WSR 11-22-012

EMERGENCY RULES

HEALTH CARE AUTHORITY


(Medicaid Program)

[ Filed October 21, 2011, 12:35 p.m. , effective October 26, 2011 ]


Effective Date of Rule: October 26, 2011.

Purpose: The legislature passed ESHB 1086, which reduces funding for maternity support services and mandates the health care authority to prioritize evidence-based practices for delivery of maternity support services and to target funding for maternity support services by leveraging local public funding for those services. In addition, upon order of the governor, the medicaid purchasing administration must reduce its budget expenditures for the current fiscal year ending June 30, 2011, by 6.3 percent.

Citation of Existing Rules Affected by this Order: Amending WAC 182-533-0300, 182-533-0320, 182-533-0325, 182-533-0370, and 182-533-0380.

Statutory Authority for Adoption: RCW 41.05.021.

Other Authority: Chapter 5, Laws of 2011, ESHB 1086 and HB 1248 which extends the allowance of emergency rule filing through fiscal year 2013.

Under RCW 34.05.350 the agency for good cause finds that state or federal law or federal rule or a federal deadline for state receipt of federal funds requires immediate adoption of a rule; and that in order to implement the requirements or reductions in appropriations enacted in any budget for fiscal year 2009, 2010, 2011, 2012 or 2013, 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: See Purpose statement above. This emergency rule is necessary to continue the emergency rule that is currently in effect under WSR 11-14-027 while the permanent rule-making process initiated under WSR 10-20-165 is completed. The agency anticipates filing the CR-102 for the proposed permanent rule sometime in November 2011.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 5, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.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 5, Repealed 0.

Date Adopted: October 21, 2011.

Kevin M. Sullivan

Rules Coordinator

OTS-4402.1


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-533-0300   Services under First Steps.   (1) Under the 1989 Maternity Care Access Act, and RCW 74.09.760 through 74.09.910, the ((department)) agency established First Steps to provide access to services for eligible women and their infants.

(2) The rules for the:

(a) Maternity support services (MSS) component of First Steps are found in WAC ((388-533-0310)) 182-533-0310 through ((388-533-0345)) 182-533-0345.

(b) Infant case management (ICM) component of First Steps are found in WAC ((388-533-0360)) 182-533-0360 through ((388-533-0386)) 182-533-0386.

(c) Childbirth education (CBE) component of First Steps are found in WAC ((388-533-0390)) 182-533-0390.

(3) 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)) 182-533-0701).

[11-14-075, recodified as 182-533-0300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 1109. 10-12-011, 388-533-0300, filed 5/21/10, effective 6/21/10. 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 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-533-0320   Maternity support services -- Client eligibility.   (1) To receive maternity support services (MSS), a client must:

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

(i) Categorically needy ((program (CNP))) (CN);

(ii) ((CNP -- Children's health insurance program)) Children's health care as described in WAC 388-505-0210;

(iii) Medically needy program (MNP); or

(iv) A pregnancy medical program as described in WAC 388-462-0015.

(b) Be within the eligibility period of a maternity cycle as defined in WAC ((388-533-0315)) 182-533-0315; and

(c) Meet any other eligibility criteria as determined by the ((department)) agency and published in the ((department's)) agency'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)) 182-533-0325. 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)) agency and published in the ((department's)) agency's current billing instructions and/or numbered memoranda. The ((department)) agency 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 this section who are enrolled in ((a department-contracted)) an agency-contracted managed care ((plan)) organization (MCO), are eligible for MSS outside their plan.

(4) See chapter ((388-534)) 182-534 WAC for clients eligible for coverage under the early periodic screening, diagnosis and treatment (EPSDT) program.

(5) Clients receiving MSS before ((July 1, 2009)) March 1, 2011, are subject to the transition plan as determined and published by the ((department)) agency in numbered memoranda.

(6) Clients who do not agree with ((a department)) an agency decision regarding eligibility for MSS have a right to a fair hearing under chapter 388-02 WAC.

[11-14-075, recodified as 182-533-0320, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 1109. 10-12-011, 388-533-0320, filed 5/21/10, effective 6/21/10. 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 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-533-0325   Maternity support services -- Provider requirements.   (1) 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))) medicaid agency;

(b) Be enrolled as an eligible provider with the ((department of social and health services' (department's) health and recovery services administration (HRSA))) medicaid agency (see WAC ((388-502-0010)) 182-502-0010);

(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)) 182-502 WAC and the ((department's)) medicaid agency'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)) medicaid agency 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.

[11-14-075, recodified as 182-533-0325, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 1109. 10-12-011, 388-533-0325, filed 5/21/10, effective 6/21/10. 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 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-533-0370   Infant case management -- Eligibility.   (1) To receive infant case management (ICM), an infant must:

(a) Be covered under one of the medical assistance programs listed in WAC ((388-533-0320)) 182-533-0320(1);

(b) Meet the age requirement for ICM which is the day after the maternity cycle (defined in WAC ((388-533-0315)) 182-533-0315) ends, through the last day of the month of the infant's first birthday;

(c) Reside with at least one parent (see WAC ((388-533-0315)) 182-533-0315 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)) 182-533-0375. 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)) agency and published in the ((department's)) agency's current billing instructions and/or numbered memoranda. The ((department)) agency may determine the maximum number of units allowed per client when directed by the legislature to achieve targeted expenditure levels for payment in any specific biennium.

(3) Clients meeting the eligibility criteria in subsection (1) of this section who are enrolled in ((a department-contracted)) an agency-contracted managed care ((plan)) organization (MCO) are eligible for ICM services outside their plan.

(4) See chapter ((388-534)) 182-534 WAC for clients eligible for coverage under the early periodic screening, diagnosis and treatment (EPSDT) program.

(5) Clients receiving ICM before ((July 1, 2009)) March 1, 2011, are subject to the transition plan as determined and published by the ((department)) agency in numbered memoranda.

(6) Clients who do not agree with ((a department)) an agency decision regarding eligibility for ICM have a right to a fair hearing under chapter 388-02 WAC.

[11-14-075, recodified as 182-533-0370, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 1109. 10-12-010, 388-533-0370, filed 5/21/10, effective 6/21/10. 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.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-533-0380   Infant case management -- Covered services.   (1) The ((department)) agency covers infant case management (ICM) services subject to the restrictions and limitations in this section and other applicable WAC.

(2) Covered services include:

(a) An initial in-person screening for ICM services which includes an assessment of risk factors, and the development of an individualized care plan;

(b) Case management services and care coordination;

(c) Linking and referring the infant and parent(s) to other services or resources;

(d) Advocating for the infant and parent(s);

(e) Follow-up contact(s) with the parent(s) to ensure the care plan continues to meet the needs of the infant and parent(s); and

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

(3) The ((department)) agency pays for covered ICM services according to WAC ((388-533-0386)) 182-533-0386.

[11-14-075, recodified as 182-533-0380, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910, and 2009 c 564 1109. 10-12-010, 388-533-0380, filed 5/21/10, effective 6/21/10. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.910. 04-13-049, 388-533-0380, filed 6/10/04, effective 7/11/04.]

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