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 infant case management services and reducing the number of infants who qualify for enhanced infant case management services under 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 388-533-0365, 388-533-0370, and 388-533-0386.
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 rules filed as WSR 09-22-034 on October 27, 2009, while the department, in collaboration with the department of health, continues to research comments received form [from] stakeholders on this rule during the permanent rule-making process. Following this, the department plans to formally adopt 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Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 3, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 3, Repealed 0.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 16, 2010.
Don Goldsby, Manager
Rules and Policies Assistance Unit4110.4
"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.
"Parent(s)"--means a person who resides with an infant and provides the infant's day-to-day care, and is:
(1) The infant's natural or adoptive parent(s);
(2) A person other than a foster parent who has been granted legal custody of the infant; or
(3) A person who is legally obligated to support the infant.
[Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, § 388-533-0365, filed 6/10/04, effective 7/11/04.]
The infant must)) Be covered under one of the
medical assistance programs listed in WAC 388-533-0320
(1)(( (a) of this chapter));
The parent(s) must need assistance in accessing or
providing care for the infant)) Meet the age requirement for
ICM which is the day after the maternity cycle (defined in WAC 388-533-0315) ends, through the last day of the month of the
infant's first birthday; (( and))
At least one or more of the following criteria
(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)) Reside with at least one parent (see WAC 388-533-0365 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. 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 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 388-533-0370(1))) subsection (1) of this section who are
enrolled in (( an MAA)) a department-contracted 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.))
(4) See chapter 388-534 WAC for clients eligible for coverage under the early periodic screening, diagnosis and treatment (EPSDT) program.
(5) Clients receiving ICM before July 1, 2009, 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 ICM 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, § 388-533-0370, filed 6/10/04, effective 7/11/04.]
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)) The ICM services must be:
(a) Provided to a client who meets the eligibility requirements in WAC 388-533-0370;
(b) Provided by a person who meets the criteria established in WAC 388-533-0375;
(c) Provided according to the department's current maternity support services/infant case management (MSS/ICM) published billing instructions and/or numbered memoranda;
(d) Documented in the infant's and/or infant's parent(s) record or chart; and
(e) Billed using:
(i) The eligible infant's department-assigned client identification number;
(ii) The appropriate procedure codes and modifiers identified in the department's current MSS/ICM published billing instructions and/or numbered memoranda; and
(iii) The department-assigned MSS/ICM provider number.
(2) The department:
(a) Pays ICM services in units of time with one unit being equal to fifteen minutes of one-to-one service delivered face-to-face;
(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.
(3) For a client enrolled in a managed care plan who is eligible to receive ICM, the department pays ICM services:
(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 ICM 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, § 388-533-0386, filed 6/10/04, effective 7/11/04.]