Date of Adoption: August 2, 1999.

Purpose: The department is establishing new WAC 388-551, Alternatives to hospital services, to combine alternative services into one chapter. The new chapter consolidates all the rules about this subject and makes it easier to find information. It also clarifies department policies and so complies with the Governor's Executive Order 97-02. The department is repealing WAC 388-86-045 and 388-87-065 to avoid duplicating rules found in the new chapter.

Citation of Existing Rules Affected by this Order: Repealing WAC 388-86-045 and 388-87-065.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.530.

Adopted under notice filed as WSR 99-11-053 on May 17, 1999.

Changes Other than Editing from Proposed to Adopted Version: Deleted material indicated by strikethrough type, additions indicated by underlined type.

WAC 388-551-2000, "...The client must be homebound, as determined by documentation provided submitted to MAA during the client's focused program review period."

WAC 388-551-2010, "'Homebound' - means a physician has certified that the client is medically or physically not capable of leaving the client's residence, and MAA has determined, by reviewing available supporting documentation, that the client meets the requirements to receive home health services, confined to the home, and under normal circumstances, lacks the ability to leave home without a considerable and taxing effort. The client may be considered homebound if absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive medical treatment."

WAC 388-551-2100 (9)(b), "When provided by a Medicaid approved infant phototherapy agency, which has a copy of MAA's approval letter on file; and..."

WAC 388-551-2210 (1)(d), "Be reviewed, and revised and signed by a physician at least every sixty-two calendar days; and signed by a physician within forty-five days of the verbal order."

WAC 388-551-2210 (2)(k)(i), "The date Any new prescription is prescribed, and..."

WAC 388-551-2210(5), "The provider must document at least the following in the client's visit notes medical record:..."

WAC 388-551-2130 (1)(c), "Pre- and postnatal skilled nursing services except as listed under WAC 388-551-2100(10);"

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.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 10, Amended 0, Repealed 2.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 10, Amended 0, Repealed 2.

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 10, Amended 0, Repealed 2. Effective Date of Rule: Thirty-one days after filing.

August 2, 1999

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

The purpose of the medical assistance administration (MAA) home health program is to reduce the costs of health care services by providing equally effective, more conservative, and/or less costly treatment in a client's home.

Home health services consist of skilled nursing and specialized therapies provided in a client's residence. Home health aide services may be provided in addition to these services. The client must be homebound, as determined by documentation submitted to MAA during the client’s focused program review period. Services provided are for acute, intermittent, short term, and intensive courses of treatment. See WAC 388-515 for clients needing chronic, long-term maintenance care.

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Words and abbreviations in bold have the following definitions for this chapter. See also WAC 388-500 for other definitions and abbreviations used by the department.

"Home health agency" means an agency or organization certified under Medicare to provide comprehensive health care on a part-time or intermittent basis to a patient in the patient's place of residence.

"Home health services" mean skilled health care (nursing, specialized therapy, and home health aide) services provided in the client's residence on a part-time or intermittent basis by a Title XVIII Medicare and Title XIX Medicaid home health provider. See also WAC 388-551-2000.

"Homebound" means a physician has certified that the client is medically or physically confined to the home, and under normal circumstances, lacks the ability to leave home without a considerable and taxing effort. The client may be considered homebound if absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive medical treatment.

"Plan of treatment (POT)" (also known as "plan of care (POC)") means a written plan of treatment that is established and periodically reviewed and signed by both a physician and a home health agency provider, that 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 not including a hospital, skilled nursing facility, or residential facility with skilled nursing services available.

"Specialized therapy" means skilled therapy services provided to homebound clients which includes:

(1) Physical;

(2) Occupational; or

(3) Speech/audiology services.

See WAC 388-551-2110.

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(1) Clients in the following MAA programs are eligible to receive home health services subject to the limitations described in this chapter. WAC 388-551 does not apply to clients enrolled in MAA's managed care plans.

(a) Categorically needy program (CNP);

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

(c) General assistance expedited (GA-X) (disability determination pending); and

(d) Medical care services (MCS) programs:

(i) General assistance - unemployable (GA-U); and

(ii) Alcoholism and drug addiction treatment and support act (ADATSA) (GA-W).

(2) Clients in the following emergency-only MAA programs are eligible to receive home health services subject to the limitations described in this chapter. Coverage is also limited to two skilled nursing visits per eligibility enrollment period. Specialized therapy services and home health aide visits are not covered:

(a) Categorically needy program (CNP) - emergency-only.

(b) Limited casualty program - medically needy program (LCP-MNP)-emergency only.

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(1) Skilled nursing services involve observation, assessment, treatment, teaching, training, management and/or evaluation requiring the skills of:

(a) A registered nurse; or

(b) A licensed practical nurse under the supervision of a registered nurse.

(2) MAA may pay for up to two skilled nursing visits per day. See WAC 388-551-2220 (3), (4) and (5).

(3) Coverage for home health nursing services is limited to homebound clients, except as listed in subsection (4) of this section.

(4) MAA covers home health nursing services for nonhomebound clients on a limited basis only when the client is unable to access similar services in a less costly setting, as documented by the provider and approved by MAA.

(5) A brief skilled nursing visit occurs when only one of the following activities is performed during a visit:

(a) An injection or blood draw;

(b) Placement of oral medications in containers (e.g., envelopes, cups, medisets); or

(c) A prefill of insulin syringes.

(6) MAA may cover brief skilled nursing visits for a client with chronic needs, for a short time, until a long term care plan is implemented.

(7) MAA limits services provided to a client enrolled in either of the emergency medical programs listed in WAC 388-551-2020 (2)(a) and (b), to two skilled nursing visits within their eligibility enrollment period.

(8) To receive infusion therapy clients must:

(a) Be willing and capable of learning and managing their infusion care; or

(b) Have a caregiver willing and capable of learning and managing the client's infusion care.

(9) MAA covers infant phototherapy:

(a) For up to five skilled nursing visits per infant;

(b) When provided by a Medicaid approved infant phototherapy agency; and

(c) When the infant is diagnosed with hyperbilirubinemia.

(10) MAA covers limited high risk obstetrical services:

(a) For a medical condition that complicates pregnancy and may result in a poor outcome for the mother, unborn, or newborn;

(b) During the span of home health agency services, if 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);

(c) When provided by a registered nurse who has either:

(i) National prenatal certification; or

(ii) A minimum of one year of labor, delivery, and postpartum experience at a hospital within the last five years; and

(d) For up to three home health visits per pregnancy.

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(1) MAA may pay for up to one specialized therapy visit per day, per type of specialized therapy.

(2) To receive specialized therapy services, a client must be homebound.

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(1) MAA may pay for up to one home health aide visit per day.

(2) MAA pays for home health aide services only when the services are provided under the supervision of and in conjunction with:

(a) Skilled nursing services; or

(b) Specialized therapy services.

(3) MAA 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.

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(1) MAA does not cover the following home health services and expenses:

(a) Medical social work services;

(b) Psychiatric skilled nursing services;

(c) Pre- and postnatal skilled nursing services except as listed under WAC 388-551-2100(10);

(d) Additional administrative costs billed above the visit rate (these costs are included in the visit rate and may not be billed separately);

(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) Home health visits made without a written physician order unless the verbal order is:

(i) Written prior to or on the date of the visit; and

(ii) Signed by the physician within forty-five days.

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A home health provider may contract with MAA to be a Medicaid provider if the provider is Title XVIII (Medicare) certified and licensed by the state as a home health agency. Providers must have an active Medicaid provider number to bill MAA.

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For any delivered home health service to be payable, MAA requires home health providers to develop and implement an individualized plan of treatment (POT) for the client.

(1) The POT must:

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

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

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

(d) Be reviewed and revised by a physician at least every sixty-two calendar days and signed by a physician within forty-five days of the verbal order;

(e) Contain specific goals and treatment plans; and

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

(2) The provider must include in the POT all of the following:

(a) The primary diagnosis (the diagnosis that is most related to the reason the client qualifies for home health services);

(b) The medical diagnoses and prognosis, including date(s) of onset or exacerbation;

(c) A discharge plan;

(d) The type(s) of equipment required;

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

(f) Specific procedures and modalities;

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

(h) Rehabilitation potential;

(i) A list of permitted activities;

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

(k) A list of medications which indicates:

(i) Any new prescription prescribed; and

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

(3) The provider must include in or attach to the POT:

(a) A description of the client's functional limits and the effects;

(b) Significant clinical findings;

(c) Dates of recent hospitalization; and

(d) If the client is not homebound, a description of why home health services are necessary. The description must include:

(i) A written statement noting coordination with, or referral to, the client's department of social and health services-assigned case manager; or

(ii) An assessment of the client and the client's access to community resources, including attempts to use appropriate alternatives to meet the client's home health needs.

(4) The individual client medical record must comply with community standards of practice, and must include documentation of:

(a) Supervisory visits for home health aide services per WAC 388-551-2120(3);

(b) All medications administered and treatments provided;

(c) All physician orders and change orders, with notation that the order was received prior to treatment;

(d) Signed physician new orders and change orders;

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

(f) Interdisciplinary team communications;

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

(h) Medical tests and results; and

(i) Pertinent medical history.

(5) The provider must document at least the following in the client's medical record:

(a) Skilled interventions per the POT;

(b) Any clinical change in client status;

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

(d) Any communications with the attending physician.

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

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

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

(c) The client's physical system assessment as identified in the POT.

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(1) Payment to home health providers is:

(a) A set visit rate 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.

(2) For clients eligible for Medicaid and Medicare, MAA 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.

(3) Providers must submit documentation to the department during any MAA focused program review period. Documentation includes, but is not limited to, the requirements listed in WAC 388-551-2210.

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

(5) MAA may take back payment for any insufficiently documented home health care service when the MAA medical director or designee determines that:

(a) The service was not medically necessary (defined in WAC 388-500-0005) or reasonable;

(b) Clients were able to receive care outside of the home (see definition of homebound in this chapter and WAC 388-551-2100(3)); or

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

(6) Covered home health services for clients enrolled in a Healthy Options managed care plan are paid for by that plan.

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