WSR 14-09-061

PERMANENT RULES

HEALTH CARE AUTHORITY

(Washington Apple Health)

[Filed April 16, 2014, 3:46 p.m., effective May 17, 2014]

Effective Date of Rule: Thirty-one days after filing.

Purpose: These revisions amend rule sections in the maternity support services (MSS) and infant case management (ICM) WACs that relate to program requirements and staff qualifications for MSS and ICM providers. The purpose of these amendments is to align the sections with existing licensing requirements in department of health WACs; and to update related rule sections, including changes from the health care authority merger. These amendments also include minor housekeeping changes that update cross references and clarify language.

Citation of Existing Rules Affected by this Order: Amending WAC 182-533-0315, 182-533-0320, 182-533-0325, 182-533-0330, 182-533-0340, 182-533-0345, 182-533-0360, 182-533-0365, 182-533-0370, 182-533-0375, 182-533-0380, 182-533-0385, and 182-533-0386.

Statutory Authority for Adoption: RCW 41.05.021.

Adopted under notice filed as WSR 14-01-027 on December 9, 2013.

Changes Other than Editing from Proposed to Adopted Version: WAC 182-533-0325 was changed to include federally qualified health centers and nonprofit organizations in the list of providers. Language was removed from WAC 182-533-0325(2) to allow services to occur in a wider range of community settings.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 3, Amended 13, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 3, Amended 13, Repealed 0.

Date Adopted: April 15, 2014.

Kevin M. Sullivan

Rules Coordinator

AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-533-0315 Maternity support services—Definitions.

The following definitions and those found in WAC ((388-500-0005)) 182-500-0005 apply to maternity support services (MSS) and infant case management (ICM) (see WAC ((388-533-0360)) 182-533-0360 through ((388-533-0386)) 182-533-0386 for ICM rules).

"Basic health messages"((—)) - For ((the purposes of)) MSS, ((means)) the preventive health education messages designed to promote healthy pregnancies, healthy newborns and healthy parenting during the first year of life.

"Care coordination"((—)) - Professional collaboration and communication between the client's MSS provider and other medical and/or health and social services providers to address the individual client's needs as identified in the care plan.

"Care plan"((—)) - A written ((plan that must be)) statement developed ((and maintained throughout the eligibility period for each client in MSS and ICM)) for a person that continues throughout the eligibility period and outlines any medical, social, environmental or other interventions to achieve an improved quality of life, including health and social outcomes.

"Case conference" - A formal or informal consultation used by the MSS interdisciplinary team to consult with each other and, when needed, other pertinent providers and/or the client to optimize the client's care.

"Case management"((—)) - Services to ((assist)) help individuals ((to gain)) access ((to)) needed medical, social, educational, and other services.

"Childbirth education (CBE)"((—Established as)) - A component of the First Steps program to provide educational sessions offered in a group setting that prepares a pregnant woman and her support person(s) for an upcoming childbirth and healthy parenting.

"Department of health (DOH)"((—)) - The state agency that works to protect and improve the health of people in Washington state.

(("Department of social and health services (department)"—The state agency that administers social and health services programs for Washington state.))

"First Steps"((—)) - The program created under the 1989 Maternity Care Access Act.

"Infant case management (ICM)"((—Established as)) - A component of the First Steps program to provide parent(s) with information and assistance in accessing needed medical, social, educational, and other services ((to)) that improve the welfare of infants.

"Infant case management (ICM) screening"((—)) - A brief in-person evaluation provided by a qualified person, under WAC 182-533-0375, to determine whether an infant and the infant's parent(s) have a specific risk factor(s).

"Linking"((—Assisting)) - Assistance to clients ((to identify)) for identifying and ((use)) using community resources to address specific medical, social and educational needs.

"Maternity cycle"((—)) - An eligibility period for maternity support services that begins during pregnancy and continues to the end of the month in which the sixtieth-day post-pregnancy occurs.

"Maternity support services (MSS)"((—Established as)) - A component of the First Steps program to provide screening, assessment, basic health messages, education, counseling, case management, care coordination, and other interventions delivered by an MSS interdisciplinary team during the maternity cycle.

"Maternity support services (MSS) interdisciplinary team"((—A group of providers)) - A provider's group of qualified staff consisting of at least a community health nurse, a certified registered dietitian, a behavioral health specialist, and, at the discretion of the ((First Steps agency)) provider, a community health worker((, who work together and communicate frequently to share specialized knowledge, skills, and experience in order to address risk factors identified in a client's care plan)). Based upon individual client need, each team member ((must be available to)) provides maternity support services and consultation. (See WAC 182-533-0327(3).)

"Medicaid agency" - The health care authority.

"Parent(s)"((—)) - A person who resides with an infant ((and)), provides the infant's day-to-day care, and ((is:

• The infant's natural or adoptive parent(s);

• A person other than a foster parent who has been granted legal custody of the infant; or

• A person who is legally obligated to support the infant)) meets the legal description under WAC 182-533-0370 (1)(c).

"Risk factors"((—)) - The biopsychosocial factors that could lead to poor birth outcomes, infant morbidity, and/or infant mortality.

"Screening" - A method for systematically identifying and documenting risk factors and client need.

"Washington apple health (WAH)" - The public health insurance programs for eligible Washington residents. Washington apple health is the name used in Washington state for medicaid, the children's health insurance program (CHIP), and state-only funded health care programs. (See WAC 182-500-0120.)

AMENDATORY SECTION (Amending WSR 12-01-097, filed 12/20/11, effective 1/20/12)

WAC 182-533-0320 Maternity support services—Client eligibility.

(1) To receive maternity support services (MSS), a client must:

(a) Be covered under ((one of the following medical assistance programs:

(i) Categorically needy (CN);

(ii) Children's health care as described in WAC 388-505-0210;

(iii) Medically needy program (MNP); or

(iv) A pregnancy medical program as described in WAC 388-462-0015.)) categorically needy, medically needy, or state-funded medical programs under Washington apple health; and

(b) Be within the eligibility period of a maternity cycle as defined in WAC 182-533-0315((; and

(c) Meet any other eligibility criteria as determined by the agency and published in the agency's current billing instructions and/or numbered memoranda.

(2) Clients who meet the eligibility criteria in this section may receive:

(a) An in-person screening by a provider who meets the criteria established in WAC 182-533-0325. Clients are screened for risk factors related to issues that may impact their birth outcomes.

(b) Up to the maximum number of MSS units of service allowed per client as determined by the agency and published in the agency's current billing instructions and/or numbered memoranda. The agency may determine the maximum number of units allowed per client when directed by the legislature to achieve targeted expenditure levels for payment of maternity support services for any specific biennium)).

(((3))) (2) Clients ((meeting)) who meet the eligibility criteria in this section ((who)) and are enrolled in an agency-contracted managed care organization (MCO)((,)) are eligible for MSS outside their plan.

(((4) See chapter 182-534 WAC for clients eligible for coverage under the early periodic screening, diagnosis and treatment (EPSDT) program.

(5) Clients receiving MSS before March 1, 2011, are subject to the transition plan as determined and published by the agency in numbered memoranda.

(6))) (3) Clients who do not agree with an ((agency)) eligibility decision ((regarding eligibility)) for MSS have a right to a fair hearing under chapter ((388-02)) 182-526 WAC.

AMENDATORY SECTION (Amending WSR 12-01-097, filed 12/20/11, effective 1/20/12)

WAC 182-533-0325 Maternity support services—Provider requirements.

Maternity support service providers may include community clinics, federally qualified health centers, local health departments, hospitals, nonprofit organizations, and private clinics.

(1) To be paid for providing maternity support services (MSS) and infant case management (ICM) services to eligible clients, ((an agency or entity)) a provider must:

(a) Be enrolled as an eligible provider with the medicaid agency (see WAC 182-502-0010).

(b) Be currently approved as an MSS/ICM provider by the medicaid agency((;

(b) Be enrolled as an eligible provider with the medicaid agency (see WAC 182-502-0010);)).

(d) Ensure that professional staff providing services:

(i) Meet the minimum regulatory and educational qualifications for the scope of services provided under WAC 182-533-0327; and

(((d) Meet)) (ii) Follow the requirements in this chapter((, chapter 182-502 WAC)) and the medicaid agency's current ((published)) billing instructions ((and numbered memoranda)).

(((2))) (e) Screen each client for risk factors.

(f) Screen clients for ICM eligibility.

(g) Conduct case conferences under WAC 182-533-0327(2).

(h) Develop and implement an individualized care plan for each client.

(i) Initiate and participate in care coordination activities throughout the maternity cycle with at least MSS interdisciplinary team members, the client's prenatal care provider, and the Women, Infants, and Children (WIC) Nutrition Program.

(j) Comply with Section 1902 (a)(23) of the Social Security Act regarding the client's freedom to choose a provider.

(k) Comply with Section 1915 (g)(1) of the Social Security Act regarding the client's voluntary receipt of services.

(2) MSS providers may provide services in any of the following locations:

(a) A provider's office or clinic.

(b) The client's residence.

(c) An alternate site that is not the client's residence. (The reason for using an alternate site for visitation instead of the home must be documented in the client's record.)

(3) An individual or service organization that has a written contractual agreement with ((an agency or entity that meets the requirements in subsection (1) of this section)) a qualified MSS provider also may ((also)) provide MSS and ICM services to eligible clients.

(a) The ((medicaid agency requires the agency or entity to)) provider must:

(i) Keep a copy of the written subcontractor agreement on file;

(ii) Ensure that an individual or service organization staff member providing MSS/ICM services (the subcontractor) meets the minimum regulatory and educational qualifications required of an MSS/ICM provider;

(iii) ((Assure)) Ensure that the ((individual or service organization)) subcontractor provides MSS/ICM services under the requirements of this chapter; and

(iv) Maintain professional, financial, and administrative responsibility for the ((individual or service organization)) subcontractor.

(b) The ((agency or entity is responsible to)) provider must:

(i) Bill for services using the ((agency's or entity's)) provider's assigned ((provider)) billing number; and

(ii) Reimburse the ((individual or service organization)) subcontractor for MSS/ICM services provided under the written agreement.

NEW SECTION

WAC 182-533-0327 Maternity support services—Professional staff qualifications and interdisciplinary team.

(1) MSS providers must use qualified professionals, as specified in this section.

(a) Behavioral health specialists who are currently credentialed or licensed in Washington by the department of health under chapters 246-809, 246-810, and 246-924 WAC as one of the following:

(i) Licensed mental health counselor.

(ii) Licensed independent clinical social worker.

(iii) Licensed social worker.

(iv) Licensed marriage and family therapist.

(v) Licensed psychologist.

(vi) Associate mental health counselor.

(vii) Associate independent clinical social worker.

(viii) Associate social worker.

(ix) Associate marriage and family therapist.

(x) Certified counselor.

(b) Certified dieticians who are currently registered with the commission on dietetic registration and certified by the Washington state department of health under chapter 246-822 WAC.

(c) Community health nurses who are currently licensed as registered nurses in the state of Washington by the department of health under chapter 246-840 WAC.

(d) Community health workers (CHWs) who have a high school diploma or the equivalent and:

(i) Have a minimum of one year of health care and/or social services experience.

(ii) Carry out all activities under the direction and supervision of a professional member or supervisor of the MSS interdisciplinary team.

(iii) Complete a training plan developed by their provider.

(2) The provider's qualified staff must participate in an MSS interdisciplinary team consisting of at least a community health nurse, a certified registered dietitian, a behavioral health specialist, and, at the discretion of the provider, a community health worker.

(a) The interdisciplinary team must work together to address risk factors identified in a client's care plan.

(b) Each qualified staff member acting within her/his area of expertise must address the variety of client needs identified during the maternity cycle.

(c) An MSS interdisciplinary team case conference is required at least once prenatally for clients who are entering MSS during pregnancy, and are eligible for the maximum level of service. Using clinical judgment and the client's risk factors, the provider may decide which interdisciplinary team members to include in case conferencing.

(3) All tribes and any county with fewer than fifty-five medicaid births per year are not required to have an MSS interdisciplinary team, although they must meet all the other requirements in this chapter. Instead of the interdisciplinary team, these counties and tribes must have at least one of the following qualified professionals, as described in subsection (1) of this section:

(a) A behavioral health specialist;

(b) A registered dietician; or

NEW SECTION

WAC 182-533-0328 Maternity support services—Documentation requirements.

Providers must fulfill the documentation requirements under WAC 182-502-0020 and the medicaid agency's current billing instructions including:

(1) Required supervision records for community health workers;

(2) Continued education verification and renewal of credentials for professional staff;

(3) Subcontracting documents, as specified under WAC 182-533-0325(3); and

(4) Client records, which include consent forms and documentation for screening, assessments, care plans, case conferences, case management, and care coordination for each client.

AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-533-0330 Maternity support services—Covered services.

(1) The ((department)) medicaid agency must cover((s)) these maternity support services (MSS) provided by an MSS interdisciplinary team((, subject to the restrictions and limitations in this section and other applicable WAC.

(2) Covered services include)):

(a) In-person screening(s) for risk factors related to pregnancy and birth outcomes;

(b) Brief assessment when indicated;

(d) Education that relates to improving pregnancy and parenting outcomes;

(((d))) (e) Interventions for risk factors identified on the care plan;

(((e))) (f) Basic health messages;

(((f))) (g) Case management services;

(((g))) (h) Care coordination;

(((h) Family planning screening and referral;

(i) Screening and referral for tobacco usage and/or exposure;

(j))) (i) Infant case management (ICM) screening((; and

(k) Additional services as determined and published in the maternity support services/infant case management (MSS/ICM) billing instructions)).

(2) The medicaid agency must determine the maximum number of units of services allowed per client when directed by the legislature to achieve targeted expenditure levels for payment of maternity support services for any specific biennium. (The maximum number of MSS units allowed per client is published in the agency's current billing instructions.)

(3) The ((department)) medicaid agency must pay((s)) for covered maternity support services according to WAC ((388-533-0345)) 182-533-0345.

AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-533-0340 Maternity support services—Noncovered services.

(1) The ((department)) medicaid agency must cover((s)) only those services ((that are)) listed in WAC ((388-533-0330)) 182-533-0330.

(2) The ((department)) medicaid agency must evaluate((s)) a request for any noncovered service under the provisions of WAC ((388-501-0160. When early periodic screening, diagnosis and treatment (EPSDT) applies, the department evaluates a request for a noncovered service according to the process in WAC 388-501-0165 to determine if it is medically necessary, safe, effective, and not experimental (see chapter 388-534 WAC for EPSDT rules))) 182-501-0160.

AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-533-0345 Maternity support services—Payment.

The ((department)) medicaid agency must pay((s)) for the covered maternity support services (MSS) described in WAC ((388-533-0330)) 182-533-0330 on a fee-for-service basis, subject to the ((following)) requirements in this section:

(1) MSS must be:

(a) Provided to a client who meets the eligibility requirements in WAC ((388-533-0320;)) 182-533-0320.

(b) Provided to a client on an individual basis in a face-to-face encounter((;)).

(c) Provided by ((an agency or entity)) a provider that meets the criteria established in WAC ((388-533-0325;)) 182-533-0325.

(d) Provided according to the ((department's)) medicaid agency's current ((published maternity support services/infant case management (MSS/ICM))) billing instructions ((and/or numbered memoranda;)).

(e) Documented in the client's record or chart((; and)).

(f) Billed using:

(i) The eligible client's ((department-assigned)) agency-assigned client identification number;

(ii) The appropriate procedure codes and modifiers identified in the ((department's)) agency's current ((published MSS/ICM)) billing instructions ((and/or numbered memoranda)); and

(iii) The ((agency's department-assigned)) agency-assigned MSS/ICM provider number. (The ((department)) medicaid agency pays the ((agency or entity)) provider for providing MSS services to eligible clients, not the ((individual or service organization that has a written agreement with the agency to provide MSS.)) provider's subcontractor who provides MSS services. See WAC 182-533-0325(3) about subcontracting for services.)

(2) The ((department)) medicaid agency:

(a) Must pay((s)) MSS in units of time with one unit being equal to fifteen minutes of one-to-one service delivered face-to-face((;)).

(b) When directed by the legislature to achieve targeted expenditure levels for payment of maternity support services for any specific biennium, may determine the maximum number of units allowed per client((; and)).

(c) ((Publishes)) Must publish the maximum number of units allowed per client in the ((MSS/ICM)) agency's current billing instructions ((and/or numbered memoranda)).

(3) The provider may request authorization for a limitation extension to exceed the number of allowed MSS units of service under WAC 182-501-0169.

(4) For a client enrolled in a managed care plan who is eligible to receive MSS, the ((department)) medicaid agency must pay((s)) for MSS((:

(a))) delivered outside the plan on a fee-for-service basis as described in this section((; and

(b) Subject to the same program rules that apply to a client who is not enrolled in a managed care plan.

(4) Limitation extension requests to exceed the number of allowed MSS units of service may be authorized according to WAC 388-501-0169)).

AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-533-0360 Infant case management—Purpose.

The purpose of infant case management (ICM) is to improve the welfare of infants by providing their parent(s) with information and assistance ((in order)) to access needed medical, social, educational, and other services (((SSA 1915(g)))).

AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-533-0365 Infant case management—Definitions.

The definitions in WAC ((388-533-0315, Maternity support services definitions,)) 182-533-0315 also apply to infant case management (ICM).

AMENDATORY SECTION (Amending WSR 12-01-097, filed 12/20/11, effective 1/20/12)

WAC 182-533-0370 Infant case management—Client eligibility.

(1) To be eligible to receive infant case management (ICM), an infant must meet all the following criteria:

(a) Be covered under ((one of the medical assistance programs listed in WAC 182-533-0320(1);)) categorically needy, medically needy, or state-funded medical programs under Washington apple health.

(b) Meet the age requirement for ICM, which is the day after the maternity cycle (defined in WAC 182-533-0315) ends, through the last day of the month of the infant's first birthday((;)).

(c) Reside with at least one parent (((see WAC 182-533-0315 for definition of parent);)) who provides the infant's day-to-day care and is:

(i) The infant's natural or adoptive parent(s);

(ii) A person other than a foster parent who has been granted legal custody of the infant; or

(iii) A person who is legally obligated to support the infant.

(d) Have a parent(s) who needs assistance in accessing medical, social, educational and/or other services to meet the infant's basic health and safety needs((; and)).

(e) Not be receiving any case management services funded through Title XIX medicaid that duplicate ICM services.

(2) ((Infants who meet the eligibility criteria in subsection (1) of this section, and the infant's parent(s), are eligible to receive:

(a) An in-person screening by a provider who meets the criteria established in WAC 182-533-0375. Infants and their parent(s) are screened for risk factors related to issues that may impact the infant's welfare, health, and/or safety.

(b) Up to the maximum number of ICM units of service allowed per client as determined by the agency and published in the agency's current billing instructions and/or numbered memoranda. The agency may determine the maximum number of units allowed per client when directed by the legislature to achieve targeted expenditure levels for payment in any specific biennium.

(3))) Clients ((meeting)) who meet the eligibility criteria ((in subsection (1) of this section who)) and are enrolled in ((an)) a medicaid agency-contracted managed care organization (MCO) are eligible for ICM services outside their plan.

(((4) See chapter 182-534 WAC for clients eligible for coverage under the early periodic screening, diagnosis and treatment (EPSDT) program.

(5) Clients receiving ICM before March 1, 2011, are subject to the transition plan as determined and published by the agency in numbered memoranda.

(6))) (3) If the infant's mother becomes pregnant during the ICM eligibility period and she is eligible for maternity support services (MSS), the infant and the infant's mother are no longer eligible to receive ICM services.

(4) Clients who do not agree with an ((agency)) eligibility decision ((regarding eligibility)) by the medicaid agency for ICM have a right to a fair hearing under chapter ((388-02)) 182-526 WAC.

AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-533-0375 Infant case management—Provider requirements.

(1) Infant case management (ICM) services ((can)) may be provided only by a qualified ((person)) infant case manager who is employed by ((an agency or entity that meets)) a provider meeting the requirements in WAC ((388-533-0325)) 182-533-0325. ((Additionally, to qualify as an ICM provider, the person))

(2) The infant case manager must meet at least one of the following qualifications under (a), (b), or (c) of this subsection:

(((1))) (a) Be a current member of the maternity support services (MSS) interdisciplinary team((;)) under WAC 182-533-0327.

(((2))) (b) Have a bachelor of arts, bachelor of science, or higher degree in a social service-related field, such as social work, behavioral sciences, psychology, child development, or mental health, plus at least one year of full-time experience working in one or more of the following areas:

(((a))) (i) Community ((social)) services;

(((b))) (ii) Social services;

(iii) Public health services;

(((c))) (iv) Crisis intervention;

(((d))) (v) Outreach and referral programs; or

(((e))) (vi) Other ((social services-))related fields.

(((3))) (c) Have an associate of arts degree, or an associate's degree in a ((closely allied)) social service-related field, such as social work, behavioral sciences, psychology, child development, or mental health, plus at least two years of full-time experience ((in an area listed in (1) of this section. In addition, at least once per calendar month, the department requires a provider qualifying under this subsection to be under the supervision of a clinical staff person who meets the criteria in (1) of this section.)) working in one or more of the following areas:

(i) Community services;

(ii) Social services;

(iii) Public health services;

(iv) Crisis intervention;

(v) Outreach and referral programs;

(vi) Other related fields.

(3) The medicaid agency requires any staff person qualifying under subsection (2)(c) of this section to be under the supervision of a clinical staff person meeting the criteria in subsection (2)(a) or (b) of this section. Clinical supervision may include face-to-face meetings and/or chart reviews.

NEW SECTION

WAC 182-533-0378 Infant case management—Documentation requirements.

Providers must fulfill the documentation requirements under WAC 182-502-0020 and the medicaid agency's current billing instructions including:

(1) Required supervision records for infant case managers;

(2) Continued education verification and renewal of credentials for professional staff; and

(3) Client records that include consent forms and documentation for screening, assessments, care plans, case management, and care coordination for each client.

AMENDATORY SECTION (Amending WSR 12-01-097, filed 12/20/11, effective 1/20/12)

WAC 182-533-0380 Infant case management—Covered services.

(1) The medicaid agency must cover((s)) infant case management (ICM) services subject to the restrictions and limitations in this section and other applicable WAC.

(((2))) Covered services include:

(a) An initial in-person screening for ICM services, which includes an assessment of risk factors((,)) and the development of an individualized care plan;

(b) Case management services and care coordination;

(d) ((Advocating)) Advocacy for the infant and parent(s); and

(e) Follow-up contact(s) with the parent(s) to ensure the care plan continues to meet the needs of the infant and parent(s)((; and

(f) Additional services as determined and published in the maternity support services/infant case management (MSS/ICM) billing instructions)).

(2) The medicaid agency may determine the maximum number of units allowed per client when directed by the legislature to achieve targeted expenditure levels for payment in any specific biennium. (The maximum number of ICM units allowed per client is published in the agency's current billing instructions.)

(3) The medicaid agency must pay((s)) for covered ICM services according to WAC 182-533-0386.

AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-533-0385 Infant case management—Noncovered services.

(1) The ((department)) medicaid agency must cover((s)) only those services that are listed in WAC ((388-533-0380)) 182-533-0380.

AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-533-0386 Infant case management—Payment.

(1) The ((department)) medicaid agency must pay((s)) for the covered infant case management (ICM) services described in WAC ((388-533-0380)) 182-533-0380 on a fee-for-service basis subject to the following requirements.

(((1))) ICM services must be:

(a) Provided to a client who meets the eligibility requirements in WAC ((388-533-0370;)) 182-533-0370.

(b) Provided by a person who meets the criteria established in WAC ((388-533-0375;)) 182-533-0375.

(c) Provided according to the ((department's)) agency's current ((published maternity support services/infant case management (MSS/ICM))) billing instructions ((and/or numbered memoranda;)).

(d) Documented in the infant's and/or ((infant's parent(s))) the parent's record or chart((; and)).

(e) Billed using:

(i) The eligible infant's ((department-assigned)) medicaid agency-assigned client identification number;

(ii) The appropriate procedure codes and modifiers identified in the ((department's)) agency's current ((published MSS/ICM)) billing instructions ((and/or numbered memoranda)); and

(iii) The ((department-assigned)) medicaid agency-assigned MSS/ICM provider number.

(2) The ((department)) medicaid agency:

(a) Must pay((s)) ICM services in units of time, with one unit being equal to fifteen minutes of one-to-one service delivered face-to-face((;)).

(c) ((Publishes)) Must publish the maximum number of units allowed per client in the ((MSS/ICM)) agency's current billing instructions ((and/or numbered memoranda)).

(3) The provider may request authorization for a limitation extension to exceed the number of allowed ICM units of service under WAC 182-501-0169.

(4) For a client enrolled in a managed care plan who is eligible to receive ICM, the ((department)) medicaid agency must pay((s)) ICM services((:

(a))) delivered outside the plan on a fee-for-service basis as described in this section((; and

(b) Subject to the same program rules that apply to a client who is not enrolled in a managed care plan.

(4) Limitation extension requests to exceed the number of allowed ICM units of service may be authorized according to WAC 388-501-0169)).