Effective Date of Rule: Immediately.

     Purpose: These rules develop reimbursement rules and define the requirements that must be met for a reimbursable skilled nursing visit when services are rendered without a face-to-face visit and are assisted by telemedicine.

     Citation of Existing Rules Affected by this Order: Amending WAC 388-551-2000, 388-551-2010, 388-551-2020, 388-551-2030, 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, chapter 74.09 RCW, and chapter 326, Laws of 2009 (SHB 1529).

     Under RCW 34.05.350 the agency for good cause finds that state or federal law or federal rule or a federal deadline for state receipt of federal funds requires immediate adoption of a rule.

     Reasons for this Finding: Amendments to these sections are required to implement chapter 326, Laws of 2009 (SHB 1529) which authorizes delivery of home health care services through telemedicine. This emergency filing is necessary to continue the emergency rules filed as WSR 10-02-041 on December 30, 2009. The permanent rules have been submitted for final adoption.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 1, Amended 11, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 1, Amended 11, Repealed 0.

     Date Adopted: April 30, 2010.

Katherine I. Vasquez

Rules Coordinator

     Home health skilled services are provided for acute, intermittent, short-term, and intensive courses of treatment. See chapters 388-515 and 388-71 WAC for programs administered to clients who need chronic, long-term maintenance care.

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. 02-15-082, § 388-551-2000, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, § 388-551-2000, filed 8/2/99, effective 9/2/99.]

     "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 an intermittent or part-time 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 an intermittent or part-time basis by a medicare-certified home health agency with a current ((medical assistance administration (MAA))) provider number. See also WAC 388-551-2000.

     "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)) disability services administration (((AASA))) (ADSA) through home and community services (HCS) or the division of developmental disabilities (DDD).

     "Plan of care (POC)" (also known as "plan of treatment (POT)") means a written plan of care that is established and periodically reviewed and signed by both ((a physician)) an ordering licensed practitioner and a home health agency provider. 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. (See WAC 388-551-2030 (2)(g)(ii) for clients in residential facilities whose home health services are not covered through ((MAA's)) department's home health program.)

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

     "Specialized therapy" means skilled therapy services provided to clients that include:

     (1) Physical;

     (2) Occupational; or

     (3) Speech/audiology services.

(See WAC 388-551-2110.)

     "Telemedicine" - For the purposes of WAC 388-551-2000 through 388-551-2220, means the use of telemonitoring to enhance the delivery of certain home health skilled nursing services through:

     (1) The collection of clinical data and the transmission of such data between a patient at a distant location and the home health provider through electronic processing technologies. Objective clinical data that may be transmitted includes, but is not limited to, weight, blood pressure, pulse, respirations, blood glucose, and pulse oximetry; or

     (2) The provision of certain education related to health care services using audio, video, or data communication instead of a face-to-face visit.

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. 02-15-082, § 388-551-2010, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, § 388-551-2010, filed 8/2/99, effective 9/2/99.]

     (a) Categorically needy program (CNP);

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

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

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. 02-15-082, § 388-551-2020, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, § 388-551-2020, filed 8/2/99, effective 9/2/99.]

     (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)) an ordering licensed practitioner'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)) The department 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)) department-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)) the department when no home health agency exists in the area a client resides; or

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

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. 02-15-082, § 388-551-2030, filed 7/15/02, effective 8/15/02.]

     (2) ((MAA)) The department 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)) a department-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)) The department limits skilled nursing visits provided to eligible clients to two per day.

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. 02-15-082, § 388-551-2100, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, § 388-551-2100, filed 8/2/99, effective 9/2/99.]

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

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. 02-15-082, § 388-551-2110, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, § 388-551-2110, filed 8/2/99, effective 9/2/99.]

     (2) ((MAA)) The department 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)) The department 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, 74.09.520, 74.09.530, and 74.09.500. 02-15-082, § 388-551-2120, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, § 388-551-2120, filed 8/2/99, effective 9/2/99.]

     (2) The department pays for one telemedicine interaction, per eligible client, per day based on the ordering licensed practitioner's home health plan of care.

     (3) To receive payment for the delivery of home health services through telemedicine, the services must involve:

     (a) An assessment, problem identification, and evaluation which includes:

     (i) Assessment and monitoring of clinical data including, but not limited to, vital signs, pain levels and other biometric measures specified in the plan of care. Also includes assessment of response to previous changes in the plan of care; and

     (ii) Detection of condition changes based on the telemedicine encounter that may indicate the need for a change in the plan of care; and

     (b) Implementation of a management plan through one or more of the following:

     (i) Teaching regarding medication management as appropriate based on the telemedicine findings for that encounter;

     (ii) Teaching regarding other interventions as appropriate to both the patient and the caregiver;

     (iii) Management and evaluation of the plan of care including changes in visit frequency or addition of other skilled services;

     (iv) Coordination of care with the ordering licensed practitioner regarding telemedicine findings;

     (v) Coordination and referral to other medical providers as needed; and

     (vi) Referral to the emergency room as needed.

     (4) The department does not require prior authorization for the delivery of home health services through telemedicine.

     (5) The department does not pay for the purchase, rental, or repair of telemedicine equipment.

[]

     (a) 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 disability services administration (ADSA).

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

     (ii) On a case-by-case basis, ((HRSA)) the department 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.

     (c) Psychiatric skilled nursing services.

     (d) Pre- and postnatal skilled nursing services, except as listed under WAC 388-551-2100 (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) HRSA 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)) licensed practitioner's order, unless the verbal order is:

     (i) Documented prior to the visit; and

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

     (2) HRSA 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) HRSA evaluates a request for any service that is listed as noncovered under the provisions of WAC 388-501-0160.

[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-551-2130, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. 02-15-082, § 388-551-2130, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, § 388-551-2130, filed 8/2/99, effective 9/2/99.]

     (1) A home health agency that:

     (a) Is Title XVIII (medicare) certified;

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

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

     (d) Is assigned a provider number.

     (2) A registered nurse (RN) who:

     (a) Is prior authorized by ((MAA)) the department 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)) the department; and

     (d) Is assigned a provider number.

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. 02-15-082, § 388-551-2200, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, § 388-551-2200, filed 8/2/99, effective 9/2/99.]

     (1) The POC must:

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

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

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

     (d) Contain specific goals and treatment plans;

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

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

     (2) The provider must include in the 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;

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

     (d) The prognosis;

     (e) The type(s) of equipment required, including telemedicine as appropriate;

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

     (g) Specific procedures and modalities;

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

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

     (j) A list of permitted activities;

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

     (l) A list of medications which indicates:

     (i) Any new prescription; and

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

     (3) The provider must include in or attach to the 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)) an ordering licensed practitioner's office, clinic, or other outpatient setting;

     (c) Significant clinical findings;

     (d) Dates of recent hospitalization;

     (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; and

     (g) Order for the delivery of home health services through telemedicine, as appropriate.

     (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 as described in WAC 388-551-2120(3);

     (c) All medications administered and treatments provided;

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

     (e) Signed ((physician)) licensed practitioner's new orders and change orders;

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

     (g) Interdisciplinary and multidisciplinary team communications;

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

     (i) Medical tests and results;

     (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 POC;

     (b) Client response to the POC:

     (c) Any clinical change in client status;

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

     (e) Any communications with the attending ((physician)) ordering licensed practitioner; and

     (f) Telemedicine findings, as appropriate.

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

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

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

     (c) If a client's wound is not healing, the client's ((physician)) ordering licensed practitioner 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 POC.

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. 02-15-082, § 388-551-2210, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, § 388-551-2210, filed 8/2/99, effective 9/2/99.]

     (2) Payment to home health providers is:

     (a) A set rate per visit 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.

     (3) For clients eligible for both medicaid and medicare, ((MAA)) the department 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.

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

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

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

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

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

     (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, 74.09.520, 74.09.530, and 74.09.500. 02-15-082, § 388-551-2220, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, § 388-551-2220, filed 8/2/99, effective 9/2/99.]

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