Preproposal statement of inquiry was filed as WSR 18-21-010.
Title of Rule and Other Identifying Information: WAC 182-545-400 Habilitative services.
Hearing Location(s): On March 26, 2019, at 10:00 a.m., at the Health Care Authority (HCA), Cherry Street Plaza, Pear Conference Room 107, 626 8th Avenue, Olympia, WA 98504. Metered public parking is available street side around building. A map is available at https://www.hca.wa.gov/assets/program/Driving-parking-checkin-instructions.pdf or directions can be obtained by calling 360-725-1000.
Date of Intended Adoption: Not sooner than March 27, 2019.
Submit Written Comments to: HCA Rules Coordinator, P.O. Box 42716, Olympia, WA 98504-2716, email firstname.lastname@example.org, fax 360-586-9727, by March 26, 2019.
Assistance for Persons with Disabilities: Contact Amber Lougheed, phone 360-725-1349, fax 360-586-9727, telecommunication relay services 711, email email@example.com, by March 20, 2019.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The agency is striking the outdated requirement in this section for a diagnosis of one of the qualifying conditions listed in the agency's provider guide for habilitative services. The agency does not require the diagnosis of a specific condition for an eligible client to receive habilitative services and has removed the list from the billing guide.
Reasons Supporting Proposal: See purpose.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: HCA, governmental.
Name of Agency Personnel Responsible for Drafting: Michael Williams, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-1346; Implementation and Enforcement: Tonja Nichols, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-1658.
The proposed rule does not impose more-than-minor costs on businesses. Following is a summary of the agency's analysis showing how costs were calculated. The revisions to this rule do not impose additional compliance costs or requirements on providers.
(1) Habilitative services assist the client in partially or fully attaining, learning, maintaining, or improving developmental-age appropriate skills that were not fully acquired as a result of a congenital, genetic, or early acquired health condition. To the extent practical, habilitative services maximize the client's ability to function in the client's environment.
(2) Eligibility is limited to clients who are enrolled in the Washington apple health alternative benefits plan defined in WAC 182-501-0060 ((and who have a diagnosis which is one of the qualifying conditions listed in the agency's provider guide for habilitative services)). Clients enrolled in an agency-contracted managed care organization (MCO) must arrange for habilitative services through their MCO.
(3) The following licensed health care professionals may enroll with the agency to provide habilitative services within their scope of practice to eligible clients:
(b) Occupational therapists;
(c) Occupational therapy assistants supervised by a licensed occupational therapist;
(d) Physical therapists;
(e) Physical therapy assistants supervised by a licensed physical therapist;
(f) Speech-language pathologists who have been granted a certificate of clinical competence by the American Speech-Language-Hearing Association; and
(g) Speech-language pathologists who have completed the equivalent educational and work experience necessary for such a certificate.
(4) The agency pays for habilitative services that are:
(a) Covered within the scope of the client's alternative benefits plan under WAC 182-501-0060;
(b) Medically necessary;
(c) Within currently accepted standards of evidence-based medical practice;
(d) Ordered by a physician, physician assistant, or an advanced registered nurse practitioner;
(e) Begun within thirty calendar days of the date ordered;
(f) Provided by one of the health care professionals listed in subsection (3) of this section;
(g) Authorized under this chapter, chapters 182-501 and 182-502 WAC, and the agency's published provider guides;
(h) Billed under this chapter, chapters 182-501 and 182-502 WAC, and the agency's published provider guides; and
(i) Provided as part of a habilitative treatment program:
(i) In an office or outpatient hospital setting;
(ii) In the home, by a home health agency as described in chapter 182-551 WAC; or
(iii) In a neurodevelopmental center, as described in WAC 182-545-900.
(5) For billing purposes under this section:
(a) Each fifteen minutes of timed procedure code equals one unit.
(b) Each nontimed procedure code equals one unit, regardless of how long the procedure takes.
(c) Duplicate services for habilitative services are not allowed for the same client when both providers are performing the same or similar procedure on the same day.
(d) The agency does not pay a health care professional for habilitative services performed in an outpatient hospital setting when the health care professional is not employed by the hospital. The hospital must bill the agency for the services.
(6) The limitations in subsection (7) of this section do not apply to eligible clients under age twenty-one.
(7) For eligible clients age twenty-one and older, the agency covers habilitative services that include an ongoing management plan for the client or the client's caregiver to support continued client progress. The agency limits habilitative services as follows:
(a) Occupational therapy, per client, per year:
(i) Without authorization:
(A) One occupational therapy evaluation;
(B) One occupational therapy reevaluation at time of discharge; and
(C) Twenty-four units of occupational therapy (which equals approximately six hours).
(ii) With expedited prior authorization (EPA), up to twenty-four additional units of occupational therapy may be available when the therapy is required as part of an initial botulinum toxin injection protocol for spasticity or dystonia and botulinum toxin has been authorized by the agency.
(b) Physical therapy, per client, per year:
(i) Without authorization:
(A) One physical therapy evaluation;
(B) One physical therapy reevaluation at time of discharge; and
(C) Twenty-four units of physical therapy (which equals approximately six hours).
(ii) With EPA, up to twenty-four additional units of physical therapy may be available when the therapy is required as part of an initial botulinum toxin injection protocol for spasticity or dystonia and botulinum toxin has been authorized by the agency.
(c) Speech therapy, per client, per year:
(i) Without authorization:
(A) One speech language pathology evaluation;
(B) One speech language pathology reevaluation at the time of discharge; and
(C) Six units of speech therapy (which equals approximately six hours).
(ii) With EPA, up to six additional units of speech therapy may be available when:
(A) The therapy is required as part of an initial botulinum toxin injection protocol for spasticity or dystonia and botulinum toxin has been authorized by the agency; or
(B) The client has a speech deficit ((caused by the qualifying condition)) which requires a speech generating device.
(d) Two durable medical equipment needs assessments, per client, per year. The agency covers devices and other durable medical equipment for habilitative purposes ((to treat conditions that qualify)) under chapter 182-543 WAC.
(e) Two program units of orthotics management and training of upper and lower extremities, per client, per day.
(f) Two program units for the provider to assess prosthetic or orthotic use, per client, per year.
(g) One muscle testing procedure, per client, per day.
(h) One wheelchair-needs assessment, per client, per year.
(8) The agency evaluates requests for habilitative services that exceed the limitations in this section under WAC 182-501-0169, for clients age twenty-one and older. For clients age nineteen and twenty, the agency evaluates such requests for medical necessity under chapter 182-534 WAC. The agency requires prior authorization for additional units when:
(a) The criteria for EPA do not apply;
(b) The number of available units under the EPA have been used and services are requested beyond the limits; or
(c) The provider requests it as a medically necessary service.
(9) The agency does not cover the following:
(a) Day habilitation services designed to provide training, structured activities, and specialized services to adults;
(b) Services to assist basic needs;
(c) Vocational services;
(d) Custodial services;
(e) Respite care;
(f) Recreational care;
(g) Residential treatment;
(h) Social services; and
(i) Educational services of any kind.