain prior authorization from MAA when filling the prescription for pharmacotherapy; and

     (vi) The prescribing provider must include both of the following on the client's prescription:

     (A) The client's estimated or actual delivery date; and

     (B) Indication ((that)) the client is participating in smoking cessation counseling.

     (g) MAA's ((reimbursement)) payment for smoking cessation counseling is subject to postpay review. See WAC 388-502-0230, Provider review and appeal, and WAC 388-502-0240, Audits and the audit appeal process for contractors/providers, for information regarding review and appeal processes for providers.

[Statutory Authority: RCW 74.08.090, 74.09.760, 74.09.770. 02-07-043, § 388-533-0400, filed 3/13/02, effective 4/13/02. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.800. 00-23-052, § 388-533-0400, filed 11/13/00, effective 12/14/00.]

     (a) Is eligible for CN or MN scope of care (see WAC 388-533-400(2));

     (b) Has a MAA-approved medical provider who has accepted responsibility for the planned home birth or birth in birthing center ((birth)) as provided in this section;

     (c) Is expected to deliver the child vaginally and without complication (i.e., with a low risk of adverse birth outcome); and

     (d) Passes MAA's risk screening criteria. MAA provides these risk-screening criteria to qualified medical services providers.

     (2) MAA approves only the following provider types to provide MAA-covered planned home births and births in birthing centers:

     (a) Physicians licensed under chapters 18.57 or 18.71 RCW;

     (b) Nurse midwives licensed under chapter 18.79 RCW; and

     (c) Midwives licensed under chapter 18.50 RCW.

     (3) Each participating birthing center must:

     (a) Be licensed as a childbirth center by the department of health (DOH) under chapter 246-349 WAC;

     (b) ((Have a valid core provider agreement with MAA;

     (c))) Be specifically approved by MAA to provide birthing center services; ((and

     (d))) (c) Have a valid core provider agreement with MAA; and

     (d) Maintain standards of care required by DOH for licensure.

     (((3))) (4) MAA suspends or terminates the core provider agreement of a birthing center if it fails to maintain DOH standards cited in subsection (((2))) (3) of this section.

     (((4) MAA approves only the following provider types to provide MAA covered births in birthing centers:

     (a) Physicians licensed under chapters 18.57 or 18.71 RCW;

     (b) Nurse midwives licensed under chapter 18.79 RCW; and

     (c) Midwives licensed under chapter 18.50 RCW.))

     (5) ((Each provider using a)) Home birth or birthing center providers must:

     (a) Obtain from the client a signed consent form in advance of the ((birthing center)) birth;

     (b) Follow MAA's risk screening criteria and consult with and/or refer the client or newborn to a physician or hospital when medically appropriate;

     (c) Have current, written, and appropriate plans for consultation, emergency transfer and transport of a client and/or newborn to a hospital;

     (d) Make appropriate referral of the newborn for ((screening)) pediatric care and medically necessary follow-up care; ((and))

     (e) Inform parents of the benefits of a newborn screening test and offer to send the newborn's blood sample to the department of health for testing; and

     (f) Have evidence of current cardiopulmonary resuscitation (CPR) training for:

     (i) Adult CPR; and

     (ii) Neonatal resuscitation.

     (6) Planned home providers must:

     (a) Provide medically necessary equipment, supplies, and medications for each client;

     (b) Have arrangements for twenty-four hour per day coverage;

     (c) Have documentation of contact with local area emergency medical services to determine the level of response capability in the area; and

     (d) Participate in a formal, state-sanctioned, quality assurance/improvement program or professional liability review process (e.g., Joint Underwriting Association (JUA), Midwives Association of Washington State (MAWS), etc.).

     (7) MAA does not cover planned home births or births in birthing centers for women identified with any of the following conditions:

     (a) Previous cesarean section;

     (b) Current alcohol and/or drug addiction or abuse;

     (c) Significant hematological disorders/coagulopathies;

     (d) History of deep venous thromboses or pulmonary embolism;

     (e) Cardiovascular disease causing functional impairment;

     (f) Chronic hypertension;

     (g) Significant endocrine disorders including pre-existing diabetes (type I or type II);

     (h) Hepatic disorders including uncontrolled intrahepatic cholestasis of pregnancy and/or abnormal liver function tests;

     (i) Isoimmunization, including evidence of Rh sensitization/platelet sensitization;

     (j) Neurologic disorders or active seizure disorders;

     (k) Pulmonary disease;

     (l) Renal disease;

     (m) Collagen-vascular diseases;

     (n) Current severe psychiatric illness;

     (o) Cancer affecting site of delivery;

     (p) Known multiple gestation;

     (q) Known breech presentation in labor with delivery not imminent; or

     (r) Other significant deviations from normal as assessed by the provider.

[Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.800. 00-23-052, § 388-533-0600, filed 11/13/00, effective 12/14/00.]

     The following section of the Washington Administrative Code is repealed:

WAC 388-533-0500

Planned home births -- Pilot project.

© Washington State Code Reviser's Office