WSR 15-14-063

PERMANENT RULES

HEALTH CARE AUTHORITY

(Washington Apple Health)

[Filed June 26, 2015, 8:35 a.m., effective July 27, 2015]

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

Purpose: The agency is amending this rule to include continuous glucose monitoring systems among equipment that this program pays for with prior authorization. This update will make the rule consistent with other sections of WAC.

Citation of Existing Rules Affected by this Order: Amending WAC 182-553-500.

Statutory Authority for Adoption: RCW 41.05.021, 41.05.160.

Adopted under notice filed as WSR 15-08-090 on March 31, 2015.

Changes Other than Editing from Proposed to Adopted Version: The agency made the following changes to the proposed rule:

WAC 182-553-500(3) The agency pays for FDA approved continuous glucose monitoring systems and related monitoring equipment and supplies with prior authorization when the client:

(a) Is either younger than nineteen years of age or enrolled in a continuous glucose monitoring trial. The trial must be approved by an institutional review board under RCW 70.02.010;

(b) Has diabetes mellitus and is insulin dependent;

(c) Has had a severe episode of hypoglycemia (blood glucose less than or equal to 50mg/dl) either requiring assistance from another person or complicated by a hypoglycemia-induced seizure;

(d) Has first tried a seventy-two-hour monitoring period;

(e) Has recurrent unexplained severe hypoglycemic events despite modifications in therapy;

(f) Is followed by a pediatric endocrinologist;

(g) Has A1c target goals deemed appropriate by a physician; and

(h) Has submitted results of self-monitoring of blood glucose levels taken at least four times per day.

The agency pays for FDA-approved continuous glucose monitoring systems and related monitoring equipment and supplies with prior authorization for a client who:

(a) Either has had one or more severe episodes of hypoglycemia or is enrolled in a trial approved by an institutional review board;

(b) Is age eighteen and younger;

(d) Is followed by an endocrinologist.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.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 0, Amended 1, Repealed 0.

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

Date Adopted: June 26, 2015.

Wendy Barcus

Rules Coordinator

AMENDATORY SECTION (Amending WSR 12-16-059, filed 7/30/12, effective 8/30/12)

WAC 182-553-500 Home infusion therapy((/)) and parenteral nutrition program—Coverage, services, limitations, prior authorization, and reimbursement.

(1) The home infusion therapy((/)) and parenteral nutrition program covers the following for eligible clients, subject to the limitations and restrictions listed:

(a) Home infusion supplies, limited to one month's supply per client, per calendar month.

(b) Parenteral nutrition solutions, limited to one month's supply per client, per calendar month.

(c) One type of infusion pump, one type of parenteral pump, and((/or)) one type of insulin pump per client, per calendar month and as follows:

(i) All rent-to-purchase infusion, parenteral, and((/or)) insulin pumps must be new equipment at the beginning of the rental period.

(ii) The agency covers the rental payment for each type of infusion, parenteral, or insulin pump for up to twelve months. ((())The agency considers a pump purchased after twelve months of rental payments.(()))

(iii) The agency covers only one purchased infusion pump or parenteral pump per client in a five-year period.

(iv) The agency covers only one purchased insulin pump per client in a four-year period.

(2) Covered supplies and equipment that are within the described limitations listed in subsection (1) of this section do not require prior authorization for reimbursement.

(3) The agency pays for FDA-approved continuous glucose monitoring systems and related monitoring equipment and supplies with prior authorization for a client who:

(a) Either has had one or more severe episodes of hypoglycemia or is enrolled in a trial approved by an institutional review board;

(b) Is age eighteen and younger;

(d) Is followed by an endocrinologist.

(4) Requests for supplies ((and/))or equipment that exceed the limitations or restrictions listed in this section require prior authorization and are evaluated on an individual basis according to the provisions of WAC 182-501-0165 and 182-501-0169.

(((4))) (5) The agency may adopt policies, procedure codes, and((/or)) rates ((that are)) inconsistent with those set by medicare ((if the agency determines that such actions are necessary)).

(((5))) (6) Agency reimbursement for equipment rentals and purchases includes the following:

(a) Instructions to a client ((or)), a caregiver, or both, on the safe and proper use of equipment provided;

(b) Full service warranty;

(d) Setup, fitting, and adjustments.

(((6) Except as provided in subsection (6) of this section, the)) (7) The agency does not pay separately for home infusion supplies and equipment or parenteral nutrition solutions, except:

(a) When a client resides in a state-owned facility (((i.e.)) e.g., state school, a developmental disabilities (((DD))) facility, a mental health facility, Western State Hospital, ((and)) or Eastern State Hospital).

(b) When a client has elected and is eligible to receive the agency's hospice benefit, unless ((both of the following apply)):

(i) The client has a preexisting diagnosis that requires parenteral support; and

(ii) The preexisting diagnosis is not related to the diagnosis that qualifies the client for hospice.

(((7))) (8) The agency pays separately for a client's infusion pump, parenteral nutrition pump, insulin pump, solutions, and((/or)) insulin infusion supplies when the client:

(a) Resides in a nursing facility; and

(b) Meets the criteria in WAC 182-553-300.