WSR 10-12-011

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed May 21, 2010, 8:35 a.m. , effective June 21, 2010 ]


Effective Date of Rule: Thirty-one days after filing.

Purpose: Revisions to this rule are necessary to: (1) Fully meet the legislatively mandated appropriation reduction in section 1109, chapter 564, Laws of 2009 (ESHB 1244) for maternity support services (First Steps program) for fiscal years 2010-2011; (2) further clarify the department's coverage policy; specifically, the rules amend sections in chapter 388-533 WAC in order to redefine the eligibility criteria for maternity support services and reduce the maximum amount of services pregnant women and their infants may receive; and (3) update and clarify other maternity support services policy.

Citation of Existing Rules Affected by this Order: Amending WAC 388-533-0300, 388-533-0310, 388-533-0315, 388-533-0320, 388-533-0325, 388-533-0330, 388-533-0340, and 388-533-0345.

Statutory Authority for Adoption: RCW 74.08.090 and 74.09.760 through 74.09.910.

Other Authority: Section 1109, chapter 564, Laws of 2009 (ESHB 1244).

Adopted under notice filed as WSR 10-08-084 on April 6, 2010.

A final cost-benefit analysis is available by contacting June Hershey, DSHS/HRSA, P.O. Box 45530, Olympia, WA 98504-5530, phone (360) 725-1293, fax (360) 664-4371, e-mail june.hershey@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Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 8, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 8, Repealed 0.

Date Adopted: May 21, 2010.

Susan N. Dreyfus

Secretary

4109.9
AMENDATORY SECTION(Amending WSR 04-13-049, filed 6/10/04, effective 7/11/04)

WAC 388-533-0300   ((Enhanced benefits for pregnant women)) Services under First Steps.   ((Pursuant to)) (1) Under the 1989 Maternity Care Access Act, ((also known as First Steps, the medical assistance administration (MAA) provides enhanced)) and RCW 74.09.760 through 74.09.910, the department established First Steps to provide access to services ((to)) for eligible women ((during and after their pregnancy. The enhanced services include:

(1))) and their infants.

(2) The rules for the:

(a) Maternity support services (((see)) (MSS) component of First Steps are found in WAC 388-533-0310 through 388-533-0345((;)).

(((2))) (b) Infant case management ((services (see)) (ICM) component of First Steps are found in WAC 388-533-0360 through 388-533-0386(();)).

(c) Childbirth education (CBE) component of First Steps are found in WAC 388-533-0390.

(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))) Other services under First Steps include:

(a) Medical services, including full medical coverage, prenatal care, delivery, post-pregnancy follow-up, dental, vision, and twelve months family planning services post-pregnancy;

(b) Ancillary services, including but not limited to, expedited medical eligibility determination, case finding and outreach; and

(c) Alcohol and drug assessment and treatment services for pregnant women available statewide and administered by the division of behavioral health and recovery (see WAC 388-533-0701).

[Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, 388-533-0300, filed 6/10/04, effective 7/11/04. 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.]


AMENDATORY SECTION(Amending WSR 04-13-049, filed 6/10/04, effective 7/11/04)

WAC 388-533-0310   Maternity support services -- Purpose.   The ((integrated)) purpose of maternity support services (MSS) ((program provides enhanced preventive health and education services to eligible pregnant women and their families during the maternity cycle. The purpose of the enhanced services is to improve birth outcomes and respond to clients' individual risks and needs. MSS is collaboratively managed by the department of health and the medical assistance administration. This MSS program combines the previous MSS and maternity case management programs)) is to:

(1) Improve and promote healthy birth outcomes. Services are delivered by an MSS interdisciplinary team to eligible pregnant and post-pregnant women and their infants.

(2) Help eligible clients to access:

(a) Prenatal care as early in the pregnancy as possible; and

(b) Healthcare for their infants.

[Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, 388-533-0310, filed 6/10/04, effective 7/11/04.]


AMENDATORY SECTION(Amending WSR 04-13-049, filed 6/10/04, effective 7/11/04)

WAC 388-533-0315   Maternity support services -- Definitions.   The following definitions and those found in WAC 388-500-0005 apply to ((the)) maternity support services (MSS) ((program)) and infant case management (ICM) (see WAC 388-533-0360 through 388-533-0386 for ICM rules).

(("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 of life.

"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)) Established as a component of the First Steps program to provide 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 and healthy parenting.

(("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 state agency ((whose mission is)) that works to protect and improve the health of people in Washington state.

"Department of social and health services (((DSHS))) (department)" -- 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 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)) 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 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))

"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 post-pregnancy 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)) 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 (MSS) 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 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.))

"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.]


AMENDATORY SECTION(Amending WSR 04-13-049, filed 6/10/04, effective 7/11/04)

WAC 388-533-0320   Maternity support services -- Client eligibility.   (1) To ((be eligible for)) receive maternity support services (MSS), a client must ((be)):

(a) Be covered under one of the following medical assistance ((administration)) programs:

(i) Categorically needy program (CNP);

(ii) ((Categorically needy program)) CNP -- Children's health insurance program; (((CNP-Children's health insurance program); or))

(iii) ((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 388-462-0015.

(b) ((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 chapter 388-534 WAC 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.]


AMENDATORY SECTION(Amending WSR 04-13-049, filed 6/10/04, effective 7/11/04)

WAC 388-533-0325   Maternity support services -- Provider requirements.   (1) ((Services under this program are provided only by approved maternity support services (MSS)/infant case management (ICM) providers. Representatives from the medical assistance administration (MAA) and the department of health (DOH) recruit and approve providers using the following criteria:

(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)) To be paid for providing maternity support services (MSS) and infant case management (ICM) services to eligible clients, an agency or entity must:

(a) Be currently approved as an MSS/ICM provider by the department of health (DOH);

(b) Be enrolled as an eligible provider with the department of social and health services' (department's) health and recovery services administration (HRSA)(see WAC 388-502-0010);

(c) Ensure that staff providing services meet the minimum regulatory and educational qualifications for the scope of services provided; and

(d) Meet the requirements in this chapter, chapter 388-502 WAC and the department's current published billing instructions and numbered memoranda.

(2) An individual or service organization that has a written agreement with an agency or entity that meets the requirements in subsection (1) of this section may also provide MSS and ICM services to eligible clients.

(a) The department requires the agency or entity to:

(i) Keep a copy of the written agreement on file;

(ii) Ensure that an individual or service organization staff member providing MSS/ICM services meets the minimum regulatory and educational qualifications required of an MSS/ICM provider;

(iii) Assure that the individual or service organization provides MSS/ICM services under the requirements of this chapter; and

(iv) Maintain professional, financial, and administrative responsibility for the individual or service organization.

(b) The agency or entity is responsible to:

(i) Bill for services using the agency's or entity's assigned provider number; and

(ii) Reimburse the individual or service organization for MSS/ICM services provided under the written agreement.

[Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, 388-533-0325, filed 6/10/04, effective 7/11/04.]


AMENDATORY SECTION(Amending WSR 04-13-049, filed 6/10/04, effective 7/11/04)

WAC 388-533-0330   Maternity support services -- Covered services.   (1) The ((medical assistance administration (MAA))) department covers maternity support services ((under the maternity support services)) (MSS) ((program)) provided by an MSS interdisciplinary team, subject to the restrictions and limitations in this section and other applicable ((published)) WAC.

(2) Covered services include:

(a) ((Community health nursing visits)) In-person screening(s) for risk factors related to pregnancy and birth outcomes;

(b) ((Nutrition visits;

(c) Behavioral health visits)) Brief assessment when indicated; ((and

(d) Community health worker visits under the direction of a professional member of the team)) (c) Education that relates to improving pregnancy and parenting outcomes;

(d) Interventions for risk factors identified on the care plan;

(e) Basic health messages;

(f) Case management services;

(g) Care coordination;

(h) Family planning screening and referral;

(i) Screening and referral for tobacco usage and/or exposure;

(j) Infant case management (ICM) screening; and

(k) Additional services as determined and published in the maternity support services/infant case management (MSS/ICM) billing instructions.

(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)) The department pays for covered maternity support services according to WAC 388-533-0345.

[Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, 388-533-0330, filed 6/10/04, effective 7/11/04.]


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

WAC 388-533-0340   Maternity support services -- Noncovered services.   (1) ((The following are considered noncovered services under the MSS program. Any service:

(a) Not within the scope of the program;

(b) Not)) The department covers only those services that are listed in WAC 388-533-0330((; or

(c) Any service provided by staff not qualified to deliver the service)).

(2) The department evaluates ((requests for services listed as noncovered under the provisions of WAC 388-501-0160)) a request for any noncovered service under the provisions of WAC 388-501-0160. When early periodic screening, diagnosis and treatment (EPSDT) applies, the department evaluates a request for a noncovered service according to the process in WAC 388-501-0165 to determine if it is medically necessary, safe, effective, and not experimental (see chapter 388-534 WAC for EPSDT rules).

[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, 388-533-0340, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, 388-533-0340, filed 6/10/04, effective 7/11/04.]


AMENDATORY SECTION(Amending WSR 04-13-049, filed 6/10/04, effective 7/11/04)

WAC 388-533-0345   Maternity support services -- ((Reimbursement)) Payment.   ((Services provided under)) The department pays for the covered maternity support services (MSS) ((program are reimbursed)) described in WAC 388-533-0330 on a fee-for-service basis subject to the following ((limitations)):

(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;)) 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/or numbered memoranda; and

(iii) The agency's department-assigned MSS/ICM provider number. The department pays the agency or entity for providing MSS to eligible clients, not the individual or service organization that has a written agreement with the agency to provide MSS.

(2) ((MAA reimburses)) The department:

(a) Pays MSS ((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) ((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.]

Washington State Code Reviser's Office