PDFWAC 182-551-2030

Skilled services—Requirements.

(1) The medicaid agency covers home health skilled services provided to eligible clients, subject to the provisions in this section and other applicable published WAC.
(2) Home health skilled services provided to eligible clients must:
(a) Meet the definition of "acute care" in WAC 182-551-2010.
(b) Provide for the treatment of an illness, injury, or disability.
(c) Be medically necessary as defined in WAC 182-500-0070.
(d) Be reasonable, based on the community standard of care, in amount, duration, and frequency.
(e) Meet face-to-face requirements described in WAC 182-551-2040.
(f) Be provided under a plan of care (POC), as defined in WAC 182-551-2010 and described in WAC 182-551-2210. Any statement in the POC must be supported by documentation in the client's medical records.
(g) Be used to prevent placement in a more restrictive setting. In addition, the client's medical records must justify the medical reason or reasons that the services should be provided and why instructing the client would be most effectively done in any setting where the client's normal life activities take place instead of at an ordering physician's office, clinic, or other outpatient setting.
(h) Be provided in any setting where normal life activities take place.
(i) The medicaid agency does not pay for services provided at a hospital, adult day care, skilled nursing facility, intermediate care facility for individuals with intellectual disabilities, or any setting in which payment is or could be made under medicaid for inpatient services that include room and board.
(ii) Clients in residential facilities contracted with the state and paid by other programs, such as home and community programs to provide limited skilled nursing services, are not eligible for medicaid agency-funded, limited skilled nursing services unless the services are prior authorized under WAC 182-501-0165.
(i) Be provided by:
(i) A home health agency that is Title XVIII (medicare)-certified;
(ii) A registered nurse (RN) prior authorized by the medicaid agency when no home health agency exists in the area where a client resides; or
(iii) An RN authorized by the medicaid agency when the RN cannot contract with a medicare-certified home health agency.
[Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Section 440.70. WSR 18-24-023, § 182-551-2030, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-03-035, § 182-551-2030, filed 1/12/16, effective 2/12/16. WSR 11-14-075, recodified as § 182-551-2030, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, chapter 74.09 RCW, and 2009 c 326. WSR 10-10-087, § 388-551-2030, filed 5/3/10, effective 6/3/10. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. WSR 02-15-082, § 388-551-2030, filed 7/15/02, effective 8/15/02.]