WSR 15-09-134 PROPOSED RULES HEALTH CARE AUTHORITY (Washington Apple Health) [Filed April 22, 2015, 9:22 a.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 14-20-110.
Title of Rule and Other Identifying Information: WAC 182-533-0320 Maternity support services—Client eligibility, 182-533-0325 Maternity support services—Provider requirements, and 182-533-0345 Maternity support services—Payment.
Hearing Location(s): Health Care Authority (HCA), Cherry Street Plaza Building, Sue Crystal Conference Room 106B, 626 8th Avenue, Olympia, WA 98504 (metered public parking is available street side around building. A map is available at http://www.hca.wa.gov/documents/directions_to_csp.pdf or directions can be obtained by calling (360) 725-1000), on May 26, 2015, at 10:00 a.m.
Date of Intended Adoption: Not sooner than May 27, 2015.
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 May 26, 2015.
Assistance for Persons with Disabilities: Contact Kelly Richters by 5:00 p.m. on May 18, 2015, 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: The agency is revising these rules in order to clarify billing requirements, allow group services, and remove language referencing fee-for-service and managed care organization. Although this language is being removed from WAC, maternity support services continues to be fee-for-service and managed care clients are eligible outside of their plan.
Reasons Supporting Proposal: See Purpose above.
Statutory Authority for Adoption: RCW 41.05.021, 41.05.160.
Statute Being Implemented: RCW 41.05.021, 41.05.160.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: HCA, governmental.
Name of Agency Personnel Responsible for Drafting: Amy Emerson, P.O. Box 42716, Olympia, WA 98504-2716, (360) 725-1348; Implementation and Enforcement: Heather Weiher, 626 8th Avenue S.E., Olympia, WA 98504, (360) 725-1293.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The agency has analyzed the proposed rules and concludes they do not impose more than minor costs for affected small business.
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.
April 22, 2015
Jason R. P. Crabbe
Rules Coordinator
AMENDATORY SECTION (Amending WSR 14-09-061, filed 4/16/14, effective 5/17/14)
WAC 182-533-0320 Maternity support services—Client eligibility.
(1) To receive maternity support services (MSS), a client must:
(a) Be covered under categorically needy, medically needy, or state-funded medical programs under Washington apple health; and
(b) Be within the eligibility period of a maternity cycle as defined in WAC 182-533-0315.
(2) ((Clients who meet the eligibility criteria in this section and are enrolled in an agency-contracted managed care organization (MCO) are eligible for MSS outside their plan.
(3))) Clients who do not agree with an eligibility decision for MSS have a right to a fair hearing under chapter 182-526 WAC.
AMENDATORY SECTION (Amending WSR 14-09-061, filed 4/16/14, effective 5/17/14)
WAC 182-533-0325 Maternity support services—Provider requirements.
Maternity support service providers may include community clinics, federally qualified health centers, local health departments, hospitals, nonprofit organizations, and private clinics.
(1) To be paid for providing maternity support services (MSS) and infant case management (ICM) services to eligible clients, a provider must:
(a) Be enrolled as an eligible provider with the medicaid agency (see WAC 182-502-0010).
(b) Be currently approved as an MSS/ICM provider by the medicaid agency.
(c) Meet the requirements in this chapter, chapter 182-502 WAC and the medicaid agency's current billing instructions.
(d) Ensure that professional staff providing services:
(i) Meet the minimum regulatory and educational qualifications for the scope of services provided under WAC 182-533-0327; and
(ii) Follow the requirements in this chapter and the medicaid agency's current billing instructions.
(e) Screen each client for risk factors.
(f) Screen clients for ICM eligibility.
(g) Conduct case conferences under WAC 182-533-0327(2).
(h) Develop and implement an individualized care plan for each client.
(i) Initiate and participate in care coordination activities throughout the maternity cycle with at least MSS interdisciplinary team members, the client's prenatal care provider, and the Women, Infants, and Children (WIC) Nutrition Program.
(j) Comply with Section 1902 (a)(23) of the Social Security Act regarding the client's freedom to choose a provider.
(k) Comply with Section 1915 (g)(1) of the Social Security Act regarding the client's voluntary receipt of services.
(2) MSS providers may provide services in any of the following locations:
(a) A provider's office or clinic.
(b) The client's residence.
(c) An alternate site that is not the client's residence. (The reason for using an alternate site for visitation instead of the home must be documented in the client's record.)
(3) An individual or service organization that has a written contractual agreement with a qualified MSS provider also may provide MSS and ICM services to eligible clients.
(a) The provider must:
(i) Keep a copy of the written subcontractor agreement on file;
(ii) Ensure that an individual or service organization staff member providing MSS/ICM services (the subcontractor) meets the minimum regulatory and educational qualifications required of an MSS/ICM provider;
(iii) Ensure that the subcontractor provides MSS/ICM services under the requirements of this chapter; and
(iv) Maintain professional, financial, and administrative responsibility for the subcontractor.
(b) The provider must:
(i) Bill for services using the provider's ((assigned billing number)) national provider identifier and MSS/ICM taxonomy; and
(ii) Reimburse the subcontractor for MSS/ICM services provided under the written agreement.
AMENDATORY SECTION (Amending WSR 14-09-061, filed 4/16/14, effective 5/17/14)
WAC 182-533-0345 Maternity support services—Payment.
The medicaid agency ((must)) pays for the covered maternity support services (MSS) described in WAC 182-533-0330 ((on a fee-for-service basis)), subject to the requirements in this section:
(1) MSS ((must be)) are:
(a) Provided to a client who meets the eligibility requirements in WAC 182-533-0320.
(b) Provided to a client ((on an individual basis in)) during a face-to-face encounter on an individual basis or in a group setting. If provided in a group setting, the group must consist of at least three but no more than twelve clients.
(c) Provided by a provider that meets the criteria ((established)) in WAC 182-533-0325. When provided in a group setting, services may not be provided by a community health worker.
(d) Provided according to the ((medicaid)) agency's ((current billing instructions)) maternity support services (MSS)/infant case management (ICM) provider guide.
(e) Documented in the client's record or chart.
(f) Billed using:
(i) The eligible client's agency-assigned client identification number;
(ii) The appropriate procedure codes ((and)), modifiers, and allowed number of units identified in the agency's ((current billing instructions)) MSS/ICM provider guide; and
(iii) The ((agency-assigned MSS/ICM provider number. (The medicaid agency pays the provider for providing MSS services to eligible clients, not the provider's subcontractor who provides MSS services. See WAC 182-533-0325(3) about subcontracting for services.))) provider's national provider identifier and MSS/ICM taxonomy.
(2) The ((medicaid)) agency:
(a) ((Must pay)) Reimburses providers for MSS-covered services using the agency's published fee schedule.
(b) Pays MSS-covered 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.
(c) Must publish the maximum number of units allowed per client in the agency's current billing instructions.)) (c) Pays MSS-covered services in units of time with one unit being more than or equal to sixty minutes for group services delivered face-to-face.
(3) The provider may request authorization for a limitation extension under WAC 182-501-0169 to exceed the number of allowed MSS units of service ((under WAC 182-501-0169.
(4) For a client enrolled in a managed care plan who is eligible to receive MSS, the medicaid agency must pay for MSS delivered outside the plan on a fee-for-service basis as described in this section)).
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