WSR 08-08-124

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed April 2, 2008, 11:49 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 08-03-091.

Title of Rule and Other Identifying Information: The department is amending WAC 388-502-0010 Payment -- Eligible providers defined, 388-531-0100 Scope of coverage for physician-related services, 388-531-0250 Who can provide and bill for physician-related services, and 388-531-1400 Psychiatric physician-related services.

Hearing Location(s): Office Building 2, Auditorium, DSHS Headquarters, 1115 Washington, Olympia, WA 98504 (public parking at 11th and Jefferson. A map is available at http://www1.dshs.wa.gov/msa/rpau/RPAU-OB-2directions.html or by calling (360) 664-6097), on May 6, 2008, at 10:00 a.m.

Date of Intended Adoption: Not sooner than May 7, 2008.

Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, delivery 4500 10th Avenue S.E., Lacey, WA 98503, e-mail schilse@dshs.wa.gov, fax (360) 664-6185, by 5 p.m. on May 6, 2008.

Assistance for Persons with Disabilities: Contact Jennisha Johnson, DSHS rules consultant, by April 29, 2008, TTY (360) 664-6178 or (360) 664-6097 or by e-mail at johnsjl4@dshs.wa.gov.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: Chapter 359, Laws of 2007 (2SHB 1088) requires the department to improve access to mental health services for children who do not meet regional support network access to care standards. Specifically, the department is revising its rules effective July 1, 2008, to allow children up to twenty hours of outpatient therapy per year, including family therapy visits. In addition, licensed mental health professionals will be allowed to provide the therapy. Currently, children are allowed up to twelve hours of outpatient therapy per year provided by a psychiatrist.

Reasons Supporting Proposal: More children will receive mental health care and the outcomes should be improved with the increase in hours of treatment per year.

Statutory Authority for Adoption: RCW 74.09.521.

Statute Being Implemented: RCW 74.09.521.

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: Kevin Sullivan, P.O. Box 45504, Olympia, WA 98504-5504, (360) 725-1344; Implementation and Enforcement: Dan Dowler, P.O. Box 45506, Olympia, WA 98504-5506, (360) 725-1567.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The content of the rule is dictated by state law which makes it exempt from the small business economic impact statement requirement per RCW 19.85.025(4).

A cost-benefit analysis is not required under RCW 34.05.328. The content of the rule is dictated by state law which makes it exempt per RCW 34.05.328 (5)(b)(v).

March 31, 2008

Stephanie E. Schiller

Rules Coordinator

3958.3
AMENDATORY SECTION(Amending WSR 03-14-106, filed 6/30/03, effective 7/31/03)

WAC 388-502-0010   Payment -- Eligible providers defined.   The department ((reimburses)) pays enrolled providers for covered ((medical)) healthcare services, equipment and supplies they provide to eligible clients.

(1) To be eligible for enrollment, a provider must:

(a) Be licensed, certified, accredited, or registered according to Washington state laws and rules; and

(b) Meet the conditions in this chapter and chapters regulating the specific type of provider, program, and/or service.

(2) To enroll, an eligible provider must sign a core provider agreement ((or a contract)) with the department and receive a unique provider number; a provider may also sign a contract to enroll. (Note: Section 13 of the core provider agreement, DSHS 09-048 (REV. 06/2002), is hereby rescinded. The department and each provider signing a core provider agreement will hold each other harmless from a legal action based on the negligent actions or omissions of either party under the terms of the agreement.)

(3) Eligible providers listed in this subsection may request enrollment. Out-of-state providers listed in this subsection are subject to conditions in ((WAC 388-502-0120)) chapter 388-502 WAC.

(a) Professionals:

(i) Advanced registered nurse practitioners;

(ii) Anesthesiologists;

(iii) Audiologists;

(iv) Chiropractors;

(v) Dentists;

(vi) Dental hygienists;

(vii) Denturists;

(viii) Dietitians or nutritionists;

(ix) Marriage and family therapists, only as provided in WAC 388-531-1400;

(x) Maternity case managers;

(((x))) (xi) Mental health counselors, only as provided in WAC 388-531-1400;

(xii) Midwives;

(((xi))) (xiii) Occupational therapists;

(((xii))) (xiv) Ophthalmologists;

(((xiii))) (xv) Opticians;

(((xiv))) (xvi) Optometrists;

(((xv))) (xvii) Orthodontists;

(((xvi))) (xviii) Osteopathic physicians;

(((xvii))) (xix) Podiatric physicians;

(((xviii))) (xx) Pharmacists;

(((xix))) (xxi) Physicians;

(((xx))) (xxii) Physical therapists;

(((xxi))) (xxiii) Psychiatrists;

(((xxii))) (xxiv) Psychologists;

(((xxiii))) (xxv) Registered nurse delegators;

(((xxiv))) (xxvi) Registered nurse first assistants;

(((xxv))) (xxvii) Respiratory therapists;

(((xxvi))) (xxviii) Social workers, only as provided in WAC 388-531-1400;

(xxix) Speech/language pathologists;

(((xvii))) (xxx) Radiologists; and

(((xviii))) (xxxi) Radiology technicians (technical only);

(b) Agencies, centers and facilities:

(i) Adult day health centers;

(ii) Ambulance services (ground and air);

(iii) Ambulatory surgery centers (Medicare-certified);

(iv) Birthing centers (licensed by the department of health);

(v) Blood banks;

(vi) Chemical dependency treatment facilities certified by the department of social and health services (DSHS), division of alcohol and substance abuse (DASA), and contracted through either:

(A) A county under chapter 388-810 WAC; or

(B) DASA to provide chemical dependency treatment services;

(vii) Centers for the detoxification of acute alcohol or other drug intoxication conditions (certified by DASA);

(viii) Community AIDS services alternative agencies;

(ix) Community mental health centers;

(x) Early and periodic screening, diagnosis, and treatment (EPSDT) clinics;

(xi) Family planning clinics;

(xii) Federally qualified health ((care)) centers (FQHC) (designated by the ((Federal Health Care Financing Administration)) Centers for Medicare and Medicaid);

(xiii) Genetic counseling agencies;

(xiv) Health departments;

(xv) HIV/AIDS case management;

(xvi) Home health agencies;

(xvii) Hospice agencies;

(xviii) Hospitals;

(xix) Indian Health Service;

(xx) Tribal or urban Indian clinics;

(xxi) Inpatient psychiatric facilities;

(xxii) Intermediate care facilities for the mentally retarded (ICF-MR);

(xxiii) Kidney centers;

(xxiv) Laboratories (CLIA certified);

(xxv) Maternity support services agencies;

(xxvi) Neuromuscular and neurodevelopmental centers;

(xxvii) Nursing facilities (approved by DSHS Aging and Adult Services);

(xxviii) Pharmacies;

(xxix) Private duty nursing agencies;

(xxx) Rural health clinics (Medicare-certified);

(xxxi) Tribal mental health services (contracted through the DSHS mental health division); and

(xxxii) Washington state school districts and educational service districts.

(c) Suppliers of:

(i) Durable and nondurable medical equipment and supplies;

(ii) Infusion therapy equipment and supplies;

(iii) Prosthetics/orthotics;

(iv) Hearing aids; and

(v) Oxygen equipment and supplies;

(d) Contractors of:

(i) Transportation brokers;

(ii) Interpreter services agencies; and

(iii) Eyeglass and contact lens providers.

(4) Nothing in this chapter precludes the department from entering into other forms of written agreements to provide services to eligible clients.

(5) The department does not enroll licensed or unlicensed practitioners who are not specifically addressed in subsection (3) of this section((, including,)). Ineligible providers include but are not limited to:

(a) Acupuncturists;

(b) Counselors, except as provided in WAC 388-531-1400;

(c) Sanipractors;

(d) Naturopaths;

(e) Homeopaths;

(f) Herbalists;

(g) Massage therapists;

(h) Social workers, except as provided in WAC 388-531-1400; or

(i) Christian Science practitioners or theological healers.

[Statutory Authority: RCW 74.08.090, 74.09.080, 74.09.120. 03-14-106, 388-502-0010, filed 6/30/03, effective 7/31/03. Statutory Authority: RCW 74.08.090, 74.09.500, and 74.09.530. 01-07-076, 388-502-0010, filed 3/20/01, effective 4/20/01; 00-15-050, 388-502-0010, filed 7/17/00, effective 8/17/00.]


AMENDATORY SECTION(Amending WSR 06-24-036, filed 11/30/06, effective 1/1/07)

WAC 388-531-0100   Scope of coverage for physician-related services -- General and administrative.   (1) The department covers ((medical)) healthcare services, equipment, and supplies listed in this chapter, according to department rules and subject to the limitations and requirements in this chapter, when they are:

(a) Within the scope of an eligible client's medical assistance program. Refer to WAC 388-501-0060 and 388-501-0065; and

(b) Medically necessary as defined in WAC 388-500-0005.

(2) The department evaluates a request for a service that is in a covered category under the provisions of WAC 388-501-0165.

(3) The department evaluates requests for covered services that are subject to limitations or other restrictions and approves such services beyond those limitations or restrictions as described in WAC 388-501-0169.

(4) The department covers the following physician-related services, subject to the conditions in subsections (1), (2), and (3) of this section:

(a) Allergen immunotherapy services;

(b) Anesthesia services;

(c) Dialysis and end stage renal disease services (refer to chapter 388-540 WAC);

(d) Emergency physician services;

(e) ENT (ear, nose, and throat) related services;

(f) Early and periodic screening, diagnosis, and treatment (EPSDT) services (refer to WAC 388-534-0100);

(g) Family planning services (refer to chapter 388-532 WAC);

(h) Hospital inpatient services (refer to chapter 388-550 WAC);

(i) Maternity care, delivery, and newborn care services (refer to chapter 388-533 WAC);

(j) Office visits;

(k) Vision-related services, refer to chapter 388-544 WAC;

(l) Osteopathic treatment services;

(m) Pathology and laboratory services;

(n) Physiatry and other rehabilitation services (refer to chapter 388-550 WAC);

(o) Podiatry services;

(p) Primary care services;

(q) Psychiatric services, provided by a psychiatrist;

(r) Psychotherapy services for children as provided in WAC 388-531-1400;

(s) Pulmonary and respiratory services;

(((s))) (t) Radiology services;

(((t))) (u) Surgical services;

(((u))) (v) Cosmetic, reconstructive, or plastic surgery, and related services and supplies to correct physiological defects from birth, illness, or physical trauma, or for mastectomy reconstruction for post cancer treatment; and

(((v))) (w) Other outpatient physician services.

(5) The department covers physical examinations for medical assistance clients only when the physical examination is one or more of the following:

(a) A screening exam covered by the EPSDT program (see WAC 388-534-0100);

(b) An annual exam for clients of the division of developmental disabilities; or

(c) A screening pap smear, mammogram, or prostate exam.

(6) By providing covered services to a client eligible for a medical assistance program, a provider who has signed an agreement with the department accepts the department's rules and fees as outlined in the agreement, which includes federal and state law and regulations, billing instructions, and department issuances.

[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, 388-531-0100, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, 388-531-0100, filed 12/6/00, effective 1/6/01.]


AMENDATORY SECTION(Amending WSR 05-12-022, filed 5/20/05, effective 6/20/05)

WAC 388-531-0250   Who can provide and bill for physician-related services.   (1) The following enrolled providers are eligible to provide and bill for physician-related medical services which they provide to eligible clients:

(a) Advanced registered nurse practitioners (ARNP);

(b) Federally qualified health centers (FQHCs);

(c) Health departments;

(d) Hospitals currently licensed by the department of health;

(e) Independent (outside) laboratories CLIA certified to perform tests. See WAC 388-531-0800;

(f) Licensed marriage and family therapists, only as provided in WAC 388-531-1400;

(g) Licensed mental health counselors, only as provided in WAC 388-531-1400;

(h) Licensed radiology facilities;

(((g))) (i) Licensed social workers, only as provided in WAC 388-531-1400;

(j) Medicare-certified ambulatory surgery centers;

(((h))) (k) Medicare-certified rural health clinics;

(((i))) (l) Providers who have a signed agreement with ((MAA)) the department to provide screening services to eligible persons in the EPSDT program;

(((j))) (m) Registered nurse first assistants (RNFA); and

(((k))) (n) Persons currently licensed by the state of Washington department of health to practice any of the following:

(i) Dentistry (refer to chapter 388-535 WAC);

(ii) Medicine and osteopathy;

(iii) Nursing;

(iv) Optometry; or

(v) Podiatry.

(2) ((MAA)) The department does not reimburse for services performed by any of the following practitioners:

(a) Acupuncturists;

(b) Christian Science practitioners or theological healers;

(c) Counselors, except as provided in WAC 388-531-1400;

(d) Herbalists;

(e) Homeopaths;

(f) Massage therapists as licensed by the Washington state department of health;

(g) Naturopaths;

(h) Sanipractors;

(i) Social workers, except those who have a master's degree in social work (MSW), ((except those)) and:

(i) Are employed by an FQHC ((or who));

(ii) Who have prior authorization to evaluate a client for bariatric surgery; or

(iii) As provided in WAC 388-531-1400.

(j) Any other licensed or unlicensed practitioners not otherwise specifically provided for in WAC 388-502-0010; or

(k) Any other licensed practitioners providing services which the practitioner is not:

(i) Licensed to provide; and

(ii) Trained to provide.

(3) ((MAA reimburses)) The department pays practitioners listed in subsection (2) of this section for physician-related services if those services are mandated by, and provided to, clients who are eligible for one of the following:

(a) The EPSDT program;

(b) A Medicaid program for qualified Medicare beneficiaries (QMB); or

(c) A waiver program.

[Statutory Authority: RCW 74.08.090, 74.09.520. 05-12-022, 388-531-0250, filed 5/20/05, effective 6/20/05; 01-01-012, 388-531-0250, filed 12/6/00, effective 1/6/01.]


AMENDATORY SECTION(Amending WSR 01-01-012, filed 12/6/00, effective 1/6/01)

WAC 388-531-1400   Psychiatric physician-related services.   (1) ((MAA limits psychotherapy to one hour per day, per client, up to a total of twelve hours per calendar year. This includes family or group psychotherapy. Psychotherapy must be provided by a psychiatrist in the office, in the client's home, or in a nursing facility)) The department covers outpatient mental health services with the following limitations:

(a) For clients eighteen years of age and younger:

(i) The department pays for only one hour per day, per client, up to a total of twenty hours per calendar year, including the psychiatric diagnostic evaluation and family therapy visits that are medically necessary to the client's treatment;

(ii) The department limits medication management services to one per day, but this service may be billed by psychiatrists and psychiatric advanced registered nurse practitioners (ARNP) in conjunction with the diagnostic interview examination, or when a psychiatrist or psychiatric ARNP performs medication management services on the same day as a different licensed mental health practitioner renders another billable mental health service; and

(iii) The mental health services must be provided in an outpatient setting by a psychiatrist, psychologist, psychiatric ARNP, social worker, marriage and family therapist, or mental health counselor who must:

(A) Be licensed, in good standing and without restriction, by the department of health under their appropriate licensure; and

(B) Have a minimum of two years experience in the diagnosis and treatment of clients eighteen years of age and younger and their families, including a minimum one year under the supervision of a mental health professional trained in child and family mental health. A licensed psychiatrist may provide these services and bill the department without meeting this requirement.

(b) For clients nineteen years of age and older:

(i) The department pays for only one hour per day, per client, up to a total of twelve hours per calendar year, including family or group therapy visits;

(ii) The department limits medication management services to one per day, but this service may be billed by psychiatrists and psychiatric ARNPs in conjunction with the diagnostic interview examination, or when a psychiatrist or psychiatric ARNP performs medication management services on the same day as a different licensed mental health practitioner renders another billable mental health service; and

(iii) The mental health services must be provided by a psychiatrist in an outpatient setting.

(2) ((MAA reimburses only one hospital call for direct psychiatric client care, per client, per day. Psychiatrists must bill the total time spent on direct psychiatric client care during each visit. Making rounds is considered direct client care and includes any one of the following)) The department covers inpatient mental health services with the following limitations:

(a) ((Brief (up to one hour), individual psychotherapy)) Must be provided by a psychiatrist;

(b) ((Family/group therapy)) Only the total time spent on direct psychiatric client care during each visit; and

(c) ((Electroconvulsive therapy; or

(d) Pharmacologic management)) One hospital call per day for direct psychiatric client care, including making rounds. Making rounds is considered direct client care and includes any one of the following:

(i) Individual psychotherapy up to one hour;

(ii) Family/group therapy; or

(iii) Electroconvulsive therapy.

(3) ((MAA reimburses psychiatrists for either hospital care or psychotherapy, but not for both on the same day)) With the exception of medication management, the department covers, with limitations, mental health services of one service per client, per day regardless of location or provider type.

(4) ((MAA reimburses)) The department pays psychiatrists ((for)) when the client receives a medical physical examination in the hospital in addition to a psychiatric diagnostic or evaluation interview examination.

(5) ((MAA reimburses only one)) The department covers psychiatric diagnostic interview ((examination in a)) evaluations at the limit of one per provider, per calendar year unless a significant change in the client's circumstances renders an additional evaluation medically necessary and is authorized by the department.

(6) ((MAA requires psychiatrists to use hospital E&M codes when billing for daily rounds.

(7) MAA)) The department does not cover ((for)) psychiatric sleep therapy.

(((8) Medication adjustment is the only psychiatric service for which MAA reimburses psychiatric ARNPs)) (7) The department covers electroconvulsive therapy and narcosynthesis only when performed by a psychiatrist.

(((9) MAA reimburses for one)) (8) The department pays psychiatric ARNPs only for mental health medication management and diagnostic interview evaluations provided to clients nineteen years of age and older.

(9) The department covers interactive ((or insight oriented call)), face-to-face visits at the limit of one per client, per day, in an ((office or)) outpatient setting. ((Individual psychotherapy, interactive services)) Interactive, face-to-face visits may be billed only for clients age twenty and younger.

(10) The client or licensed healthcare provider may request a limitation extension only when the client exceeds the total hour limit described in subsection (1) of this section, and for no other limitation of service in this section. The department will evaluate these requests in accordance with WAC 388-501-0169.

(11) DSHS providers must comply with chapter((s 275-55 and 275-57)) 388-865 WAC for hospital inpatient psychiatric admissions, and must follow rules adopted by the ((division of)) mental health division or the appropriate regional support network (RSN). ((MAA does not reimburse for those psychiatric services that are eligible for reimbursement under those agencies.))

(12) Accepting payment under more than one contract or agreement with the department for the same service for the same client constitutes duplication of payment. If a client is provided services under multiple contracts or agreements, each provider must maintain documentation identifying the type of service provided and the contract or agreement under which it is provided to ensure it is not a duplication of service.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, 388-531-1400, filed 12/6/00, effective 1/6/01.]

Washington State Code Reviser's Office