HEALTH CARE AUTHORITY

(Medicaid Program)

Children in special education must be receiving Title XIX Medicaid under a Washington apple health (WAH) categorically needy program (CNP) or WAH medically needy program (MNP) to be eligible for school-based health care services. Eligible children enrolled in a managed care organization (MCO) receive school-based health care services on a fee-for-service basis.

(1) To be eligible for the kidney center services described in this section, a ((client)) person must be diagnosed with end-stage renal disease (ESRD) or acute renal failure and be covered under ((one of the following programs)):

(a) ((Categorically needy program (CNP);

(e))) One of the Washington apple health programs listed in the table in WAC 182-501-0060;

(b) Alien emergency medical; or

(((f))) (c) Qualified medicare beneficiary (QMB)—(MAA pays only for medicare premium, coinsurance and deductible).

(2) Managed care enrollees must have dialysis services arranged directly through their designated plan.

This section applies to eligible ((clients)) persons who are twenty years of age and younger.

(1) Vision care is available to ((clients)) persons who are eligible for services under one of the ((following medical assistance)) Washington apple health programs((:

(f))) listed in the table in WAC 182-501-0060 or be eligible for the alien emergency medical (AEM) program as described in WAC ((388-438-0115, when the medical services are necessary to treat a qualifying emergency medical condition only)) 182-507-0110.

(2) Eligible ((clients)) persons who are enrolled in ((a department contracted)) an agency-contracted managed care organization (MCO) are eligible under fee-for-service for covered vision care that are not covered by their plan and subject to the provisions of this chapter and other applicable WAC.

(1) The following health professionals may enroll with the agency, as defined in WAC 182-500-0010, to provide outpatient rehabilitation (which includes occupational therapy, physical therapy, and speech therapy) within their scope of practice to eligible ((clients)) persons:

(a) A physiatrist;

(b) A licensed occupational therapist;

(c) A licensed occupational therapy assistant (OTA) supervised by a licensed occupational therapist;

(d) A licensed physical therapist;

(e) A physical therapist assistant supervised by a licensed physical therapist;

(f) A speech-language pathologist who has been granted a certificate of clinical competence by the American Speech, Hearing and Language Association; and

(g) A speech-language pathologist who has completed the equivalent educational and work experience necessary for such a certificate.

(2) ((Clients in the following agency)) Persons covered by one of the Washington apple health programs listed in the table in WAC 182-501-0060 or receiving home health care services as described in chapter 182-551 WAC (subchapter II) are eligible to receive outpatient rehabilitation as described in this chapter((:

(ii) Receiving home health care services as described in chapter 182-551 WAC, subchapter II)).

(3) ((Clients)) Persons who are enrolled in an agency-contracted managed care organization (MCO) must arrange for outpatient rehabilitation directly through his or her agency-contracted MCO.

(4) The agency pays for outpatient rehabilitation when the services are:

(a) Covered;

(b) Medically necessary;

(c) Within the scope of the eligible ((client's)) person's medical care program;

(d) Ordered by a physician, physician's assistant (PA) or an advanced registered nurse practitioner (ARNP);

(e) Within currently accepted standards of evidence-based medical practice;

(f) Authorized, as required within this chapter, chapters 182-501 and 182-502 WAC, and the agency's published billing instructions and numbered memoranda;

(g) Begun within thirty calendar days of the date ordered;

(h) Provided by one of the health professionals listed in subsection (1) of this section;

(i) Billed according to this chapter, chapters 182-501 and 182-502 WAC, and the agency's published billing instructions and numbered memoranda; and

(j) Provided as part of an outpatient 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;

(iii) In a neurodevelopmental center, as described in WAC 182-545-900; or

(iv) For children with disabilities, age two or younger, in natural environments including the home and community setting in which children without disabilities participate, to the maximum extent appropriate to the needs of the child.

(5) For eligible ((clients)) persons, twenty years of age and younger, the agency covers unlimited outpatient rehabilitation.

(6) For ((clients)) persons twenty-one years of age and older, the agency covers a limited outpatient rehabilitation benefit.

(7) Outpatient rehabilitation services for ((clients)) persons twenty-one years of age and older must:

(a) Restore, improve, or maintain the ((client's)) person's level of function that has been lost due to medically documented injury or illness; and

(b) Include an on-going management plan for the ((client)) person and/or the ((client's)) person's caregiver to support timely discharge and continued progress.

(8) For eligible adults, twenty-one years of age and older, the agency limits coverage of outpatient rehabilitation as follows:

(a) Occupational therapy, per ((client)) person, 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, up to twenty-four additional units of occupational therapy may be available to continue treatment initiated under the original twenty-four units when the criteria below is met:

(A) To continue treatment of the original qualifying condition; and

(B) The ((client's)) person's diagnosis is any of the following:

(I) Acute, open, or chronic nonhealing wounds;

(II) Brain injury, which occurred within the past twenty-four months, with residual cognitive and/or functional deficits;

(III) Burns - Second or third degree only;

(IV) Cerebral vascular accident, which occurred within the past twenty-four months, with residual cognitive and/or functional deficits;

(V) Lymphedema;

(VI) Major joint surgery - Partial or total replacement only;

(VII) Muscular-skeletal disorders such as complex fractures which required surgical intervention or surgeries involving spine or extremities (e.g., arm, hand, shoulder, leg, foot, knee, or hip);

(VIII) Neuromuscular disorders which are affecting function (e.g., amyotrophic lateral sclerosis (ALS), active infective polyneuritis (Guillain-Barre));

(IX) Reflex sympathetic dystrophy;

(X) Swallowing deficits due to injury or surgery to face, head, or neck;

(XI) Spinal cord injury which occurred within the past twenty-four months, resulting in paraplegia or quadriplegia; or

(XII) As part of a botulinum toxin injection protocol when botulinum toxin has been prior authorized by the agency.

(b) Physical therapy, per ((client)) person, 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 expedited prior authorization, up to twenty-four additional units of physical therapy may be available to continue treatment initiated under the original twenty-four units when the criteria below is met:

(A) To continue treatment of the original qualifying condition; and

(B) The ((client's)) person's diagnosis is any of the following:

(I) Acute, open, or chronic nonhealing wounds;

(II) Brain injury, which occurred within the past twenty-four months, with residual functional deficits;

(III) Burns - Second and/or third degree only;

(IV) Cerebral vascular accident, which occurred within the past twenty-four months, with residual functional deficits;

(V) Lymphedema;

(VI) Major joint surgery - Partial or total replacement only;

(VII) Muscular-skeletal disorders such as complex fractures which required surgical intervention or surgeries involving spine or extremities (e.g., arm, hand, shoulder, leg, foot, knee, or hip);

(VIII) Neuromuscular disorders which are affecting function (e.g., amyotrophic lateral sclerosis (ALS), active infective polyneuritis (Guillain-Barre));

(IX) Reflex sympathetic dystrophy;

(X) Spinal cord injury, which occurred within the past twenty-four months, resulting in paraplegia or quadriplegia; or

(XI) As part of a botulinum toxin injection protocol when botulinum toxin has been prior approved by the agency.

(c) Speech therapy, per ((client)) person, 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 expedited prior authorization, up to six additional units of speech therapy may be available to continue treatment initiated under the original six units when the criteria below is met:

(A) To continue treatment of the original qualifying condition; and

(B) The ((client's)) person's diagnosis is any of the following:

(I) Brain injury, which occurred within the past twenty-four months, with residual cognitive and/or functional deficits;

(II) Burns of internal organs such as nasal oral mucosa or upper airway;

(III) Burns of the face, head, and neck - Second or third degree only;

(IV) Cerebral vascular accident, which occurred within the past twenty-four months, with residual functional deficits;

(V) Muscular-skeletal disorders such as complex fractures which require surgical intervention or surgery involving the vault, base of the skull, face, cervical column, larynx, or trachea;

(VI) Neuromuscular disorders which are affecting function (e.g., amyotrophic lateral sclerosis (ALS), active infection polyneuritis (Guillain-Barre));

(VII) Speech deficit due to injury or surgery to face, head, or neck;

(VIII) Speech deficit which requires a speech generating device;

(IX) Swallowing deficit due to injury or surgery to face, head, or neck; or

(X) As part of a botulinum toxin injection protocol when botulinum toxin has been prior approved by the agency.

(d) Durable medical equipment (DME) needs assessments, two per ((client)) person, per year.

(e) Orthotics management and training of upper and/or lower extremities, two program units, per ((client)) person, per day.

(f) Orthotic/prosthetic use, two program units, per ((client)) person, per year.

(g) Muscle testing, one procedure, per ((client)) person, per day. Muscle testing procedures cannot be billed in combination with each other. These procedures can be billed alone or with other physical and occupational therapy procedures.

(h) Wheelchair needs assessment, one per ((client)) person, per year.

(9) For the purposes of this chapter:

(a) Each fifteen minutes of timed procedure code equals one unit; and

(b) Each nontimed procedure code equals one unit, regardless of how long the procedure takes.

(10) For expedited prior authorization (EPA):

(a) A provider must establish that:

(i) The ((client's)) person's condition meets the clinically appropriate EPA criteria outlined in this section; and

(ii) The services are expected to result in a reasonable improvement in the ((client's)) person's condition and achieve the ((client's)) person's therapeutic individual goal within sixty calendar days of initial treatment;

(b) The appropriate EPA number must be used when the provider bills the agency;

(c) Upon request, a provider must provide documentation to the agency showing how the ((client's)) person's condition met the criteria for EPA; and

(d) A provider may request expedited prior authorization once per year, per ((client)) person, per each therapy type.

(11) The agency evaluates a request for outpatient rehabilitation that is in excess of the limitations or restrictions, according to WAC 182-501-0169. Prior authorization may be requested for additional units when:

(a) The criteria for an expedited prior authorization does not apply;

(b) The number of available units under the EPA have been used and services are requested beyond the limits;

(c) A new qualifying condition arises after the initial six visits are used.

(12) Duplicate services for outpatient rehabilitation are not allowed for the same ((client)) person when both providers are performing the same or similar procedure(s).

(13) The agency does not pay separately for outpatient rehabilitation that are included as part of the reimbursement for other treatment programs. This includes, but is not limited to, hospital inpatient and nursing facility services.

(14) The agency does not reimburse a health care professional for outpatient rehabilitation 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.

(1) Except for clients in the Family Planning Only and TAKE CHARGE programs, fee-for-service clients are eligible for ambulance transportation to covered services with the following limitations:

(a) Clients in the following Washington apple health (WAH) programs are eligible for ambulance services within Washington state or bordering cities only, as designated in WAC 182-501-0175:

(i) Medical care services (MCS) as described in WAC 182-508-0005;

(ii) ((Alcoholism and Drug Addiction Treatment and Support Act (ADATSA) as described in WAC 182-508-0320;

(iii))) Alien emergency medical (AEM) services as described in chapter 182-507 WAC.

(b) Clients in the WAH categorically needy/qualified medicare beneficiary (CN/QMB) and WAH medically needy/qualified medicare beneficiary (MN/QMB) programs are covered by medicare and medicaid, with the payment limitations described in WAC 182-546-0400(5).

(2) Clients enrolled in an agency-contracted managed care organization (MCO) must coordinate:

(a) Ground ambulance services through their designated MCO, subject to the MCO coverage and limitations; and

(b) Air ambulance services through the agency under fee-for-service, subject to the coverage and limitations within this chapter.

(3) Clients enrolled in the agency's primary care case management (PCCM) program are eligible for ambulance services that are emergency medical services or that are approved by the PCCM in accordance with the agency's requirements. The agency pays for covered services for these clients according to the agency's published medicaid provider guides and provider notices.

(4) Clients under the Involuntary Treatment Act (ITA) are not eligible for ambulance transportation coverage outside the state of Washington. This exclusion from coverage applies to individuals who are being detained involuntarily for mental health treatment and being transported to or from bordering cities. See also WAC 182-546-4000.

(5) See WAC 182-546-0800 and 182-546-2500 for additional limitations on out-of-state coverage and coverage for clients with other insurance.

(6) The agency does not pay for ambulance services for jail inmates and persons living in a correctional facility. See WAC 182-503-0505(5).

(1) The ((department)) agency pays for nonemergency transportation for ((medical assistance)) Washington apple health (WAH) clients as described in WAC 182-501-0060, including ((clients)) persons enrolled in ((a department-contracted)) an agency-contracted managed care organization (MCO), to and from health care services when the health care service(s) meets the requirements in WAC ((388-546-5500)) 182-546-5500.

(2) ((Clients)) Persons assigned to the patient review and coordination (PRC) program according to WAC ((388-501-0135)) 182-501-0135 may be restricted to certain providers.

(a) Brokers may authorize transportation of a PRC client to only those providers to whom the ((client)) person is assigned or referred by their primary care provider (PCP), or for covered services which do not require referrals.

(b) If a ((client)) person assigned to PRC chooses to receive service from a provider, pharmacy, and/or hospital that is not in the ((client's)) person's local community, the ((client's)) person's transportation is limited per WAC 388-546-5700.

(1) A ((client)) person who elects to receive hospice care must be eligible for one of the ((following medical assistance)) Washington apple health programs listed in the table in WAC 182-501-0060 or be eligible for the alien emergency medical (AEM) program (see WAC 182-507-0110), subject to the restrictions and limitations in this chapter and other WAC((:

(d) Alien emergency medical (AEM) as described in WAC 182-507-0110, when the medical services are necessary to treat a qualifying emergency medical condition)).

(2) A hospice agency is responsible to verify a ((client's)) person's eligibility with the ((client)) person or the ((client's)) person's department of social and health services (DSHS) home and community services (HCS) office or community services office (CSO).

(3) A ((client)) person enrolled in one of the medicaid agency's managed care organizations (MCO) must receive all hospice services, including facility room and board, directly through that MCO. The MCO is responsible for arranging and providing all hospice services for an MCO client.

(4) A ((client)) person who is also eligible for medicare hospice under part A is not eligible for hospice care through the medicaid agency's hospice program. The medicaid agency does pay hospice nursing facility room and board for these ((clients)) persons if the ((client)) person is admitted to a nursing facility or hospice care center (HCC) and is not receiving general inpatient care or inpatient respite care. See also WAC 182-551-1530.

(5) A ((client)) person who meets the requirements in this section is eligible to receive hospice care through the medicaid agency's hospice program when all of the following is met:

(a) The ((client's)) person's physician certifies the ((client)) person has a life expectancy of six months or less.

(b) The ((client)) person elects to receive hospice care and agrees to the conditions of the "election statement" as described in WAC 182-551-1310.

(c) The hospice agency serving the ((client)) person:

(i) Notifies the medicaid agency's hospice program within five working days of the admission of all ((clients)) persons, including:

(A) Medicaid-only ((clients)) persons;

(B) Medicaid-medicare dual eligible ((clients)) persons;

(C) Medicaid ((clients)) persons with third-party insurance; and

(D) Medicaid-medicare dual eligible ((clients)) persons with third-party insurance.

(ii) Meets the hospice agency requirements in WAC 182-551-1300 and 182-551-1305.

(d) The hospice agency provides additional information for a diagnosis when the medicaid agency requests and determines, on a case-by-case basis, the information that is needed for further review.

(1) ((Clients)) Persons in the ((following)) Washington apple health (WAH) fee-for-service programs listed in the table in WAC 182-501-0060 are eligible to receive home health services subject to the limitations described in this chapter. ((Clients)) Persons enrolled in ((a department-contracted)) an agency-contracted managed care organization (MCO) receive all home health services through their designated plan.

(2) The ((department)) agency does not cover home health services under the home health program for ((clients)) persons in the CNP-emergency medical only and LCP-MNP-emergency medical only programs. The ((department)) agency or its designee evaluates a request for home health skilled nursing visits on a case-by-case basis under the provisions of WAC ((388-501-0165)) 182-501-0165, and may cover up to two skilled nursing visits within the eligibility enrollment period if the following criteria are met:

(a) The ((client)) person requires hospital care due to an ((emergent)) emergency medical condition as described in WAC ((388-500-0005)) 182-500-0030; and

(b) The ((department)) agency or its designee authorizes up to two skilled nursing visits for follow-up care related to the emergent medical condition.

(1) ((Clients in)) To receive respiratory care, a person must be eligible for one of the ((following medical assistance)) Washington apple health programs ((are eligible for respiratory care:

(e))) listed in the table in WAC 182-501-0060 or be eligible for the alien emergency medical (AEM) (as described in WAC ((388-438-0110, when the medical services are necessary to treat a qualifying emergency medical condition)) 182-507-0110).

(2) ((Clients)) Persons who are enrolled in an agency-contracted managed care organization (MCO) must arrange for all respiratory care directly through his or her MCO.

(3) For ((clients)) persons residing in skilled nursing facilities, boarding homes, and adult family homes, see WAC 182-552-0150.

(4) ((Clients)) Persons who are eligible for services under medicare and medicaid (medically needy program-qualified medicare beneficiaries) are eligible for respiratory care.

(1) ((Clients in the following medical assistance programs are eligible)) To receive home infusion therapy and parenteral nutrition, subject to the limitations and restrictions in this section and other applicable WAC((:

(d) Limited casualty program - Medically needy program (LCP-MNP))), a person must be eligible for one of the Washington apple health programs listed in the table in WAC 182-501-0060.

(2) ((Clients)) Persons enrolled in ((a department-contracted)) an agency-contracted managed care organization (MCO) are eligible for home infusion therapy and parenteral nutrition through that plan.

(3) ((Clients)) Persons eligible for home health program services may receive home infusion related services according to WAC ((388-551-2000 through 388-551-3000)) 182-551-2000 through 182-551-3000.

(4) To receive home infusion therapy, a ((client)) person must:

(a) Have a written physician order for all solutions and medications to be administered.

(b) Be able to manage their infusion in one of the following ways:

(i) Independently;

(ii) With a volunteer caregiver who can manage the infusion; or

(iii) By choosing to self-direct the infusion with a paid caregiver (see WAC 388-71-0580).

(c) Be clinically stable and have a condition that does not warrant hospitalization.

(d) Agree to comply with the protocol established by the infusion therapy provider for home infusions. If the ((client)) person is not able to comply, the ((client's)) person's caregiver may comply.

(e) Consent, if necessary, to receive solutions and medications administered in the home through intravenous, enteral, epidural, subcutaneous, or intrathecal routes. If the ((client)) person is not able to consent, the ((client's)) person's legal representative may consent.

(f) Reside in a residence that has adequate accommodations for administering infusion therapy including:

(i) Running water;

(ii) Electricity;

(iii) Telephone access; and

(iv) Receptacles for proper storage and disposal of drugs and drug products.

(5) To receive parenteral nutrition, a ((client)) person must meet the conditions in subsection (4) of this section and:

(a) Have one of the following that prevents oral or enteral intake to meet the ((client's)) person's nutritional needs:

(i) Hyperemesis gravidarum; or

(ii) An impairment involving the gastrointestinal tract that lasts three months or longer.

(b) Be unresponsive to medical interventions other than parenteral nutrition; and

(c) Be unable to maintain weight or strength.

(6) A ((client)) person who has a functioning gastrointestinal tract is not eligible for parenteral nutrition program services when the need for parenteral nutrition is only due to:

(a) A swallowing disorder;

(b) Gastrointestinal defect that is not permanent unless the ((client)) person meets the criteria in subsection (7) of this section;

(c) A psychological disorder (such as depression) that impairs food intake;

(d) A cognitive disorder (such as dementia) that impairs food intake;

(e) A physical disorder (such as cardiac or respiratory disease) that impairs food intake;

(f) A side effect of medication; or

(g) Renal failure or dialysis, or both.

(7) A ((client)) person with a gastrointestinal impairment that is expected to last less than three months is eligible for parenteral nutrition only if:

(a) The ((client's)) person's physician or appropriate ((medial [medical])) medical provider has documented in the ((client's)) person's medical record the gastrointestinal impairment is expected to last less than three months;

(b) The ((client)) person meets all the criteria in subsection (4) of this section;

(c) The ((client)) person has a written physician order that documents the ((client)) person is unable to receive oral or tube feedings; and

(d) It is medically necessary for the gastrointestinal tract to be totally nonfunctional for a period of time.

(8) A ((client)) person is eligible to receive intradialytic parenteral nutrition (IDPN) solutions when:

(a) The parenteral nutrition is not solely supplemental to deficiencies caused by dialysis; and

(b) The ((client)) person meets the criteria in subsection (4) and (5) of this section and other applicable WAC.

(1) To receive oral or tube-delivered enteral nutrition products, equipment, and related supplies, ((clients)) a person must be eligible for one of the ((following medical assistance)) Washington apple health programs((:

(3))) listed in the table in WAC 182-501-0060 or be eligible for the alien emergency medical (AEM) program (see WAC 182-507-0110).

(2) For clients who reside in a nursing facility, adult family home, assisted living facility, boarding home, or any other residence where the provision of food is included in the daily rate, oral enteral nutrition products are the responsibility of the facility to provide in accordance with chapters 388-76, 388-97 and 388-78A WAC.

(((4))) (3) For clients who reside in a state-owned facility (i.e. state school, developmental disabilities (DD) facility, mental health facility, Western State Hospital, and Eastern State Hospital) enteral nutrition products, equipment, and related supplies are the responsibility of the state-owned facility to provide.

(((5))) (4) Clients who have elected and are eligible to receive the department's hospice benefit must arrange for enteral nutrition products, equipment and related supplies directly through the hospice benefit.

(((6))) (5) Children who qualify for supplemental nutrition from the women, infants, and children (WIC) program must receive supplemental nutrition directly from that program unless the client meets the limited circumstances in WAC 388-554-500 (1)(d).