Medicaid. Medicaid is a federal-state partnership with programs established in the federal Social Security Act and implemented at the state level with federal matching funds. Medicaid is Washington state's largest public assistance program, providing health insurance for state residents who meet certain eligibility criteria.
There are three agencies involved in determining Medicaid eligibility: the Health Care Authority (HCA), Department of Social and Health Services (DSHS), and the federal Social Security Administration (SSA). HCA administers Medicaid programs for people who qualify based on their income. This includes about 95 percent of managed care recipients in Washington State. DSHS administers Medicaid programs for people who receive long-term care or are elderly or disabled. This represents about 5 percent of managed care recipients in Washington State.
Private Duty Nursing for Children. Private duty nursing services are administered by the Developmental Disabilities Administration (DDA) in DSHS through the Medically Intensive Children’s Program for children ages 17 and younger. This optional Medicaid program helps to keep families together by providing equally effective, less restrictive, and less costly treatment in a client’s home for children who would otherwise require institutional level of care.
Private duty nursing services consist of four or more hours of continuous skilled nursing services provided in the home to eligible clients with complex medical needs that cannot be managed within the scope of intermittent home health services.
Beginning September 1, 2026, HCA must require or provide payment to a home health agency for complex care services as a component of the private duty nursing benefit when provided to a Medicaid enrollee, who is under the age of 18 and receiving private duty nursing services when:
HCA must seek a state plan amendment or waiver, as applicable, from the federal Centers for Medicare and Medicaid Services to implement this payment as a part of the private duty nursing benefit.
HCA must submit a report by September 1, 2029, to assess the complex care services payment program's viability including data analyzing the program's effectiveness. HCA must use available data and not require home health agencies to submit data necessary for creating the report.
HCA must recognize accrediting organizations that it determines have standards that allow home health agencies to properly train caregivers to safely provide complex care services in accordance with federal nursing aide training and competency evaluation program standards.
A caregiver providing complex care services who has successfully completed the training may change employers without having to repeat the required training course.
The home health agency employing the caregiver providing complex care services must assume all of the caregiver's training costs and may not require the caregiver to reimburse the home health agency for the training cost.
When determining the enrollee's eligibility for complex care services, HCA may only consider the child's income and not the income of any other person living in the household.
Complex care services means the provision of the care services by the parent, guardian, family member, or other close association that is the equivalent of a family relation of the enrollee to a person under 18 years old who is receiving private duty nursing when provided under a licensed registered nurse's direction.
Complex care services may include patient transfer; patient positioning; patient ambulation; patient feeding; personal care; catheter care; medication administration; tracheostomy care; enteral care, therapy, and feeding administration; formula preparation; comprehensive respiratory care, chest physiotherapy, and cough assistance; and other HCA-approved tasks.