SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
Effective Date of Rule: February 24, 2010.
Purpose: Under sections 201 and 209 of the operating budget for fiscal years 2010 and 2011, funding for maternity support services (First Steps program) is reduced by twenty percent from current levels. The department is amending language in sections in chapter 388-533 WAC, in order to meet these targeted budget expenditure levels. The changes include redefining the eligibility criteria for maternity support services and reducing the number of pregnant women and their infants who qualify for enhanced maternity support services. The maximum number of units eligible clients may receive has been reduced.
Citation of Existing Rules Affected by this Order: Amending WAC 388-533-0315, 388-533-0320, and 388-533-0345.
Statutory Authority for Adoption: RCW 74.08.090 and 74.09.760 through 74.09.910.
Other Authority: 2009-11 omnibus operating budget (ESHB 1244).
Under RCW 34.05.350 the agency for good cause finds that in order to implement the requirements or reductions in appropriations enacted in any budget for fiscal years 2009, 2010, or 2011, which necessitates the need for the immediate adoption, amendment, or repeal of a rule, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the fiscal needs or requirements of the agency.
Reasons for this Finding: This emergency filing is necessary to continue the current emergency rule for sections in chapter 388-533 WAC with respect to maternity support services, filed as WSR 09-22-033 on October 27, 2009, while the department, in collaboration with the department of health, continues to research comments received from stakeholders on this rule during the regular rule-making process. Following this, the department plans to formally propose the permanent rule in early 2010.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 3, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.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 3, Repealed 0.
Date Adopted: February 18, 2010.
Don Goldsby, Manager
Rules and Policies Assistance Unit4109.4
"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)) preventive health
education messages designed to promote healthy pregnancies,
healthy newborns and healthy parenting during the first year
"Care coordination"--Professional collaboration and communication between the client's MSS provider and other medical and/or health and social services providers to address the individual client's needs as identified in the care plan.
"Care plan"--A written plan that must be developed and maintained throughout the eligibility period for each client in MSS and ICM.
"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)) that prepares a pregnant
woman and her support person(s) for an upcoming childbirth.
"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 state agency ((
mission is)) that works 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 state.
"First Steps" -- The program created under 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
"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)) Established as a component of the First Steps
program to provide parent(s) with information and assistance
in accessing needed medical, social, educational, and other
services to improve the welfare of infants.
"Infant case management (ICM) screening"--A brief in-person evaluation provided by a qualified person to determine whether an infant and the infant's parent(s) have a specific risk factor(s).
"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
"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))
"Linking"--Assisting clients to identify and use community resources to address specific medical, social and educational needs.
"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)" -- ((
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)) Established as a component of the
First Steps program to provide screening, assessment, basic
health messages, education, counseling, case management, care
coordination, and other interventions delivered by an MSS
interdisciplinary team during the maternity cycle.
"Maternity support services (MCC) interdisciplinary team"--A group of providers consisting of at least a community health nurse, a certified registered dietitian, a behavioral health specialist, and, at the discretion of the First Steps agency, a community health worker, who work together and communicate frequently to share specialized knowledge, skills, and experience in order to address risk factors identified in a client's care plan. Based upon individual client need, each team member must be available to provide maternity support services and consultation.
"Medical assistance administration (MAA)" -- The
administration within DSHS authorized to administer medical
"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.))
"Parent(s)"--A person who resides with an infant and provides the infant's day-to-day care, and is:
• The infant's natural or adoptive parent(s);
• A person other than a foster parent who has been granted legal custody of the infant; or
• A person who is legally obligated to support the infant.
"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)) poor birth
outcomes, infant morbidity, and/or infant mortality. (( 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.))
[Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, § 388-533-0315, filed 6/10/04, effective 7/11/04.]
(a) Be covered under one of the following medical
(i) Categorically needy program (CNP);
Categorically needy program)) CNP -- Children's
health insurance program; (( (CNP-Children's health insurance
Categorically needy program -- Emergency medical
only (CNP-Emergency medical only); and)) Medically needy
program (MNP); or
(iv) A pregnancy medical program as described in WAC 388-562-0015.
Pregnant or still within the maternity cycle)) Be
within the eligibility period of a maternity cycle as defined
in WAC 388-533-0315; and
(c) Meet any other eligibility criteria as determined by the department and published in the department'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. 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 and published in the department's current billing instructions and/or numbered memoranda. The department 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 ((
WAC 388-533-0320(1))) this section who are enrolled in (( an MAA))
a department-contracted 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.))
(4) See WAC 388-534-0100 for clients eligible for coverage under the early periodic screening, diagnosis and treatment (EPSDT) program.
(5) Clients receiving MSS before July 1, 2009, are subject to the transition plan as determined and published by the department in numbered memoranda.
(6) Clients who do not agree with a department decision regarding eligibility for MSS have a right to a fair hearing under chapter 388-02 WAC.
[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.]
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;))
MSS must be:
(a) Provided to a client who meets the eligibility requirements in WAC 388-533-0320;
(b) Provided to a client on an individual basis in a face-to-face encounter;
(c) Provided by an agency (or entity) that meets the criteria established in WAC 388-533-0325;
(d) Provided according to the department's current published maternity support services/infant case management (MSS/ICM) billing instructions and/or numbered memoranda;
(e) Documented in the client's record or chart; and
(f) Billed using:
(i) The eligible client's department-assigned client identification number;
(ii) The appropriate procedure codes and modifiers identified in the department's current published MSS/ICM billing instructions; and
(iii) The agency's department-assigned MSS/ICM provider number.
MAA reimburses)) The department:
(a) Pays for MSS ((
services)) in units of time with one
unit being equal to fifteen minutes of one-to-one service
(b) When directed by the legislature to achieve targeted expenditure levels for payment of maternity support services for any specific biennium, may determine the maximum number of units allowed per client; and
(c) Publishes the maximum number of units allowed per client in the MSS/ICM billing instructions and/or numbered memoranda.
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)) For a client enrolled in a managed care plan who is eligible to receive MSS, the department pays for MSS:
(a) Delivered outside the plan on a fee-for-service basis as described in this section; and
(b) Subject to the same program rules that apply to a client who is not enrolled in a managed care plan.
(4) Limitation extension requests to exceed the number of allowed MSS units of service may be authorized according to WAC 388-501-0169.
[Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, § 388-533-0345, filed 6/10/04, effective 7/11/04.]