WSR 17-17-105 PROPOSED RULES HEALTH CARE AUTHORITY (Washington Apple Health) [Filed August 18, 2017, 4:15 p.m.] Original Notice. Preproposal statement of inquiry was filed as WSR 17-08-008. Title of Rule and Other Identifying Information: Amending WAC 182-551-3000 Private duty nursing services for clients seventeen years of age and younger; and new WAC 182-551-3100 Private duty nursing services for clients age seventeen and younger—Client eligibility, 182-551-3200 Private duty nursing services for clients age seventeen and younger—Client requirements, 182-551-3300 Private duty nursing services for clients age seventeen and younger—Application requirements, and 182-551-3400 Private duty nursing services for clients age seventeen and younger—Authorization. Hearing Location(s): On September 26, 2017, at 10:00 a.m., at the Cherry Street Plaza, Sue Crystal Room 106A, 626 8th Avenue, Olympia, WA 98504. Metered public parking is available street side around building. A map is available at www.hca.wa.gov/documents/directions_to_csp.pdf or directions can be obtained by calling 360-725-1000. Date of Intended Adoption: Not sooner than September 27, 2017. Submit Written Comments to: HCA Rules Coordinator, P.O. Box 42716, Olympia, WA 98504-2716, email arc@hca.wa.gov, fax 360-589-9727, by September 26, 2017. Assistance for Persons with Disabilities: Contact Amber Lougheed, phone 360-725-1349, fax 360-586-9727, TTY 800-848-5429 or 711, email amber.lougheed@hca.wa.gov, by September 22, 2017. Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The agency is amending WAC 182-551-3000 Private duty nursing services for clients age seventeen and younger—General, as follows: (1) Renaming the title to reflect that it contains general information about private duty nursing for clients age seventeen and younger; (2) removing the definition of "private duty nursing" and moving it to a new section for definitions; (3) adding information about receiving services through a managed care organization (MCO); (4) adding information about coverage for services when the client has third-party liability (TPL) coverage; (5) removing and moving to new sections all information regarding client eligibility, provider requirements, application requirements, and authorization; and (6) housekeeping changes. Changes to WAC 182-551-3000 explain that private duty nursing services are provided to fee-for-service clients through the medically intensive children's program (MICP) and further clarify how services are provided through MCOs and when clients have TPL coverage. The agency is creating new WAC 182-551-3050 Private duty nursing services for clients age seventeen and younger—Definitions, to define terms not previously found in WAC regarding private duty nursing services. The agency is creating new sections for client eligibility, provider requirements, application requirements, and authorization (new WAC 182-551-3100 through 182-551-3400). These sections are being added to make information easier to find. Additionally, the language in the new WAC sections contains some changes (from the original language in WAC 182-551-3000) to clarify information and update policy. Reasons Supporting Proposal: See Purpose above. Rule is not necessitated by federal law, federal or state court decision. Name of Proponent: Health care authority, governmental. Name of Agency Personnel Responsible for Drafting: Katie Pounds, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-1346; Implementation and Enforcement: Nancy Hite, P.O. Box 45530, Olympia, WA 98504-5530, 360-725-1611. A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to health care authority rules unless requested by the joint administrative rules review committee or applied voluntarily. This rule proposal, or portions of the proposal, is exempt from requirements of the Regulatory Fairness Act because the proposal: Is exempt under RCW 19.85.025(4).
Explanation of exemptions: The agency has determined that the proposed filing does not impose a disproportionate cost impact on small businesses or nonprofits. August 18, 2017 Wendy Barcus Rules Coordinator
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-551-3000 Private duty nursing services for clients age seventeen ((years of age)) and younger—General.
((This section applies to private duty nursing services for eligible clients on fee-for-service programs.)) (1) Private duty nursing services are provided to fee-for-service clients through the medically intensive children's program (MICP). The MICP provides private duty nursing services to clients age seventeen and younger, whose complex medical needs cannot be managed within the scope of intermittent home health services.
(2) Managed care clients receive private duty nursing services through their ((plans)) managed care organization (MCO) (see chapter ((388-538)) 182-538 WAC). (((1) "Private duty nursing" means four hours or more of continuous skilled nursing services provided in the home to eligible clients with complex medical needs that cannot be managed within the scope of intermittent home health services. Skilled nursing service is the management and administration of the treatment and care of the client, and may include, but is not limited to:
(a) Assessments (e.g., respiratory assessment, patency of airway, vital signs, feeding assessment, seizure activity, hydration, level of consciousness, constant observation for comfort and pain management);
(b) Administration of treatment related to technological dependence (e.g., ventilator, tracheotomy, bilevel positive airway pressure, intravenous (IV) administration of medications and fluids, feeding pumps, nasal stints, central lines);
(c) Monitoring and maintaining parameters/machinery (e.g., oximetry, blood pressure, lab draws, end tidal CO2s, ventilator settings, humidification systems, fluid balance, etc.); and
(d) Interventions (e.g., medications, suctioning, IV's, hyperalimentation, enteral feeds, ostomy care, and tracheostomy care).
(2) To be eligible for private duty nursing services, a client must meet all the following:
(a) Be seventeen years of age or younger (see chapter 388-71 WAC for information about private duty nursing services for clients eighteen years of age and older);
(b) Be eligible for categorically needy (CN) or medically needy (MN) scope of care (see WAC 388-501-0060 and 388-501-0065);
(c) Need continuous skilled nursing care that can be provided safely outside an institution; and
(d) Have prior authorization from the department.
(3) The department contracts only with home health agencies licensed by Washington state to provide private duty nursing services and pays a rate established by the department according to current funding levels.
(4) A provider must coordinate with a division of developmental disabilities case manager and request prior authorization by submitting a complete referral to the department, which includes all of the following:
(a) The client's age, medical history, diagnosis, and current prescribed treatment plan, as developed by the individual's physician;
(b) Current nursing care plan that may include copies of current daily nursing notes that describe nursing care activities;
(c) An emergency medical plan which includes notification of electric, gas and telephone companies as well as local fire department;
(d) Psycho-social history/summary which provides the following information:
(i) Family constellation and current situation;
(ii) Available personal support systems;
(iii) Presence of other stresses within and upon the family; and
(iv) Projected number of nursing hours needed in the home, after discussion with the family or guardian.
(e) A written request from the client or the client's legally authorized representative for home care.
(5) The department approves requests for private duty nursing services for eligible clients on a case-by-case basis when:
(a) The information submitted by the provider is complete;
(b) The care provided will be based in the client's home;
(c) Private duty nursing will be provided in the most cost-effective setting;
(d) An adult family member, guardian, or other designated adult has been trained and is capable of providing the skilled nursing care;
(e) A registered or licensed practical nurse will provide the care under the direction of a physician; and
(f) Based on the referral submitted by the provider, the department determines:
(i) The services are medically necessary for the client because of a complex medical need that requires continuous skilled nursing care which can be provided safely in the client's home;
(ii) The client requires more nursing care than is available through the home health services program; and
(iii) The home care plan is safe for the client.
(6) Upon approval, the department will authorize private duty nursing services up to a maximum of sixteen hours per day except as provided in subsection (7) of this section, restricted to the least costly equally effective amount of care.
(7) The department may authorize additional hours:
(a) For a maximum of thirty days if any of the following apply:
(i) The family or guardian is being trained in care and procedures;
(ii) There is an acute episode that would otherwise require hospitalization, and the treating physician determines that noninstitutionalized care is still safe for the client;
(iii) The family or guardian caregiver is ill or temporarily unable to provide care;
(iv) There is a family emergency; or
(v) The department determines it is medically necessary.
(b) After the department evaluates the request according to the provisions of WAC 388-501-0165 and 388-501-0169.
(8) The department adjusts the number of authorized hours when the client's condition or situation changes.
(9) Any hours of nursing care in excess of those authorized by the department are the responsibility of the client, family or guardian.)) Providers must follow the policies and procedures of the client's MCO.
(3) For clients with third-party liability (TPL) coverage (see WAC 182-500-0105) that includes private duty nursing, the procedures and policies in this section apply when determining coverage of additional hours under MICP.
NEW SECTION
WAC 182-551-3050 Private duty nursing services for clients age seventeen and younger—Definitions.
The following definitions and those found in chapter 182-500 WAC apply to this subchapter.
"Continuous skilled nursing" means skilled nursing services considered medically necessary and requires four or more hours of consecutive skilled nursing care.
"Nursing care consultant" means a registered nurse employed by the department of social and health services (DSHS) to provide and evaluate clinical eligibility for the medically intensive children's program (MICP).
"Private duty nursing" means four hours or more of continuous skilled nursing services that are actively spent providing skilled nursing care. Skilled nursing care is provided in the home to eligible clients with complex medical needs that cannot be managed within the scope of intermittent home health services. Skilled nursing services are the management and administration of the treatment and care of the client.
"Skilled nursing care" means the medical care provided by a licensed nurse or delegate working under the direction of a physician as described in RCW 18.79.260.
NEW SECTION
WAC 182-551-3100 Private duty nursing services for clients age seventeen and younger—Client eligibility.
(1) To be eligible for private duty nursing services under the medically intensive children's program (MICP), clients must:
(a) Be age seventeen or younger;
(b) Have informal support by a person who has been trained to provide designated skilled nursing care and is able to perform the care as required;
(c) Require four hours of continuous skilled nursing care at a level that cannot be delegated at the time of the initial assessment and can be provided safely outside of a hospital in a less restrictive setting;
(d) Have prior authorization from the department of social and health services/developmental disabilities administration (DSHS/DDA);
(e) Have exhausted all other funding sources for private duty nursing services, according to RCW 74.09.185, prior to accessing these services through the medically intensive children's program (MICP);
(f) Meet financial eligibility under subsection (2) of this section; and
(g) Meet medical eligibility under subsection (3) of this section.
(2) To be financially eligible for private duty nursing services, clients must meet medicaid eligibility requirements under the categorically needy program, the medically needy program, or alternative medical program (see WAC 182-501-0060).
(3) To be medically eligible for private duty nursing services, clients must:
(a) Be assessed by a DSHS/DDA nursing care consultant and determined medically eligible for MICP; and
(b) Require two or more tasks of complex skilled nursing care such as:
(i) System assessments, including multistep approaches of systems (e.g., respiratory assessment, airway assessment, vital signs, nutritional and hydration assessment, complex gastrointestinal assessment and management, seizure management requiring intervention, or level of consciousness);
(ii) Administration of treatment for complex respiratory issues related to technological dependence requiring multistep approaches on a day-to-day basis (e.g., ventilator tracheostomy);
(iii) Assessment of complex respiratory issues and interventions with use of oximetry, titration of oxygen, ventilator settings, humidification systems, fluid balance, or any other cardiopulmonary critical indicators based on medical necessity;
(iv) Skilled nursing interventions of intravenous/parenteral administration of multiple medications and nutritional substances on a continuing or intermittent basis with frequent interventions; or
(v) Skilled nursing interventions of enteral nutrition and medications requiring multistep approaches daily.
NEW SECTION
WAC 182-551-3200 Private duty nursing services for clients age seventeen and younger—Provider requirements.
Providers qualified to deliver private duty nursing under the medically intensive children's program must have the following:
(1) A home health agency license with the state of Washington to provide private duty nursing services;
(2) A contract with the department of social and health services/developmental disabilities administration (DSHS/DDA) to provide private duty nursing services; and
(3) A signed core provider agreement with the medicaid agency.
NEW SECTION
WAC 182-551-3300 Private duty nursing services for clients age seventeen and younger—Application requirements.
Clients requiring private duty nursing services must submit a complete signed medically intensive children's program (MICP) application (DSHS form 15-398). The MICP application must include the following:
(1) DSHS 14-012 consent form;
(2) DSHS 14-151 request for DDA eligibility determination form for clients not already determined DDA eligible;
(3) DSHS 03-387 notice of practices for client medical information;
(4) Appropriate and current medical documentation including medical plan of treatment or plan of care (WAC 246-335-080) with the client's age, medical history, diagnoses, and the parent/guardian contact information including address and phone number;
(5) A list of current treatments or treatment records;
(6) Information about ventilator, bilevel positive airway pressure (BiPAP), or continuous positive airway pressure (CPAP) hours per day or frequency of use;
(7) History and physical from current hospital admission, recent discharge summary, or recent primary physician exam;
(8) A recent interim summary, discharge summary, or clinical summary;
(9) Recent nursing charting within the past five to seven days of hospitalization or in-home nursing documentation;
(10) Current nursing care plan that may include copies of current daily nursing notes that describe nursing care activities;
(11) An emergency medical plan that includes strategies to address loss of power and environmental disasters such as methods to maintain life-saving medical equipment supporting the client. The plan may include notification of electric and gas companies and the local fire department;
(12) A psycho-social history/summary with the following information, as available:
(a) Family arrangement and current situation;
(b) Available personal support systems; and
(c) Presence of other stresses within and upon the family.
(13) Statement that the home care plan is safe for the child and is agreed to by the child's parent or legal guardian;
(14) Information about other family supports such as medicaid, school hours, or hours paid by a third-party insurance or trust; and
(15) For a client with third-party insurance or a managed care organization (MCO), a denial letter from the third-party insurance or MCO that states the private duty nursing services will not be covered.
NEW SECTION
WAC 182-551-3400 Private duty nursing services for clients age seventeen and younger—Authorization.
(1) The department of social and health services/developmental disabilities administration (DSHS/DDA) authorizes requests for private duty nursing services for eligible clients on a case-by-case basis when:
(a) The application requirements under WAC 182-551-3300 are met; and
(b) The nursing care consultant's review determines the services are medically necessary based on WAC 182-500-0070 and 182-501-0165.
(2) DSHS/DDA only authorizes medically necessary private duty nursing hours. The program manager may authorize up to sixteen hours per day.
(a) DSHS/DDA may adjust the number of authorized hours when the client's condition or situation changes.
(b) Any hours of private duty nursing provided to the client that are more than the number of hours authorized by DSHS/DDA are the financial responsibility of the client, the client's family, or the client's guardian.
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