WSR 13-18-033

PROPOSED RULES

HEALTH CARE AUTHORITY

(Medicaid Program)

[Filed August 28, 2013, 10:34 a.m.]

Original Notice.

Preproposal statement of inquiry was filed as WSR 13-12-028.

Title of Rule and Other Identifying Information: WAC 182-537-0200 School-based health care services for children in special education—Definitions, 182-537-0350 School-based health care services for children in special education—Provider qualifications, and 182-537-0600 School-based health care services for children in special education—School district requirements for billing and payment.

Hearing Location(s): Health Care Authority (HCA), Cherry Street Plaza Building, Sue Crystal Conference Room 106A, 626 8th Avenue, Olympia, WA 98504 (metered public parking is available street side around building. A map is available at http://maa.dshs.wa.gov/pdf/CherryStreetDirectionsNMap.pdf or directions can be obtained by calling (360) 725-1000), on October 8, 2013, at 10:00 a.m.

Date of Intended Adoption: Not sooner than October 9, 2013.

Submit Written Comments to: HCA Rules Coordinator, P.O. Box 45504, Olympia, WA 98504-5504, delivery 626 8th Avenue, Olympia, WA 98504, e-mail arc@hca.wa.gov, fax (360) 586-9727, by 5:00 p.m. on October 8, 2013.

Assistance for Persons with Disabilities: Contact Kelly Richters by September 30, 2013, TTY (800) 848-5429 or (360) 725-1307 or e-mail kelly.richters@hca.wa.gov.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: Effective March 18, 2013, the United States Department of Education revised 34 C.F.R. 300.154(d) related to parental consent for school districts to access public benefits or insurances. Parental consent is no longer required annually to pay for medicaid health care-related services under the Individual Disability Education Act (IDEA) Part B. For this reason, medicaid agency will no longer require annual prior, informal, written notification for parents or guardians by school districts to submit claims for third-party insurance or medicaid reimbursement. In addition, two changes were made in the definition section; and clarification was added that school districts' qualified health care providers must be enrolled with the medicaid agency, and that the supervising therapist must see the child face-to-face at the beginning of services and at least once more during the school year.

Reasons Supporting Proposal: To comply with 34 C.F.R. 300.154(d) and chapter 182-502 WAC concerning provider enrollment.

Statutory Authority for Adoption: RCW 41.05.021.

Statute Being Implemented: RCW 74.09.500.

Rule is necessary because of federal law, 34 C.F.R. 300.154(d).

Name of Proponent: HCA, governmental.

Name of Agency Personnel Responsible for Drafting: Katey Simetra, P.O. Box 42716, Olympia, WA 98504-2716, (360) 725-1842; Implementation and Enforcement: James Harvey, P.O. Box 45530, Olympia, WA 98504-5530, (360) 725-1153.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The agency has analyzed the proposed rules and has concluded that they do not impose costs for small businesses and the joint administrative rules review committee has not requested the preparation of a small business economic impact statement.

A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to HCA rules unless requested by the joint administrative rules review committee or applied voluntarily.

August 28, 2013

Kevin M. Sullivan

Rules Coordinator

AMENDATORY SECTION (Amending WSR 13-05-017, filed 2/7/13, effective 3/10/13)

WAC 182-537-0200 School-based health care services for children in special education—Definitions.

The following definitions and those found in chapter 182-500 WAC apply to this chapter:

"Agency" - See WAC 182-500-0010.

"Amount, duration, and scope" - A written statement within the individualized education program (IEP) that addresses sufficiency of services to achieve a particular goal (a treatment plan for how much of a health care related service will be provided, how long a service will be provided, and what the service is).

"Assessment" - For purposes of this chapter an assessment is made-up of medically necessary tests given to an individual child by a licensed professional to evaluate whether a child is determined to be a child with a disability, and in need of special education and related services. Assessments are a part of the evaluation and re-evaluation processes and must accompany the IEP.

"Child with a disability" - For purposes of this chapter, a child with a disability is a child evaluated and determined to need special education and related services because of a disability in one or more of the following eligibility categories:

• Autism;

• Deaf/blindness;

• Developmental delay for children ages three through nine, with an adverse educational impact, the results of which require special education and related direct services;

• Hearing loss (including deafness);

• Mental retardation;

• Multiple disabilities;

• Orthopedic impairment;

• Other health impairment;

• Serious emotional disturbance (emotional behavioral disturbance);

• Specific learning disability;

• Speech or language impairment;

• Traumatic brain injury; and

• Visual impairment (including blindness).

"Core provider agreement" - The basic contract the agency holds with providers serving medical assistance clients.

"Direct health care related services" - Services provided directly to a child either one-on-one or in a group setting. This does not include special education.

"Evaluation" - Procedures used to determine whether a child has a disability, and the nature and extent of the special education and related services are needed. (See WAC 392-172A-03005 through 392-172A-03080.)

"Face-to-face supervision" or "direct supervision" - Supervision that is conducted on-site, in-view, by an experienced licensed health care professional to assist the supervisee to develop the knowledge and skills to practice effectively, including administering the treatment plan.

"Fee-for-service" - See WAC 182-500-0035.

"Health care related services" - Developmental, corrective, and other supportive services required to assist an eligible child to benefit from special education. For the purposes of the school-based health care services program, related services include:

• Audiology;

• Counseling;

• Nursing;

• Occupational therapy;

• Physical therapy;

• Psychological assessments; and

• Speech-language therapy.

"Individualized education program (IEP)" - A written statement of an educational program for a child eligible for special education. (See WAC 392-172A-03090 through 392-172A-03135.)

"Medically necessary" - See WAC 182-500-0070.

"National provider identifier (NPI)" - See WAC 182-500-0075.

"Plan of care" or "treatment plan" - A written document that outlines the health care related needs of a child in special education. The plan is based on input from the health care professional and written approval from the parent or guardian.

"Provider" - See WAC 182-500-0085.

"Qualified health care provider" - See WAC 182-537-0350.

"Reevaluation" - Procedures used to determine whether a child continues to be in need of special education and related services. (See WAC 392-172A-03015.)

"Regular consultation" - Face-to-face contact between the supervisor and supervisee that occurs no less than once per month.

"Revised Code of Washington (RCW)" - Washington state law.

"School-based health care services program" or "SBS" - School-based health care services for children in special education that are diagnostic, evaluative, habilitative, rehabilitative in nature((, and must be based on medical necessity)); are based on the child's medical needs; and are included in the child's individualized education plan (IEP). The agency pays school districts for school-based health care services delivered to ((medicaid-enrolled)) medicaid-eligible children in special education ((in accordance with)) under Section ((1905)) 1903(c) of the Social Security Act, and to individuals under the Disabilities Education Act (IDEA) Part B.

"School-based health care services program specialist" or "SBHS specialist" - An individual identified in the interagency agreement school district reimbursement contract.

"Special education" - Specially designed instruction, at no cost to the parents, to meet the unique needs of a student eligible for special education, including instruction conducted in the classroom, in the home, in hospitals and institutions, and in other settings, and instruction in physical education. Refer to WAC 392-172A-01175.

"Washington Administrative Code (WAC)" - Codified rules of the state of Washington.

AMENDATORY SECTION (Amending WSR 13-05-017, filed 2/7/13, effective 3/10/13)

WAC 182-537-0350 School-based health care services for children in special education—Provider qualifications.

The medicaid agency pays school districts to provide certain health care-related services (see WAC 182-537-0400). These services must be delivered by qualified health care providers who are enrolled with the medicaid agency and hold a current professional license:

(1) Audiology services must be delivered by a licensed audiologist.

(2) Counseling services must be delivered by:

(a) A licensed independent social worker (LiCSW);

(b) A licensed advanced social worker (LiACSW);

(d) A licensed mental health counselor associate (LMHCA) under the supervision of a department of health-approved licensed supervisor.

(3) Nursing services must be delivered by:

(a) A licensed registered nurse (RN);

(b) A licensed practical nurse (LPN) who is supervised by an RN; or

(c) A noncredentialed school employee who is delegated certain limited health care tasks by an RN and is supervised according to professional practice standards (see RCW 18.79.260).

(4) Occupational therapy services must be delivered by:

(a) A licensed occupational therapist (OT); or

(b) A licensed occupational therapist assistant (OTA) who is supervised by a licensed occupational therapist.

(5) Physical therapy services must be delivered by:

(a) A licensed physical therapist (PT); or

(b) A licensed physical therapist assistant (PTA) who is supervised by a licensed physical therapist.

(6) Psychological services must be delivered by a licensed psychologist.

(7) Speech therapy services must be delivered by:

(a) A licensed speech-language pathologist (SLP); or

(b) A speech-language pathology assistant (SLPA) who:

(i) Has graduated from a speech-language pathology assistant program((,)) at a board-approved institution; and

(ii) Is directly supervised (([by])) by a speech-language pathologist with a current certificate of clinical competence (CCC).

(8) For services provided under the supervision of a physical therapist, occupational therapist or speech-language pathologist, nurse, or counselor/social worker, the following requirements apply:

(a) The nature, frequency, and length of the supervision must be provided in accordance with professional practice standards, and be sufficient to ensure a child receives quality therapy services;

(b) The supervising therapist must see the child face-to-face at the beginning of services and ((periodically)) at least once more during the school year;

(c) At a minimum, supervision must be face-to-face communication between the supervisor and the supervisee once per month. Supervisors are responsible for approving and cosigning all treatment notes written by the supervisee before submitting claims for payment; and

(d) Documentation of supervisory activities must be recorded and available to the agency or its designee upon request.

(9) ((It is the responsibility of)) The school district ((to)) must assure providers meet the professional licensing and certification requirements.

(10) Licensing exemptions found in the following regulations do not apply to federal medicaid reimbursement for the services indicated below:

(a) Counseling as found in RCW 18.225.030;

(b) Psychology as found in RCW 18.83.200;

(d) Speech therapy as found in RCW 18.35.195.

AMENDATORY SECTION (Amending WSR 13-05-017, filed 2/7/13, effective 3/10/13)

WAC 182-537-0600 School-based health care services for children in special education—School district requirements for billing and payment.

To receive payment from the medicaid agency for providing school-based health care services to eligible children, a school district must:

(1) Have a current, signed core provider agreement (CPA) with the agency. A copy of the CPA must be on-site within the school district((;)).

(2) Have a current, signed, and executed interagency agreement with the agency. A copy of the agreement must be on-site within the school district((;)) for review as requested.

(3) Meet the applicable requirements in chapter 182-502 WAC((; and)).

(4) Comply with the agency's current, published ProviderOne billing and resource guide((;)).

(5) Bill according to the agency's current, published school-based health care services for children in special education medicaid provider guide, the school-based health care services fee schedule, and the intergovernmental transfer (IGT) process. After school districts receive their invoice from the agency, they ((have)) must provide their local match to the agency within one hundred twenty days ((to provide the agency with their local match;)).

(6) Meet the applicable requirements in chapter 182-537 WAC((;)).

(7) Provide only health care related services identified through a current individualized education program (IEP)((;)).

(8) Use only licensed health care professionals, as described in WAC 182-537-0350 and the school-based care services for children in special education medicaid provider guide((;)).

(9) Meet documentation requirements in WAC 182-537-0700((; and

(10) Give parents or guardians prior, informal, written notification on an annual basis, that the school district may be submitting claims for third-party insurance or medicaid reimbursement)).