WSR 02-15-082

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed July 15, 2002, 4:01 p.m. ]

Date of Adoption: July 10, 2002.

Purpose: To meet the requirements of the centers for Medicare and Medicaid services (CMS), the department is amending home health services sections in chapter 388-551 WAC that refer to "homebound" criteria. The rules also update rule content for the home health program, including the addition of a new section, and reflect current department policy and business practices. The department is also changing references to "Plan of treatment (POT)" to "Plan of care (POC)" to be consistent with Department of Health (DOH) rules.

Citation of Existing Rules Affected by this Order: Amending WAC 388-551-2000, 388-551-2010, 388-551-2020, 388-551-2100, 388-551-2110, 388-551-2120, 388-551-2130, 388-551-2200, 388-551-2210, and 388-551-2220.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500.

Adopted under notice filed as WSR 02-08-089 on April 3, 2002.

Changes Other than Editing from Proposed to Adopted Version: Deletions are indicated by strike through and additions by underline:

WAC 388-551-2010 Home health services -- Definitions.

1. "Home health aide" means an individual registered or certified as a nursing assistant under chapter 18.88 RCW who, under the direction and supervision of a registered nurse or licensed therapist, assists in the delivery of nursing or therapy related activities, or both. to patients of a home health or hospice agency, or hospice care center.


Clarifies that the definition for "home health aide" is defined for the purposes of MAA's Home Health Program by deleting references "to patients of a home health or hospice agency or hospice care center."


2. "Home health aide services" means services provided by a home health aide only when a client has an acute, intermittent, short-term need for the services of a registered nurse, physical therapist, occupational therapist, or speech therapist who is employed by or under contract with a home health agency. Such services are provided under the supervision of the previously identified authorized practitioners, and include, but are not limited to, ambulation and exercise, assistance with self-administered medications, reporting changes in a client's condition and needs, and completing appropriate records.


Clarifies what home health aide services include.

3. "Residence" means a client's home or place of living. , including an adult family home and/or boarding home, but not including a hospital, skilled nursing facility, or residential facility with skilled nursing services available (See WAC 388-551-2030 (2)(g)(ii) for clients in residential facilities whose home health services are not covered through MAA's home health program.)


Clarifies the definition of "residence" to include residential facilities that house clients whose home health services are not covered through MAA's Home Health Program.


WAC 388-551-2020 Home health services -- Eligible clients.

4. (1) Clients in the following fee-for-service MAA programs are eligible to receive home health services subject to the limitations described in this chapter. Clients enrolled in a healthy options managed plan receive all home health services through their designated plan, subject to the plan's coverages and limitations.


Clarifies that a client eligible under a Healthy Options managed care plan receives all home health services through their designated plan.

5. (2) Clients in the following emergency-only MAA programs are eligible to receive home health services, subject to the limitations described in this chapter. Coverage is limited to two skilled nursing visits per eligibility enrollment period. Specialized therapy services and home health aide visits are not covered.

(a) CNP-emergency medical only; and

(b) LCP-MNP-emergency medical only.

See WAC 388-551-2100(3) for limitations of coverage under these programs.

MAA does not cover home health services under the home health program for clients in the CNP-emergency medical only and LCP-MNP-emergency medical only programs. MAA evaluates a request for home health skilled nursing visits on a case-by-case basis under the provisions of WAC 388-501-0165, and may cover up to two skilled nursing visits within the eligibility enrollment period if the following criteria are met:

(a) The client requires hospital care due to an emergent medical condition as described in WAC 388-500-0005; and

(b) MAA authorizes up to two skilled nursing visits for follow-up care related to the emergent medical condition.


Clarifies that MAA evaluates requests for home health services for clients receiving medical benefits under the CNP-emergency medical only and LCP-MNP-emergency medical only programs under the provisions of WAC 388-501-0165 and lists the limitations of coverage.


WAC 388-551-2030 Home health skilled services -- Requirements.

6. (2)(g) Be provided in the client's residence, as defined in WAC 388-551-2010.

(i) MAA does not reimburse for services if provided....

(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 MAA-funded limited skilled nursing services unless the services are prior authorized under the provisions of WAC 388-501-0165.


Clarifies that clients in residential facilities contracted with the state and paid by other programs to provide limited skilled nursing services are not eligible for MAA-funded limited skilled nursing services unless the services are prior authorized under the provisions of WAC 388-501-0165.


7. (2)(h) Be provided by:

(i) A home health agency that is Title XVIII (Medicare) certified and state-licensed.;

(ii) A registered nurse (RN) prior authorized by MAA when no home health agency exists in the area a client resides; or

(iii) An RN authorized by MAA when the RN is unable to contract with a Medicare-certified home health agency.


Deletes "and state-licensed" in subsection (2). If the agency is Medicare-certified, the agency is state-licensed. Adds (i) and (ii) to (h) in subsection (2) to identify other providers that may provide home health services under the Home Health Program.


WAC 388-551-2100 Covered home health services -- Nursing.

8. (3) MAA limits skilled nursing visits provided to eligible clients to two per day. , except clients eligible under either of the emergency medical programs listed in WAC 388-551-2020 (2)(a) and (b) are limited to two skilled nursing visits within the eligibility enrollment period.


Deletes the limitations for clients eligible under the CNP-emergency medical only and LCP-MNP-emergency medical only programs. MAA does not cover home health services under the Home Health Program for these clients except under the provisions of WAC 388-501-0165. Added language to clarify this policy in WAC 388-551-2020(2).


WAC 388-551-2200 Home health services -- Eligible providers.

9. A home health agency may contract with MAA to be a provider if the agency The following may contract with MAA to provide home health services through the home health program, subject to the restrictions or limitations in this section and other applicable published WAC:

(1) A home health agency that:

(a) Is Title XVIII (Medicare) certified;

(2) (b) Is department of health (DOH) licensed as a home health agency;

(3) Meets DOH requirements;

(4) (c) Submits a completed, signed core provider agreement to MAA; and

(5) (d) Is assigned a provider number.


Deletes subsection that is not necessary.


10. (2) A registered nurse (RN) who:

(a) Is prior authorized by MAA to provide intermittent nursing services when no home health agency exists in the area a client resides;

(b) Is unable to contract with a Medicare-certified home health agency;

(c) Submits a completed, signed core provider agreement to MAA; and

(d) Is assigned a provider number.


Adds language that clarifies when a registered nurse may provide intermittent nursing services under the Home Health Program.


WAC 388-551-2210 Home health services -- Provider requirements.

11. (2)(a) The client's name, date of birth, and address (to include name of residential care facility, if applicable);

(a)(b) The primary diagnosis…;

(b)(c) All secondary medical diagnoses…;

(c)(d) The prognosis;

(d)(e) The type(s) of equipment required;

(e)(f) A description of each planned service…;

(f)(g) Specific procedures and modalities;

(g)(h) A description of the client's mental status;

(h)(i) A description of the client's rehabilitation potential;

(i)(j) A list of permitted activities;

(j)(k) A list of safety measures taken on behalf of the client; and

(k)(l) A list of medication which indicates:

(i) Any new prescription; and

(ii) Which medications are changed for dosage or route of administration.


Adds criteria the provider must include in the client's plan of care (POC).

12. (6)(c) Referral to a wound care specialist, if wound If a client's wound is not healing, the client's physician has been notified, the client's wound management program has been appropriately altered and, if possible, the client has been referred to a wound care specialist; and


Clarifies that it must be documented in the client's plan of care that a client's physician must be notified when the client's wound is not healing, that the client's wound management program has been appropriately altered, and that the client has been referred to a wound care specialist, if appropriate.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 1, Amended 10, 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 0, Amended 0, 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 10, Repealed 0.
Effective Date of Rule: Thirty-one days after filing.

July 10, 2002

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3014.11
AMENDATORY SECTION(Amending WSR 99-16-069, filed 8/2/99, effective 9/2/99)

WAC 388-551-2000   Home health services--General.   The purpose of the medical assistance administration (MAA) home health program is to reduce the costs of health care services by providing equally effective, ((more conservative, and/or less costly treatment in a client's home)) less restrictive quality care to the client in the client's residence, subject to the restrictions and limitations in this subchapter.

((Home health services consist of skilled nursing and specialized therapies provided in a client's residence. Home health aide services may be provided in addition to these services. The client must be homebound, as determined by documentation submitted to MAA during the client's focused program review period.)) Home health skilled services are provided ((are)) for acute, intermittent, short-term, and intensive courses of treatment. See chapter 388-515 and 388-71 WAC for programs administered to clients ((needing)) who need chronic, long-term maintenance care.

[Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, 388-551-2000, filed 8/2/99, effective 9/2/99.]


AMENDATORY SECTION(Amending WSR 99-16-069, filed 8/2/99, effective 9/2/99)

WAC 388-551-2010   Home health services--Definitions.   ((Words)) The following definitions and abbreviations ((in bold have the following definitions for this chapter. See also chapter 388-500 WAC for other definitions and abbreviations used by the department.)) and those found in WAC 388-500-0005 apply to this subchapter:

"Acute care" means care provided by a home health agency for clients who are not medically stable or have not attained a satisfactory level of rehabilitation. These clients require frequent intervention by a registered nurse or licensed therapist.

"Brief skilled nursing visit" means a registered nurse, or a licensed practical nurse under the supervision of a registered nurse, performs only one of the following activities during a visit to a client:

(1) An injection;

(2) Blood draw; or

(3) Placement of medications in containers.

"Chronic care" means long-term care for medically stable clients.

"Full skilled nursing visit" means a registered nurse, or a licensed practical nurse under the supervision of a registered nurse, performs one or more of the following activities during a visit to a client:

(1) Observation;

(2) Assessment;

(3) Treatment;

(4) Teaching;

(5) Training;

(6) Management; and

(7) Evaluation.

"Home health agency" means an agency or organization certified under Medicare to provide comprehensive health care on ((a)) an intermittent or part-time ((or intermittent)) basis to a patient in the patient's place of residence.

"Home health aide" means an individual registered or certified as a nursing assistant under chapter 18.88 RCW who, under the direction and supervision of a registered nurse or licensed therapist, assists in the delivery of nursing or therapy related activities, or both.

"Home health aide services" means services provided by a home health aide only when a client has an acute, intermittent, short-term need for the services of a registered nurse, physical therapist, occupational therapist, or speech therapist who is employed by or under contract with a home health agency. Such services are provided under the supervision of the previously identified authorized practitioners and include, but are not limited to, ambulation and exercise, assistance with self-administered medications, reporting changes in a client's condition and needs, and completing appropriate records.

"Home health skilled services" means skilled health care (nursing, specialized therapy, and home health aide) services provided in the client's residence on ((a part-time or)) an intermittent or part-time basis by a ((Title XVIII Medicare and Title XIX Medicaid home health provider)) Medicare-certified home health agency with a current medical assistance administration (MAA) provider number. See also WAC 388-551-2000.

(("Homebound" means a physician has certified that the client is medically or physically confined to the home, and under normal circumstances, lacks the ability to leave home without a considerable and taxing effort. The client may be considered homebound if absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive medical treatment.))

"Long-term care" is a generic term referring to various programs and services, including services provided in home and community settings, administered directly or through contract by the department's aging and adult services administration (AASA) or division of developmental disabilities (DDD).

"Plan of ((treatment (POT))) care (POC)" (also known as "plan of ((care (POC))) treatment (POT)") means a written plan of ((treatment)) care that is established and periodically reviewed and signed by both a physician and a home health agency provider((, that)). The plan describes the home health care to be provided at the client's residence. See WAC 388-551-2210.

"Residence" means a client's home or place of living ((not including a hospital, skilled nursing facility, or residential facility with skilled nursing services available)). (See WAC 388-551-2030 (2)(g)(ii) for clients in residential facilities whose home health services are not covered through MAA's home health program.)

"Review period" means the three-month period the medical assistance administration (MAA) assigns to a home health agency, based on the address of the agency's main office, during which MAA reviews all claims submitted by that agency.

"Specialized therapy" means skilled therapy services provided to ((homebound)) clients ((which)) that include((s)):

(1) Physical;

(2) Occupational; or

(3) Speech/audiology services.

(See WAC 388-551-2110.)

[Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, 388-551-2010, filed 8/2/99, effective 9/2/99.]


AMENDATORY SECTION(Amending WSR 99-16-069, filed 8/2/99, effective 9/2/99)

WAC 388-551-2020   Home health services--Eligible clients.   (1) Clients in the following fee-for-service MAA programs are eligible to receive home health services subject to the limitations described in this chapter. ((Chapter 388-551 WAC does not apply to)) Clients enrolled in ((MAA's)) a healthy options managed care ((plans)) plan receive all home health services through their designated plan.

(a) Categorically needy program (CNP);

(b) Limited casualty program - medically needy program (LCP-MNP);

(c) General assistance expedited (GA-X) (disability determination pending); and

(d) Medical care services (MCS) under the following programs:

(i) General assistance - unemployable (GA-U); and

(ii) Alcoholism and drug addiction treatment and support act (ADATSA) (GA-W).

(2) ((Clients in the following emergency-only MAA programs are eligible to receive home health services subject to the limitations described in this chapter. Coverage is also limited to two skilled nursing visits per eligibility enrollment period. Specialized therapy services and home health aide visits are not covered:

(a) Categorically needy program (CNP) - emergency-only.

(b) Limited casualty program - medically needy program (LCP-MNP)- emergency only)) MAA does not cover home health services under the home health program for clients in the CNP-emergency medical only and LCP-MNP-emergency medical only programs. MAA evaluates a request for home health skilled nursing visits on a case-by-case basis under the provisions of WAC 388-501-0165, and may cover up to two skilled nursing visits within the eligibility enrollment period if the following criteria are met:

(a) The client requires hospital care due to an emergent medical condition as described in WAC 388-500-0005; and

(b) MAA authorizes up to two skilled nursing visits for follow-up care related to the emergent medical condition.

[Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, 388-551-2020, filed 8/2/99, effective 9/2/99.]


NEW SECTION
WAC 388-551-2030   Home health skilled services -- Requirements.   (1) MAA reimburses for covered home health skilled services provided to eligible clients, subject to the restrictions or limitations 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 388-551-2010.

(b) Provide for the treatment of an illness, injury, or disability.

(c) Be medically necessary as defined in WAC 388-500-0005.

(d) Be reasonable, based on the community standard of care, in amount, duration, and frequency.

(e) Be provided under a plan of care (POC), as defined in WAC 388-551-2010 and described in WAC 388-551-2210. Any statement in the POC must be supported by documentation in the client's medical records.

(f) Be used to prevent placement in a more restrictive setting. In addition, the client's medical records must justify the medical reason(s) that the services should be provided in the client's residence instead of a physician's office, clinic, or other outpatient setting. This includes justification for services for a client's medical condition that requires teaching that would be most effectively accomplished in the client's home on a short-term basis.

(g) Be provided in the client's residence((:)).

(i) MAA does not reimburse for services if provided at the workplace, school, child day care, adult day care, skilled nursing facility, or any other place that is not the client's place of residence.

(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 MAA-funded limited skilled nursing services unless the services are prior authorized under the provisions of WAC 388-501-0165.

(h) Be provided by:

(i) A home health agency that is Title XVIII (Medicare) certified;

(ii) A registered nurse (RN) prior authorized by MAA when no home health agency exists in the area a client resides; or

(iii) An RN authorized by MAA when the RN is unable to contract with a Medicare-certified home health agency.

[]

Reviser's note: The unnecessary underscoring and deletion in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
AMENDATORY SECTION(Amending WSR 99-16-069, filed 8/2/99, effective 9/2/99)

WAC 388-551-2100   Covered home health services--Nursing.   (1) MAA covers home health acute care skilled nursing services ((involve observation, assessment, treatment, teaching, training, management and/or evaluation requiring the skills of:

(a) A registered nurse; or

(b) A licensed practical nurse under the supervision of a registered nurse.

(2) MAA may pay for up to two skilled nursing visits per day. See WAC 388-551-2220 (3), (4) and (5).

(3) Coverage for home health nursing services is limited to homebound clients, except as listed in subsection (4) of this section.

(4) MAA covers home health nursing services for nonhomebound clients on a limited basis only when the client is unable to access similar services in a less costly setting, as documented by the provider and approved by MAA.

(5) A brief skilled nursing visit occurs when only one of the following activities is performed during a visit:

(a) An injection or blood draw;

(b) Placement of oral medications in containers (e.g., envelopes, cups, medisets); or

(c) A prefill of insulin syringes.

(6) MAA may cover brief skilled nursing visits for a client with chronic needs, for a short time, until a long term care plan is implemented.

(7) MAA limits services provided to a client enrolled in either of the emergency medical programs listed in WAC 388-551-2020 (2)(a) and (b), to two skilled nursing visits within their eligibility enrollment period.

(8) To receive infusion therapy clients must:

(a) Be willing and capable of learning and managing their infusion care; or

(b) Have a caregiver willing and capable of learning and managing the client's infusion care.

(9) MAA covers infant phototherapy:

(a) For up to five skilled nursing visits per infant;

(b) When provided by a Medicaid approved infant phototherapy agency; and

(c) When the infant is diagnosed with hyperbilirubinemia.

(10) MAA covers limited high risk obstetrical services:

(a) For a medical condition that complicates pregnancy and may result in a poor outcome for the mother, unborn, or newborn;

(b) During the span of home health agency services, if enrollment in or referral to the following providers of First Steps has been verified:

(i) Maternity support services (MSS); or

(ii) Maternity case management (MCM);

(c) When provided by a registered nurse who has either:

(i) National prenatal certification; or

(ii) A minimum of one year of labor, delivery, and postpartum experience at a hospital within the last five years; and

(d) For up to three home health visits per pregnancy)) listed in this section when furnished by a qualified provider. MAA evaluates a request for covered services that are subject to limitations or restrictions, and approves such services beyond those limitations or restrictions when medically necessary, under the standard for covered services in WAC 388-501-0165.

(2) MAA covers the following home health acute care skilled nursing services, subject to the limitations in this section:

(a) Full skilled nursing services that require the skills of a registered nurse or a licensed practical nurse under the supervision of a registered nurse if the services involve one or more of the following:

(i) Observation;

(ii) Assessment;

(iii) Treatment;

(iv) Teaching;

(v) Training;

(vi) Management; and

(vii) Evaluation.

(b) A brief skilled nursing visit if only one of the following activities is performed during the visit:

(i) An injection;

(ii) Blood draw; or

(iii) Placement of medications in containers (e.g., envelopes, cups, medisets).

(c) Home infusion therapy only if the client:

(i) Is willing and capable of learning and managing the client's infusion care; or

(ii) Has a volunteer caregiver willing and capable of learning and managing the client's infusion care.

(d) Infant phototherapy for an infant diagnosed with hyperbilirubinemia:

(i) When provided by an MAA-approved infant phototherapy agency; and

(ii) For up to five skilled nursing visits per infant.

(e) Limited high-risk obstetrical services:

(i) For a medical diagnosis that complicates pregnancy and may result in a poor outcome for the mother, unborn, or newborn;

(ii) For up to three home health visits per pregnancy if:

(A) Enrollment in or referral to the following providers of First Steps has been verified:

(I) Maternity support services (MSS); or

(II) Maternity case management (MCM); and

(B) The visits are provided by a registered nurse who has either:

(I) National perinatal certification; or

(II) A minimum of one year of labor, delivery, and postpartum experience at a hospital within the last five years.

(3) MAA limits skilled nursing visits provided to eligible clients to two per day.

[Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, 388-551-2100, filed 8/2/99, effective 9/2/99.]


AMENDATORY SECTION(Amending WSR 99-16-069, filed 8/2/99, effective 9/2/99)

WAC 388-551-2110   ((Covered)) Home health services--Specialized therapy.   (1) MAA ((may pay for up to one)) limits specialized therapy ((visit)) visits to one per client, per day, per type of specialized therapy. Specialized therapy is defined in WAC 388-551-2010.

(2) ((To receive)) MAA does not allow duplicate services for any specialized therapy ((services, a client must be homebound)) for the same client when both providers are performing the same or similar procedure(s).

[Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, 388-551-2110, filed 8/2/99, effective 9/2/99.]


AMENDATORY SECTION(Amending WSR 99-16-069, filed 8/2/99, effective 9/2/99)

WAC 388-551-2120   Home health aide services((--Aides)).   (1) MAA ((may pay for up to one)) limits home health aide ((visit)) visits to one per day.

(2) MAA ((pays)) reimburses for home health aide services, as defined in WAC 388-551-2010, only when the services are provided under the supervision of, and in conjunction with, practitioners who provide:

(a) Skilled nursing services; or

(b) Specialized therapy services.

(3) MAA covers home health aide services only when a registered nurse or licensed therapist visits the client's residence at least once every fourteen days to monitor or supervise home health aide services, with or without the presence of the home health aide.

[Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, 388-551-2120, filed 8/2/99, effective 9/2/99.]


AMENDATORY SECTION(Amending WSR 99-16-069, filed 8/2/99, effective 9/2/99)

WAC 388-551-2130   Noncovered home health services((--Noncovered)).   (1) MAA does not cover the following home health services ((and expenses)) under the home health program, unless otherwise specified:

(a) ((Medical)) Chronic long-term care skilled nursing visits or specialized therapy visits for a medically stable client when a long-term care skilled nursing plan or specialized therapy plan is in place through the department of social and health services aging and adult services administration (AASA) or division of developmental disabilities (DDD).

(i) MAA considers requests for interim chronic long-term care skilled nursing services or specialized therapy services for a client while the client is waiting for AASA or DDD to implement a long-term care skilled nursing plan or specialized therapy plan; and

(ii) On a case-by-case basis, MAA may authorize long-term care skilled nursing visits or specialized therapy visits for a client for a limited time until a long-term care skilled nursing plan or specialized therapy plan is in place. Any services authorized are subject to the restrictions and limitations in this section and other applicable published WACs.

(b) Social work services((;

(b))).

(c) Psychiatric skilled nursing services((;

(c))).

(d) Pre- and postnatal skilled nursing services, except as listed under WAC 388-551-2100(((10);

(d) Additional administrative costs billed above the visit rate (these costs are included in the visit rate and may not be billed separately);)) (2)(e).

(e) Well-baby follow-up care((;)).

(f) Services performed in hospitals, correctional facilities, skilled nursing facilities, or a residential facility with skilled nursing services available((;)).

(g) Home health aide services that are not provided in conjunction with skilled nursing or specialized therapy services((;)).

(h) Health care for a medically stable client (e.g., one who does not have an acute episode, a disease exacerbation, or treatment change)((;)).

(i) Home health specialized therapies and home health aide visits for clients in the following programs:

(i) CNP - emergency medical only; and

(ii) LCP-MNP - emergency medical only((;)).

(j) Skilled nursing visits for a client when a home health agency cannot safely meet the medical needs of that client within home health services program limitations (e.g., for a client to receive infusion therapy services, the caregiver must be willing and capable of managing the client's care)((;)).

(k) More than one of the same type of specialized therapy and/or home health aide visit per day((;)).

(l) MAA does not reimburse for duplicate services for any specialized therapy for the same client when both providers are performing the same or similar procedure(s).

(m) Home health visits made without a written physician's order, unless the verbal order is:

(i) ((Written)) Documented prior to ((or on the date of)) the visit; and

(ii) The document is signed by the physician within forty-five days of the order being given.

(2) MAA does not cover additional administrative costs billed above the visit rate (these costs are included in the visit rate and will not be paid separately).

(3) MAA evaluates a request for any service that is listed as noncovered under the provisions of WAC 388-501-0165.

[Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, 388-551-2130, filed 8/2/99, effective 9/2/99.]


AMENDATORY SECTION(Amending WSR 99-16-069, filed 8/2/99, effective 9/2/99)

WAC 388-551-2200   Home health services--Eligible providers.   The following may contract with MAA to provide home health services through the home health program, subject to the restrictions or limitations in this section and other applicable published WAC:

(1) A home health ((provider may contract with MAA to be a Medicaid provider if the provider)) agency that:

(a) Is Title XVIII (Medicare) certified ((and));

(b) Is department of health (DOH) licensed ((by the state)) as a home health agency((. Providers must have an active Medicaid provider number to bill MAA));

(c) Submits a completed, signed core provider agreement to MAA; and

(d) Is assigned a provider number.

(2) A registered nurse (RN) who:

(a) Is prior authorized by MAA to provide intermittent nursing services when no home health agency exists in the area a client resides;

(b) Is unable to contract with a Medicare-certified home health agency;

(c) Submits a completed, signed core provider agreement to MAA; and

(d) Is assigned a provider number.

[Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, 388-551-2200, filed 8/2/99, effective 9/2/99.]


AMENDATORY SECTION(Amending WSR 99-16-069, filed 8/2/99, effective 9/2/99)

WAC 388-551-2210   Home health services -- Provider((s--)) requirements.   For any delivered home health service to be payable, MAA requires home health providers to develop and implement an individualized plan of ((treatment (POT))) care (POC) for the client.

(1) The ((POT)) POC must:

(a) Be documented in writing and be located in the client's home health medical record;

(b) Be developed ((and)), supervised, and signed by a licensed registered nurse or licensed therapist;

(c) Reflect the physician's orders and client's current health status;

(d) Contain specific goals and treatment plans;

(e) Be reviewed and revised by a physician at least every sixty((-two)) calendar days ((and)), signed by a physician within forty-five days of the verbal order, and returned to the home health agency's file;

(((e) Contain specific goals and treatment plans;)) and

(f) Be available to department staff or its designated contractor(s) on request.

(2) The provider must include in the ((POT)) POC all of the following:

(a) The client's name, date of birth, and address (to include name of residential care facility, if applicable);

(b) The primary diagnosis (the diagnosis that is most related to the reason the client qualifies for home health services) or the diagnosis that is the reason for the visit frequency;

(((b) The))

(c) All secondary medical diagnoses ((and prognosis)), including date(s) of onset or exacerbation;

(((c) A discharge plan))

(d) The prognosis;

(((d))) (e) The type(s) of equipment required;

(((e))) (f) A description of each planned service and goals related to the services provided;

(((f))) (g) Specific procedures and modalities;

(((g))) (h) A description of the client's mental status;

(((h))) (i) A description of the client's rehabilitation potential;

(((i))) (j) A list of permitted activities;

(((j))) (k) A list of safety measures taken on behalf of the client; and

(((k))) (l) A list of medications which indicates:

(i) Any new prescription ((prescribed)); and

(ii) Which medications are changed for dosage or route of administration.

(3) The provider must include in or attach to the ((POT)) POC:

(a) A description of the client's functional limits and the effects;

(b) Documentation that justifies why the medical services should be provided in the client's residence instead of a physician's office, clinic, or other outpatient setting;

(c) Significant clinical findings;

(((c))) (d) Dates of recent hospitalization; ((and

(d) If the client is not homebound, a description of why home health services are necessary. The description must include:

(i) A written statement noting coordination with, or referral to, the client's department of social and health services-assigned case manager; or

(ii) An assessment of the client and the client's access to community resources, including attempts to use appropriate alternatives to meet the client's home health needs))

(e) Notification to the DSHS case manager of admittance; and

(f) A discharge plan, including notification to the DSHS case manager of the planned discharge date and client disposition at time of discharge.

(4) The individual client medical record must comply with community standards of practice, and must include documentation of:

(a) Visit notes for every billed visit;

(b) Supervisory visits for home health aide services ((per)) as described in WAC 388-551-2120(3);

(((b))) (c) All medications administered and treatments provided;

(((c))) (d) All physician orders, new orders, and change orders, with notation that the order was received prior to treatment;

(((d))) (e) Signed physician new orders and change orders;

(((e))) (f) Home health aide services as indicated by a registered nurse or licensed therapist in a home health aide care plan;

(((f))) (g) Interdisciplinary and multidisciplinary team communications;

(((g))) (h) Inter-agency and intra-agency referrals;

(((h))) (i) Medical tests and results; ((and

(i))) (j) Pertinent medical history; and

(k) Notations and charting with signature and title of writer.

(5) The provider must document at least the following in the client's medical record:

(a) Skilled interventions per the ((POT)) POC;

(b) Client response to the POC:

(c) Any clinical change in client status;

(((c))) (d) Follow-up interventions specific to a change in status with significant clinical findings; and

(((d))) (e) Any communications with the attending physician.

(6) The provider must include the following documentation in the client's visit notes when appropriate:

(a) Any teaching, assessment, management, evaluation, ((patient)) client compliance, and client response;

(b) Weekly documentation of wound care, size (dimensions), drainage, color, odor, and identification of potential complications and interventions provided; ((and))

(c) If a client's wound is not healing, the client's physician has been notified, the client's wound management program has been appropriately altered and, if possible, the client has been referred to a wound care specialist; and

(d) The client's physical system assessment as identified in the ((POT)) POC.

[Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, 388-551-2210, filed 8/2/99, effective 9/2/99.]


AMENDATORY SECTION(Amending WSR 99-16-069, filed 8/2/99, effective 9/2/99)

WAC 388-551-2220   Home health services -- Provider((s--)) payments.   (1) In order to be reimbursed, the home health provider must bill MAA according to the conditions of payment under WAC 388-502-0150 and other issuances.

(2) Payment to home health providers is:

(a) A set rate per visit ((rate)) for each discipline provided to a client;

(b) Based on the county location of the providing home health agency; and

(c) Updated by general vendor rate changes.

(((2))) (3) For clients eligible for both Medicaid and Medicare, MAA may pay for services described in this chapter only when Medicare does not cover those services. The maximum payment for each service is Medicaid's maximum payment.

(((3))) (4) Providers must submit documentation to ((the department during any MAA focused program)) MAA during the home health agency's review period. Documentation includes, but is not limited to, the requirements listed in WAC 388-551-2210.

(((4))) (5) After MAA receives the documentation, the MAA(('s)) medical director or designee reviews the client's medical records for program compliance and quality of care.

(((5))) (6) MAA may take back or deny payment for any insufficiently documented home health care service when the MAA medical director or designee determines that:

(a) The service ((was not medically necessary (defined in WAC 388-500-0005) or reasonable;

(b) Clients were able to receive care outside of the home (see definition of homebound in this chapter and WAC 388-551-2100(3)); or

(c))) did not meet the conditions described in WAC 388-550-2030; or

(b) The service was not in compliance with program policy.

(((6))) (7) Covered home health services for clients enrolled in a Healthy Options managed care plan are paid for by that plan.

[Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, 388-551-2220, filed 8/2/99, effective 9/2/99.]

Washington State Code Reviser's Office