Date of Adoption: February 28, 2002.

     Purpose: To amend WAC 388-533-0400 Maternity care and newborn delivery. The department recognizes that smoking during pregnancy is associated with poor maternal, fetal, and infant outcomes. In order to help improve these outcomes, the department is adding coverage for smoking cessation counseling/education services for Medicaid pregnant women. The rule clearly states who is eligible for the program, who may provide and be reimbursed for program services, and the specific services for which providers are reimbursed.

     Citation of Existing Rules Affected by this Order: Amending WAC 388-533-0400 Maternity care and newborn delivery.

     Statutory Authority for Adoption: RCW 74.08.090, 74.09.760, 74.09.770.

      Adopted under notice filed as WSR 02-03-098 on January 18, 2002.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 1, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.
     Effective Date of Rule: Thirty-one days after filing.

February 28, 2002

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

     (a) "Birthing center" means a specialized facility licensed as a childbirth center by the department of health (DOH) under chapter 246-349 WAC.

     (b) "Bundled services" means those services that are integral to a major procedure that may be bundled with the major procedure for the purposes of reimbursement. Under this chapter, certain bundled services must be billed separately (unbundled) when the services are provided by different providers.

     (c) "Facility fee" means that portion of MAA's reimbursement that covers the hospital or birthing center charges. This does not include MAA's reimbursement for the professional fee defined below.

     (d) "Global fee" means the fee MAA pays for total obstetrical care. Total obstetrical care includes all bundled antepartum care, delivery services and postpartum care.

     (e) "High-risk" pregnancy means any pregnancy that poses a significant risk of a poor birth outcome.

     (f) "Professional fee" means that portion of MAA's reimbursement that covers the services that rely on the provider's professional skill or training, or the part of the reimbursement that recognizes the provider's cognitive skill. (See WAC 388-531-1850 for reimbursement methodology).

     (2) MAA covers full scope maternity care and newborn delivery services to its clients who qualify for categorically needy (CN) or medically needy (MN) scope of care (see WAC 388-462-0015 for client eligibility). See subsection (21) of this section for client eligibility limitations for smoking cessation counseling provided as part of antepartum care services.

     (3) MAA does not provide full scope maternity care and delivery services to its clients who qualify for medically indigent (MI) scope of care (see WAC 388-462-0015 for client eligibility). Clients who qualify for MI scope of care have hospital delivery coverage only.

     (4) MAA does not provide maternity care and delivery services to its clients who are eligible for:

     (a) Family planning only (a pregnant client under this program should be referred to the local community services office for eligibility review); or

     (b) Any other program not listed in this section.

     (5) MAA requires providers of maternity care and newborn delivery services to meet all of the following. Providers must:

     (a) Be currently licensed by the state of Washington's department of health (DOH) and/or department of licensing;

     (b) Have signed core provider agreements with MAA;

     (c) Be practicing within the scope of their licensure; and

     (d) Have valid certifications from the appropriate federal or state agency, if such is required to provide these services (e.g., federally qualified health centers (FQHCs), laboratories certified through the Clinical Laboratory Improvement Amendment (CLIA), etc.).

     (6) MAA covers total obstetrical care services (reimbursed under a global fee). Total obstetrical care includes all of the following:

     (a) Routine antepartum care that begins in any trimester of a pregnancy;

     (b) Delivery (intrapartum care/birth) services; and

     (c) Postpartum care. This includes family planning counseling.

     (7) When an eligible client receives all the services listed in subsection (6) of this section from one provider, MAA reimburses that provider in one of the following ways:

     (a) Through a global obstetrical fee; or

     (b) Through separate fees in any combination:

     (i) First trimester antepartum care;

     (ii) Second trimester antepartum care;

     (iii) Third trimester antepartum care;

     (iv) Delivery services (intrapartum care); and

     (v) Postpartum care.

     (8) When an eligible client receives services from more than one provider, MAA reimburses each provider for the services furnished. The separate services that MAA reimburses appear in subsection (7)(b) of this section.

     (9) MAA reimburses for antepartum care services in one of the following two ways:

     (a) Under a global fee (for total obstetrical care); or

     (b) Under separate trimester care fees.

     (10) MAA's fees for antepartum care include all of the following:

     (a) An initial and any subsequent patient history;

     (b) All physical examinations;

     (c) Recording and tracking the client's weight and blood pressure;

     (d) Recording fetal heart tones;

     (e) Routine chemical urinalysis (including all urine dipstick tests); and

     (f) Maternity counseling.

     (11) MAA covers certain antepartum services in addition to the bundled services listed in subsection (10) of this section. MAA reimburses separately for any the following:

     (a) A prenatal assessment fee for a pregnant client (limited to one prenatal assessment fee per pregnancy per provider);

     (b) An enhanced prenatal management fee (a monthly fee for medically necessary increased prenatal monitoring). MAA provides a list of diagnoses and/or conditions that MAA identifies as justifying more frequent monitoring visits. MAA reimburses for either (b) or (c) of this subsection, but not both;

     (c) A prenatal management fee for "high-risk" maternity clients. This monthly fee is payable to either a physician or a certified nurse midwife. MAA reimburses for either (b) or (c) of this subsection, but not both;

     (d) Necessary prenatal laboratory tests except routine chemical urinalysis, including all urine dipstick tests, as described in subsection (10)(e) of this section; and/or

     (e) Treatment of medical problems that are not related to the pregnancy. MAA pays these fees to physicians or advanced registered nurse practitioners.

     (12) MAA covers high-risk pregnancies. MAA considers a pregnant client to have a high-risk pregnancy when the client:

     (a) Has any high-risk medical condition (whether or not it is related to the pregnancy); or

     (b) Has a diagnosis of multiple births.

     (13) MAA covers delivery services for clients with high-risk pregnancies, described in subsection (12) of this section, when the delivery services are provided in a hospital.

     (14) MAA covers the facility fee for delivery services in the following settings:

     (a) Inpatient hospital; or

     (b) Birthing centers.

     (15) MAA covers the professional fee for delivery services in the following settings:

     (a) Hospitals, to a provider who meets the criteria in subsection (5) of this section and who has privileges in the hospital;

     (b) Planned home birth settings for providers who are participating in MAA's home birth pilot project; or

     (c) Birthing centers, as described in WAC 388-533-0600.

     (16) MAA covers hospital delivery services for an eligible client as defined in subsections (2), (3), and (4)(b) of this section. MAA's bundled reimbursement for the professional fee for hospital delivery services include:

     (a) The admissions history and physical examination;

     (b) The management of uncomplicated labor (intrapartum care);

     (c) The vaginal delivery of the newborn (with or without episiotomy or forceps); and

     (d) Cesarean delivery of the newborn.

     (17) MAA pays only a labor management fee to a provider who begins intrapartum care and unanticipated medical complications prevent that provider from following through with the birthing services.

     (18) In addition to the MAA reimbursement for professional services in subsection (16) of this section, MAA may reimburse separately for services provided by any of the following professional staff:

     (a) A stand-by physician in cases of high risk delivery and/or newborn resuscitation;

     (b) A physician assistant when delivery is by cesarean section;

     (c) A registered nurse - "first assist" when delivery is by cesarean section;

     (d) A physician, advanced registered nurse practitioner, or licensed midwife for newborn examination as the delivery setting allows; and/or

     (e) An obstetrician/gynecologist specialist for external cephalic version and consultation.

     (19) In addition to the professional delivery services fee in subsection (16) or the global/total fees (i.e., those that include the hospital delivery services) in subsections (6) and (7) of this section, MAA allows additional fees for any of the following:

     (a) High-risk vaginal delivery;

     (b) Multiple vaginal births. MAA's typical reimbursement covers delivery of the first child. For each subsequent child, MAA reimburses at fifty percent of the provider's usual and customary charge, up to MAA's maximum allowable fee; or

     (c) High-risk cesarean section delivery.

     (20) MAA does not reimburse separately for any of the following:

     (a) More than one child delivered by cesarean section during a surgery. MAA's cesarean section surgery fee covers one or multiple surgical births;

     (b) Post-operative care for cesarean section births. This is included in the surgical fee. Post-operative care is not the same as or part of postpartum care.

     (21) In addition to the services listed in subsection (11) of this section, MAA covers counseling for tobacco dependency for eligible pregnant women through two months post-pregnancy. This service is commonly referred to as smoking cessation education or counseling.

     (a) MAA covers smoking cessation counseling for only those fee-for-service clients who are eligible for categorically needy (CN) scope of care. See (f) of this subsection for limitations on prescribing pharmacotherapy for eligible CN clients. Clients enrolled in managed care may participate in a smoking cessation program through their plan.

     (b) MAA pays a fee to certain providers who include smoking cessation counseling as part of an antepartum care visit or a post-pregnancy office visit (which must take place within two months following live birth, miscarriage, fetal death, or pregnancy termination). MAA reimburses only the following providers for smoking cessation counseling:

     (i) Physicians;

     (ii) Physician assistants (PA) working under the guidance and billing under the provider number of a physician;

     (iii) Advanced registered nurse practitioners (ARNP), including certified nurse midwives (CNM); and

     (iv) Licensed midwives (LM).

     (c) MAA covers one smoking cessation counseling session per client, per day, up to ten sessions per client, per pregnancy. The provider must keep written documentation in the client's file for each session. The documentation must reflect the information in (e) of this subsection.

     (d) MAA covers two levels of counseling. Counseling levels are:

     (i) Basic counseling (fifteen minutes), which includes (e)(i), (ii), and (iii) of this subsection; and

     (ii) Intensive counseling (thirty minutes), which includes the entirety of (e) of this subsection.

     (e) Smoking cessation counseling consists of providing information and assistance to help the client stop smoking. Smoking cessation counseling includes the following steps (refer to MAA's physician-related services (RBRVS) and births and birthing centers billing instructions for specific counseling suggestions and billing requirements):

     (i) Asking the client about her smoking status;

     (ii) Advising the client to stop smoking;

     (iii) Assessing the client's willingness to set a quit date;

     (iv) Assisting the client to stop smoking, which includes developing a written quit plan with a quit date. If the provider considers it appropriate for the client, the "assisting" step may also include prescribing smoking cessation pharmacotherapy as needed (see (f) of this subsection); and

     (v) Arranging to track the progress of the client's attempt to stop smoking.

     (f) A provider may prescribe pharmacotherapy for smoking cessation for a client when the provider considers the treatment is appropriate for the client. MAA covers certain pharmacotherapy for smoking cessation as follows:

     (i) MAA covers Zyban™ only;

     (ii) The product must meet the rebate requirements described in WAC 388-530-1125;

     (iii) The product must be prescribed by a physician, ARNP, or physician assistant;

     (iv) The client for whom the product is prescribed must be eighteen years of age or older;

     (v) The pharmacy provider must obtain prior authorization from MAA when filling the prescription for pharmacotherapy; and

     (vi) The prescribing provider must include both of the following on the client's prescription:

     (A) The client's estimated or actual delivery date; and

     (B) Indication that the client is participating in smoking cessation counseling.

     (g) MAA's reimbursement for smoking cessation counseling is subject to post-pay review. See WAC 388-502-0230, Provider review and appeal, and WAC 388-502-0240, Audits and the audit appeal process for contractors/providers, for information regarding review and appeal processes for providers.

[Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.800. 00-23-052, § 388-533-0400, filed 11/13/00, effective 12/14/00.]

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