WSR 02-07-016

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed March 8, 2002, 4:51 p.m. ]

Date of Adoption: March 8, 2002.

Purpose: Adopting amended WAC 388-534-0100 and new WAC 388-534-0200, to implement a program to encourage providers to increase the number of children receiving foster care placement services who receive early periodic screening, diagnosis, and treatment (EPSDT) screens, and if necessary, subsequent referrals for treatment. Providers may receive an enhanced payment for providing EPSDT screens to these children. The department is also eliminating the name "Healthy Kids" from this rule so the state program name will be the same as [the federal program (EPSDT)].

Citation of Existing Rules Affected by this Order: Amending WAC 388-534-0100.

Statutory Authority for Adoption: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090, 42 C.F.R., Part 441, Subpart B.

Adopted under notice filed as WSR 02-03-099 on January 18, 2002.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 1, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 1, Amended 1, Repealed 0.
Effective Date of Rule: Thirty-one days after filing.

March 5, 2002

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3037.1
AMENDATORY SECTION(Amending WSR 01-02-076, filed 12/29/00, effective 1/29/01)

WAC 388-534-0100   ((Healthy kids/))EPSDT.   (1) Persons who are eligible for Medicaid are eligible for ((healthy kids (HK))) coverage through the early and periodic screening, diagnosis, and treatment (EPSDT) program up through the day before their twenty-first birthday. ((This coverage is called early and periodic screening, diagnosis and treatment (EPSDT) in federal rule.))

(2) Access and services for ((healthy kids)) EPSDT are governed by federal rules at 42 CFR, Part 441, Subpart B which were in effect as of January 1, 1998.

(a) The standard for coverage for ((healthy kids)) EPSDT is that the services, treatment or other measures are:

(i) Medically necessary;

(ii) Safe and effective; and

(iii) Not experimental.

(b) ((Healthy kids)) EPSDT services are exempt from specific coverage or service limitations which are imposed on the rest of the CN and MN program. Examples of service limits which do not apply to the ((healthy kids)) EPSDT program are the specific numerical limits in WAC 388-545-300, 388-545-500, and 388-545-700((, etc)).

(c) Services not otherwise covered under the Medicaid program are available to children under ((healthy kids)) EPSDT. The services, treatments and other measures which are available include but are not limited to:

(i) Nutritional counseling;

(ii) Chiropractic care;

(iii) Orthodontics; and

(iv) Occupational therapy (not otherwise covered under the MN program).

(d) Prior authorization and referral requirements are imposed on medical service providers under ((healthy kids)) EPSDT. Such requirements are designed as tools for determining that a service, treatment or other measure meets the standards in subsection (2)(a) of this section.

(3) Transportation requirements of 42 CFR 441, Subpart B are met through a contract with transportation brokers throughout the state.

[Statutory Authority: RCW 74.08.090. 01-02-076, 388-534-0100, filed 12/29/00, effective 1/29/01; 00-11-183, recodified as 388-534-0100, filed 5/24/00, effective 5/24/00. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, 388-86-027, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090. 90-12-061 (Order 3019), 388-86-027, filed 5/31/90, effective 7/1/90; 82-01-001 (Order 1725), 388-86-027, filed 12/3/81; 81-10-015 (Order 1647), 388-86-027, filed 4/27/81; 80-15-034 (Order 1554), 388-86-027, filed 10/9/80; 79-12-047 (Order 1457), 388-86-027, filed 11/26/79; Order 1112, 388-86-027, filed 4/15/76; Order 738, 388-86-027, filed 11/22/72.]


NEW SECTION
WAC 388-534-0200   Enhanced payments for EPSDT screens for children receiving foster care placement services from the department of social and health services (DSHS).   The medical assistance administration (MAA) reimburses providers an enhanced flat fee for EPSDT screens provided to children receiving certain foster care placement services from the department of social and health services (DSHS). See MAA's EPSDT billing instructions for specific billing code requirements and the fee.

(1) For the purposes of this section, foster care is defined as twenty-four hour per day, temporary, substitute care for a child:

(a) Placed away from the child's parents or guardians in licensed, paid, out-of-home care; and

(b) For whom the department or a licensed or certified child placing agency has placement and care responsibility.

(2) MAA pays an enhanced flat fee to the providers listed in subsection (3) of this section for EPSDT screens provided to only those children receiving foster care placement services from DSHS.

(3) The following providers are eligible to perform EPSDT screens and bill MAA the enhanced rate for children receiving foster care placement services from DSHS:

(a) EPSDT clinics;

(b) Physicians;

(c) Advanced registered nurse practitioners (ARNPs);

(d) Physician assistants (PAs) working under the guidance and MAA provider number of a physician;

(e) Nurses specially trained through the department of health (DOH) to perform EPSDT screens; and

(f) Registered nurses working under the guidance and MAA provider number of a physician or ARNP.

(4) In order to be paid an enhanced fee, services furnished by the providers listed in subsection (3) of this section must meet the federal requirements for EPSDT screens at 42 CFR Part 441 Subpart B, which were in effect as of December 1, 2001.

(5) The provider must retain documentation of the EPSDT screens in the client's medical file. The provider must use the DSHS Well Child Exam forms or provide equivalent information. DSHS Well Child Exam forms are available at no charge by sending a request in writing or by fax to:

DSHS Warehouse

PO Box 45816

Olympia, WA. 98504-5816

Fax: 360-664-0597

(6) MAA conducts evaluations of client files and payments made under this program. MAA may recover the enhanced payment amount when:

(a) The client was not receiving foster care placement services from DSHS as defined in subsection (1) of this section when the EPSDT screen was provided; or

(b) Documentation was not in the client's medical file (see subsection (5) of this section).

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Washington State Code Reviser's Office